Nur 165 Q/A FINAL reveiw
11. A client with a serum sodium of 115 mEq/L has been
receiving 3% NS at 50 ml/hr for 16 hours. This morning the
client feels tired and short of breath.
Which of the following interventions is a priority?
A. Turn down the infusion
B. Check the latest sodium level
C. Assess for signs of fluid overload
D. Place a call to the physician Correct Answers C Assess for
signs of fluid overload
Assessment should be done first
18. A client with pneumonia presents with the following arterial
blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and
PO2 of 45, which of the following is the most appropriate
nursing intervention?
A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler's position
D. Assist the client to breathe into a paper bag Correct Answers
C. Place client in high-Fowler's position
19. A client with COPD feels short of breath after walking to the
bathroom on 2 liters of oxygen nasal cannula. The morning's
ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2
at 88% on 2 liters. Which of the following should be the nurse's
first intervention?
,A. Call the physician and report the change in client's condition
B. Turn the client's O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing
technique Correct Answers ... D. Encourage the client to rest
and to use pursed-lip breathing technique
Explanation
Clients with COPD, especially those who are in a chronic
compensated respiratory acidosis, are very sensitive to changes
in O2 flow, because hypoxemia rather than high CO2 levels
stimulates respirations. Deep breaths are not helpful, because
clients with COPD have difficulty with air trapping in alveoli.
There is no need to call the physician, since this client is
presently most likely at baseline.
2. The nurse evaluates which of the following clients to be at
risk for developing hypernatremia?
A. 50-year-old with pneumonia, diaphoresis, and high fevers
B. 62-year-old with congestive heart failure taking loop diuretics
C. 39-year-old with diarrhea and vomiting
D. 60-year-old with lung cancer and syndrome of inappropriate
antidiuretic hormone (SIADH) Correct Answers A. 50-year-
old with pneumonia, diaphoresis, and high fevers.
Explanation
Diaphoresis and a high fever can lead to free water loss through
the skin, resulting in hypernatremia. Loop diuretics are more
likely to result in a hypovolemic hyponatremia. Diarrhea and
, vomiting cause both sodium and water losses. Clients with
syndrome of inappropriate antidiuretic hormone (SIADH) have
hyponatremia, due to increased water reabsorption in the renal
tubules.
24. Which of the following assessment findings would indicate
to the nurse that a client's diabetic ketoacidosis is deteriorating?
A. Deep tendon reflexes decreasing from +2 to +1
B. Bicarbonate rising from 20 mEq/L to 22 mEq/L
C. Urine pH less than 6
D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
Correct Answers ...A. Deep tendon reflexes decreasing from
+2 to +1
Explanation
A decrease in deep tendon reflexes is a sign that pH is dropping
and that metabolic acidosis is worsening to diabetic
ketoacidosis. An increase in bicarbonate would indicate that the
acidosis is being corrected. A urine pH less than 6 indicates the
kidneys are excreting acid. Serum potassium levels are expected
to fall because acidosis is corrected and potassium moves back
into the intracellular space.
29. A client who is post-gallbladder surgery has a nasogastric
tube, decreased reflexes, pulse of 110 weak and irregular, and
blood pressure of 80/50 and is weak, mildly confused, and has a
serum of potassium of 3.0 mEq/L. Based on the assessment data,
which of the following is the priority intervention?
A. Withhold furosemide (Lasix)
11. A client with a serum sodium of 115 mEq/L has been
receiving 3% NS at 50 ml/hr for 16 hours. This morning the
client feels tired and short of breath.
Which of the following interventions is a priority?
A. Turn down the infusion
B. Check the latest sodium level
C. Assess for signs of fluid overload
D. Place a call to the physician Correct Answers C Assess for
signs of fluid overload
Assessment should be done first
18. A client with pneumonia presents with the following arterial
blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and
PO2 of 45, which of the following is the most appropriate
nursing intervention?
A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler's position
D. Assist the client to breathe into a paper bag Correct Answers
C. Place client in high-Fowler's position
19. A client with COPD feels short of breath after walking to the
bathroom on 2 liters of oxygen nasal cannula. The morning's
ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2
at 88% on 2 liters. Which of the following should be the nurse's
first intervention?
,A. Call the physician and report the change in client's condition
B. Turn the client's O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing
technique Correct Answers ... D. Encourage the client to rest
and to use pursed-lip breathing technique
Explanation
Clients with COPD, especially those who are in a chronic
compensated respiratory acidosis, are very sensitive to changes
in O2 flow, because hypoxemia rather than high CO2 levels
stimulates respirations. Deep breaths are not helpful, because
clients with COPD have difficulty with air trapping in alveoli.
There is no need to call the physician, since this client is
presently most likely at baseline.
2. The nurse evaluates which of the following clients to be at
risk for developing hypernatremia?
A. 50-year-old with pneumonia, diaphoresis, and high fevers
B. 62-year-old with congestive heart failure taking loop diuretics
C. 39-year-old with diarrhea and vomiting
D. 60-year-old with lung cancer and syndrome of inappropriate
antidiuretic hormone (SIADH) Correct Answers A. 50-year-
old with pneumonia, diaphoresis, and high fevers.
Explanation
Diaphoresis and a high fever can lead to free water loss through
the skin, resulting in hypernatremia. Loop diuretics are more
likely to result in a hypovolemic hyponatremia. Diarrhea and
, vomiting cause both sodium and water losses. Clients with
syndrome of inappropriate antidiuretic hormone (SIADH) have
hyponatremia, due to increased water reabsorption in the renal
tubules.
24. Which of the following assessment findings would indicate
to the nurse that a client's diabetic ketoacidosis is deteriorating?
A. Deep tendon reflexes decreasing from +2 to +1
B. Bicarbonate rising from 20 mEq/L to 22 mEq/L
C. Urine pH less than 6
D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
Correct Answers ...A. Deep tendon reflexes decreasing from
+2 to +1
Explanation
A decrease in deep tendon reflexes is a sign that pH is dropping
and that metabolic acidosis is worsening to diabetic
ketoacidosis. An increase in bicarbonate would indicate that the
acidosis is being corrected. A urine pH less than 6 indicates the
kidneys are excreting acid. Serum potassium levels are expected
to fall because acidosis is corrected and potassium moves back
into the intracellular space.
29. A client who is post-gallbladder surgery has a nasogastric
tube, decreased reflexes, pulse of 110 weak and irregular, and
blood pressure of 80/50 and is weak, mildly confused, and has a
serum of potassium of 3.0 mEq/L. Based on the assessment data,
which of the following is the priority intervention?
A. Withhold furosemide (Lasix)
