Clicker Questions - Exam 2

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurses findings?

(respiratory acidosis = low pH, high bicarb, high CO2) Atelectasis = slow, shallow breaths, holding onto CO2 Answer = pH: 7.25, pCO2: 50 mmHg

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted?

3.5

Your patient is NPO and is receiving continuous tube feeding via PEG tube. All of the following are appropriate nursing actions EXCEPT A. Check blood sugar AC/HS B. Keep the bead of bed at or above a 30-degree angle C. Place feeding on hold when placing patient in a supine position D. Checking residual every 4 hours

A. Check blood sugar AC/HS

While a client is receiving TPN, it is MOST important for the nurse to monitor

All are correct, but C serum glucose and electrolytes.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A. Administer TPN through a nasogastric or gastrostomy tube. B. Handle TPN using strict aseptic technique. C. Auscultate for the presence of bowel sounds prior to administering TPN. D. Designate a peripheral IV site for TPN administration.

B. Handle TPN using strict aseptic technique.

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? A. A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. B. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. D. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? A. Continue the infusion until the remaining 300 mL is infused. B. Change the filter on the tubing, and continue with the infusion. C. Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution. D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose?

Evaluate absorption of the last feeding

A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid/base imbalance?

Hyperglycemia = Metabolic Acidosis DKA = diabetic keto acidosis, too much blood sugar, body cannot use sugar so body uses fat for energy

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic Alkalosis

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving?

The patient's ammonia level decreased from 160 to 120 mg/dL

A nurse reviews a client's arterial blood gas results and notes a pH of 7.50, a PCO2 of 30 mmHg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition?

pH = high CO2 = low HCO3 = normal initially, but will decrease in order to correct the imbalance/ match up Respiratory Alkalosis, uncompensated (because the bicarb has not come down yet)

The nurse is reviewing the arterial blood gas of a client and notes that the pH is 7.31, pCO2 is 50 mmHg, and HCO3 level is 27 mEq/L. Which disturbance is present in this client?

pH = low CO2 = high HCO3 = high low pH means acidosis. Is it respiratory or metabolic? It is respiratory because metabolic acidosis means LOW bicarb. Respiratory acidosis means HIGH carbonic acid. Answer = Respiratory Acidosis

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mmHg, PaO2 of 86 mmHg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result?

pH = normal CO2 = normal O2 = normal HCO3 = normal Normal Results