Question

A nurse is caring for a client who has COPD. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

Answer 1

Correct Answers:

Respiratory acidosis

Rationale :

🟪 Clients with Chronic Obstructive Pulmonary Disease (COPD) retain carbon dioxide due to hypoventilation and impaired gas exchange.

🟪 This retention of CO₂ leads to an increase in carbonic acid, causing respiratory acidosis.

🟪 Arterial blood gas results typically show low pH and elevated PaCO₂.

🟪 Long-term compensation by the kidneys may increase bicarbonate (HCO₃⁻), but the primary disturbance remains respiratory.

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Answer 2

Correct Answers:

Don sterile gloves before inserting the indwelling urinary catheter.

Rationale :

🟩 Sterile technique is essential during urinary catheter insertion to prevent urinary tract infections (UTIs).

🟩 The nurse should don sterile gloves after setting up the sterile field and before handling the catheter and sterile supplies.

🟩 Testing the balloon is not necessary and can compromise the sterility of the catheter.

🟩 Only water-based lubricant should be used, and a new cotton swab should be used for each stroke when cleaning the meatus.

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Answer 3

Correct Answers:

Store oxygen tanks upright.

Rationale :

🟨 Oxygen tanks must be stored upright and secured to prevent them from tipping over, which could cause an explosion if the valve breaks.

🟨 Using petroleum-based products near oxygen increases the risk of combustion, so only water-based lubricants should be used.

🟨 Tanks should be kept at least 10 feet away from open flames or heat sources—not just 4 feet.

🟨 Blankets made of wool or synthetic materials can generate static electricity, increasing fire risk; cotton blankets are preferred.

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Answer 4

Correct Answers:

Metabolic alkalosis

Rationale :

🟧 Vomiting causes a loss of hydrochloric acid (HCl) from the stomach, resulting in an increase in blood bicarbonate levels.

🟧 This leads to metabolic alkalosis, characterized by elevated pH and HCO₃⁻ levels.

🟧 Clients may also show signs of hypokalemia and hypoventilation as compensation.

🟧 Treatment includes correcting fluid and electrolyte imbalances.

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Answer 5

Correct Answers:

Pulmonary artery

Rationale :

🔵 In pulmonary circulation, deoxygenated blood is pumped from the right ventricle into the pulmonary artery, which carries it to the lungs.

🔵 This is the only artery in the body that carries deoxygenated blood.

🔵 In the lungs, gas exchange occurs, and oxygenated blood returns to the left atrium via the pulmonary veins.

🔵 Understanding this flow is essential for interpreting cardiovascular and respiratory conditions.

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Answer 6

Correct Answers:

Metallic taste in mouth

Rationale :

🟪 Oxygen toxicity occurs when high concentrations of oxygen are delivered over a prolonged period, leading to cellular damage and neurologic symptoms.

🟪 One of the early signs of oxygen toxicity includes a metallic taste in the mouth.

🟪 Other findings may include visual changes, chest pain, and seizures in severe cases.

🟪 Muscle twitching is more commonly associated with electrolyte imbalance, not oxygen toxicity.

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Answer 7

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🟩 Confirm the client’s identity using two identifiers to ensure safety.

🟩 Provide privacy to maintain dignity and comfort.

🟩 Assist into Sims’ position, which provides optimal access to the rectum.

🟩 Insert the enema tubing gently into the rectum per procedure guidelines.

🟩 This sequence ensures safe, respectful, and effective enema administration.

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Answer 8

Correct Answers:

I need to catheterize myself twice a day.

Rationale :

🟨 Individuals with paraplegia typically require intermittent catheterization every 4–6 hours, not just twice daily.

🟨 Catheterizing only twice daily may result in urinary retention, bladder distention, or infection.

🟨 The other statements (about exercise, suppository use, and hydration) are appropriate strategies for managing mobility and elimination.

🟨 This statement indicates a knowledge deficit and requires further teaching.

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Answer 9

Correct Answers:

Add fluid and fiber to the diet.

Rationale :

🟦 Increasing fluid intake helps soften stools, while adding dietary fiber (e.g., fruits, vegetables, whole grains) promotes bowel motility.

🟦 This is a non-invasive and foundational intervention for managing constipation, especially in older adults.

🟦 Stool softeners can be helpful but should be used in addition to, not instead of, lifestyle measures.

🟦 Gas-producing foods may cause bloating but don’t contribute to constipation directly.

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Answer 10

Correct Answers:

Dullness percussed over the client's lung fields

Rationale :

🟥 Pleural effusion involves the accumulation of fluid in the pleural space, which impairs lung expansion and ventilation.

🟥 On physical exam, fluid in the pleural space results in dullness to percussion over the affected area, rather than resonance.

🟥 Other expected findings include decreased breath sounds and dyspnea.

🟥 Crackles and crepitus are more consistent with consolidation or subcutaneous emphysema, not effusion.

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PN Fundamentals of Nursing Exam 2~NS117 Winter-2023(Monroe College)

No.

1 :
A nurse is caring for a client who has COPD. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

2 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

3 :
A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

4 :
A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

5 :
A nurse is assisting with teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations?

6 :
A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

8 :
A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?

9 :
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

10 :
A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

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PN Fundamentals of Nursing Exam 2~NS117 Winter-2023(Monroe College)

No.

1 : A nurse is caring for a client who has COPD. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

2 : A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

3 : A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

4 : A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

5 : A nurse is assisting with teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations?

6 : A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?

7 : A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

8 : A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?

9 : A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

10 : A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

1 :
A nurse is caring for a client who has COPD. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

2 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

3 :
A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

4 :
A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

5 :
A nurse is assisting with teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations?

6 :
A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

8 :
A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?

9 :
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

10 :
A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?