

Arterial blood gas levels are obtained for the client. If the client’s results are pH 7.48, CO2 42

mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base

imbalances?

Selected Answer: D.

Metabolic alkalosis

Correct Answer: D.

Metabolic alkalosis

Response

Feedback:

The client’s pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at

42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32

mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic

alkalosis. In metabolic acidosis the client’s pH would be below 7.35, and the

bicarbonate would be below 22 mEq/L. In respiratory acidosis the client’s pH

would be below 7.35, and the CO2 would be elevated above 45 mm Hg. In

respiratory alkalosis the client’s pH would be above 7.45, and the CO2 would

be below 35 mm Hg.Cognitive Level: analysisNCLEX Blueprint: Physiological

Adaptation

 Question 2

The nurse would suspect that a client who frequently uses which medication is at risk for

developing metabolic alkalosis?

Selected Answer: A.

Calcium carbonate (Tums)

Correct Answer: A.

Calcium carbonate (Tums)

Response

Feedback:

Excessive use of oral antacids can lead to metabolic alkalosis. Use of

ibuprofen and Tylenol is not associated with the development of metabolic

alkalosis. Overdoses of aspirin can be associated with the development of

respiratory alkalosis, and eventually can lead to metabolic acidosis.

Cognitive Level: ApplicationNCLEX Blueprint: Physiological Adaptation

 Question 3

The nurse records a patient’s hourly urine output from an indwelling catheter as

follows:0700: 36 mL0800: 45 mL0900: 85 mL1000: 62 mL1100: 50 mL1200: 48 mL1300:

94 mL1400: 78 mL1500: 60 mLThe nurse can conclude that the patient’s urine output

should be described as which of the following?

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Selected Answer: B.

Within normal limits

Correct Answer: B.

Within normal limits

Response

Feedback:

Urine accounts for the greatest amount of fluid loss. Normal urine output for

an average-sized adult is approximately 1,500 mL in 24 hr. Urine output

varies according to intake and activity but should remain at least 30 to 50

mL per hour. The patient’s urine output is within the normal range. This

patient has an indwelling catheter, which will result in continual flow of

urine.Cognitive level: analysisNCLEX Blueprint: basic care and comfort

 Question 4

A client is admitted with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33;

PaCO 2 42; HCO 3 – 20. The nurse concludes this client has which acid–base imbalance?

Selected Answer: A.

Uncompensated metabolic acidosis

Correct Answer: A.

Uncompensated metabolic acidosis

Response

Feedback:

The pH and HCO3– are decreased, indicating metabolic acidosis. The

PaCO2 is normal, indicating that compensatory mechanisms have not

started working. Compensated or uncompensated respiratory acidosis is

incorrect because the primary disturbance is metabolic, as indicated by the

low bicarbonate level. Compensated metabolic acidosis is incorrect because

with compensation, a decrease in PaCO2 to restore balance would be

expected. Cognitive Level: AnalyzingNCLEX Blueprint: Physiological

Adaptation

 Question 5

Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that

apply.

B.

Monitor I&O daily.

C.

Encourage fluid intake.

D.

Monitor electrolyte balance.

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Correct Answers: B.

Monitor I&O daily.

C.

Encourage fluid intake.

D.

Monitor electrolyte balance.

Response

Feedback:

Hypovolemia occurs when more fluid is lost than is taken into the body.

Monitoring I&O provides information to evaluate the status of the problem.

Encouraging fluid intake helps to correct the problem. It is good to monitor

electrolytes because electrolyte imbalance can occur with hypovolemia

(although it may not occur at first). Deep-breathing techniques do not

address fluid balance; there is no evidence that the patient has a respiratory

disorder.Cognitive level: ApplicationNCLEX Blueprint: physiological

adaptation

 Question 6

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient

understands teaching on immunosuppression when she states which of the following?

Selected

Answer:

C.

"The medications that I take will help prevent my body from attacking

my new kidney."

Correct

Answer:

C.

"The medications that I take will help prevent my body from attacking

my new kidney."

Response

Feedback:

Immunosuppressant therapy is initiated to inhibit optimal immune response.

This is necessary in the case of transplantation, because the normal immune

response would cause the body to recognize the new tissue as foreign and

attack it. The body will identify the new kidney as foreign and will not treat

it as the original kidney. While patients with transplants must be careful

about exposure to others, especially those who are or might be ill, and

practice adequate and consistent infection control techniques, they don't

have to avoid people or social interaction. The new kidney brings foreign

cells regardless of relationship between donor and recipient.Cognitive

Level: ApplicationNCLEX Blueprint: Health promotion and Maintenance

 Question 7

The nurse assessed four patients at the beginning of the shift. Which finding should the

nurse report most urgently to the physician?

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