NUR 326 Exam 1 with 100% Correct
Answers
The nurse is assessing a patient diagnosed with diabetic ketoacidosis. The assessment
reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has
been initiated. What should the nurse do about the hyperventilation?
A. Request an order for pain medication and oxygen at 6 L/min
B. Lubricate the patient's lips and allow continued hyperventilation
C. Have the patient breathe into a paper bag to stop hyperventilating
D. Contact the physician immediately regarding this complication - ANS-B. Lubricate the
patient's lips and allow continued hyperventilation
A patient is experiencing their first severe, acute asthma episode. The episode began 2
hours ago. What blood gas values should the nurse expect?
A. pH high, PaCO2 high, HCO3− high
B. pH high, PaCO2 low, HCO3− low
C. pH low, PaCO2 high, HCO3− normal
D. pH low, PaCO2 high, HCO3− high - ANS-C. pH low, PaCO2 high, HCO3− normal
A severe acute asthma episode impairs the excretion of carbonic acid, causing
respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer
than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3−
normal.
Which patient should the nurse closely monitor for the risk factors of metabolic
acidosis?
A. A patient diagnosed with acute meningococcal meningitis
B. A patient with a pancreatic fistula that is draining
C. A patient with severe hyperaldosteronism
D. A patient with Type B chronic obstructive pulmonary disease (COPD) and
pneumonia - ANS-B. A patient with a pancreatic fistula that is draining
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic
acidosis from bicarbonate loss.
The nurse is caring for a patient with severe metabolic alkalosis. Which intervention is
the highest priority?
,A. Ensure the upper side rails of the patient's bed are up.
B. Administer intravenous NaHCO3 as ordered.
C. Teach the family about metabolic alkalosis.
D. Measure the urine output and skin turgor. - ANS-A. Ensure the upper side rails of the
patient's bed are up.
Severe metabolic alkalosis causes a decreased level of consciousness; raising the side
rails is a safety intervention in that situation. Safety interventions are a higher priority
than teaching.
Which questions should the nurse ask when assessing for risk factors for metabolic
acidosis? (Select all that apply)
A. Have you been vomiting today?
B. What type of antacid did you take?
C. Are you still feeling short of breath?
D. When did your kidneys stop working?
E. How long have you had diarrhea?
F. Which weight loss diet are you using? - ANS-D. When did your kidneys stop
working?
E. How long have you had diarrhea?
F. Which weight loss diet are you using?
The nurse is auscultating a patient's bowel sounds and notes a long, thin, fading scar on
the patient's abdomen in the right lower quadrant. What is the best explanation for the
scar's appearance?
A. Fibrous tissue replacing damaged tissue when injury is extensive
B. A surgical incision
C. The development of chronic inflammation
D. Optimal functioning of the inflammatory process after an injury - ANS-A. Fibrous
tissue replacing damaged tissue when injury is extensive
Which of the following patients is at higher risk for inflammatory reactions?
A. 54-year-old woman in menopause
B. 2-year-old girl with a healthy diet
C. 38-year-old man who is obese
D. 79-year-old man with diabetes - ANS-D. 79-year-old man with diabetes
A nurse in the acute care setting is caring for a patient who has rubor of an area of
injury on the left lower extremity. What is the cause for this finding?
A. Exudate
B. Neutrophils
C. Extravasation
, D. Vasodilation - ANS-D. Vasodilation
A patient comes to the clinic stating, "My left arm is red and swollen. It hurts badly
enough that I couldn't go to work today." The healthcare provider orders computer-
assisted tomography (CT) scanning of the left upper extremity. Which statement by the
patient indicates understanding of the reason for the procedure?
A. "This test will help to better determine where the injury actually is and how severe it
is."
B. "This will tell you what I did to my elbow because I really don't know what happened."
C. "The healthcare provider wants me to have this so that the pain will stop."
D. "I need to have this done because the healthcare provider thinks my arm is broken." -
ANS-A. "This test will help to better determine where the injury actually is and how
severe it is."
The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient. What
information does this test provide?
A. Indicates a diagnosis of systemic lupus
B. Identifies the location of inflammation within the body
C. Determines specific causes of inflammation
D. Confirms the nonspecific presence of inflammation - ANS-D. Confirms the
nonspecific presence of inflammation
You are caring for a patient with cirrhosis of the liver being treated for edema, ascites
and portal hypertension. They are placed on a low sodium diet for support and started
on a higher dose of diuretics alongside scheduled paracentesis for support. Which lab
value would you report to the physician if noted prior to initiating therapy and orders?
A. Potassium of 3.0
B. Sodium of 147
C. Albumin of 3.2
D. Magnesium of 2.0 - ANS-A. Potassium of 3.0
A patient is transferred to your facility from a rural health clinic due to cirrhosis with an
elevated blood ammonia level. Which medication would you question if ordered by the
transferring physician?
A. Plavix
B. Lactulose
C. Vitamin K
D. Metoprolol - ANS-A. Plavix
You are completing an assessment of a client with end stage liver disease. Which
finding is most important to report to the physician?
Answers
The nurse is assessing a patient diagnosed with diabetic ketoacidosis. The assessment
reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has
been initiated. What should the nurse do about the hyperventilation?
A. Request an order for pain medication and oxygen at 6 L/min
B. Lubricate the patient's lips and allow continued hyperventilation
C. Have the patient breathe into a paper bag to stop hyperventilating
D. Contact the physician immediately regarding this complication - ANS-B. Lubricate the
patient's lips and allow continued hyperventilation
A patient is experiencing their first severe, acute asthma episode. The episode began 2
hours ago. What blood gas values should the nurse expect?
A. pH high, PaCO2 high, HCO3− high
B. pH high, PaCO2 low, HCO3− low
C. pH low, PaCO2 high, HCO3− normal
D. pH low, PaCO2 high, HCO3− high - ANS-C. pH low, PaCO2 high, HCO3− normal
A severe acute asthma episode impairs the excretion of carbonic acid, causing
respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer
than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3−
normal.
Which patient should the nurse closely monitor for the risk factors of metabolic
acidosis?
A. A patient diagnosed with acute meningococcal meningitis
B. A patient with a pancreatic fistula that is draining
C. A patient with severe hyperaldosteronism
D. A patient with Type B chronic obstructive pulmonary disease (COPD) and
pneumonia - ANS-B. A patient with a pancreatic fistula that is draining
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic
acidosis from bicarbonate loss.
The nurse is caring for a patient with severe metabolic alkalosis. Which intervention is
the highest priority?
,A. Ensure the upper side rails of the patient's bed are up.
B. Administer intravenous NaHCO3 as ordered.
C. Teach the family about metabolic alkalosis.
D. Measure the urine output and skin turgor. - ANS-A. Ensure the upper side rails of the
patient's bed are up.
Severe metabolic alkalosis causes a decreased level of consciousness; raising the side
rails is a safety intervention in that situation. Safety interventions are a higher priority
than teaching.
Which questions should the nurse ask when assessing for risk factors for metabolic
acidosis? (Select all that apply)
A. Have you been vomiting today?
B. What type of antacid did you take?
C. Are you still feeling short of breath?
D. When did your kidneys stop working?
E. How long have you had diarrhea?
F. Which weight loss diet are you using? - ANS-D. When did your kidneys stop
working?
E. How long have you had diarrhea?
F. Which weight loss diet are you using?
The nurse is auscultating a patient's bowel sounds and notes a long, thin, fading scar on
the patient's abdomen in the right lower quadrant. What is the best explanation for the
scar's appearance?
A. Fibrous tissue replacing damaged tissue when injury is extensive
B. A surgical incision
C. The development of chronic inflammation
D. Optimal functioning of the inflammatory process after an injury - ANS-A. Fibrous
tissue replacing damaged tissue when injury is extensive
Which of the following patients is at higher risk for inflammatory reactions?
A. 54-year-old woman in menopause
B. 2-year-old girl with a healthy diet
C. 38-year-old man who is obese
D. 79-year-old man with diabetes - ANS-D. 79-year-old man with diabetes
A nurse in the acute care setting is caring for a patient who has rubor of an area of
injury on the left lower extremity. What is the cause for this finding?
A. Exudate
B. Neutrophils
C. Extravasation
, D. Vasodilation - ANS-D. Vasodilation
A patient comes to the clinic stating, "My left arm is red and swollen. It hurts badly
enough that I couldn't go to work today." The healthcare provider orders computer-
assisted tomography (CT) scanning of the left upper extremity. Which statement by the
patient indicates understanding of the reason for the procedure?
A. "This test will help to better determine where the injury actually is and how severe it
is."
B. "This will tell you what I did to my elbow because I really don't know what happened."
C. "The healthcare provider wants me to have this so that the pain will stop."
D. "I need to have this done because the healthcare provider thinks my arm is broken." -
ANS-A. "This test will help to better determine where the injury actually is and how
severe it is."
The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient. What
information does this test provide?
A. Indicates a diagnosis of systemic lupus
B. Identifies the location of inflammation within the body
C. Determines specific causes of inflammation
D. Confirms the nonspecific presence of inflammation - ANS-D. Confirms the
nonspecific presence of inflammation
You are caring for a patient with cirrhosis of the liver being treated for edema, ascites
and portal hypertension. They are placed on a low sodium diet for support and started
on a higher dose of diuretics alongside scheduled paracentesis for support. Which lab
value would you report to the physician if noted prior to initiating therapy and orders?
A. Potassium of 3.0
B. Sodium of 147
C. Albumin of 3.2
D. Magnesium of 2.0 - ANS-A. Potassium of 3.0
A patient is transferred to your facility from a rural health clinic due to cirrhosis with an
elevated blood ammonia level. Which medication would you question if ordered by the
transferring physician?
A. Plavix
B. Lactulose
C. Vitamin K
D. Metoprolol - ANS-A. Plavix
You are completing an assessment of a client with end stage liver disease. Which
finding is most important to report to the physician?
