NCSBN - National Council of State Boards of Nursing Physiological Adaptation Questions and Answers

Question 1

A nurse is reviewing the arterial blood gas (ABG) results for a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD). The results are: pH 7.28, PaCO2 58 mm Hg, PaO2 65 mm Hg, and HCO3 25 mEq/L. Which acid-base imbalance should the nurse identify?

Accepted Answer

Respiratory acidosis, uncompensated

Answer

The pH of 7.28 is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 of 58 mm Hg is elevated (normal: 35-45 mm Hg), indicating a respiratory cause for the acidosis. The HCO3 of 25 mEq/L is within the normal range (22-26 mEq/L), signifying that the kidneys have not yet started to compensate for the imbalance. Therefore, the client has uncompensated respiratory acidosis, a common finding in COPD exacerbations where CO2 is retained.

Question 2

A nurse is caring for a client with advanced chronic kidney disease (CKD). Which laboratory finding is an expected physiological adaptation to this condition?

Accepted Answer

Hyperphosphatemia

Answer

In advanced chronic kidney disease, the kidneys' ability to excrete phosphate is impaired, leading to an accumulation of phosphate in the blood, known as hyperphosphatemia. This is often accompanied by hypocalcemia because the excess phosphate binds with calcium. The kidneys also fail to excrete potassium and creatinine, leading to hyperkalemia and elevated serum creatinine, not decreased levels.

Question 3

A client is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). The nurse observes the client's breathing pattern as very deep, rapid, and labored. The nurse correctly identifies this breathing pattern as which of the following?

Accepted Answer

Kussmaul respirations

Answer

Kussmaul respirations are a deep, rapid, and labored breathing pattern that is the body's compensatory mechanism for severe metabolic acidosis, such as that seen in DKA. The body attempts to exhale excess carbon dioxide (an acid) to raise the blood pH back toward a normal level. Cheyne-Stokes, apneustic, and Biot's are other abnormal breathing patterns related to different neurological or physiological conditions.

Question 4

A nurse is assessing a client who sustained multiple traumatic injuries and is in the compensatory stage of hypovolemic shock. Which clinical manifestation should the nurse expect?

Accepted Answer

Cool, clammy skin

Answer

In the compensatory stage of hypovolemic shock, the sympathetic nervous system is activated to maintain perfusion to vital organs. This causes peripheral vasoconstriction, shunting blood from the skin to the core, which results in cool, clammy skin. The compensatory response also includes tachycardia (increased heart rate) and tachypnea (increased respiratory rate) to improve oxygen delivery. Blood pressure is often maintained during this initial stage and only drops significantly in the later, progressive stage of shock.

Question 5

An older adult client is brought to the emergency department from an un-airconditioned home during a heat wave. The client has an altered mental status, a temperature of 105.1°F (40.6°C), and hot, dry skin. The nurse should recognize these findings as characteristic of which condition?

Accepted Answer

Heat stroke

Answer

Heat stroke is a medical emergency characterized by a core body temperature above 104°F (40°C), central nervous system dysfunction (e.g., altered mental status, confusion), and anhidrosis (the absence of sweating), which leads to hot, dry skin. This indicates a failure of the body's thermoregulatory mechanisms. In contrast, heat exhaustion involves profuse sweating and less severe neurological impairment.

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Physiological Adaptation Questions and Answers