Nursing Acceleration Challenge Exam I PN-RN Physiological Adaptation Questions and Answers 1 — Questions and Answers
Question 1: A client with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased shortness of breath. An arterial blood gas (ABG) analysis reveals the following: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret these findings?
- Metabolic Acidosis, Uncompensated
- Respiratory Alkalosis, Compensated
- Respiratory Acidosis, Uncompensated (Correct answer)
- Metabolic Alkalosis, Partially Compensated
Correct answer: Respiratory Acidosis, Uncompensated
The pH of 7.28 is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 of 55 mmHg is elevated (normal is 35-45 mmHg), which points to a respiratory cause. The HCO3 of 26 mEq/L is within the normal range (22-26 mEq/L), indicating that the metabolic system has not yet compensated for the respiratory acidosis.
Question 2: A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?
- Hypercalcemia
- Hypokalemia (Correct answer)
- Hyponatremia
- Hypomagnesemia
Correct answer: Hypokalemia
Furosemide is a loop diuretic that can cause significant potassium loss. Muscle weakness, fatigue, and cardiac dysrhythmias are classic signs of hypokalemia. The characteristic ECG changes associated with hypokalemia include flattened or inverted T waves, prominent U waves, and ST-segment depression.
Question 3: A client is brought to the emergency department following a significant traumatic injury with suspected internal bleeding. Which of the following findings is considered an early compensatory sign of hypovolemic shock?
- Bradycardia
- Hypotension
- Tachycardia (Correct answer)
- Decreased respiratory rate
Correct answer: Tachycardia
In the initial stage of hypovolemic shock, the body attempts to compensate for the decreased blood volume and maintain cardiac output. The sympathetic nervous system is activated, leading to an increased heart rate (tachycardia) to circulate the remaining volume more effectively. Hypotension is a later sign, indicating that compensatory mechanisms are failing.
Question 4: A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). The nurse notes that the client is breathing very deeply and rapidly. The nurse recognizes this respiratory pattern, Kussmaul respirations, as the body's attempt to compensate for which acid-base imbalance?
- Respiratory Alkalosis
- Metabolic Alkalosis
- Respiratory Acidosis
- Metabolic Acidosis (Correct answer)
Correct answer: Metabolic Acidosis
Diabetic ketoacidosis leads to an accumulation of ketones, which are acidic, causing metabolic acidosis. The respiratory system compensates by increasing the rate and depth of breathing (Kussmaul respirations) to exhale more carbon dioxide (an acid), thereby attempting to raise the blood pH back toward normal.
Question 5: When assessing a surgical incision two days after an operation, which of the following findings indicates a normal physiological response during the inflammatory phase of wound healing?
- Copious thick, yellow drainage
- Localized warmth, redness, and swelling (Correct answer)
- Coolness of the skin surrounding the incision
- A foul odor emanating from the wound
Correct answer: Localized warmth, redness, and swelling
The inflammatory phase of wound healing, which occurs in the first few days after injury, is characterized by increased blood flow to the area. This results in localized warmth, redness (erythema), and swelling (edema) as white blood cells and other healing factors are delivered to the site. This is a normal and expected physiological response.
Question 6: A nurse is reviewing the lab results for a client with end-stage renal disease. The serum potassium level is 6.2 mEq/L. Which of the following is the priority nursing assessment?
- Assessing for peripheral edema
- Monitoring bowel sounds
- Evaluating skin turgor and mucous membranes
- Monitoring cardiac rate and rhythm (Correct answer)
Correct answer: Monitoring cardiac rate and rhythm
Hyperkalemia (an elevated potassium level) is a life-threatening emergency primarily because of its effect on the heart's electrical conduction system. It can lead to dangerous and fatal dysrhythmias, such as ventricular fibrillation and cardiac arrest. Therefore, continuous cardiac monitoring is the highest priority assessment.
Nursing Acceleration Challenge Exam I PN-RN Physiological Adaptation Questions and Answers 1
A client with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased shortness of breath.
An arterial blood gas (ABG) analysis reveals the following: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L.
How should the nurse interpret these findings?