Question set B: ten items, physiological adaptation
an answer grid matching page 68, with two extra pre-printed columns holding each item's Client Needs tag and clinical judgment step.
Set rules. Twelve minutes. This set is intentionally lopsided toward one area of the test plan. Do not read your score here as a global percentage.
Item type mix: 3 MC · 2 SATA · 1 ORD · 2 FIB · 1 MATRIX · 1 DDT
1. A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which finding requires the nurse's immediate action?
- Peaked T waves with a widening QRS complex on the cardiac monitor
- Bilateral lower extremity muscle weakness
- Reports of nausea and abdominal cramping
- Hyperactive bowel sounds in all four quadrants
Answer: ______
2. A client is admitted for observation after a closed head injury. Which findings suggest early increasing intracranial pressure? Select all that apply.
- Restlessness and irritability in a previously calm client
- Headache that worsens with coughing or straining
- Vomiting that occurs without preceding nausea
- Hypotension with a narrowing pulse pressure
- Sluggish pupillary response on one side
- Bilateral fixed and dilated pupils
Answer: ______
3. A client with chronic obstructive pulmonary disease has these arterial blood gas values: pH 7.34, partial pressure of carbon dioxide 58 mm Hg, bicarbonate 31 mEq/L, partial pressure of oxygen 62 mm Hg. How should the nurse interpret them?
- Partially compensated respiratory acidosis with hypoxemia
- Fully compensated respiratory acidosis with normal oxygenation
- Partially compensated metabolic alkalosis
- Combined respiratory and metabolic acidosis
Answer: ______
4. A prescription reads: infuse 1 gram of vancomycin in 250 mL of 0.9% sodium chloride over 90 minutes. At what rate in milliliters per hour should the nurse set the infusion pump? Round to the nearest whole number.
Answer: ______ mL per hour
5. A client is on postoperative day 2 after an open abdominal hysterectomy. For each finding, select whether it is expected or unexpected.
| Finding | EXPECTED | UNEXPECTED |
|---|---|---|
| Oral temperature 100.2°F | ☐ | ☐ |
| New unilateral calf pain with swelling and warmth | ☐ | ☐ |
| Serosanguineous drainage staining a small area of the dressing | ☐ | ☐ |
| Abdominal distention with absent bowel sounds and vomiting | ☐ | ☐ |
| Incisional pain of 4 out of 10, relieved by the prescribed analgesic | ☐ | ☐ |
| Urine output of 20 mL per hour for the last 3 hours | ☐ | ☐ |
Answer: ______
6. A client with a T4 spinal cord injury reports a pounding headache. Blood pressure is 188/104, pulse 52, with flushing and diaphoresis above the level of injury. Place the nursing actions in the order they should be performed.
- Check for fecal impaction using an anesthetic lubricant.
- Notify the health care provider.
- Sit the client upright with the head of the bed elevated.
- Assess for bladder distention and check the urinary catheter for kinking or obstruction.
- Loosen constrictive clothing and remove tight garments and devices.
Answer: ______
7. A client with a grade III splenic laceration from blunt abdominal trauma is under observation. Which findings are consistent with compensated hypovolemic shock? Select all that apply.
- Heart rate 118
- Narrowing pulse pressure
- Cool, pale skin with capillary refill of 4 seconds
- Restlessness and anxiety
- Heart rate 52
- Urine output of 70 mL per hour
Answer: ______
8. Read the nurses' note and complete the sentence by choosing one option from each list.
> 1400. Client is 1 day after right upper lobectomy with a chest tube to a closed drainage system at prescribed suction. Continuous vigorous bubbling noted in the water seal chamber, not varying with respiration. Respirations 22. Oxygen saturation 94% on 2 liters per minute by nasal cannula. Dressing dry and occlusive.
"This finding indicates [1], and the nurse should first [2]."
List 1: an air leak in the system · expected tidaling · normal function of the suction control chamber · complete lung re-expansion List 2: assess the system from the client's dressing along the tubing to the drainage unit · clamp the chest tube for 30 minutes · increase the wall suction · milk and strip the tubing
Answer: [1] ______ [2] ______
9. A client with type 1 diabetes is found unresponsive at home. A point-of-care glucose reads 32 mg/dL. There is no intravenous access. Which action should the nurse take?
- Place oral glucose gel between the client's cheek and gum.
- Administer glucagon 1 mg intramuscularly.
- Start an infusion of 5% dextrose in water and titrate to a glucose above 70 mg/dL.
- Wait for the emergency medical services team to establish access before treating.
Answer: ______
10. A client weighing 176 lb has a prescription for dopamine at 5 micrograms per kilogram per minute. The infusion bag contains 400 mg of dopamine in 250 mL of 5% dextrose in water. At what rate in milliliters per hour should the nurse set the pump? Round to the nearest whole number.
Answer: ______ mL per hour
Margin note: "lopsided on purpose."
> Confidence: ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 > → P76 for the scorecard.
Takeaway. A deliberately skewed set is a probe, not a verdict, and it is the only way to find a single-domain hole.