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Acid/ Base Balance
Communication/ Education
Nursing skills and Priorities
Urgent/ Emergent Care
Pharmacology
100
What is the normal range of pH in the body? A. 35-45 B. 22-26 C. 7.35 – 7.45 D. not listed
What is 7.35 - 7.45
100
An 80-year-old woman is being prepared for hip replacement surgery after she slipped on the ice outside her home chasing her poodle. After the consent has been signed with the physician, the patient says to the nurse, “Hi, honey, I’ve decided I don’t want this silly surgery. I think I’ll manage ok without it.” Which response by the nurse is most appropriate? A. I understand. However, you already signed the consent form, so there’s no turning back now. B. I understand surgery is scary. What has made you change your mind? C. The physician has done many of these types of surgeries. You are in good hands. D. I respect your decision. We will prepare your for discharge.
What is B. I understand surgery is scary. What has made you change your mind? Rationale: It is the responsibility of the surgeon, not the nurse, to explain the surgical procedure and obtain an informed consent. A patient must understand the need for the procedure, risks involved, expected results, and alternative options before a surgery can be legally and ethically performed. The patient always has the right to refuse the surgery at any point prior. Nurses should always provide
100
The nurse auscultates rhonchi in a patient with a tracheostomy and performs endotracheal suctioning to clear the secretions. Which nursing interventions are most appropriate to limit the risks associated with suctioning. (Select all that apply.) a. Apply suction only while withdrawing the catheter b. Instill sterile normal saline to loosen secretions c. Limit aspiration time to 10 seconds with each suction pass d. Maintain sterile technique throughout suctioning procedure e. Pre-Oxygenate with 100% oxygen
What is A. Apply suction only while withdrawing the catheter, C. limit aspiration time to 10 seconds with each suction pass D. maintain sterile technique throughout suctioning procedure E.Pre-oxygenate with 100% oxygen Rationale: Endotracheal suctioning is performed to maintain a patent airway if a client cannot mobilize secretions independently. Inserting a catheter into the airway compromises the sterility of the lower airway and increases the risk for infection. Suctioning removes oxygen in addition to secretions, placing the client at risk for hypoxemia. High suction levels or the contact of the catheter with the trachea can cause trauma, such as barotrauma, damage to tracheal mucosa, and microatelectasis. In order to decrease the occurrence of these complications: • Use strict sterile technique throughout suctioning process. • Pre-oxygenate with 100% oxygen (hyperoxygenation) for 3-4 breaths. • Aspirate during withdrawal of catheter only, limiting each suction pass to 10 seconds. • Allow client 4-5 recovery breaths between suction passes to replenish oxygen. (Option 2) Instilling 5-10 mL of sterile normal saline solution (NSS) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some facilities, the installation of NSS into the airway prior to suctioning is not recommended. It can dislodge bacteria, causing increased bacterial colonization, and can stimulate excessive coughing. Educational objective: Endotracheal suctioning increases risks for pulmonary infection, hypoxemia, microatelectasis, and mucosal tissue damage. To decrease these suctioning-associated risks, use sterile technique, preoxygenate, apply suction only while withdrawing catheter, and limit aspiration time. Avoid the use of saline lavage and frequent suction passes without adequate rest between.
100
Which treatment is indicated for asystole? A. Cardiopulmonary Resuscitation (CPR) B. Atropine C. Transcutaneous pacing D. Defibrillation
What is Cardiopulmonary Resuscitation (CPR) Rationale: high quality CPR is the only indicated treatment for asystole.
100
The nurse is preparing to initiate intravenous heparin therapy. Heparin 1,000 units per mL to be diluted in 100ml 0.9% NaCl is ordered. Heparin 10,000 units per mL is available in the medication room. Which action by the nurse is most appropriate? A. notify the pharmacy and obtain the original strength ordered B. Dilute the 10,000 unit/mL solution in1000mL 0.9% NaCl to obtain the correct dosage C. Question the order with the prescribing healthcare provider D. Ask another nurse to help interpret the order.
What is A. notify the pharmacy and obtain the original strength ordered. Rationale: • Medications should be administered exactly as they are ordered • The order is correct, but the strength available is not. The best course of action is to obtain the proper strength • Heparin is a high-alert medication because it comes in multiple strengths. Processes to ensure the proper strength should be put in place, including placing different strengths in different locations. The nurse should be particularly alert to the strength of the preparation when giving heparin.
200
The nurse in interpreting the following blood gas values: pH 7.47, CO2 50mmHg, HCO3 35mEq/L. How should the nurse interpret these values? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Alkalosis D. Metabolic Acidosis E. These are normal values.
What is Metabolic Alkalosis Rationale: Metabolic alkalosis with compensation, most likely this patient presents with decreased respiratory rate in an attempt to compensate by decreasing the amount of CO2 expired from the body.
200
You are caring for a hospice client in the home who is at the end of life. Which of the following is an example of spiritual wellness? A. making amends to others for past wrongdoings B. fear of pain as the result of God’s punishment C. feeling guilty in order to pay for past sins D. hallucinations about the afterlife
What is A. making amends to others for past wrongdoings Rationale: making amends to others for past wrongdoings is an example of spiritual wellness at the end of life. Apologizing for one’s failures and expressing thoughts of love and acceptance of others perhaps for the first time are end-of-life conversations that also can fall under the umbrella of spiritual wellness. Many of these discussions relieve guilt and anxiety. Feelings of guilt, despair, and distress are not indications that the client has achieved spiritual wellness at this end of life.
200
A client is diagnosed with lower-extremity deep venous thrombosis (DVT) after a cross-country road trip. Which clinical manifestations most characteristic of a DVT does the nurse expect to assess? Select all that apply. A. Blue, cyanotic toes B. Calf pain C. Dry, shiny, hairless skin D. Edema E. Warmth and erythema
What is B. calf pain, D. edema, E. warmth and erythema Rationale: Evidence of DVT includes pain, tenderness, and warmth around the area along with edema. Blue, cyanotic toes would indicate complete blockage of a vessel, occluding blood flow to the extremity. Dry, shiny, hairless skin in an indication of PVD.
200
You are a nurse working on the telemetry floor. The monitor tech calls about your 56 year old patient Joe Cool, that he has an EKG abnormality. You received a call earlier from the lab that this patients serum potassium was 2.8 mEq/L. What EKG abnormality was most likely reported by the monitor tech? A. Peaked T Waves B. Shorted QT C. Prolonged QT D. Shortened PR interval E. Flattened Twaves
What is E. Flattened T waves Rationale: A serum potassium level of less than 3.5 mEq/L indicates hypokalemia; flattened Twaves and prominent u waves are likely to be seen on the EKG. Low potassium levels may also cause cardiac arrhythmias. ST segment depression and prolonged QRD complex may occur.
200
A patient is given an intramuscular injection of depot medroxyprogesterone acetate (Depo-Provera). The nurse instructs the patient about common side effects including: (Select all that apply) A. Increased spotting or amenorrhea B. Dizziness C. Incrased bone density D. Weight loss E. Weight gain
What is A. increased spotting or amenorrhea E. weight gain Rationale: •The most common side effects of medroxyprogesterone acetate (Depo-Provera) are weight gain, decreased bone density, increased spotting, or amenorrhea. •Weight loss and increased bone density are not side effects of Depo-Provera. •Dizziness has been reported but is rare, not a common side effect. The nurse should teach the common side effects.
300
Which of the following imbalances would a patient with these ABG values be experiencing? pH: 7.2, CO2: 21mmHg, HCO3 22mEq/L? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis
What is Metabolic Acidosis NCLEX Tip: Always interpret acid base imbalances systematically. First, the pH is low indicating acidosis. The CO2 is also low. The HCO3 is low indicating a metabolic problem.
300
A concerned parent suspects that her 6 year-old boy has attention deficit hyperactivity disorder. The parent asks the nurse about the major characteristics of ADHD. The correct response by the nurse is A. Impulsivity, inattention, and hyperactivity B. Inattentions, hyperactivity, and obsessiveness C. Inattention, hyperactivity, an impaired interpersonal functioning D. Inattention, hypersomnia, and hyperactivity
What is A. Impulsivity, inattention, and hyperactivity Rationale: ADHD is a persistent pattern of inattention, hyperactivity, and impulsiveness. •Inattention creates difficulty with initiating and completing tasks, and it interferes with daily activities. They become easily distracted and often may not seem to listen. •Impulsivity causes them to act before they think and they have difficulty with such tasks as waiting for their turn in a game. •With hyperactivity, children may shift excessively from one activity to another, exhibiting excessive or exaggerated muscle activity.
300
An obese patient is diagnosed with pulmonary embolism (PE). Which assessment data would the nurse expect to find? Select all that apply. A. Bradycardia B. Chest pain C. Chills and fever D. Hypoxemia E. Tachypnea F. Tracheal deviation
What is B. Chest pain, D. Hypoxemia, E. Tachypnea Rationale: A pulmonary embolus is a blood clot that usually originates from the deep veins of the legs (>90%), travels to the pulmonary circulation, and obstructs a pulmonary artery or one of its branches, resulting in decreased perfusion in relation to ventilation and impaired gas exchange (hypoxemia). Clients are at risk for formation of venous thromboembolism (VTE) when the conditions detailed in Virchow's Triad are present. Clients at risk for PE include those with prolonged immobilization (eg, during hospitalization if not ambulatory), obesity, recent surgery, varicose veins, smoking, heart failure, advanced age, or history of VTE. The assessment data most characteristic of PE include: • Dyspnea (85%) • Pleuritic chest pain (60%) • Tachycardia • Tachypnea • Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar ventilation, shunting) • Apprehension and anxiety A more atypical presentation can be associated with a larger sized PE, and may include manifestations of cardiopulmonary compromise and hemodynamic instability (eg, right ventricular dysfunction, pulmonary hypertension, systemic hypotension, syncope, loss of consciousness, distended neck veins). (Option 1) A classic manifestation of PE is tachycardia to compensate for hypoxemia (not bradycardia). (Option 3) Chills and fever can indicate the presence of an infection and are not characteristic of PE. However, a low-grade fever without chills can occur 1-2 weeks after PE due to inflammation. (Option 6) Tracheal deviation is a symptom of tension pneumothorax. The trachea deviates from midline toward the unaffected side, away from the collapsed lung. Educational objective: Classic clinical manifestations of PE include dyspnea, pleuritic chest pain, tachycardia, tachypnea, hypoxemia, and feelings of apprehension and anxiety. Risk factors for PE include those detailed in Virchow's Triad (eg, hypercoagulability, venous stasis, and endothelial damage). Massive PE can cause syncope and hemodynamic instability.
300
A 55-year-old, male patient is experiencing muscle weakness, abdominal cramps, and diarrhea. After lab results reveal a serum potassium level of 7.1 mEq/L, what would the nurse expect to happen next? A. Administer a bolus of potassium B. Administer Oral potassium C. Administer glucose and insulin infusion D. Have the patient ambulate for 30 minutes and reassess
What is C. administer glucose and insulin infusion Rationale: Hyperkalemia is defined as a serum potassium level of higher than 5.0 mEq/L. Because the patient is hyperkalemic, you would not want to administer potassium at all ( and you NEVER want to give a bolus of potassium). Patients with hyperkalemia are given infusions of glucose and insulin to drive potassium into the ells, thereby decreasing the extracellular potassium levels. Having the patient ambulate is not an appropriate intervention here.
300
A patient arrives in the clinic for her annual pelvic exam and refill of oral contraceptives. The nurse understands the importance of assessing which of the following for a patient taking oral contraceptives? A. Urinalysis B. Oxygen saturation C. Blood pressure D. BUN and creatinine
What is C. blood pressure Rationale: •Hypertension is a common side effect of oral contraceptives. The nurse should assess the patient's blood pressure. •The nurse should also assess for other possible side effects including abnormal vaginal bleeding, or unilateral numbness, weakness, or leg pain due to the risk of VTE. •Incorrect: Oral contraceptives do not commonly have an impact on kidney function, blood glucose, or oxygen saturation. A urinalysis would not be regularly performed.
400
A person was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/l and pH 7.1. What is the underlying acid-base disorder? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis
What is Metabolic acidosis Rationale: The pH is below normal so there is an acidosis. The PCO2 and HCO3- are both below normal, so the underlying condition is a metabolic acidosis.
400
While educating a patient recently diagnosed with gastroesophageal reflux disease (GERD), the nurse should include which of the following non-pharmacological interventions? (Select all that apply) A. Smoking Cessation B. Eat dark chocolate C. Increase caffeine intake D. Weight loss E. Elevating the head of the bed F. Avoid spicy foods
What is A. Smoking Cessation, D. Weight Loss, E. Elevating the head of the bed, F. Avoiding spicy foods Rationale: Lifestyle modifications that can improve symptoms of GERD include weight loss, elevating the head of the bed, smoking cessation, and avoiding spicy foods, alcohol, chocolate, and caffeine.
400
Which of the following findings reflect concerning vital signs that require further nursing assessment and intervention? Select all that apply. A. After albuterol administration, 5-year-old patient reports tremor and has a pulse of 120bpm. B. After hydromorphone 1mg IVP, blood pressure decreases from 130/80 mmHg to 110/70mmHg. C. Patient receiving blood transfusion; pre-transfusion: BP 120/80 mmHg and pulse 80/min; now; 90/70mmHg and 100/min D. Fetal heart rate monitored during labor changes from 140/min to 100/min with decelerations E. Nurse preparing to administer prescribed nifedipie; blood pressure is 90/60 mmHg
What is C.Patient receiving blood transfusion; pre-transfusion: BP 120/80mmHg and pulse 80/min; now; 90/70 and 100/min D. fetal heart rate monitored during labor change from 140/min to 100/min with decelerations E. Nurse preparing to administer prescribed nifedipine, blood pressure is 90/60mmHg
400
A 19-year-old, female patient arrives in the ED after she took a handful of oxycodone pills. She is unconscious and breathing at a rate of 7 breaths per minute. Which acid base imbalance is the patient at risk of developing? A. Respiratory Alkalosis B. Metabolic Alkalosis C. Metabolic Acidosis D. Respiratory Acidosis
What is Respiratory Acidosis Rationale: Think about this. When you breathe, you expel CO2 (or Acid). In this question, when the patient has taken a few too many opiates, which causes respiratory depression. When patients don’t breathe they don’t expel CO2, and it builds up/ In that time, this leads to respiratory acidosis.
400
Which medication would the nurse expect the physician to order for a patient at increased risk for peptic ulcers following a severe traumatic injury? A. pantoprazole B. Sucralfate C. Ondansetron D. Loperamide
What is A. pantoprazole Rationale: •Pantoprazole is a proton pump inhibitor used to reduce gastric acid secretion in the prevention and treatment of gastric ulcers. •Stress ulceration usually begins in the proximal region of the stomach in the hours following major trauma or serious illness. •Incorrect: Ondansetron is a serotonin 5-HT3 receptor antagonist used to treat nausea. •Incorrect: Sucralfate is a cytoprotective agent used in the treatment of gastric ulcers and their prevention when associated with NSAID use. •Incorrect: Loperamide is an antidiarrheal.
500
The nurse is caring for a patient with the following blood gas results: pH 7.52, pCO2: 30mmHg, HCO3 24 mEq/L. The nurse would interpret these values as which acid base disorder? Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis These are normal findings
What is Respiratory Alkalosis Rationale: The first step is to look at the pH. A pH higher than 7.45 is alkalosis. The second step is to examine the partial pressure of carbon dioxide in the blood, or pCO2, which is regulated primarily through respiration. Respiratory alkalosis is indicated by a pH of more than 7.45 and pCO2 of less than 35mmHg.
500
A 60-year-old patient presents to the ED suffering from acute pancreatitis. As the nurse is gathering the patients health history, her husband rushes into the hospital in a panic, demanding to know what has happened to his wife. Which of the following causes does the nurse include in her education about acute pancreatitis? (select all that apply)
What is A. Ethanol, B. Scorpion sting, D. gallstones Rationale: all of these things can contribute to pancreatitis. Educate patient on the importance of quitting alcohol. Gallstones may require surgical intervention. Treatment of pancreatitis may include treating underlying causes as well as maintaining patient comfort.
500
An elderly client with pneumonia has a temperature of 102.2 F (39 C), blood pressure 98/66 mm Hg, pulse 115/min, and respirations 30/min. Assessment reveals crackles in the right lower lobe, dusky nail beds, and dry mucus membranes. Arrange the nursing actions chronologically to prioritize care. All options must be used. 1. Blood cultures for temp >102 (38.9C) 2. Normal Saline at 125ml/hr 3. Levofloxacin 750mg IV Q24hr 4. Oxygen per NC at 4LPM 5. Teaching IS Use
What is 4. Oxygen per NC at 4LPM 2. NS at 125ml/hr 1. Blood cultures for temp >102 (39C) 3. Levofloxacin 750mg IV Q24hr 5. Teach IS use Rationale: The nurse must prioritize nursing actions appropriately by identifying the client's current health status and acuity level, threats to survival (airway, breathing, circulation), safety issues (infection), and desired outcomes.
500
You are the charge nurse in the ICU. You are alerted by a staff nurse that her patient is not doing well and asks for your assistance. When you arrive to the room you find the patient agonal any cyanotic. while obtaining a current set of vitals, the patient becomes asystolic. CPR is initiated, and the code cart is brought to the room. What is the first medication this patient should receive? A. Atropine 1mg/ IVP B. Amiodrone 300mg/ IVP C. Epinephrine 1mg/ IVP D. Magnesium 2gm/ IVP
What is C. Epinephrine 1mg IVP. Rationale. Epinephrine is the first line drug in a code. Remember, ALL dead people get EPI! this drug can be repeated every 3-5 minutes. Amiodarone, 300mg is the next drug of choice for patients in VTACH/ Vfib... Remember, High quality CPR is the key for any code situation. and We never shock asystole.
500
The nurse is caring for a client with a remote history of a GI bleed and a recent MI. The provider prescribed daily enteric-coated aspirin. Which of the following statements would require correction by the nurse? A. I should never chew my aspirin B. I can chew or swallow my aspirin whole C. I should report coffee-ground emesis or tarry stools D. I should never give aspirin to my 1-year-old child
What is B. I can chew or swallow my aspirin whole. Rationale: • The nurse will correct any statement that is false. • Enteric coated aspirin are made to bypass the stomach and be digested by the intestines to reduce the risk of gastric ulcers. Enteric coated aspirin should never be chewed in someone with a history of GI bleeds because this would increase the risk of gastrointestinal bleeding. • Aspirin is approved for use in children over the age of 2 (not younger), but caution is advised because after certain viral illnesses (particularly influenza or chicken pox) children and teenagers can develop Reye syndrome. Reye syndrome causes swelling of the liver and brain and can cause permanent brain damage or death. • Coffee ground emesis or tarry stools are both signs of a potential GI bleed and should be reported immediately. Regular aspirin intake increases risk for GI bleeding.