What this section covers: Physiological Adaptation (11-17% of items), part of Physiological Integrity.
12 free practice questions
Click an answer: you see at once whether it is right, with the explanation.
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Question 1A client with kidney failure has a serum potassium of 6.4 mEq/L. Which change on the cardiac monitor is most characteristic of this imbalance?
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Answer: D — Tall, peaked T waves.
Kidney failure reduces potassium excretion, and as potassium rises the ECG shows tall, peaked T waves, then a prolonged PR interval and a widened QRS complex. A prolonged QT interval is typical of low calcium, a sawtooth pattern is atrial flutter, and ST elevation in a heart attack pattern points to a STEMI.
Checked against: OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance, Table 10.7 and Figure 10.10
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Question 2The day after a total thyroidectomy, a client reports tingling around the mouth. The nurse inflates a blood pressure cuff above the systolic pressure for 3 minutes, and the client's hand goes into spasm. This finding suggests which imbalance?
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Answer: C — Low serum calcium.
A hand spasm when a cuff is inflated above systolic pressure for 3 minutes is a positive Trousseau sign, a sign of hypocalcemia. Low calcium after thyroid surgery can follow injury to or removal of the parathyroid glands, which make the hormone that keeps blood calcium up.
Checked against: OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance, Nursing Care of Patients with Hypocalcemia; 21.3 Thyroid and Parathyroid Disorders
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Question 3An older adult admitted with a urinary tract infection is newly confused. Vital signs: temperature 38.7 C (101.7 F), heart rate 118/min, respiratory rate 26/min, blood pressure 94/58 mm Hg. Using the quick SOFA (qSOFA) screen, what is the client's score?
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Answer: B — 3, a positive screen that calls for urgent evaluation for sepsis.
qSOFA gives one point each for a systolic blood pressure of 100 mm Hg or less, altered mental status, and a respiratory rate of 22/min or more; this client meets all three, and a score of 2 or more flags a high risk of poor outcome from sepsis. Temperature and heart rate are not part of qSOFA, no laboratory value is needed, and current sepsis guidelines advise against using qSOFA alone as the only screening tool.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock, Assessments and Diagnostics (qSOFA); Sepsis-3 definitions (Singer et al., JAMA 2016) for the exact cut-offs; Surviving Sepsis Campaign 2021
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Question 4A client has a chest tube connected to a drainage system to treat a pneumothorax. The nurse sees intermittent bubbling in the water seal chamber. How should the nurse interpret this?
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Answer: A — It is expected, because air is being removed from the pleural space.
When a chest drain is treating a pneumothorax, air is pulled from the pleural space through the system, so intermittent bubbles in the water seal chamber (for example when the client exhales or coughs) are expected and should decrease as the pneumothorax resolves. Continuous bubbling would suggest an air leak, and a tube is never clamped as a routine response.
Checked against: OpenStax Medical-Surgical Nursing, 11.6 Disorders of the Lower Respiratory System: Pneumothorax, Medical Therapies (drainage device parts)
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Question 5A client admitted with a head injury has these trends over 2 hours. Which set of findings is most consistent with Cushing's triad from rising intracranial pressure?
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Answer: D — BP 168/70 mm Hg, pulse 52/min, irregular breathing.
Cushing's triad is a widened pulse pressure, bradycardia, and an irregular breathing pattern, and it signals worsening intracranial pressure that can lead to herniation. A low blood pressure with a fast pulse fits shock, not rising intracranial pressure.
Checked against: OpenStax Medical-Surgical Nursing, 17.1 Intracranial Pressure Changes, Clinical Manifestations of IICP
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Question 6A client with type 1 diabetes has skipped insulin doses for 2 days during a flu-like illness and now has deep, rapid breathing and a fruity breath odor. Blood glucose is 480 mg/dL. Which arterial blood gas result should the nurse expect?
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Answer: C — pH 7.22, PaCO2 28 mm Hg, HCO3 12 mEq/L.
Diabetic ketoacidosis causes metabolic acidosis: ketones lower the pH and the bicarbonate. The deep, rapid breathing is the lungs blowing off CO2 to compensate, which is why the PaCO2 is low. The other results show respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
Checked against: OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance, Metabolic Acidosis; 21.2 Diabetes Mellitus, Table 21.6
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Question 7Five minutes after a unit of packed red blood cells is started, the client reports new low back pain and chills. The heart rate has risen and the blood pressure has dropped from baseline. What is the nurse's first action?
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Answer: A — Stop the transfusion.
Low back pain, chills, a rising heart rate and a falling blood pressure soon after a transfusion starts suggest a hemolytic transfusion reaction, so the nurse stops the transfusion immediately and notifies the provider. Flushing the old tubing would push more of the donor blood into the client; the blood tubing is disconnected and normal saline is started with new tubing.
Checked against: OpenStax Clinical Nursing Skills, 13.4 Blood Transfusions, Transfusion Reactions and Hemolytic Transfusion Reaction
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Question 8Three days after abdominal surgery, a client coughs hard and says, "It feels like something gave way." The nurse sees loops of bowel protruding through the incision. What should the nurse do?
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Answer: D — Cover the wound with a sterile towel soaked in sterile 0.9% sodium chloride, place the client in low Fowler's position with knees slightly bent, and call the provider.
Evisceration is an emergency. A sterile towel soaked in sterile normal saline protects the exposed organs, and low Fowler's position with bent knees lowers pressure on the abdomen; the nurse stays with the client, keeps them NPO, and has the provider notified because surgery is needed. Dry gauze would stick to the tissue, and coughing raises pressure on the wound.
Checked against: OpenStax Clinical Nursing Skills, 8.3 Wound Management, Dehiscence and Evisceration
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Question 9A client who had surgery this morning has a urine output of 20 mL/h for the past 2 hours, a heart rate of 118/min, and a blood pressure of 92/58 mm Hg. What should the nurse do?
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Answer: B — Report the findings to the provider promptly.
A urine output of 30 mL per hour reflects adequate kidney perfusion; less than that, together with a fast heart rate and a low blood pressure, can mean low blood volume and poor perfusion. Falling output should be reported so the plan of care can be changed.
Checked against: OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock, Assessment; 27.3 Hospitalized Postoperative Patient
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Question 10A client on a telemetry unit is found unresponsive with no pulse, and the monitor shows ventricular fibrillation. What should the nurse do?
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Answer: C — Call the code team and start high-quality CPR until the defibrillator is ready.
Pulseless ventricular fibrillation is a cardiac arrest: the code team is activated, high-quality CPR is started, and a defibrillator or AED delivers a shock as soon as possible. Synchronized cardioversion is used for rhythms such as atrial fibrillation in a patient with a pulse, and delaying CPR raises the risk of death.
Checked against: OpenStax Medical-Surgical Nursing, 12.2 Dysrhythmia, Safety: Interventions with CPR and the Defibrillator for Ventricular Fibrillation
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Question 11The nurse is teaching a client with a new tracheostomy how to change the ties that hold the tube in place. Which statement by the client shows correct understanding?
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Answer: A — "I will hold the tube in place while I change the ties, and I should be able to fit 2 fingers under them.".
The tube must be held in place during a tie change so it is not dislodged, and the ties should be snug but allow 2 fingers underneath so they are not too tight. Ties that are far too loose could let the tube come out.
Checked against: MedlinePlus, Tracheostomy care, Caring for Your Tracheostomy
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Question 12One hour after a vaginal birth, the nurse finds that the client's fundus is soft and boggy and the bleeding is heavy. What should the nurse do first?
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Answer: D — Massage the fundus until it becomes firm.
Uterine atony is the most common cause of early postpartum hemorrhage; a boggy uterus lets the spiral arteries keep bleeding. Fundal massage stimulates contraction and is almost always the first intervention, followed by uterotonic medications such as oxytocin if prescribed. Hysterectomy is the last resort.
Checked against: OpenStax Maternal-Newborn Nursing, 21.2 Postpartum Hemorrhage, Fundal Massage
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