EXAM 4 QUESTIONS

The nurse is caring for a patient who has been admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH?

The patient’s respirations are very deep and rapid.

The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient’s arrival at the hospital. Which results will the nurse expect to see?

pH 7.27, PaCO₂ 58 mm Hg, HCO₃⁻ 24 mEq/L, PaO₂ 60 mm Hg

The nurse is caring for a dyspneic patient with a long history of smoking. The blood gas report shows:

 pH 7.33

 PaCO₂ 47 mm Hg

 PaO₂ 78 mm Hg

 HCO₃⁻ 26 mEq/l

Respiratory acidosis

A nurse is caring for a patient whose ABG results reveal the following:

 pH 7.56

 PaCO₂ 32 mm Hg

 HCO₃⁻ 42 mEq/L

 PaO₂ 90 mm Hg Which condition will the nurse expect to see in the patient’s chart as the underlying cause of these results?

Gastroenteritis with severe nausea, vomiting, and diarrhea

The nurse is caring for a patient with bulimia. The patient vomits after eating and is experiencing tingling of the fingers and toes and muscle cramps.

Metabolic alkalosis

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hours. The nurse should expect which of the following acid–base imbalances to result from vomiting for 24 hours?

Metabolic alkalosis

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect?

Answer: pH 6.98, PaO₂ 100 mm Hg, PaCO₂ 30 mm Hg, HCO₃⁻ 18 mEq/

A patient’s ABG results are:

 pH 7.30

 PaCO₂ 50 mm Hg

 HCO₃⁻ 26 mEq/L

What is the interpretation?

Respiratory acidosis, uncompensated

Which organ system is the most rapid in responding to changes in the pH?

Respiratory system

The nurse recognizes that prolonged vomiting may lead to

metabolic alkalosis

In respiratory alkalosis, the nurse expects to see which ABG change?

PaCO₂ < 35 mm Hg

The primary buffer system in extracellular fluid is

bicarbonate buffer

A patient with COPD has the following ABG results:

 pH 7.36

 PaCO₂ 55 mm Hg

 HCO₃⁻ 32 mEq/L

What is the interpretation?

Fully compensated respiratory acidosis

Which condition is most likely to cause metabolic acidosis?

Severe diarrhea

A patient’s ABG shows:

 pH 7.50

 PaCO₂ 38 mm Hg

 HCO₃⁻ 32 mEq/L

What is the most likely cause?

Diuretic overdose

In metabolic acidosis, the body compensates by

Increasing respiratory rate

Which ABG results indicate uncompensated metabolic alkalosis?

 pH 7.48

 PaCO₂ 40 mm Hg

 HCO₃⁻ 32 mEq/L

Uncompensated metabolic alkalosis

A client who recently lost their partner says, “How could you possibly understand what I am

going through?” What is the best response by the nurse?

“You’re right, I can’t fully understand. Would you like to share how you feel?”

A carpenter with left-sided hemiplegia can no longer work. What role issue is this?

Role strain

Which interventions help a client recently diagnosed with type 2 diabetes cope and adjust? (Select all that apply)

 Suggest coping skills

 Let the client help create the treatment plan

 Help with time management

 Encourage expression of feelings

 Suggest coping skills

 Let the client help create the treatment plan

 Help with time management

 Encourage expression of feelings

A client says, “My body is so different now after a mastectomy.” What is the best nursing response?

“Tell me more about how your body feels to you.”

Which clients are at increased risk for body image disturbances? (Select all that apply)

 Client with mastectomy

 Client with stroke and right-sided hemiplegia

 Client with cardiac catheterization

 Client with mastectomy

 Client with stroke and right-sided hemiplegia

A client recovering from a heart attack says, “Things might be different with my partner.” What should the nurse say?

“You’re concerned about sexual function. Let’s talk.”

A client with a colostomy says, “I’ll never be able to take care of this at home.” What does this suggest?

Poor self-concept

Which activity helps enhance an older adult’s self-concept?

Reviewing old photos

Which adolescent is most likely to have high self-esteem?

Latino female with strong ethnic pride

A five-year-old is in which developmental stage according to Erikson?

Initiative versus guilt

A client says, “I’m such a loser. I only kept that job for a month.” What outcome should the nurse set?

Client will name two life areas in which they function well

A patient says one part of self-concept is coping. How should the nurse respond?

Provide clarification. Coping is not a component of self-concept.

A 15-year-old with multiple partners says they’re unsure how to stay safe. What is the nurse’s best response?

“STIs and pregnancies are risks. Let’s talk about protection.”

A client had unprotected sex with an HIV-positive partner. What should the nurse do first?

Explain HAART as a treatment

A woman taking antidepressants after fertility issues says, “My sex drive is gone.” Which diagnosis is more important?

Sexual dysfunction

A nurse suggests lubricant for vaginal dryness. Which part of the PLISSIT model is this?

SS (Specific Suggestions)

A nurse is planning a class on STIs. Who is the priority audience?

Men who have sex with men

During a sexual assessment, which question is most important?

“Do you think your partner is attractive?” (assessing sexual attraction/interest)

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply)

 Use lay terms

 Determine client understanding often

 Allow uninterrupted conversation between interpreter and client

 Use lay terms

 Determine client understanding often

 Allow uninterrupted conversation between interpreter and client

Two clients share the same religion. What should the nurse consider?

Religious beliefs can affect people differently

A client is crying while reading a religious book and asks to be left alone. What should the nurse do?

Ensure privacy for a while

A client following Islamic practices is hospitalized. Which action shows culturally responsive care?

Ask if they would like to schedule prayer times

A client refuses a blood transfusion due to a religious belief. What’s the nurse’s best response?

“Let’s talk with your spiritual leaders to explore options.”

A coworker asks the nurse, “What is spirituality?”

“It’s awareness of your inner self.”

A patient says they’re spiritual but not religious. How should the nurse interpret this?

This is reasonable

Which statement is an example of faith?

“I believe in life after death.”

A terminally ill client’s family assists with ADLs. What should the nurse tell them?

Letting them do some tasks helps them feel in control

A client with stage IV lung cancer says, “If I could live to see my child’s wedding, I’ll quit smoking.” What stage of grief is this?

Bargaining

A grieving partner says, “I hate them for leaving me.” Which responses by the nurse should support healthy mourning? (Select all that apply)

 “Would you like to speak with the chaplain?”

 “It’s normal to feel angry at your loved one.”

 “Tell me more about how you’re feeling.”

 “Would you like to speak with the chaplain?”

 “It’s normal to feel angry at your loved one.”

 “Tell me more about how you’re feeling.”

A client is expected to die within 24 hours. What findings should the nurse include when preparing the family?

Decreased muscle tone

After a client dies, the family wants to review the body. What action should the nurse take? (Select all that apply)

Remove all medical equipment

 Apply clean linens and gowns

 Keep body completely flat

 Dim the room lights

Remove all medical equipment

 Apply clean linens and gowns

 Keep body completely flat

 Dim the room lights

A client who had a stroke is experiencing aphasia. What should the nurse do to promote communication? (Select all that apply)

 Use simple words

 Give plenty of time to respond

 Avoid comments that discourage them

 Use simple words

 Give plenty of time to respond

 Avoid comments that discourage them

A client with methamphetamine toxicity has sensory overload. What is the best intervention?

Provide a patient room with limited stimulation

A client reporting hearing problems. What suggests sensorineural hearing loss in the left ear? (Select all that apply)

 Weber’s test lateralizes to the right

 Rinne test shows air conduction > bone conduction

 Weber’s test lateralizes to the right

 Rinne test shows air conduction > bone conduction

A client takes multiple medications. Which of these increase the risk of ototoxicity? (Select all that apply)

 Furosemide

 Ibuprofen

 Amiodarone

 Furosemide

 Ibuprofen

 Amiodarone

A client with new hearing aids says, “I use a damp cloth to clean the outside.” How should the nurse respond?

“That’s correct.”

What sensory change is expected in older adults?

Trouble seeing at night

A stroke patient is tearful and struggling to communicate before discharge. What should the nurse do?

Refer to home health

A patient has both hearing and vision loss. Which psychosocial nursing diagnosis is most appropriate?

Impaired socialization

A patient reports vertigo during assessment. Which deficit should the nurse assess further?

Balance

A client has glaucoma. What nursing diagnosis should address safety concerns?

Risk for falls

A client is on gentamicin for infection. What assessment is the priority?

Hearing

A patient with a traumatic brain injury is often confused but knows where they are. What can

help reduce confusion?

Place a calendar at the bedside