PN1 Exam 3 Questions & Answers

PN1 Exam 3 • Question 1 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 imbala ...

PN1 Exam 3 • Question 1 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? • Question 2 The nurse would suspect that a client who frequently uses which medication is at risk for developing metabolic alkalosis? • 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? • 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? • Question 5 Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply. • 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? • Question 7 The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? • Question 8 The nurse is completing a physical assessment with a client. Which of the following findings could be caused by impaired immune function in the client? • Question 9 Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? • Question 10 A patient is receiving an IV infusion of lactated Ringer’s solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? • Question 11 The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to • Question 12 The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) • Question 13 A mother overhears two nurses discussing the incubation period for a measles outbreak. The mother asks the nurses why it is important to know this. The nurses’ reply would include which statement about the incubation period? • Question 14 The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? • Question 15 Which of the following would the nurse identify as age-related changes in immunologic function that occur in the older adult? (Select all that apply.) • Question 16 Which client is at greatest risk for dehydration? • Question 17 An older adult client tells the nurse that her granddaughter has chickenpox. The client is afraid to visit because she is afraid of getting shingles from her granddaughter. What is the nurse’s best response? • Question 18 When a client’s serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? • Question 19 Which body fluid lies in the spaces between the body cells? • Question 20 A client with hypocalcemia is taking supplemental vitamin D. When the client asks the purpose of this therapy, what explanation should the nurse give? • Question 21 A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following? • Question 22 A 5-year-old child is brought into the clinic after being stung by an insect. The child appears to be going into anaphylactic shock. Which nursing action is of highest priority? • Question 23 A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? • Question 24 A client has a reduction in immune function. What is the nurse’s priority action for this client? • Question 25 A nurse is reviewing a metabolic panel laboratory report of a client on diuretic therapy for congestive heart failure. The report is as follows: sodium, 142 mEq/L; potassium, 2.5 mEq/L; calcium, 8.5 mEq/L; and chloride, 98 mEq/L. Which of the following electrolyte disturbances should the nurse report to the physician? • Question 26 When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? • Question 27 The nurse is using the Braden Scale to determine a client’s risk for developing a pressure ulcer. Which of the following areas are assessed with this scale? • Question 28 The nurse instructs a client to use good handwashing and cover her nose and mouth when sneezing. These efforts will reduce others’ exposure to molecules that can elicit an immune response or: • Question 29 Which of the following is the principal site for regulation of fluid and electrolyte balance? • Question 30 The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? • Question 31 The nurse is concerned that a client will develop an overwhelming infection because which of the following laboratory values is low? • Question 32 A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? • Question 33 A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time? • Question 34 The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? • Question 35 Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) • Question 36 The nurse is reviewing the results of a laboratory test to measure the amount of immunoglobulins in a client’s blood. Which of the following should have the highest value? • Question 37 The mother of a newborn baby is concerned that the baby will develop illnesses from being around so many people. The nurse should explain that the baby has immunity that is present at birth or: • Question 38 A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the client’s nutritional history is of primary importance since: • Question 39 What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? • Question 40 A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. The nurse plans to teach the patient to • Question 41 Which client is at highest risk of compromised immunity? • Question 42 The physician is going to order a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered? • Question 43 The nurse is caring for a client with fluid volume excess who has edematous skin. Which of the following is an appropriate nursing consideration for this client? • Question 44 During a routine screening, a client has a positive response to intradermal injection of purified protein derivative (PPD or Mantoux test). The nurse draws which conclusion about this result? • Question 45 A client is demonstrating signs of the inflammatory response. The nurse would assess which of the following in this client? (Select all that apply.) • Question 46 The nurse, after reviewing a client’s immunization history, realizes that which of the following pathogen toxoids would not be given to an individual to develop an immune response? • Question 47 The nurse is caring for a client who has undergone a kidney transplant. The client asks the nurse what will happen when his body realizes that the kidney is not “his.” What is the nurse’s best response? • Question 48 The nurse is providing discharge teaching for a client following a liver transplant. Which statement by the client indicates that additional teaching is needed? • Question 49 A client presents with dyspnea, pruritus, and localized swelling of the forearm after being stung by a bee. What is the priority nursing intervention? • Question 50 To enhance meeting the psychosocial needs of a client on transmission-based precautions, the nurse should place highest priority on which of the following?