NUR2392: Multidimensional Care II / MDC II Exam 2
A patient is brought into the ED with respiratory depression. The patient has a
history of COPD. What acid-base imbalance is most likely?
(ANS – Respiratory Acidosis. The patient likely has a build-up of CO2, causing
respiratory acidosis.
The nurse is evaluating the lab work of a patient who has uncontrolled metabolic
acidosis. Which lab result would result from this condition?
A) pH 7.4
B) PaO2 98 mm Hg
C) bicarbonate 38 mEq/ L
D) serum potassium 5.7 mEq/L
(ANS –
D) serum potassium 5.7 mEq/L. Serum potassium increases during acidosis to try
to buffer the acidic conditions.
The nurse is reviewing the standing orders for a patient who was admitted for
evaluation of chest pain. The patient has a history of chronic obstructive
pulmonary disease (COPD) and his laboratory results and assessment reveal that he
has mild respiratory acidosis. The nurse would question which order?
A.Encourage oral fluids
B.Keep head of bed elevated
C.Oxygen therapy at 4 L/min as needed
D.Bedrest with bathroom privileges only
(ANS – C) Oxygen therapy at 4L/ Min as needed. Oxygen therapy is often ordered
for respiratory acidosis. However, COPD patients have a difficult time off-loading
carbon dioxide and giving too much oxygen can cause these patients to have a
decrease in respiratory drive, leading to respiratory arrest.
A client has acute alcohol intoxication. What acid-base imbalance is the client at
risk for?
(ANS – metabolic acidosis.
A client comes into the ED with respiratory acidosis. What type of medication
would the nurse likely administer?
(ANS – bronchodilators
A client comes into the ED with a high fever and is hyperventilating. His ABG
results are pH 7.51, PaCO2 28 mm Hg, and HCO3 24 mEq/L. The nurse should
identify that the client has which acid-base imbalance?
(ANS – Respiratory Alkalosis. Because the client is breathing rapidly, he is
exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide
decreases the hydrogen ion level of the blood, causing the pH to increase and
resulting in respiratory alkalosis.
A nurse is caring for a client who has metabolic alkalosis. As the client
compensates for this ac
id-base imbalance, which of the following mechanisms should the nurse expect the
client’s body to use?
(ANS – Hypoventilation.
Hypoventilation is the mechanism that helps clients compensate for metabolic
alkalosis.
A nurse is inserting an NG tube for a client who is beginning enteral feedings.
What action should the nurse take to verify tube placement before administering
initial feeding?(ANS – Verify tube placement with radiography
Which patient statement alerts the nurse to perform a thorough GI history and
focused assessment?
A.”I don’t like the taste of spicy foods.”
B.”I got dentures four years ago.”
C.”I experience occasional constipation.”
D.”I take ibuprofen three times daily for arthritis.”
(ANS – D. large amounts of aspirin or NSAIDs can cause peptic ulcer disease and
GI bleeding.
After abdominal surgery, which question should the nurse ask the patient to
determine whether peristaltic movement is returning?
A.”Have you passed flatus?”
B.”Are you hungry”
C.”Do you have any nausea?”
D.”Is your pain level manageable?”
(ANS – A). Passing gas is evidence of peristaltic movement
When administering a new GI medication to an older patient, the nurse anticipates
what?
A.A higher-than-normal dose may be needed.