Chapter 2 NCLEX test questions ABGs, TB

Chapter 2 NCLEX test questions ABG's, TB, 5.0 (1 review) Students also studied Terms in this set (44) Science MedicineNursing Save ABGs Practice Questions 17 terms Kennnnnnna11 Preview NCLEX ABG's Questions 52 terms Olivia_Monarrez Preview Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview ABG pr 12 terms Ste As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action is best for the nurse to take?

• Ask if these wishes have been discussed with the health

care provider.

• Place a "Do Not Resuscitate" (DNR) notation in the

patient's care plan.

• Inform the patient that a notarized advance directive

must be included in the record or resuscitation must be performed.

• Advise the patient to designate a person to make

health care decisions when the patient is not able to make them independently.A A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret

the following 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

ANS: D

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• Blood pressure is 90/40 mm Hg.
• Urine output is 30 mL over the last hour.
• Oral fluid intake is 100 mL for the last 8 hours.
• There is prolonged skin tenting over the sternum.

ANS: A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

• "Increase fluids if your mouth feels dry.
• "More fluids are needed if you feel thirsty."
• "Drink more fluids in the late evening hours."
• "If you feel lethargic or confused, you need more to

drink."

ANS: A

An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality.The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

• Assess for facial muscle spasms.
• Ask the patient about loose stools.
• Suggest that the patient avoid orange juice with meals.
• Ask the health care provider to order a basic metabolic

panel.

ANS: D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level.Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• Assign the patient to a room near the nurse's station.
• Place the patient in a room nearest to the water

fountain.

• Place the patient on telemetry to monitor for peaked T

waves.

• Assign the patient to a semi-private room and place an

order for a low-salt diet.

ANS: A

The patient should be placed near the nurse's station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction.IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

• Administer the KCl as a rapid IV bolus.
• Infuse the KCl at a rate of 10 mEq/hour.
• Only give the KCl through a central venous line.
• Discontinue cardiac monitoring during the infusion.

ANS: B

IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients.KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

• Lung sounds
• Urinary output
• Peripheral pulses
• Peripheral edema

ANS: A

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

• Oral digoxin (Lanoxin) 0.25 mg daily
• Ibuprofen (Motrin) 400 mg every 6 hours
• Metoprolol (Lopressor) 12.5 mg orally daily
• Lantus insulin 24 U subcutaneously every evening

ANS: A

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

• Pallor
• Edema
• Confusion
• Restlessness

B The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG)

results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and

HCO3 16 mEq/L. How should the nurse interpret these results?

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory acidosis
• Respiratory alkalosis

ANS: A

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?

• Grape juice
• Milk carton
• Mixed green salad
• Fried chicken breast

ANS: B

Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

• Skin turgor
• Heart sounds
• Mental status
• Capillary refill

ANS: C

Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

• Notify the patient's health care provider.
• Obtain an order to draw a potassium level.
• Review the magnesium level on the patient's chart.
• Teach the patient about the risk of magnesium-

containing antacids

ANS: A

The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

• Discontinue the nasogastric suction.
• Give the patient the PRN IV morphine sulfate 4 mg.
• Notify the health care provider about the ABG results.
• Teach the patient how to take slow, deep breaths when

anxious.

ANS: B

The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

• Arterial blood pH is 7.32.
• Serum calcium is 18 mg/dL.
• Serum potassium is 5.1 mEq/L.
• Arterial oxygen saturation is 91%.

ANS: B

The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

• Obtain the baseline weight.
• Check the patient's blood pressure.
• Draw blood for serum electrolyte levels.
• Ask about any extremity numbness or tingling.

ANS: B

Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status.