Nur 504 / Nur504 Respiratory And Renal Exam 2

The hand grasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team which body system will the nurse assess first to prevent harm for a client who has metabolic acidosis? a. GI system b. respiratory system c. cardiovascular system d. autonomic nervous system For which client does the nurse remain alert for the possibility of respiratory acidosis? a. client with increased urinary output b. client who is anxious and breathing rapidly c. client receiving IV normal saline bolus d. client with multiple rib fractures rationale: they may have shallow breathing d/t pain resulting in poor gas exchange Which conditions cause a client to develop acidosis? select all a. ventilator at too low a tidal volume b. sepsis c. severe diarrhea d. hypovolemic shock e. prolonged nasogastric suctioning f. hyperventilation a. ventilator at too low a tidal volume b. sepsis c. severe diarrhea d. hypovolemic shock Which problem does the nurse expect resulted in a clients acid-base imbalance during an illness that causes vomiting for 2 days? a. alkalosis from over elimination of hydrogen ions b. acidosis from overproduction of hydrogen ions c. alkalosis from overproduction of bicarbonate ions d. acidosis from under elimination of bicarbonate ions Which lab value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek’s sign? a. serum calcium b. serum magnesium c. serum glucose level d. serum sodium Following a motor vehicle collision, a patient has a chest tube inserted to the left upper chest. the tube begins to drain dark red fluid. what does the nurse determine? a. the chest tube was inserted improperly b. this is an expected result for this patient c. an artery was nicked when the chest tube was placed d. the patient is experiencing a hemothorax The nurse is caring for a patient who had a chest tube inserted for the treatment of a pneumothorax. which assessment finding best indicates to the nurse that a chest tube is no longer needed? a. there is minimal drainage from the chest tube b. ABG results are within normal limits c. the patient states he is not experiencing dyspnea d. no fluctuation in the water seal chamber occurs when no suction is applied A client is admitted to the ICU with confirmed opioid overdose. The ABG results reflect a pH of 7.27, PaCO2 of 55, and HCO3 of 26. Based on the client's condition and blood gas analysis, the nurse must work to correct which of the following? a. decreased GI motility b. rapid respirations c. shallow respirations d. decreased level of consciousness An unconscious client with an opioid overdose is triaged in the ED. ABG values reflect respiratory acidosis. Which of the following interventions address the cause of this clients respiratory acidosis? a. initiate BiPAP b. administer naloxone c. administer salmeterol d. give oxygen at 4 LPM