Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a Paco2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis.
The arterial blood gas results show a low pH (acidosis) and an elevated Paco2 (partial pressure of carbon dioxide), which indicates respiratory acidosis. This condition occurs when there is inadequate removal of carbon dioxide through ventilation, leading to an accumulation of carbonic acid in the blood and a decrease in pH.
B. Metabolic acidosis.
Metabolic acidosis would present with a low pH and a low bicarbonate (HCO3-) level, not an elevated Paco2.
C. Metabolic alkalosis.
Metabolic alkalosis would present with a high pH and an elevated bicarbonate (HCO3-) level, not an elevated Paco2.
D. Respiratory alkalosis.
Respiratory alkalosis would present with a high pH and a decreased Paco2, not an elevated Paco2 as seen in this case.
This question is an excerpt from Nurse Dive's nursing test bank - ATI custom Fluid and Electrolyte Exam Summer 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
The arterial blood gas results show a low pH (acidosis) and an elevated Paco2 (partial pressure of carbon dioxide), which indicates respiratory acidosis. This condition occurs when there is inadequate removal of carbon dioxide through ventilation, leading to an accumulation of carbonic acid in the blood and a decrease in pH.
Choice B rationale:
Metabolic acidosis would present with a low pH and a low bicarbonate (HCO3-) level, not an elevated Paco2.
Choice C rationale:
Metabolic alkalosis would present with a high pH and an elevated bicarbonate (HCO3-) level, not an elevated Paco2.
Choice D rationale:
Respiratory alkalosis would present with a high pH and a decreased Paco2, not an elevated Paco2 as seen in this case.
Similar Questions
A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?
A. 10 mg/dL.
A BUN (Blood Urea Nitrogen) level of 10 mg/dL is within the normal range, indicating normal kidney function. There is no indication to report this value to the provider for a dehydrated client.
B. 18 mg/dL.
A BUN level of 18 mg/dL is within the normal range as well. This value does not suggest significant dehydration, so it is not necessary to report it to the provider in this context.
C. 13 mg/dL.
A BUN level of 13 mg/dL is also within the normal range, and similar to choices A and B, it does not indicate severe dehydration that requires immediate reporting to the provider.
D. 25 mg/dL.
A BUN level of 25 mg/dL is elevated, which may indicate dehydration, kidney dysfunction, or other issues affecting fluid balance. Since the client is dehydrated, this elevated value needs to be reported to the provider for further evaluation and appropriate intervention.
Full Explanation
25 mg/dL.
Choice A rationale:
A BUN (Blood Urea Nitrogen) level of 10 mg/dL is within the normal range, indicating normal kidney function. There is no indication to report this value to the provider for a dehydrated client.
Choice B rationale:
A BUN level of 18 mg/dL is within the normal range as well. This value does not suggest significant dehydration, so it is not necessary to report it to the provider in this context.
Choice C rationale:
A BUN level of 13 mg/dL is also within the normal range, and similar to choices A and B, it does not indicate severe dehydration that requires immediate reporting to the provider.
Choice D rationale:
A BUN level of 25 mg/dL is elevated, which may indicate dehydration, kidney dysfunction, or other issues affecting fluid balance. Since the client is dehydrated, this elevated value needs to be reported to the provider for further evaluation and appropriate intervention.
A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.
A. Expect urination to increase.
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
B. Expect to feel weak and dizzy.
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
C. Take the medication before going to sleep.
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
D. Report swelling of the face or hands.
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
E. Monitor body weight daily.
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
Full Explanation
A, D, and E.
Choice A rationale:
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
Choice B rationale:
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
Choice C rationale:
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
Choice D rationale:
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
Choice E rationale:
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?
A. Hypokalemia.
Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.
B. Hypercalcemia.
Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.
C. Hypovolemia.
Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.
D. Hyperglycemia.
Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.
Full Explanation
Choice A rationale:
Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.
Choice B rationale:
Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.
Choice C rationale:
Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.
Choice D rationale:
Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.