Question

ati fundamental test 2024 (nursing process)
76.a nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. the nurse should suspect that the client has developed which of the following imbalances?
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis
77.a nurse is administering a cold application to a client. which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?
a. hypotension
b. numbness
c. shivering
d. reduced blood viscosity
78.a nurse is caring for a client who requests pain medication. which of the following actions should the nurse perform first?
a. reposition the client.
b. administer the medication.
c. determine the location of the pain.
d. review the effects of the pain medication.
79.a nurse is caring for a client who has respiratory acidosis. which of the following ph levels should the nurse expect?
a. ph 7.31
b. ph 7.39
c. ph 7.48
d. ph 7.50

Explanation:

• Question 76: Hyperventilation causes excessive loss of carbon dioxide (\(CO_2\)). Since \(CO_2\) is acidic (\(H_2CO_3\) when dissolved in water), its loss leads to a decrease in acidity (increase in pH). Respiratory system is involved (due to hyperventilation - a breathing pattern), so it is respiratory alkalosis. Metabolic imbalances would be due to non - respiratory causes (e.g., kidney issues for metabolic acidosis/alkalosis). Respiratory acidosis would be due to hypoventilation (retention of \(CO_2\)).
• Question 77: Shivering is a systemic response. It indicates that the body is trying to generate heat in response to the cold application, which is a systemic (whole - body) thermoregulatory response. Hypotension is not a typical first - line systemic response to a cold application. Numbness is a local response (to the area where the cold is applied). Reduced blood viscosity is a physiological effect but not an indication to discontinue due to a systemic response.
• Question 78: Using the nursing process (assessment, diagnosis, planning, implementation, evaluation), the first step when a client requests pain medication is to assess. Determining the location of the pain is part of the assessment (collecting data about the pain). Repositioning is an intervention (implementation). Administering medication is also an implementation step. Reviewing the effects is an evaluation step.
• Question 79: Respiratory acidosis is characterized by a low pH (less than 7.35). Normal pH is 7.35 - 7.45. pH 7.31 is less than 7.35. pH 7.39 is within the normal range. pH 7.48 and 7.50 are above the normal range (indicating alkalosis).

Answer:

• Question 76: D. Respiratory alkalosis
• Question 77: C. Shivering
• Question 78: C. Determine the location of the pain
• Question 79: A. pH 7.31