ATI CBC Level 2 Test Correct 100%

what does pH tell you - Answer the expression of the balance between carbon dioxide and bicarbonate what causes a lower pH in the body - Answer the greater the concentration of hydrogen, the more acidic the body fluids what causes a higher pH in the body - Answer the lower the concentration of hydrogen, the more alkaline the body fluids hyperventilation and hydrogen ions - Answer causes a decrease in hydrogen ions hypoventilation and hydrogen ions - Answer causes an increase in hydrogen ions normal pH for the blood - Answer 7.35-7.45 what causes respiratory acidosis - Answer hypoventilation what causes hypoventilation - Answer - respiratory depression from opioids, poisons - brain tumors, stroke, trauma - muscle weakness, flail chest, obesity, sleep apnea - airway obstruction - pneumothorax manifestations of respiratory acidosis - Answer - tachycardia (severe is bradycardia), tachypnea, hypertension - anxiety, irritability, confusion, coma - ineffective, shallow, rapid breathing - pale or cyanotic nursing care for a patient with respiratory acidosis - Answer - oxygen therapy - maintain patent airway - positioning and breathing techniques what causes respiratory alkalosis - Answer hyperventilation what causes hyperventilation - Answer - fear, anxiety, intracerebral trauma, excessive mechanical ventilation - hypoxemia from asphyxiation, high altitudes, shock, pneumonia lab values for respiratory alkalosis - Answer PaCO2: less than 35 pH: greater than 7.45 HCO3: less than 24 lab values for respiratory acidosis - Answer PaCO2: greater than 45 pH: less than 7.35 HCO3: greater than 28 manifestations of respiratory alkalosis - Answer - tachypnea - inability to concentrate, numbness, tingling - tachycardia, dysrhythmias - rapid deep respirations nursing care for respiratory alkalosis - Answer - oxygen therapy - anxiety reduction interventions - rebreathing techniques what causes metabolic acidosis - Answer - diabetic ketoacidosis - starvation - heavy exercise, seizure activity, hypoxia - liver failure - diarrhea lab values for metabolic acidosis - Answer pH: less than 7.35 HCO3: less than 24 PaCO2: greater than 35 manifestations of metabolic acidosis - Answer - dysrhythmias - bradycardia, weak pulses, hypotension, tachypnea - headache, drowsiness, confusion - rapid deep respirations (kussmaul) causes of metabolic alkalosis - Answer - oral ingestion of excess amount of antacids - blood transfusions, TPN - prolonged vomiting, NG suction lab values for metabolic alkalosis - Answer pH: greater than 7.45 HCO3: greater than 28 PaCO2: greater than 45 manifestations of metabolic alkalosis - Answer - tachycardia, hypotensive - atrial tachycardia - numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion - depressed skeletal muscles resulting in ineffective breathing how to determine the type of imbalance - Answer - look at pH first (less than 7.35 acidosis, greater than 7.45 alkalosis) - look at PaCO2 and HCO3 a nurse is caring for a client admitted with confusion and lethargy. the client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72, HR 116, RR 42 and deep, which of the following should the nurse expect? A. pH 7.68 PaCo2 38 HCO3 28 B. pH 7.48 PaCO2 28 HCO3 23 C. pH 6.98 PaCO2 30 HCO3 18 - Answer C. a nurse is obtaining arterial blood gases for a client who has vomited for 24 hours. the nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hours? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis - Answer D. A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. which of the following statements by a unit nurse indicates the teaching has been effective a. metabolic acidosis can occur due to diabetic ketoacidosis b. metabolic acidosis can occur in a client who has myasthenia gravis c. metabolic acidosis can occur in a client who has asthma d. metabolic acidosis can occur due to cancer - Answer A a nurse is assessing a client who has pancreatitis. the client's arterial blood gases reveal metabolic acidosis. which of the following are expected findings? a. tachycardia b. hypertension c. bounding pulses d. hyperreflexia e. dysrhythmia f. tachypnea - Answer E, F complications of sedatives (benzodiazepines, barbiturates) - Answer - respiratory depression - drowsiness - dizziness - FLUMACENIL is reversal agent complications of opioids - Answer - respiratory depression - drowsiness - dizziness - constipation - urinary retention - NALOXONE is reversal agent parenteral anticoagulants - Answer - heparin - enoxaparin - dalteparin - fondaparinux toxicity/overdose of heparin and enoxaparin - Answer - administer PROTAMINE how to evaluate effectiveness of heparin - Answer - aPTT levels of 60-80 seconds oral anticoagulant - Answer - warfarin toxicity/overdose of warfarin - Answer - administer vitamin K rapid acting insulins - Answer - insulin lispro - insulin aspart - insulin glulisine regular insulin - Answer short acting NPH insulin - Answer intermediate acting insulin glargine - Answer long acting nursing care for hypoglycemia - Answer - blood glucose less than 70 - administer glucose - administer a snack of 15 g carbs (4 oz orange juice, 2 oz grape juice, 8 oz milk) lipohypertrophy - Answer instruct clients to systematically rotate injection sites and to allow 1 inch between injection sites adverse reactions to exenatide - Answer - nausea, vomiting, diarrhea, pancreatitis warfarin adverse effects - Answer - hemorrhage - hepatitis - toxicity risk factors for benign prostatic hyperplasia - Answer - increased age - smoking, alcohol use - sedentary lifestyle, obesity - western diet - diabetes expected findings of BPH - Answer - urinary frequency - incontinence - incomplete emptying of the bladder - dribbling post voiding - nocturia - diminished force of urinary stream - straining with urination - frequent UTIs - can lead to kidney damage client education for BPH - Answer - avoid drinking large amounts of fluids at one time - void when the urge is initially felt - avoid bladder stimulants (caffeine, alcohol) - avoid antihistamines, decongestants finesteride - Answer - used for BPH - can take 6 months-1 year before effects are evident - impotence and decrease in libido are adverse effects tamsulosin - Answer - used for BPH - causes relaxation of the bladder outlet and prostate gland - decrease pressure on the urethra - postural hypertension can occur TURP - Answer - transurethral resection of the prostate - trims away excess prostatic tissue , enlarging the passageway of the urethra postop nursing actions for a TURP - Answer - placement of an indwelling three way catheter (for urine and continuous bladder irrigation) - monitor for bleeding (bright red bleeding, report to provider) - ambulate as soon as possible - expected output is 150-200 ml every 3-4 hours client education for a TURP - Answer - avoid heavy lifting - drink 12 or more 8 oz glasses of water each day - avoid NSAIDs due to increased risk for bleeding - avoid bladder stimulants