Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Anna's mother has been suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L.
What acid-base disorder is shown?
A. Respiratory Acidosis. Partially Compensated
Respiratory Acidosis, both compensated and uncompensated, is characterized by an elevated PaCO2, which is not present in this case.
B. Metabolic Alkalosis, Partially Compensated
The elevated pH (7.5) and HCO3 (34 mmol/L) indicate metabolic alkalosis. The elevated pH and the slightly elevated PaCO2 (40 mm Hg) suggest the partially compensated state, which is the respiratory compensation attempting to correct the alkalosis.
C. Respiratory Alkalosis. Uncompensated
The fact that the PaCO2 is not low rules out respiratory alkalosis.
D. Metabolic Alkalosis, Uncompensated
The arterial blood gas values indicate a high pH (7.5), a normal PaCO2 (40 mm Hg), and an elevated HCO3 (34 mmol/L), which are indicative of metabolic alkalosis. However, the elevated pH and the slightly elevated PaCO2 (40 mm Hg) suggest a partially compensated state.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam 8. Take the full exam now
Full Explanation
A. Respiratory Acidosis, both compensated and uncompensated, is characterized by an elevated PaCO2, which is not present in this case.
B. The elevated pH (7.5) and HCO3 (34 mmol/L) indicate metabolic alkalosis. The elevated pH and the slightly elevated PaCO2 (40 mm Hg) suggest the partially compensated state, which is the respiratory compensation attempting to correct the alkalosis.
C. The fact that the PaCO2 is not low rules out respiratory alkalosis.
D. The arterial blood gas values indicate a high pH (7.5), a normal PaCO2 (40 mm Hg), and an elevated HCO3 (34 mmol/L), which are indicative of metabolic alkalosis. However, the elevated pH and the slightly elevated PaCO2 (40 mm Hg) suggest a partially compensated state.
Similar Questions
A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?
A. A decrease in blood pressure
Vasopressin does not typically affect blood pressure significantly.
B. A decrease in blood sugar
Vasopressin is not used to lower blood sugar levels; it is primarily used for water retention.
C. A decrease in urine output
Vasopressin, also known as antidiuretic hormone (ADH), acts on the kidneys to decrease urine output, making this the expected outcome of therapy.
D. A decrease in specific gravity
Specific gravity of urine may increase with vasopressin therapy due to decreased urine output, rather than decrease.
Full Explanation
A. Vasopressin does not typically affect blood pressure significantly.
B. Vasopressin is not used to lower blood sugar levels; it is primarily used for water retention.
C. Vasopressin, also known as antidiuretic hormone (ADH), acts on the kidneys to decrease urine output, making this the expected outcome of therapy.
D. Specific gravity of urine may increase with vasopressin therapy due to decreased urine output, rather than decrease.
A nurse is caring for a client on a medical-surgical unit.
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider.
Nurses Notes
Oxygen saturation 95%
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
A. The client's voice is hoarse.
None
B. The client reports tingling around the mouth
None
C. Moderate serosanguinous drainage noted on neck dressing.
None
D. The client has a slight tremor noted in both hands.
None
E. The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
None
F. The client appears restless
None
G. Oxygen saturation 95%
None
Full Explanation
The nurse should report the hoarseness of the client's voice, which could indicate recurrent laryngeal nerve damage, which is a risk associated with thyroid surgery. Tingling around the mouth may suggest hypocalcemia, a common complication after thyroidectomy due to accidental removal or damage to the parathyroid glands. The moderate serosanguinous drainage on the neck dressing could signify bleeding or infection, which requires immediate attention. The noted tremor in both hands and the increase in temperature could be signs of a thyroid storm, a rare but life-threatening condition.
Furthermore, the client's restlessness could be a response to discomfort or could indicate a more serious issue, such as an impending thyrotoxic crisis. Oxygen saturation at 95% is within normal limits postoperatively; however, it should be monitored closely.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
A. Urine output of 50 mL in 4hr
A urine output of 50 mL in 4 hours is inadequate and may indicate decreased renal perfusion. Magnesium sulfate can further compromise renal perfusion, so this finding warrants careful evaluation and potential adjustment of the infusion rate.
B. Respiratory rate of 16/min
This indicates that the client is not experiencing respiratory depression, a potential side effect of magnesium sulfate toxicity.
C. Diminished deep tendon reflexes
Diminished deep tendon reflexes is an expected finding in magnesium sulfate toxicity.
D. Heart rate of 56/min
A heart rate of 56/min is below the normal range for an adult but may be a common finding in clients receiving magnesium sulfate due to its cardiac depressant effects.
Full Explanation
A. A urine output of 50 mL in 4 hours is inadequate and may indicate decreased renal perfusion. Magnesium sulfate can further compromise renal perfusion, so this finding warrants careful evaluation and potential adjustment of the infusion rate.
B. This indicates that the client is not experiencing respiratory depression, a potential side effect of magnesium sulfate toxicity.
C. Diminished deep tendon reflexes is an expected finding in magnesium sulfate toxicity.
D. A heart rate of 56/min is below the normal range for an adult but may be a common finding in clients receiving magnesium sulfate due to its cardiac depressant effects.