Question 1

The client with DKA has a blood sugar of 320 mg/dL, a respiratory rate of 32 breaths/min, and a deep, regular respiratory effort. The nurse should implement interventions for which acid-base imbalance?

Accepted Answer

Answer reason: The deep, regular, rapid breathing pattern described is consistent with Kussmaul respirations, a compensatory response to blow off CO2 and raise pH. Therefore, nursing interventions should target the underlying metabolic acidosis by treating DKA (e.g., fluids, insulin, and electrolyte management) rather than a primary respiratory disorder. A common distractor is respiratory alkalosis, but that would involve primary hyperventilation without an acid load driving compensation.

Question 2

The nurse is reviewing the urinalysis results on four different adult clients. Which client would the nurse anticipate to receive an I.V. fluid bolus?

Accepted Answer

Answer reason: Mrs. Wu: specific gravity 1.045 Urine specific gravity reflects urine concentration and indirectly hydration status; a high value indicates concentrated urine commonly seen with dehydration or intravascular volume depletion. A bolus of isotonic I.V. fluid is an expected intervention when assessment data suggest hypovolemia and the goal is rapid restoration of circulating volume. A value of 1.045 is markedly elevated above typical adult ranges and is more consistent with significant fluid deficit than the other results. In contrast, 1.005 suggests very dilute urine, which is not the pattern that would prompt a fluid bolus for dehydration based on this lab alone. Therefore this client’s urinalysis most strongly supports anticipating an I.V. fluid bolus.

Question 3

The nurse is caring for a client who is diagnosed with diabetes insipidus. The nurse assesses the client carefully based on the understanding that which of the following complications must be prevented?

Accepted Answer

Answer reason: The major preventable complication is hypovolemia, which progresses to dehydration, orthostatic changes, and hypotension if fluid losses are not replaced. Ongoing high urine output is the driver of the volume deficit and is a key assessment finding that signals risk for circulatory collapse. Findings like high urine specific gravity are inconsistent with this disorder, since urine is typically very dilute.

Question 4

The nurse is planning care for the infant newly hospitalized with intussusception. Which problem should the nurse establish as the priority?

Accepted Answer

Answer reason: In intussusception, bowel edema and compromised perfusion can accelerate fluid losses, making circulatory stability the most urgent, life-threatening concern. Prioritizing fluid volume supports airway-breathing-circulation principles and prepares the infant for urgent reduction (air/contrast enema) or surgery. Pain control is important, but it is secondary to preventing hemodynamic compromise from ongoing fluid and electrolyte losses. Nutrition and skin integrity are longer-term concerns once stabilization is achieved.

Question 5

The nurse is caring for the client who is 1-day postthyroidectomy. Which assessment findings should prompt the nurse to check the client’s serum calcium level?

Accepted Answer

Answer reason: Hypocalcemia increases neuromuscular excitability, producing perioral/fingertip tingling, muscle cramps, and classic signs such as Chvostek’s. These findings are more specific for low calcium than nonspecific weakness or volume-related symptoms. Prompt calcium assessment helps prevent progression to laryngospasm, seizures, and dysrhythmias.

Question 6

The hospitalized client has a serum magnesium level of 0.9 mg/dL. Which intervention is the nurse’s priority?

Accepted Answer

Answer reason: Severe hypomagnesemia places the patient at immediate risk for life-threatening dysrhythmias and neuromuscular instability, making rapid correction the priority. A magnesium of 0.9 mg/dL is critically low, and IV replacement is the fastest and most reliable way to restore serum levels in a hospitalized patient. Dietary measures and oral supplementation act too slowly and may be limited by GI absorption to address an urgent risk. While loop diuretics can contribute to magnesium wasting, modifying the cause does not correct the current critical deficiency quickly enough to protect the patient.

Question 7

The nurse determines that the client with heart failure is at risk for excess fluid volume. Which physiological change resulting from heart failure supports the risk for excess fluid volume?

Accepted Answer

Answer reason: Increased ADH promotes renal water reabsorption in the collecting ducts, expanding intravascular volume and worsening fluid retention. This mechanism directly increases risk for excess fluid volume and edema in heart failure. In contrast, increased GFR and increased sodium excretion would tend to promote fluid loss, not accumulation; increased cardiac output would reduce compensatory water retention rather than drive it.

Question 8

The nurse is teaching the client with hypoparathyroidism. Which recommendation should the nurse make knowing that the client is of the Orthodox Jewish faith?

Accepted Answer

Answer reason: Caffeine can increase urinary calcium excretion, and many carbonated beverages (especially cola) contain phosphates that can bind calcium and worsen hypocalcemia risk. Religious dietary laws can limit certain food choices, so a beverage-based recommendation is broadly applicable without creating kosher conflicts. Options emphasizing iodine address thyroid disorders, not parathyroid-related calcium regulation, and dairy with each meal may conflict with kosher separation of meat and milk at meals.

Question 9

The nurse is caring for a patient who is experiencing a cardiac dysrhythmia. The nurse knows that cardiac dysrhythmias are often caused by an electrolyte imbalance. Which electrolyte imbalance can cause the cardiac dysrhythmia known as torsades de pointes?

Accepted Answer

Answer reason: Torsades de pointes is a polymorphic ventricular tachycardia classically associated with prolonged QT and is strongly linked to low magnesium, which destabilizes myocardial repolarization and promotes early afterdepolarizations. Low magnesium also impairs potassium handling at the cellular level, further increasing QT prolongation risk and ventricular irritability. This makes magnesium depletion a high-yield reversible electrolyte trigger that is treated urgently with IV magnesium sulfate even if the serum level is normal. In contrast, hyperkalemia more typically causes peaked T waves, PR prolongation, QRS widening, and can progress to sine-wave patterns rather than torsades.

Question 10

A client with type 1 diabetes mellitus is confused, weak, diaphoretic, and has palpitations. What action should the nurse take first?

Accepted Answer

Answer reason: These symptoms are classic for hypoglycemia, which requires immediate glucose to prevent neurologic deterioration. Because the client is symptomatic but not described as unconscious or unable to swallow, the safest first action is rapid oral carbohydrate (15–20 g) to raise blood glucose quickly. IV dextrose is typically reserved for severe hypoglycemia or when the patient cannot take oral intake, and glucagon is used when IV access is not available and the patient cannot safely swallow. Administering fast-acting insulin would worsen hypoglycemia and is therefore unsafe.

Question 11

Three weeks after developing ARF following trauma, the hospitalized client has a significantly increased urinary output. Which assessment finding should the nurse report to the HCP immediately?

Accepted Answer

Answer reason: Hypotension with compensatory tachycardia is an early sign of hypovolemia that can quickly progress to shock and decreased renal perfusion, so it requires immediate provider notification and prompt fluid management. Weight loss may occur with diuresis but is less urgent than hemodynamic instability. Normal breath sounds and a potassium of 3.7 mEq/L are not acute threats in this context.

Question 12

The infant with prolonged vomiting secondary to pyloric stenosis has ABGs drawn. Which ABG results should the nurse expect when reviewing the laboratory report if the infant has an acid-base imbalance?

Accepted Answer

Answer reason: Metabolic alkalosis is characterized on ABG by an elevated pH with an elevated serum bicarbonate (the primary metabolic change). Infants with pyloric stenosis commonly develop hypochloremic, hypokalemic metabolic alkalosis from ongoing emesis and volume contraction. Options showing low pH reflect acidosis, and high pH with low bicarbonate would suggest respiratory alkalosis or a mixed/compensated picture rather than the expected primary disturbance here.

Question 13

The nurse is caring for the toddler 8 hours post injury. The toddler has second- and third-degree burns over 20% of the body. Which is the most critical nursing problem that the nurse should ensure is included in the child's plan of care?

Accepted Answer

Answer reason: With 20% TBSA full/partial-thickness burns and only 8 hours post-injury (the peak risk window), maintaining circulating volume and perfusion is the immediate life-threatening priority. Addressing mobility, nutrition, and temperature regulation is important but is secondary to stabilizing hemodynamics and preventing end-organ hypoperfusion. Early recognition and aggressive fluid resuscitation guided by urine output and perfusion findings is central to preventing complications and mortality.

Question 14

A client with Crohn’s disease is admitted with fever, weight loss, leg cramping, diarrhea, frequent premature ventricular contractions, and abdominal pain. The nurse reviews the client’s lab data and determines immediate intervention is required when the results identify which of the following?

Accepted Answer

Answer reason: This electrolyte disturbance can progress to dangerous dysrhythmias, so it requires prompt replacement and cardiac monitoring. In contrast, leukocytosis and an increased ESR are expected markers of inflammation/infection but are not typically as immediately life-threatening as a potassium-related dysrhythmia risk. Hypoalbuminemia reflects chronic malnutrition/protein loss and warrants treatment, but it is usually not the most urgent problem in the setting of symptomatic arrhythmias.

Question 15

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. The nurse is aware that the client is at risk for which of the following?

Accepted Answer

Answer reason: Volume depletion from fluid loss activates renal mechanisms that conserve sodium and water at the expense of potassium excretion, worsening potassium depletion. Additionally, alkalosis promotes intracellular shifting of potassium, contributing to low serum potassium. The combined effect makes alkalosis with hypokalemia the expected and most clinically important risk to anticipate and monitor.

Question 16

The client with ESRD has 2+ pitting edema, and a total serum protein is 5.8 g/dL. The client is 6 feet tall and weighs 180 lb. The nurse concludes that this client’s edema likely resulted from which physiological process?

Accepted Answer

Answer reason: This shifts fluid into the interstitial compartment, producing pitting edema. In ESRD, protein loss and/or dilutional hypoalbuminemia from fluid retention can contribute to reduced oncotic pressure, aligning with the low total protein value provided. By contrast, decreased capillary hydrostatic pressure would oppose filtration and would be less likely to cause edema.

Question 17

The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?

Accepted Answer

Answer reason: Post-craniotomy patients are at risk for serious fluid balance disturbances that can signal neurologic or endocrine complications (e.g., impaired perfusion, SIADH, renal hypoperfusion), so urine output must remain adequate. An output of 250 mL in 24 hours is marked oliguria and suggests possible acute kidney injury or significant fluid retention requiring urgent assessment and intervention. In contrast, mild headache is expected after craniotomy and can be managed with prescribed analgesia while monitoring for worsening signs. A sodium of 137 mEq/L is within normal range, and dizziness on standing most commonly reflects orthostatic changes rather than a direct surgical complication when isolated.

Question 18

The nurse is caring for a postoperative client who has had a surgical removal of the pituitary gland (hypophysectomy) and has developed diabetes insipidus (DI). The nurse is aware that if fluids are restricted, the client is at risk for which of the following?

Accepted Answer

Answer reason: If oral/IV fluids are restricted, ongoing free-water losses rapidly lead to intravascular volume depletion and dehydration. Loss of free water in excess of sodium increases serum osmolality and raises serum sodium, resulting in hypernatremia. In contrast, fluid overload with hyponatremia is more consistent with excess ADH effect (e.g., SIADH), not DI.

Question 19

The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse’s best immediate intervention?

Accepted Answer

Answer reason: A blood glucose of 48 mg/dL is clinically significant hypoglycemia requiring immediate treatment to prevent neuroglycopenic complications such as seizure or loss of consciousness. For a conscious client who can swallow, the first-line action is 15 g of rapid-acting carbohydrate, followed by reassessment and additional treatment if still low. Giving scheduled regular/NPH insulin would further lower glucose and worsen the emergency. Obtaining confirmatory serum testing delays needed care when a bedside value already indicates a critical low requiring prompt correction.

Question 20

The client develops SIADH secondary to a pituitary tumor. The client’s assessment findings include thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed, should the nurse implement to treat SIADH?

Accepted Answer

Answer reason: Restrict fluids to 800 to 1000 ml. per day SIADH causes excess ADH activity leading to free-water retention, dilutional hyponatremia, and weight gain. The safest first-line nursing intervention is to limit free water intake to reduce further dilution and help raise serum sodium while monitoring neurologic status. Giving vasopressin would worsen water retention and hyponatremia. Hypotonic saline (0.3% NaCl) would also lower serum osmolality further and exacerbate hyponatremia; hypertonic saline is reserved for severe symptomatic cases and is not what is ordered here.

Question 21

The 9-year-old child with a history of type 1 DM for the past 6 years is diagnosed with DKA and will soon be arriving at the hospital. Which intervention should the nurse plan to initiate upon the child’s arrival?

Accepted Answer

Answer reason: Give 0.9% or 0.45% NaCl for the maintenance IV fluid. Initial DKA management prioritizes rapid restoration of intravascular volume and renal perfusion with isotonic fluids, then adjustment to hypotonic fluids based on sodium and hydration status. This action addresses life-threatening dehydration and helps reduce hyperglycemia by dilution and improved clearance before insulin fully corrects ketosis. Potassium should not be added until urine output is established and the serum potassium is known, because total-body potassium is depleted but serum values may be high initially. Bicarbonate is rarely indicated in pediatric DKA due to risk of cerebral edema and is reserved for extreme acidemia, and insulin should be given IV (not subcutaneously) after initial fluid resuscitation.

Question 22

The nurse is caring for the 2-month-old hospitalized for dehydration secondary to gastroenteritis. The nurse’s assessment findings include irritability; pulse, 180 bpm; RR, 48 bpm; BP, 80/50 mm Hg; and dry mucous membranes. Which additional assessment finding supports moderate dehydration?

Accepted Answer

Answer reason: A sunken anterior fontanelle is a classic infant-specific finding that correlates with clinically significant fluid loss. Capillary refill under 2 seconds is generally normal and would not support moderate dehydration. Absence of tears can occur with dehydration but is less specific in a 2-month-old who may not reliably produce visible tears.

Question 23

The nurse reviews the serum laboratory results of four clients. Based on the findings, which client should the nurse assess first?

Accepted Answer

Answer reason: The client with heart failure whose ionized serum calcium level is 3.8 mg/dL Ionized calcium directly affects myocardial contractility and cardiac conduction, so clinically significant abnormalities can rapidly precipitate dysrhythmias and hemodynamic instability. An ionized calcium of 3.8 mg/dL is markedly abnormal and, in a client with heart failure, raises immediate concern for impaired cardiac function and rhythm complications requiring prompt assessment and potential treatment (e.g., IV calcium if indicated). By comparison, sodium 145 mg/dL is within normal limits, potassium 3.5 mEq/L is low-normal, and phosphorus 2.4 mg/dL is only mildly low and typically less immediately life-threatening. Prioritization therefore favors evaluating the client with the highest risk for acute cardiac compromise.

Question 24

The child is prescribed oral rehydration therapy to treat dehydration from vomiting and diarrhea. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Oral rehydration therapy for mild to moderate pediatric dehydration uses an oral rehydration solution (balanced glucose and electrolytes) administered in a calculated volume over a defined time to restore intravascular volume and correct electrolyte losses. A typical initial replacement is about 50 mL/kg over 4 hours for mild dehydration (and higher volumes for moderate), which aligns with this dosing and timing. Plain water (sterile or tap) lacks sodium and glucose and can worsen hyponatremia and does not adequately replace diarrheal electrolyte losses. Giving the volume “every hour” is not the standard initial plan and risks over-rapid administration and worsened vomiting rather than steady, tolerated replacement.

Question 25

The nurse is caring for the comatose client receiving IV fluids at the amount that equals urine output. The client is losing weight. Which should be the nurse’s reasoning for the client’s weight loss?

Accepted Answer

Answer reason: Even when IV intake matches measured urine output, patients still lose water via unmeasured routes such as insensible losses from skin and lungs plus small GI losses. In a comatose client these ongoing non-urinary losses may not be replaced if fluids are titrated only to urine output, producing a negative fluid balance. A net loss of body water reduces body weight (approximately 1 kg per 1 L). The other options either underestimate typical total non-urinary losses or focus on a single component rather than the combined expected daily amount.

Question 26

The nurse is caring for the client whose condition has progressed from an acute lung injury from near-drowning to ARDS. Which intervention should the nurse question with the HCP?

Accepted Answer

Answer reason: A large bolus followed by a high maintenance rate risks fluid overload and further impairs gas exchange, especially when a conservative fluid strategy is generally favored once perfusion is adequate. Prone positioning and PEEP are evidence-based strategies to improve ventilation-perfusion matching and recruit alveoli in ARDS. Corticosteroids may be considered in selected ARDS contexts, but the most clearly unsafe order to question here is aggressive fluid administration without a stated shock indication.

Question 27

In a client with diabetes insipidus, a nurse could expect which characteristics of the urine?

Accepted Answer

Answer reason: Pale in color; specific gravity less than 1.006 Diabetes insipidus is characterized by absent or ineffective ADH, causing the kidneys to be unable to concentrate urine. This leads to very large volumes of dilute urine, which appears pale and has a low urine specific gravity. A value below about 1.005–1.010 is typical of hypotonic urine seen in DI, aligning with a specific gravity less than 1.006. Options describing concentrated urine or high specific gravity reflect conditions like dehydration or SIADH rather than DI.

Question 28

The daughter of the 82-year-old client with Alzheimer’s disease contacts a clinic because her father has been unwilling to drink any fluids for over 24 hours. Which statement by the nurse is most appropriate?

Accepted Answer

Answer reason:  Refusal of fluids for >24 hours in an older adult with dementia raises concern for dehydration and an underlying acute problem, so the nurse should first further assess severity and associated red-flag symptoms. This open-ended question gathers key data (mental status change, fever, vomiting/diarrhea, dysphagia, decreased urine output, dizziness) that determines urgency and the safest disposition. Immediate directives for IV fluids or lab draws may be appropriate, but require assessment findings to justify emergent referral versus same-day evaluation. Advising to wait until tomorrow risks delaying care if significant dehydration or an acute illness is present.

Question 29

The child has an asthma attack and is treated with epinephrine while in the ED. Despite receiving epinephrine, the child is still agitated, sweating profusely, and has an oxygen saturation of 89% and a R of 30 bpm. Breath sounds are diminished, and wheezing is absent. Based on this information, the nurse should anticipate interventions to treat which acid-base imbalance?

Accepted Answer

Answer reason: Rising PaCO2 drives the pH down, producing a primary respiratory acidosis rather than the early asthma pattern of respiratory alkalosis from hyperventilation. The low oxygen saturation supports significant ventilation-perfusion mismatch and impending respiratory failure. Nursing/ED interventions therefore prioritize aggressive bronchodilation and ventilation support (e.g., beta-agonists, corticosteroids, possible assisted ventilation) aimed at reversing hypercapnia.

Question 30

A client is brought into the emergency department with a brain stem contusion. Two days after admission, the client has a large amount of urine and a serum sodium level of 155 mEq/L. Which condition may be developing?

Accepted Answer

Answer reason: The resulting free-water loss concentrates serum sodium, producing hypernatremia such as 155 mEq/L along with high urine output. This pattern fits central diabetes insipidus developing after head trauma. SIADH would cause water retention with low urine output and hyponatremia, the opposite of what is described. Type 1 diabetes mellitus can cause polyuria but is typically accompanied by marked hyperglycemia and osmotic diuresis rather than isolated hypernatremia after brain trauma.

Question 31

A child is admitted with complaints of weight loss and lack of energy. The child’s ears and cheeks are flushed, and the nurse observes an acetone odor to the child’s breath. The child’s blood glucose level is 325 mg/dl, his blood pressure is 104/60 mm Hg, his pulse is 88 beats/minute, and respirations are 16 breaths/minute. Which does the nurse expect the physician to order first?

Accepted Answer

Answer reason: Administration of I.V. fluids in boluses of 20 ml/kg Diabetic ketoacidosis is driven by insulin deficiency causing hyperglycemia and osmotic diuresis, leading to significant dehydration and electrolyte losses that must be corrected urgently. Initial management prioritizes rapid intravascular volume restoration with isotonic fluid boluses to improve perfusion and stabilize circulation before focusing on glucose correction. Starting insulin first can worsen hypovolemia-related shock risk and can precipitate dangerous electrolyte shifts (notably hypokalemia) if rehydration and electrolyte assessment/repletion are not addressed. Glucagon is for severe hypoglycemia, and sliding-scale subcutaneous insulin is inappropriate for acute DKA management.

Question 32

The intensive care unit nurse is preparing to admit a new client who has diabetic ketoacidosis. Which of the following orders does the nurse anticipate in the care of this client?

Accepted Answer

Answer reason: Rapidly infuse an IV bolus of 0.9% sodium chloride DKA causes profound osmotic diuresis with hypovolemia, so immediate priority is rapid intravascular volume restoration to improve perfusion and support renal clearance of glucose and ketones. Isotonic 0.9% saline is the initial fluid of choice because it expands the extracellular/intravascular space without causing abrupt shifts in serum osmolality. Insulin is started after initial fluids and potassium assessment/repletion because insulin will drive potassium into cells and can precipitate life-threatening hypokalemia. Hypotonic 0.45% saline is typically considered later based on corrected sodium, and adding dextrose is done when glucose approaches ~200–250 mg/dL during ongoing insulin therapy, not at the higher threshold shown.

Question 33

In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n)?

Accepted Answer

Answer reason: Newborns rely on glucose stores and nonshivering thermogenesis (brown fat) to generate heat, so hypoglycemia quickly impairs heat production and worsens cold stress. A glucose of 25 mg/dL is markedly low and signals depleted energy reserves, making temperature instability more likely and more dangerous. Cold stress also increases metabolic demand, which can further drop glucose and create a worsening cycle of hypothermia and hypoglycemia, requiring prompt warming and glucose support. In contrast, a hematocrit of 58%, an RBC count of 5 million/mcL, and a WBC count of 15,000/mm3 can be within expected neonatal ranges and are not primary drivers of impaired thermoregulation.

Question 34

The client who has undergone a parathyroidectomy is experiencing muscle twitching and spasms. The nurse suspects that the client is experiencing which complication?

Accepted Answer

Answer reason: Neuromuscular irritability from low calcium produces muscle twitching, cramps, and spasms and can progress to tetany and laryngospasm if untreated. This is a classic postoperative complication after parathyroid/thyroid surgery and warrants checking calcium levels and readiness to give IV calcium gluconate. In contrast, elevated vitamin D or elevated parathyroid hormone would tend to increase calcium rather than trigger tetany-like symptoms.

Question 35

The nurse in the emergency department is caring for a client with burn injuries to the torso and lower extremities who has 32% of their total body surface area (TBSA) burned. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Warmed isotonic crystalloids (e.g., LR) are first-line early resuscitation and also help prevent hypothermia, which worsens coagulopathy and outcomes. Urine output monitoring via Foley is important but follows initiation of resuscitation because it is used to titrate fluids rather than prevent the initial shock state. Covering wounds and obtaining ABGs are supportive/diagnostic steps that do not address the immediate life-threatening risk of burn shock.

Question 36

A nurse is caring for a client with a potassium of 6.5 mEq/L. Heart monitor shows the PR interval remains constant and each QRS complex is less than 100 ms wide. Which action by the nurse is priority?

Accepted Answer

Answer reason: Hyperkalemia is immediately life-threatening due to risk of malignant dysrhythmias, so the priority is to rapidly lower effective serum potassium and stabilize conduction. With K+ 6.5 mEq/L but no ECG evidence of membrane instability (no QRS widening and no PR prolongation), the fastest appropriate first-line action is shifting potassium intracellularly using IV regular insulin with dextrose to prevent hypoglycemia. IV calcium gluconate is primarily for cardioprotection when ECG changes are present and does not lower serum potassium, so it is not the best priority here. Kayexalate and dialysis remove potassium from the body but act more slowly or require more setup, making them less immediate than insulin/dextrose for urgent correction.

Question 37

The nurse provides care for a client with lactic acidosis following prolonged cardiopulmonary resuscitation (CPR). Which arterial blood gas (ABG) result does the nurse anticipate for this client?

Accepted Answer

Answer reason:  Lactic acidosis from prolonged CPR reflects tissue hypoperfusion and anaerobic metabolism, producing a primary metabolic acidosis. The expected ABG shows acidemia with a low bicarbonate as the primary abnormality, and a compensatory respiratory alkalosis pattern with decreased PaCO2 from hyperventilation (or assisted ventilation). This option matches metabolic acidosis (low pH, low HCO3) with appropriate compensation (low PaCO2). Option A instead suggests respiratory acidosis with elevated PaCO2 and an elevated bicarbonate, which does not fit lactic acidosis as the primary problem.

Question 38

In the oliguric phase of acute renal failure, the nurse should assess the client for?

Accepted Answer

Answer reason: This fluid overload increases hydrostatic pressure in the pulmonary capillaries, raising the risk for crackles, dyspnea, decreased oxygenation, and acute respiratory compromise. Acid-base changes in this phase more typically trend toward metabolic acidosis due to impaired hydrogen ion excretion, not alkalosis. Potassium is more likely to rise (hyperkalemia) because renal excretion is reduced, making the low-potassium option inconsistent with expected physiology.

Question 39

A nurse in the pediatric ward is caring for a client who has had 6 episodes of diarrhea over the last 2 hours. Which of the following acid-base imbalances should the nurse anticipate?

Accepted Answer

Answer reason: With frequent stools over a short period, bicarbonate depletion and dehydration can develop quickly, especially in pediatrics. The body may compensate with increased respiratory rate (blowing off CO2), but the primary disorder remains metabolic. Metabolic alkalosis is more associated with gastric acid loss from vomiting or NG suction rather than diarrhea.

Question 40

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider’s prescription?

Accepted Answer

Answer reason: The immediate, priority intervention is rapid isotonic fluid resuscitation to restore intravascular volume and improve perfusion before aggressive glucose lowering. Insulin is typically started after initial fluids and careful potassium assessment, and an extremely large dose of intermediate-acting insulin is inappropriate for acute titration. Sodium bicarbonate is not routinely indicated in HHS (and is reserved for severe acidemia, more typical of DKA), while airway intervention is guided by inability to protect the airway rather than being the primary expected order for HHS itself.

Question 41

The nurse is caring for a male client with end-stage renal disease who receives hemodialysis three times weekly. Which of the following client findings should receive highest priority?

Accepted Answer

Answer reason: Increase in standing scale weight of 5 pounds (2.3 kg) in one day A rapid 2.3 kg (5 lb) weight gain over 24 hours in an ESRD client most strongly indicates acute fluid retention, which can quickly progress to pulmonary edema, uncontrolled hypertension, and heart failure. This is an immediately actionable, high-risk change that requires prompt assessment of respiratory status, edema, blood pressure, and need for urgent dialysis or fluid restriction adjustments. Markedly decreased urine output can be expected in end-stage renal disease and is not as time-sensitive by itself unless accompanied by respiratory compromise. A strong AV fistula thrill is a normal finding indicating patency, and an elevated creatinine is expected in ESRD and typically not the most urgent single finding compared with signs of acute volume overload.

Question 42

In neonatal septicemia, which of the following measure is used to improve perfusion;?

Accepted Answer

Answer reason: The most immediate intervention to improve perfusion is isotonic crystalloid volume expansion, typically given as a bolus to restore intravascular volume and support cardiac output. Dextrose bolus corrects hypoglycemia but does not reliably correct shock-related hypoperfusion, and vitamin K is unrelated to hemodynamic resuscitation. Antibiotics are essential for source control and survival but do not rapidly reverse low perfusion in the initial minutes of resuscitation without concurrent fluid support.

Question 43

A patient has had diarrhea for the past 72 hours. Which of the symptoms would support a diagnosis of hypovolemia?

Accepted Answer

Answer reason: This commonly presents as lightheadedness or dizziness, especially when changing positions. By contrast, dehydration typically produces concentrated/dark urine and tachycardia rather than light urine or a slowed pulse. Moist mucous membranes would argue against significant volume depletion, since hypovolemia often causes dry mucous membranes and poor skin turgor.

Question 44

The nurse provides care for a burn injury patient who is prescribed fluid resuscitation therapy for 24 hours. Which clinical manifestation should the nurse consider as the best indicator that the fluid resuscitation therapy is effective?

Accepted Answer

Answer reason: Adequate burn resuscitation is best judged by end-organ perfusion, and hourly urine output is the most reliable bedside marker in the first 24 hours. A urine output around 0.5 mL/kg/hr (often targeted at ~30–50 mL/hr in many adults) indicates sufficient renal blood flow and circulating volume. A decreasing urine specific gravity supports improving intravascular volume status with less concentrated urine. In contrast, tachycardia and borderline hypotension can persist from pain, stress, or ongoing hypovolemia and are less specific indicators of effective resuscitation.

Question 45

A patient diagnosed with diabetic ketoacidosis (DKA) exhibits polyuria, polydipsia, and polyphagia. Upon assessment the patient has a temperature of 102.6 F (39.2 C), acetone breath, deep respirations at a rate of 28 per minute with dry, cracked lips. Which is the priority nursing diagnosis for this patient?

Accepted Answer

Answer reason: DKA causes severe osmotic diuresis from hyperglycemia, leading to rapid intravascular volume depletion and dehydration. The findings of polyuria, polydipsia, dry/cracked lips, tachypnea/Kussmaul respirations, and ketone (acetone) breath point to significant dehydration with metabolic derangements that can progress to shock if not corrected. In priority nursing diagnosis frameworks (ABCs/circulation), restoring circulating volume and correcting fluid-electrolyte losses is more immediately life-preserving than addressing learning needs or nutrition. Fever may suggest infection as a trigger, but treating the acute circulatory deficit is the urgent first priority while infection is evaluated and managed concurrently.

Question 46

A nurse is caring for a client who has sustained severe thermal burns. Which of the following laboratory abnormalities should the nurse anticipate?

Accepted Answer

Answer reason: Severe burns cause a major capillary leak and plasma loss into the interstitial space, producing intravascular volume depletion and hemoconcentration early after injury. This raises the hematocrit despite overall fluid losses, so an elevated value is expected before adequate fluid resuscitation is achieved. Hypoglycemia is not typical in acute burn stress, which more commonly produces stress hyperglycemia. While hyperkalemia and metabolic acidosis can occur with extensive tissue injury and hypoperfusion, the most consistent early laboratory pattern in major burns is hemoconcentration with elevated hematocrit.

Question 47

The client has a sodium level of 125 mEq/L. Which nursing assessment supports the healthcare provider’s diagnosis of hyponatremia related to fluid overload?

Accepted Answer

Answer reason: Dependent pitting edema is a classic assessment finding indicating increased hydrostatic pressure and fluid retention, supporting hypervolemic hyponatremia. In contrast, hypotension, weak thready pulse, and lightheadedness are more consistent with hypovolemia or shock states rather than fluid overload. Therefore, edema best aligns with the stated etiology of hyponatremia.

Question 48

A 55-year-old, male patient presents to the emergency department with renal failure. He has abdominal cramps, diarrhea, and muscle weakness. The patient is placed on the ECG monitor, and the nurse notes an increase in amplitude of the T wave. What should be the nurse's priority intervention?

Accepted Answer

Answer reason: Peaked T waves in a patient with renal failure and neuromuscular symptoms strongly indicate hyperkalemia, which can rapidly deteriorate into lethal dysrhythmias. Insulin with glucose is a rapid temporizing therapy that shifts potassium intracellularly, lowering serum potassium while definitive removal (e.g., dialysis) is arranged. A rapid response may be appropriate if instability is present, but the question asks for the priority intervention based on the ECG change, and immediate potassium-shifting therapy directly addresses the life-threatening cause. Spironolactone is potassium-sparing and would worsen hyperkalemia, while lactulose targets hyperammonemia/constipation rather than potassium toxicity.

Question 49

A client’s arterial blood gases (ABG) reveal pH 7.6, HCO3 26 mEq/L, and PaCO2 38 mm Hg. Which illness does this indicate?

Accepted Answer

Answer reason: The pH is elevated (7.6), indicating alkalosis. The HCO3 is normal and the PaCO2 is not elevated, ruling out metabolic causes. This pattern is consistent with respiratory alkalosis due to decreased CO2 levels relative to pH.

Question 50

Which factor does a nurse identify as a major cause of metabolic alkalosis in a client who had a colon resection?

Accepted Answer

Answer reason: Nasogastric suction removes gastric contents rich in hydrochloric acid (HCl), leading to loss of hydrogen ions and an increase in serum bicarbonate, which results in metabolic alkalosis. Hyperventilation causes respiratory alkalosis, not metabolic. Pain management and general IV therapy are not primary causes of metabolic alkalosis unless specific agents or imbalances are involved.

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