Nur 220 Exam 1 Practice Exam Questions And Answers Graded A+

A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. 1. Renal failure client 2. Asthma client 3. Pneumonia client 4. Diabetic mellitus client 5. Patient with copious vomiting 6. Patient with copious diarrhea - correct answers 1. Renal failure client 4. Diabetic mellitus client 6. Patient with copious diarrhea The client with ARDS has fine basilar crackles and shallow respirations at 28 breaths per minute. In addition to monitoring ABGs, the nurse should do which of the following? Select all that apply. 1. Administer a sedative 2. Keep the HOB flat 3. Administer humidified O2 4. Auscultate the lungs - correct answers 3. Administer humidified O2 4. Auscultate the lungs You're caring for a patient with acute respiratory failure. You monitor for what manifestations of the condition? Select all that apply. 1. Severe dyspnea 2. Nausea 3. Decreased level of consciousness 4. Cerebral hypoxia 5. Respiratory acidosis - correct answers 1. Severe dyspnea 3. Decreased level of consciousness 4. Cerebral hypoxia 5. Respiratory acidosis The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a corticosteroid drug. Which of the following client actions indicate that he is using the MDI correctly? Select all that apply. 1. Mouth is rinsed with water following administration 2. Client waits 5 minutes between puffs 3. Head is tilted down while inhaling the medication 4. Client lies supine for 15 minutes following administration 5. The inhaler is held upright - correct answers 1. Mouth is rinsed with water following administration 5. The inhaler is held upright The nurse is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which of the following is of biggest concern? 1. The patient has many abdominal bruises 2. The patient's blood pressure is 90/46 3. The activated partial thromboplastin time (aPTT) is 2x the patient's baseline 4. The patient's stool is dark green and liquid - correct answers 2. The patient's blood pressure is 90/46 What nursing action has the greatest potential to prevent PE among hospital patients? 1. Passive ROM for the upper/lower extremities 2. Early ambulation and the use of compression stockings 3. Incentive spirometry, deep breathing, and coughing exercises 4. Maintain SpO2 levels 90% using supplemental oxygen - correct answers 2. Early ambulation and the use of compression stockings The patient who is receiving subcutaneous heparin injections to prevent recurrence of pulmonary embolism has the following orders: -heparin sodium 6000 units SQ Q12H You have a vial with 10,000 units in 2mL sterile water. How many mL will you administer? - correct answers 1.2 mL In developing a teaching plan for a patient who is being discharged with a warfarin prescription after having a pulmonary embolus, the nurse will include information about which of the following? 1. where to schedule activated partial thromboplastin time (aPTT) testing 2. avoidance of a high protein diet 3. how to obtain enteric-coated aspirin 4. foods that are high in vitamin K - correct answers 4. foods that are high in vitamin K What nursing interventions should be included in the care plan for the patient at risk for pulmonary embolism? Select all that apply. 1. Encourage liberal fluid intake 2. Assist with leg elevations above the heart 3. Instruct patient to dangle legs over side of bed for 30 minutes 4x a day 4. Use elastic stockings 5. Apply sequential compression device - correct answers 1. Encourage liberal fluid intake 2. Assist with leg elevations above the heart 4. Use elastic stockings 5. Apply sequential compression device The patient has been converted from heparin to warfarin prior to discharge. What should the nurse include in discharge instructions? 1. Coumadin will continue to break up the clot over a period of weeks 2. It is important to take the same brand of medicine 3. Anticoagulant therapy will only last 4 to 6 weeks 4. He should take a vitamin supplement containing vitamin K - correct answers 2. It is important to take the same brand of medicine Which of the following clinical manifestations indicates an allergic reaction to the contrast medium during a pulmonary angiogram? 1. Difficulty in breathing 2. Hematoma 3. Absent distal pulses 4. Urge to cough - correct answers 1. Difficulty in breathing You're caring for a patient on a vent. Which interventions should you implement to prevent complications? Select all that apply. 1. Elevate the head of the bed at least 30 degrees up 2. Inspect the pilot balloon 3. Administer pantoprazole (protonix) as prescribed 4. Perform mouth care every 2 hours. - correct answers 1. Elevate the head of the bed at least 30 degrees up 2. Inspect the pilot balloon 3. Administer pantoprazole (protonix) as prescribed 4. Perform mouth care every 2 hours. The patient needs 2.5 mg of isoetharine via nebulizer. You have a vial of isoetharine labeled 10 mg/mL. How many mL do you need to draw up to place in the nebulizer? - correct answers 0.25 mL A patient with ACS has returned to the coronary care unit after having a PCTA. Which of these assessment data indicate the need for immediate intervention by the nurse? 1. Heart rate of 100 beats/min 2. Chest pain level at 8 out of 10 point scale 3. Blood pressure (BP) 104/56 mm Hg 4. Pedal pulses 2+ - correct answers 2. Chest pain level at 8 out of 10 point scale A patient with chronic stable angina is being treated with metoprolol. The nurse will suspect that the patient is experiencing a side effect of the metoprolol if: 1. the patient is restless and agitated 2. the blood pressure is 190/110 mm Hg 3. the cardiac monitor shows a heart rate of 45 4. the patient complains about feeling anxious - correct answers 3. the cardiac monitor shows a heart rate of 45 A patient with a non-ST segment elevation myocardial infarction (STEMI) is receiving heparin. What is the purpose of heparin? 1. Heparin will dissolve the clot that is blocking blood flow to the heart. 2. Coronary artery plaque size and adherence are decreased with heparin. 3. Heparin will prevent the development of clots in the coronary arteries. 4. Platelet aggregation is enhanced by IV heparin infusion. - correct answers 3. Heparin will prevent the development of clots in the coronary arteries. Which of these nursing interv