ABGs, TB, Chapter 2 NCLEX Test

ABG's, TB, Chapter 2 NCLEX Test Questions with Verified Answers

As a nurse admits a patient in the final stages of kidney disease, the patient states, "If my heart or breathing stop, I do not want to be resuscitated." What is the best action for the nurse to take?

• Inquire if these wishes have been discussed with the healthcare provider.
• Record a "Do Not Resuscitate" (DNR) note in the patient's care plan.
• Inform the patient that a notarized advance directive must be present in the record to avoid

resuscitation.

• Suggest the patient appoint someone to make healthcare decisions if they become unable to do

so independently. ✔✔a

A patient involved in a car accident has had a tracheostomy inserted to continue mechanical ventilation. How should the nurse interpret these arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory acidosis
• Respiratory alkalosis ✔✔d 1 / 3

The pH indicates alkalosis, and the low PaCO2 suggests a respiratory cause. The other options do not match the pH and HCO3 levels.

The nurse is caring for a patient with severe burns and potential hypovolemia. Which assessment finding is most concerning?

• Blood pressure is 90/40 mm Hg.
• Urine output is 30 mL over the last hour.
• Oral fluid intake is 100 mL in the last 8 hours.
• Skin tenting over the sternum is prolonged. ✔✔a

The low blood pressure suggests the patient might be going into hypovolemic shock due to fluid loss from burns, needing immediate intervention. The other signs also indicate fluid loss but aren't as urgent as hypotension.

The home health nurse visits an alert and oriented older adult with a history of dehydration.What instructions should the nurse give about fluid intake?

• "Increase your fluid intake if your mouth feels dry."
• "Drink more fluids if you feel thirsty."
• "Consume more fluids late in the evening."
• "If you feel lethargic or confused, drink more fluids." ✔✔a 2 / 3

An alert older adult can self-monitor for dryness of the mouth. Thirst sensation decreases with age and isn't a reliable indicator of dehydration. Older adults might restrict fluids in the evening to sleep better. Changes in consciousness aren't easily noticed or acted upon by the patient.

A patient on a potassium-wasting diuretic for hypertension complains of general weakness. What should the nurse do?

• Check for facial muscle spasms.
• Ask the patient about diarrhea.
• Advise the patient to avoid orange juice with meals.
• Request the healthcare provider to order a basic metabolic panel. ✔✔d

General weakness can be a sign of hypokalemia. The nurse should check potassium levels once the metabolic panel is ordered. Facial muscle spasms are linked to hypocalcemia. Orange juice is high in potassium and would be beneficial if the patient is hypokalemic. Diarrhea is associated with hyperkalemia.

A newly admitted patient is diagnosed with hyponatremia. When assigning rooms, what should the charge nurse do?

• Assign the patient to a room close to the nurse's station.
• Place the patient in a room near the water fountain.
• Put the patient on telemetry to monitor for peaked T waves.
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