nur 445 exam 5 UPDATED ACTUAL
Questions and CORRECT Answers
Kussmaul respirations, dehydration, abdominal pain, elevated blood glucose level (289 mg/dL),
high hemoglobin A1C (13%), and abnormal pH (7.29, indicating acidosis) suggest - CORRECT
ANSWER - diabetic ketoacidosis (DKA). Immediate action - administering IV insulin and
isotonic IV fluids/ normal saline) to rehydrate the client and correct electrolyte imbalances.
•HHS is characterized by extreme hyperglycemia and severe dehydration without - CORRECT
ANSWER - significant ketoacidosis. Fluid resuscitation with isotonic •fluids/ normal
saline) is the priority
diabetes insipidus (DI) - polyuria, polydipsia, hypernatremia, and low urine osmolality.
Desmopressin (synthetic ADH) is the - CORRECT ANSWER - first-line treatment, and
hypotonic IV fluids help correct dehydration. Serum sodium and urine output must be closely
monitored to assess treatment effectiveness
In DI, Neuromuscular excitability, such as muscle twitching, cramping, or seizures, can indicate
- CORRECT ANSWER - severe hyponatremia, which is a life-threatening condition. High
urine output and low urine specific gravity expected
•Furosemide (a loop diuretic) promotes diuresis, which would worsen polyuria in diabetes
insipidus. Clients with DI require - CORRECT ANSWER - fluid replacement and
desmopressin (synthetic ADH) to control excessive urine output. Monitoring urine output is
essential for assessing treatment effectiveness.
high urine sodium level of 300 mEq/day and urine osmolality of 1,352 mOsm/kg indicate that -
CORRECT ANSWER - the kidneys are producing concentrated urine, which is
characteristic of SIADH.
Addisonian crisis - IV hydrocortisone is the treatment of choice to replace cortisol, and IV
normal saline is required to - CORRECT ANSWER - correct hypotension and sodium
depletion. Serum potassium and blood glucose should be closely monitored due to the risk of
hyperkalemia and hypoglycemia.
,•In Addison's disease, sodium levels are typically low due to insufficient aldosterone, so sodium
restriction is - CORRECT ANSWER - inappropriate. Clients with adrenal crisis require
fluid resuscitation with isotonic solutions/ normal saline), corticosteroid replacement, and close
monitoring of potassium levels due to the risk of hyperkalemia
•Hypokalemia (serum potassium <3.0 mEq/L) is the most concerning finding in Cushing's
syndrome, as it can lead to life-threatening arrhythmias and muscle weakness. The nurse should
question - CORRECT ANSWER - the order to monitor white blood cell count daily in a
client with Cushing's syndrome because the condition typically results in immune suppression
due to elevated cortisol levels. Weigh daily, admin o2, corticosteroids
Thyroid storm - life-threatening hypermetabolic state that causes extreme tachycardia,
hypertension, and fever. IV beta-blockers/ propranolol) are - CORRECT ANSWER - the
first-line intervention to reduce heart rate and myocardial oxygen demand. clinical
manifestations indicative of a thyroid storm are tachycardia, hyperthermia, low TSH, and
elevated T3 and T4.
Myxedema coma - life-threatening form of severe hypothyroidism characterized by bradycardia,
hypothermia, hypotension, LOC, and respiratory depression. The priority intervention is -
CORRECT ANSWER - the administration of IV levothyroxine to replace thyroid
hormones.
Hypocalcemia is a potential complication after thyroid surgery due to inadvertent removal or
damage to the - CORRECT ANSWER - parathyroid glands. Tingling, muscle twitching,
and perioral numbness suggest low calcium levels. IV calcium gluconate is the treatment of
choice.
"Perform oral care every 2 hours" to prevent the development of - CORRECT ANSWER -
ventilator-associated pneumonia (VAP).
low pH of 7.20, (HCO3 of 10, PaCO2 of 33, PaO2 of 48 mmHg indicates hypoxemia, which is
common in cardiogenic shock. Together, these findings suggest that the client is experiencing -
CORRECT ANSWER - metabolic acidosis with partial respiratory compensation and
hypoxemia due to the impaired oxygenation associated with cardiogenic shock.
, low pH (7.30) and elevated PaCO2 (50 mmHg) indicate respiratory acidosis, which is
uncompensated as the HCO3 remains normal (24 mEq/L). The low PaO2 (55 mmHg) indicates -
CORRECT ANSWER - hypoxemia, which is expected in acute decompensated heart
failure with pulmonary edema, as fluid accumulation in the lungs impairs gas exchange.
elevated pH (7.50) and low PaCO2 (30 mmHg) indicate respiratory alkalosis, which is
uncompensated since the HCO3 is within the normal range (24 mEq/L). This condition is
commonly seen in clients experiencing - CORRECT ANSWER - hyperventilation due to
anxiety, pain, or hypoxia— which can occur in clients with unstable angina as they experience
chest pain and increased respiratory rate.
A recent central line placement can cause - CORRECT ANSWER - accidental lung
puncture/ iatrogenic pneumothorax), leading to air leakage into the pleural space.
Early ambulation is one of the most effective ways to prevent - CORRECT ANSWER -
venous stasis and reduce the risk of developing a pulmonary embolism. typically presents with
sudden dyspnea, pleuritic chest pain, and clear lung sounds due to an obstruction in pulmonary
circulation rather than a primary lung issue.
Keeping the head of the bed elevated at 30-45 degrees helps prevent - CORRECT
ANSWER - aspiration and improve oxygenation, which can reduce the risk of ARDS -
severe hypoxemia that is not responsive to supplemental oxygen - ex. 75% o2 on 100% o2 face
mask.
Acute respiratory failure (ARF) is confirmed by severe hypoxemia (PaO₂ < 60 mmHg) or
hypercapnia (PaCO₂ > 50 mmHg with pH < 7.35). A PaO₂ of 55 mmHg despite supplemental
oxygen - CORRECT ANSWER - meets the criteria for hypoxemic respiratory failure.
Key interventions for STEMI/ MI include administering sublingual nitroglycerine to relieve pain,
placing the client on - CORRECT ANSWER - 2L nasal cannula for oxygenation,
completing vital signs to monitor cardiovascular status, and administering intravenous morphine
sulfate for pain relief
Questions and CORRECT Answers
Kussmaul respirations, dehydration, abdominal pain, elevated blood glucose level (289 mg/dL),
high hemoglobin A1C (13%), and abnormal pH (7.29, indicating acidosis) suggest - CORRECT
ANSWER - diabetic ketoacidosis (DKA). Immediate action - administering IV insulin and
isotonic IV fluids/ normal saline) to rehydrate the client and correct electrolyte imbalances.
•HHS is characterized by extreme hyperglycemia and severe dehydration without - CORRECT
ANSWER - significant ketoacidosis. Fluid resuscitation with isotonic •fluids/ normal
saline) is the priority
diabetes insipidus (DI) - polyuria, polydipsia, hypernatremia, and low urine osmolality.
Desmopressin (synthetic ADH) is the - CORRECT ANSWER - first-line treatment, and
hypotonic IV fluids help correct dehydration. Serum sodium and urine output must be closely
monitored to assess treatment effectiveness
In DI, Neuromuscular excitability, such as muscle twitching, cramping, or seizures, can indicate
- CORRECT ANSWER - severe hyponatremia, which is a life-threatening condition. High
urine output and low urine specific gravity expected
•Furosemide (a loop diuretic) promotes diuresis, which would worsen polyuria in diabetes
insipidus. Clients with DI require - CORRECT ANSWER - fluid replacement and
desmopressin (synthetic ADH) to control excessive urine output. Monitoring urine output is
essential for assessing treatment effectiveness.
high urine sodium level of 300 mEq/day and urine osmolality of 1,352 mOsm/kg indicate that -
CORRECT ANSWER - the kidneys are producing concentrated urine, which is
characteristic of SIADH.
Addisonian crisis - IV hydrocortisone is the treatment of choice to replace cortisol, and IV
normal saline is required to - CORRECT ANSWER - correct hypotension and sodium
depletion. Serum potassium and blood glucose should be closely monitored due to the risk of
hyperkalemia and hypoglycemia.
,•In Addison's disease, sodium levels are typically low due to insufficient aldosterone, so sodium
restriction is - CORRECT ANSWER - inappropriate. Clients with adrenal crisis require
fluid resuscitation with isotonic solutions/ normal saline), corticosteroid replacement, and close
monitoring of potassium levels due to the risk of hyperkalemia
•Hypokalemia (serum potassium <3.0 mEq/L) is the most concerning finding in Cushing's
syndrome, as it can lead to life-threatening arrhythmias and muscle weakness. The nurse should
question - CORRECT ANSWER - the order to monitor white blood cell count daily in a
client with Cushing's syndrome because the condition typically results in immune suppression
due to elevated cortisol levels. Weigh daily, admin o2, corticosteroids
Thyroid storm - life-threatening hypermetabolic state that causes extreme tachycardia,
hypertension, and fever. IV beta-blockers/ propranolol) are - CORRECT ANSWER - the
first-line intervention to reduce heart rate and myocardial oxygen demand. clinical
manifestations indicative of a thyroid storm are tachycardia, hyperthermia, low TSH, and
elevated T3 and T4.
Myxedema coma - life-threatening form of severe hypothyroidism characterized by bradycardia,
hypothermia, hypotension, LOC, and respiratory depression. The priority intervention is -
CORRECT ANSWER - the administration of IV levothyroxine to replace thyroid
hormones.
Hypocalcemia is a potential complication after thyroid surgery due to inadvertent removal or
damage to the - CORRECT ANSWER - parathyroid glands. Tingling, muscle twitching,
and perioral numbness suggest low calcium levels. IV calcium gluconate is the treatment of
choice.
"Perform oral care every 2 hours" to prevent the development of - CORRECT ANSWER -
ventilator-associated pneumonia (VAP).
low pH of 7.20, (HCO3 of 10, PaCO2 of 33, PaO2 of 48 mmHg indicates hypoxemia, which is
common in cardiogenic shock. Together, these findings suggest that the client is experiencing -
CORRECT ANSWER - metabolic acidosis with partial respiratory compensation and
hypoxemia due to the impaired oxygenation associated with cardiogenic shock.
, low pH (7.30) and elevated PaCO2 (50 mmHg) indicate respiratory acidosis, which is
uncompensated as the HCO3 remains normal (24 mEq/L). The low PaO2 (55 mmHg) indicates -
CORRECT ANSWER - hypoxemia, which is expected in acute decompensated heart
failure with pulmonary edema, as fluid accumulation in the lungs impairs gas exchange.
elevated pH (7.50) and low PaCO2 (30 mmHg) indicate respiratory alkalosis, which is
uncompensated since the HCO3 is within the normal range (24 mEq/L). This condition is
commonly seen in clients experiencing - CORRECT ANSWER - hyperventilation due to
anxiety, pain, or hypoxia— which can occur in clients with unstable angina as they experience
chest pain and increased respiratory rate.
A recent central line placement can cause - CORRECT ANSWER - accidental lung
puncture/ iatrogenic pneumothorax), leading to air leakage into the pleural space.
Early ambulation is one of the most effective ways to prevent - CORRECT ANSWER -
venous stasis and reduce the risk of developing a pulmonary embolism. typically presents with
sudden dyspnea, pleuritic chest pain, and clear lung sounds due to an obstruction in pulmonary
circulation rather than a primary lung issue.
Keeping the head of the bed elevated at 30-45 degrees helps prevent - CORRECT
ANSWER - aspiration and improve oxygenation, which can reduce the risk of ARDS -
severe hypoxemia that is not responsive to supplemental oxygen - ex. 75% o2 on 100% o2 face
mask.
Acute respiratory failure (ARF) is confirmed by severe hypoxemia (PaO₂ < 60 mmHg) or
hypercapnia (PaCO₂ > 50 mmHg with pH < 7.35). A PaO₂ of 55 mmHg despite supplemental
oxygen - CORRECT ANSWER - meets the criteria for hypoxemic respiratory failure.
Key interventions for STEMI/ MI include administering sublingual nitroglycerine to relieve pain,
placing the client on - CORRECT ANSWER - 2L nasal cannula for oxygenation,
completing vital signs to monitor cardiovascular status, and administering intravenous morphine
sulfate for pain relief
