NU 448 Adult Health III Exam 1

NU 448 Adult Health III Exam 1 NU 448 Adult Health III Exam 1 NU 448 Adult Health III Exam 1 Adult Health III Exam 1  Question 1 2.5 out of 2.5 points A client with chronic obstructive pulmonary disease (COPD) arrives in the emergency department (ED) reporting shortness of breath and dyspnea on minimal exertion. Which of the following findings would be a priority for the nurse to report to the health care provider? Answers : SaO2 level is 91% bibasilar lung crackles the client is sitting in the tripod position the client’s respirations have decreased to 10 breaths/min Response Feedback: The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min. Crackles, tripod position and SaO2 of 91% are all common findings for a client with COPD. Lewis 2017, pgs. abck  Question 2 0 out of 2.5 points The nurse caring for a client scheduled for surgery administers prescribed intravenous (IV) midazolam hydrochloride and the client then demonstrates signs of an overdose. The nurse should collaborate with the surgical team to do which of the following actions next? Answers: administer prescribed epinephrine prepare to defibrillate the client ventilate the client with an oxygenated bag-valve mask titrate prescribed intravenous flumazenil Response Feedback: The nurse should have a bag-valve mask in the client’s room because midazolam hydrochloride can lead to respiratory acidosis if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or to receive epinephrine unless cardiac compromise developed after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the midazolam, but first the nurse should ventilate the client. Lewis 2017, pgs. 288stem, 1610stem, k, bcd by omission  Question 3 2.5 out of 2.5 points The nurse has attended a staff education conference about fluid balance. Which of the following statements, if made by the nurse, would indicate a correct understanding of homeostatic mechanisms in the body that regulate body fluid? Select all that apply. Answers : "Clients with increased levels of aldosterone are at risk for fluid loss." "The amount of fluid loss through exhalation has no impact on fluid balance." "I will monitor urine output to measure the kidney's effect on fluid volume balance." "Clients who have a lack of antidiuretic hormone (ADH) are at risk for fluid volume deficit (FVD)." "Thirst triggers a mechanism in the hypothalamus to maintain fluid balance." Response Feedback: The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes increased aldosterone which results in sodium and water retention. Approximately 300 ml of water is lost daily through exhalation (insensible water loss). Low levels of antidiuretic hormone (ADH) have an impact on fluid balance. The thirst center in the hypothalamus regulates oral intake by sensing intracellular dehydration. The kidneys regulate extracellular fluid (ECF) volume by selective retention and excretion of body fluids. Lewis 2017, pgs. 274-275kde  Question 4 0 out of 2.5 points The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L Answers: respiratory acidosis metabolic alkalosis respiratory alkalosis metabolic acidosis Response Feedback: The ABGs shown indicate the pH is low which would mean acidosis. The PaCO2 is within normal levels and the HCO3 is low indicating a metabolic disturbance. Remember the acronym ROME when interpreting ABGs. Lewis 2017, pgs. 290-291kbcd  Question 5 0 out of 2.5 points The nurse is reviewing the arterial blood gas (ABG) results for a client who was admitted with a bowel obstruction and has nasogastric tube (NG) with continuous suction. Which of the following ABGs would indicate to the nurse the client is experiencing a complication from the NG tube? Answers: pH = 7.50 PaCO2 = 40 HCO3 = 39 pH = 7.28 PaCO2 = 41 HCO3 = 19 pH = 7.30 PaCO2 = 50 HCO3 =25 pH = 7.47 PaCO2 = 30 HCO3 = 22 Response Feedback: Clients who have a prescription for continuous suction are at increased risk for metabolic alkalosis indicated by pH =7.50 CO2 = 40 HCO3 = 39, due to a loss of hydrogen and chloride ions from gastric fluids. Gastric fluids are acidic.  Question 6 0 out of 2.5 points The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take? Answers: Administer prescribed antibiotics. Decrease the intravenous fluids. Assist the client to ambulate to increase their metabolic rate. Encourage the client to increase their fluid intake. Response Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. abkd  Question 7 0 out of 2.5 points The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following actions by the nurse would help prevent ventilator associated pneumonia (VAP)? Answers: maintaining the head of the client's bed elevated at least 10 degrees suctioning of the client's oral cavity secretions every shift practicing meticulous hand hygiene ensuring the respiratory therapist changes the ventilator circuit tubing every 4 hours Response Feedback: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. The client will need oral suctioning more frequently than every shift and at least 30-degree head of the bed elevation. It is not necessary to change the ventilator circuit tubing every 4 hours. The more frequently the circuit is broken, the greater the risk for pathogen entry. Lewis 2017, p. 1623kbcd  Question 8 0 out of 2.5 points The nurse in the emergency department (ED) is caring for a client who reports acute dyspnea, pain and anxiety. The client’s blood pressure is 140/85 mm/Hg, pulse is 110 beats/minute and SaO2 is 85%. ABG values are; pH 7.50, PaCO2 29 mm/Hg, and HCO3 24 mm/Hg. Which of the following actions should the nurse take? Select all that apply. Answers: encourage the client to breathe slowly obtain a medical history from the client to determine the cause of symptoms administer oxygen therapy administer prescribed pain medication prepare the client for intravenous therapy to promote compensation Response Feedback: The client is experiencing respiratory alkalosis based on the ABG levels. The pH is high and the PaCO2 is low. The nurse should administer oxygen, and pain medication and encourage the client to slow the breathing because pain can cause respiratory alkalosis and hyperventilation increases the pH levels. Obtaining as much of a medical history from the client as possible is key to treating the cause. With respiratory alkalosis, compensation is typically not possible because the client requires aggressive treatment of the hypoxemia. Lewis 2017 pgs. 288-289ck, stem, k  Question 9 0 out of 2.5 points The nurse is caring for a client who is receiving positive pressure ventilation and high levels of PEEP via endotracheal intubation for acute respiratory distress syndrome (ARDS). The nurse should contact respiratory therapy for which of the following findings? Answers: The client’s temperature increased from 98.8o F. to 100.1o F in the last hour. The client’s blood pressure decreased from 110/68 mm/Hg to 89/60 mm/Hg in the last hour. The client’s FIO2 is at 65%. The client’s PaO2 is at 75%. Response Feedback: The nurse should contact respiratory therapy for the decrease in blood pressure. Client’s receiving high levels of PEEP can experience a reduction in blood return to the left side of the heart from hyperinflation of the alveoli and compression of the pulmonary capillary bed which then causes dramatic reduction in BP. The PEEP should be adjusted to correct the BP. The client’s temperature is unrelated to respiratory therapy and the FIO2 and PaO2 are within expected levels. Lewis 2017, pg. 1624Kbc, d by omission.  Question 10 2.5 out of 2.5 points A client is admitted to the intensive care unit (ICU) after a motor vehicle collision (MVC) in which the client received blunt trauma to the chest. The client is in acute respiratory failure and is intubated and minimally sedated. Which of the following should the ICU nurse monitor when caring for the client? Select all that apply. Answers : ability to communicate verbally oral intake arterial blood gases (ABGs) respiratory system vital signs (VS) Response Feedback: Clients are usually managed in the intensive care unit. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. In addition, the nurse assesses the entire respiratory system and implements strategies (eg, turning schedule, mouth care, skin care, range of motion of extremities) to prevent complications. The nurse also assesses the client's understanding of the management strategies that are used and initiates some form of communication to enable the client to express concerns and needs to the health care team. The other options are incorrect; a client in respiratory failure is intubated. The client cannot communicate verbally and cannot take in anything orally. Lewis 2017, pgs.