NUR 160 EXAM 2 HONDROS 2026 EXAM
SCRIPT COMPLETE QUESTIONS AND
SOLUTIONS
◉ Hyperthermia. Answer: S/S: Coma, confusion, tachycardia,
fainting, headache, muscle cramps, fatigue, vomiting, seizures. NI:
Monitor temp, ice (back of neck, armpits, groin with barrier), slowly
lower temp, alternate ibuprofen/Tylenol; Monitor IV rate, assess
I&O, encourage fluids, turn q2 hours, assess lung sounds, cough and
deep breathe, evaluate wound, perform leg exercises, incentive
spirometer
◉ Infection. Answer: S/S: Fever, drainage, redness, pain, confusion,
fatigue. NI: Sterile technique when changing dressing, monitoring
vital signs, document findings, notify doc/surgeon, follow orders
◉ Sepsis. Answer: S/S: Fever, urinary retention, tachycardia, nausea,
vomiting, diarrhea, confusion. NI: Monitor vital signs, assess
orientation, watch for behaviors, use evidence-based practice
◉ Pneumonia. Answer: S/S: Fever, chest pain, coughing, headaches,
SOB, cyanosis, muscle aches, fatigue. NI: Vital signs, incentive
spirometer, early ambulation, sputum culture, pt education, O2
therapy if needed, re-positioning frequently, encourage fluids
, ◉ UTI. Answer: S/S: Frequent urination, foul smelling urine, urine
urgency, abdominal pain, fever, change in behavior. NI: Encourage
fluid intake, vital signs, note color, consistency, odor, assess for
sediment, collect urine specimen
◉ Respiratory Acidosis. Answer: Causes: Asthma, COPD, Acute
Pulmonary Edema, Sedation. S/S: lethargy, occipital h/a, decrease of
deep tendon reflexes, coma, dyspnea, hypotension. Lab values: pH-
Under 7.35, CO2- Above 45. Tx: Clear airway, Mechanical ventilation,
Antibiotics, Diuretics, bronchodilators, Steroids, O2, CPAP
◉ Respiratory Alkalosis. Answer: Causes: Anxiety, fever,
hyperventilation, pregnancy, severe obesity, neuromuscular
disorders. S/S: Anxious appearance, irritability, tingling, fainting,
tetany, muscle weakness. Lab values: pH- Above 7.45, CO2- below.
Tx: Breathing into paper bag, rebreather mask, Anti-anxiety meds,
relaxation technique
◉ Metabolic Acidosis. Answer: Causes: Diarrhea, Renal failure,
diabetes mellitus, alcohol abuse. S/S: Coma, Kussmaul resps.,
warm/flushed skin, diarrhea, weakness, abdominal pain. Lab values:
pH: Under 7.35, HCO3- Under 22. Tx: Sodium bicarbonate, sodium
nitrate
◉ Metabolic Alkalosis. Answer: Causes: Gastric acid loss,
hypomagnesia, hypocalcemia, diuretics. S/S: Irritability, seizures,
atrial tachycardia, slow, shallow resps w/ periods of apnea, tingling
SCRIPT COMPLETE QUESTIONS AND
SOLUTIONS
◉ Hyperthermia. Answer: S/S: Coma, confusion, tachycardia,
fainting, headache, muscle cramps, fatigue, vomiting, seizures. NI:
Monitor temp, ice (back of neck, armpits, groin with barrier), slowly
lower temp, alternate ibuprofen/Tylenol; Monitor IV rate, assess
I&O, encourage fluids, turn q2 hours, assess lung sounds, cough and
deep breathe, evaluate wound, perform leg exercises, incentive
spirometer
◉ Infection. Answer: S/S: Fever, drainage, redness, pain, confusion,
fatigue. NI: Sterile technique when changing dressing, monitoring
vital signs, document findings, notify doc/surgeon, follow orders
◉ Sepsis. Answer: S/S: Fever, urinary retention, tachycardia, nausea,
vomiting, diarrhea, confusion. NI: Monitor vital signs, assess
orientation, watch for behaviors, use evidence-based practice
◉ Pneumonia. Answer: S/S: Fever, chest pain, coughing, headaches,
SOB, cyanosis, muscle aches, fatigue. NI: Vital signs, incentive
spirometer, early ambulation, sputum culture, pt education, O2
therapy if needed, re-positioning frequently, encourage fluids
, ◉ UTI. Answer: S/S: Frequent urination, foul smelling urine, urine
urgency, abdominal pain, fever, change in behavior. NI: Encourage
fluid intake, vital signs, note color, consistency, odor, assess for
sediment, collect urine specimen
◉ Respiratory Acidosis. Answer: Causes: Asthma, COPD, Acute
Pulmonary Edema, Sedation. S/S: lethargy, occipital h/a, decrease of
deep tendon reflexes, coma, dyspnea, hypotension. Lab values: pH-
Under 7.35, CO2- Above 45. Tx: Clear airway, Mechanical ventilation,
Antibiotics, Diuretics, bronchodilators, Steroids, O2, CPAP
◉ Respiratory Alkalosis. Answer: Causes: Anxiety, fever,
hyperventilation, pregnancy, severe obesity, neuromuscular
disorders. S/S: Anxious appearance, irritability, tingling, fainting,
tetany, muscle weakness. Lab values: pH- Above 7.45, CO2- below.
Tx: Breathing into paper bag, rebreather mask, Anti-anxiety meds,
relaxation technique
◉ Metabolic Acidosis. Answer: Causes: Diarrhea, Renal failure,
diabetes mellitus, alcohol abuse. S/S: Coma, Kussmaul resps.,
warm/flushed skin, diarrhea, weakness, abdominal pain. Lab values:
pH: Under 7.35, HCO3- Under 22. Tx: Sodium bicarbonate, sodium
nitrate
◉ Metabolic Alkalosis. Answer: Causes: Gastric acid loss,
hypomagnesia, hypocalcemia, diuretics. S/S: Irritability, seizures,
atrial tachycardia, slow, shallow resps w/ periods of apnea, tingling
