NCLEX Practice Exam 5
Dave, a 6-year-old boy, was rushed to the hospital following her mother’s complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?
Vomiting, hypokalemia, overdosage of NaHCO3 and NGT suctioning are considered risk factors of metabolic alkalosis.
A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. Option C: PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.
A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is:
The normal range for PaCO2 is from 35 to 45 mm Hg.
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. Option A: The conjunctiva can have normal deposits of fat, which give a yellowish hue. Option B: The soles of the feet can be yellow if they are calloused. Option D: The shins would be an area of darker pigment.
An old man 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. As a well-rounded nurse, you know that the normal value for HCO3 is:
The normal value for bicarbonate (HCO3) is 22-26 mmol/L or mEq/L. It may vary slightly among different laboratories. The given values show the common measurement range of results for these tests. Some laboratories use different measurements or may test different specimens.
A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Option A: Warm environment reduces pain and minimizes sickling, it would not be a priority. Option B: Although hydration is important, it would not require a bolus. Option D: Demerol is acidifying to the blood and increases sickling.
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, Options A, B, and C: Bleeding, splenomegaly, and blood pressure changes do not occur.
The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?
A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found on pathologic examination of the excised lymph node. Option B: Lymphoblasts are immature cells found in the bone marrow of patients with acute lymphoblastic leukemia. Option C: Gaucher's cells are large storage cells found in patients with Gaucher's disease. Option D: Rieder's cells are myeloblasts found in patients with acute myelogenous leukemia.
An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae. Options A, B, and C: The skin in the abdomen, thorax, and earlobes might be too dark to make an assessment.
A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided?
Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation is also known as overbreathing. When someone is hyperventilating, they tend to breathe very deeply or very rapidly.
In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder?
NGT suctioning, vomiting, hypokalemia and overdosage of NaHCO3 are considered risk factors of metabolic alkalosis.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
The client should be positioned upright and leaning forward, to prevent aspiration of blood. Options A, B, and D: Direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.
A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?
During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Options A, B, and D: Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.
An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is:
Normal blood pH must be maintained within a narrow range of 7.35-7.45 to ensure the proper functioning of metabolic processes and the delivery of the right amount of oxygen to tissues. Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.
Liza's mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the client at risk for if medical attention is not provided?
Salicylate overdose causes a high anion gap metabolic acidosis in both children and adults. Adults commonly develop a mixed acid-base disorder as a respiratory alkalosis due to direct respiratory centre stimulation occurs as well. This second disorder is uncommon in children.
Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?
Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. Options A, B, and D: This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation.