Fundamentals of Nursing Quiz (36-40)

Fundamentals of Nursing Quiz no. 36 - 40

36. A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determined the adequacy of the:

a) ulnar circulation
b) carotid circulation
c) femoral circulation
d) popliteal circulation

37. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that he client is at risk for which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

38. A nurse caring for a client with an ileostomy understands that he client is most at risk for developing which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

39. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

a) respirations that cease for several seconds
b) respirations that are regular but abnormally slow
c) respirations that are labored and increased in depth and rate
d) respirations that are abnormally deep, regular, and increased in rate

40. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next?

a) prepare to administer an antidote
b) draws a sample for type and crossmatch and transfuse the client
c) draws a sample for an activated partial thromboplastin time (aPTT)
d) draws a sample for prothrombin (PT) and international normalized ratio (INR) level






Fundamentals of Nursing Quiz:
ANSWERS AND RATIONALE

36) A

- Before radial puncture for obtaining an arterial specimen for arterial blood gases, you should perform an Allen’s test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options B, C, and D are incorrect options.

37) B

- Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options A, C, and D are incorrect.

38) A

- Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options B, C, and D are incorrect because they do not occur in the client with an ileostomy.

39) D

- Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

40) D

- The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy.


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Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts