Semester 1 Lecture Exam 3 Charito

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The patient has severe metabolic alkalosis. Which intervention has the highest priority? Raise the side rails on the patient's bed. Measure the urine output and skin turgor. Teach the family about metabolic alkalosis. Administer intravenous NaHCO3 as ordered.

Raise the side rails on the patient's bed. Severe metabolic alkalosis causes a decreased level of consciousness; raising the side rails is a safety intervention in that situation. Safety interventions are a higher priority than teaching. An order to administer intravenous NaHCO

How is the relationship between the concepts of cognition and nutrition best expressed? A. Unidirectional B. Time dependent C. Indirect D. Reciprocal

Reciprocal

What concept of death should a nurse expect a 4-year-old child to have? Cessation of life Reversible separation Only affects old people Force takes one away from family

Reversible separation Preschoolers view death as a separation; they believe that the deceased will return to life. This is part of their fantasy world; they view death as possibly a kind of sleep rather than a cessation of life and expect the deceased to return or wake up. The preschooler does not yet have the understanding that older people are more likely to die. The preschooler believes that the separation was initiated by the deceased, not by another force.

The nurse is caring for a patient with emphysema. The patient is complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding alerts the nurse that the patient is going into respiratory failure? A. The patient has bibasilar lung crackles. B. The patient is sitting in the tripod position. C. The patient's respirations have decreased from 30 to 10 breaths/minute. D. The patient's pulse oximetry indicates an O2 saturation of 91%.

The patient's respirations have decreased from 30 to 10 breaths/minute. A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with chronic obstructive pulmonary disease (COPD). An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis? (Select all that apply.) Have you been vomiting today? When did your kidneys stop working? How long have you had diarrhea? Are you still feeling short of breath? What type of antacid did you take? Which weight loss diet are you using?

When did your kidneys stop working? How long have you had diarrhea? Which weight loss diet are you using? Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids. Shortness of breath might be related to a cause of respiratory acidosis. recent hx of vomiting and diarrhea use of medication use of EtOH

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism

a. Alveolar macrophages

The nurse observes that during morning care the patient is complaining of leg pain when ambulating to the bathroom. The nurse assists the patient back into bed and notices that the patient's leg pain is relieved. Further assessment reveals bilateral pedal edema. The nurse knows that the cause of the patient's leg pain is most likely which of the following: a. The pain indicates an inadequate amount of blood to transport oxygen to meet the demands of leg muscles. b. The pain indicates a muscle spasm. c. The patient is having a myocardial infarction. d. The pain is due to over-exertion during morning care

a. The pain indicates an inadequate amount of blood to transport oxygen to meet the demands of leg muscles. (Impaired perfusion often results in leg pain as related to peripheral arterial disease (PAD). PAD leg pain is often relieved with rest and worsens with walking. Leg pain that is relieved with rest is called intermittent claudication and means that there is an inadequate supply of blood being transported to the muscles. Edema also develops from the obstruction of venous blood flow.Although pain is common during a muscle spasm, it is usually not relieved with rest. During a myocardial infarction, pain is often felt in the chest and not in the lower extremities.Although pain may occur from exercise, acute leg pain with the presence of edema indicates a perfusion problem and warrants further investigation.)

*A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.

a. acid-base balance b. oxygenation status c. acidity of the blood d. bicarbonate (HCO3-) in arterial blood Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3-), and arterial oxygen saturation (SaO2) in arterial blood. The overall balance of electrolytes cannot be determined with ABGs.

The most common early clinical manifestations of ARDS that the nurse may observe are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. hypotension and tachycardia. d. respiratory distress and frothy sputum.

a. dyspnea and tachypnea.

When assessing activity-exercise patterns related to respiratory health, the nurse inquires about a. dyspnea during rest or exercise. b. recent weight loss or weight gain. c. ability to sleep through the entire night. d. willingness to wear O2 equipment in public.

a. dyspnea during rest or exercise.

A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

a. metabolic acidosis. The pH and HCO3 indicate that the patient has a metabolic acidosis. The other options are incorrect.

To promote the release of surfactant, the nurse encourages the patient to a. take deep breaths. b. cough five times per hour to prevent alveolar collapse. c. decrease fluid intake to reduce fluid accumulation in the alveoli. d. sit with head of bed elevated to promote air movement through the pores of Kohn.

a. take deep breaths.

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a.Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c.Pull the call bell out of the wall socket. d.Assess the client's pulse oximetry.

a.Elevate the head of the bed and apply oxygen.

*The nurse would not expect full compensation to occur for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

b) Respiratory alkalosis Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.

*The nurse would not expect full compensation to occur for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

*A 72-year-old man presents to the emergency room. The patient appears diaphoretic and anxious, and has noted peripheral edema. The patient's vital signs are blood pressure of 100/40, heart rate of 130 and irregular, and respiratory rate of 26. How does the nurse interpret these findings? a. The patient is having a myocardial infarction. b. The patient has impaired central perfusion. c. The patient has a virus. d. Pain medication should be administered to this patient.

b. The patient has impaired central perfusion. (This patient has the classic symptoms of impaired central perfusion. Central perfusion occurs when cardiac output is optimal and blood is pumped to all of the organs and tissues from the arteries, through the capillaries, and then back to the heart through the veins. The nurse needs to administer oxygen. Chest pain is often present with myocardial infarction, along with elevated blood pressure readings and electrocardiogram changes. Viral illness commonly presents with other symptoms such as body ache or gastrointestinal issues, and typically has little or no effect on the heart rate. Pain management is not indicated for patients who do not present with pain. Also, the question is asking what assessment the nurse has made, and is not asking about interventions.)

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.

b. apprehension and restlessness.

When auscultating the chest of an older patient in respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.

b. begin listening at the lung bases

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b.Urinary output of 10 mL/hr c.Heart rate of 100 beats/min d.Dry cough

b.Urinary output of 10 mL/hr Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.

*A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep."

c. "You need to stay in the hospital for further evaluation." (skills) Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill.

The nurse knows that primary prevention strategies to prevent impaired perfusion in the patient include which of the following recommendations by the American Heart Association (AHA): a. Routine blood pressure monitoring b. Administering furosemide (Lasix) to a patient with active congestive heart failure (CHF) symptoms c. Eating a healthy diet and exercising most days of the week d. Monitoring routine serum lipids

c. Eating a healthy diet and exercising most days of the week (Primary prevention strategies include measures that promote health and prevent disease from developing. The American Heart Association recommends eating a heart-healthy diet, exercising most days of the week, taking a low-dose aspirin, and not smoking. Routine blood pressure monitoring is considered secondary prevention, which also includes screening and early diagnosis of health issues.Although administering a diuretic such as furosemide to a patient who presents with active CHF symptoms is considered an optimal treatment of symptoms, this is not considered a primary prevention strategy. Testing for routine serum lipids is considered secondary prevention.)

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? a. Cardiogenic shock b. Hypervolemic shock c. Hemorrhagic shock d. Septic shock

c. Hemorrhagic shock The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? a. Ideas of grandeur b. Need for attention c. Marked memory loss d. Difficulty in accepting the diagnosis

c. Marked memory loss A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

c. arterial oxygen partial pressure.

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

*The nurse knows that including teaching on modifiable risk factors for impaired perfusion in the patient's plan of care includes which of the following: a. Impaired perfusion increases with age. b. Genetics play a role in impaired perfusion. c. Exercise should be kept at a minimum to prevent a myocardial infarction. d. A smoking cessation plan should be in place.

d. A smoking cessation plan should be in place. (The importance of distinguishing between modifiable versus nonmodifiable risk factors is imperative when determining what sort of lifestyle changes can be discussed when formulating the patient's plan of care. Impaired perfusion can affect all people and age groups regardless of gender, race, or economic status. Smoking cessation is an example of a modifiable risk factor for impaired perfusion that can be included in the patient's plan of care. Modifiable risk factors can be changed by the patient through teaching from the nurse. Although impaired perfusion can increase with age, this is an example of an unmodifiable risk factor (something that the patient cannot change). Genetics is an example of an unmodifiable risk factor for impaired perfusion. A sedentary lifestyle can lead to obesity, which would then become a modifiable risk factor for impaired perfusion.)

Which assessment finding of the respiratory system does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields

d. Bronchial breath sounds in the lower lung fields

Which of the following would be a potential cause for respiratory acidosis? a. Diarrhea b. Vomiting c. Hyperventilation d. Hypo-ventilation

d. Hypo-ventilation

A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. increased CO2 and decreased O2 in the blood. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. decrease in intrathoracic pressure relative to pressure at the airway.

d. decrease in intrathoracic pressure relative to pressure at the airway.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis. The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1 pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) 2 pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) 3 pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) 4 pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L

pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO 3 - will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? A. pH: 7.28; PCO 2: 28; HCO 3: 18 B. pH: 7.30; PCO 2: 54; HCO 3: 28 C. pH: 7.50; PCO 2: 49; HCO 3: 32 D. pH: 7.52; PCO 2: 26; HCO 3: 20

pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.

Hypoventilation leads to _____________, Hyperventilation leads to _____________

respiratory acidosis respiratory alkalosis

59 year old male with hx of AIDS present with cough and chest pain with breathing. They nurse should inspect for? (select all that apply A. breathing effort B. color of lips C. thorax D. extremitites inspection on the skin and mucous membranes, level of consciousness, edema, pulses in the neck and (lewis text p.833.)

(AIDS--> risk factor for impaired gas)

Adequate ventilation is apparent when?

-breathing is effortless -O2 sat is between 95-100% -skin/nail beds are appropriate color -thorax is symmetric with thoracic expansion -Trachea is midline -breath sounds are clear bilately

Populations at risk? and why are they at risk?

-infants (b/c of fetal hemoglobin) -young children (less alveolar surface area, narrow branching of peripheral airways, easily obstructed) -and older adults (stiffer chest walls, loss of elastic recoil, weaker respiratory muscles)

Match the following to: 1. Ischemia 2. Hypoxia 3. Anoxia 4. Hypoxemia A. insufficient oxygen reaching the cells B. reduced oxygenation of arterial blood C. total lack of oxygen in the body tissues D. insufficent flow of oxygenated blood to the tissues

1--> D 2--> A 3--> C 4---> B

Normal HCO3 (bicarbonate)

22-26 mEq/L

Normal PaCO2 (Partial Pressure of Carbon Dioxide in Arterial Blood) range ?

35-45 mm Hg

The nurse is using Piaget's theory to assess the cognitive development in a child. What is most likely to be the age of the child who has reached a developmental milestone by grasping the concept of conservation of numbers for the first time? 5 years 7 years 9 years 12 years

5 years There appears to be a developmental sequence in children's capacity to conserve matter. Children usually grasp conservation of numbers between the ages of 5 and 6 years. So, in this scenario, the child who is most likely to have grasped the concept of conservation of numbers for the first time is likely to 5 years old. Conservation of liquids, mass, and length usually is accomplished at about ages 6 to 7 years old. Conservation of weight is understood sometime later, around ages 9 to 10 years old. The child begins to understand conservation of volume or displacement last, between ages 9 and 12 years old.

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. 65-year-old with pulmonary fibrosis B. 24-year-old with uncontrolled type 1 diabetes C. 45-year-old who has been vomiting for 3 days D. 54-year-old who takes sodium bicarbonate for indigestion

A 65-year-old with pulmonary fibrosis The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. A 65-year-old with pulmonary fibrosis B. A 24-year-old with uncontrolled type 1 diabetes C. A 45-year-old who has been vomiting for 3 days D. A 54-year-old who takes sodium bicarbonate for indigestion

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic acidosis? Type B chronic obstructive pulmonary disease (COPD) and pneumonia Acute meningococcal meningitis A pancreatic fistula that is draining Severe hyperaldosteronism

A pancreatic fistula that is draining The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss. Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion. Meningitis can stimulate hyperventilation, which causes respiratory alkalosis. Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? A. "Your father may be having mini-strokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion."

A. "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified.

Which nerves are located in the brain stem A. 3-12 B. 1-12 C. 6-12 D. non of the above

A. 3-12

The nurse thinks the patient has hypoxemia what could help the nurse confirm this A. ABG levels B. Pulse oximetry reading

A. ABG levels

According to available research, which is a primary risk factor for cognitive impairment? A. Advancing age B. Female gender C. Caucasian D. Northern European ancestry

A. Advancing age

Unmodifiable risk factors for impaired perfusion. (select all that apply) A. Age B. Smoking C. Gender D. Elevated cholesterol E. Sedentary lifesyle F. Family history (genetics) G. Trauma H. Congenital heat dz I. DM type 1 J. DM type 2

A. Age C. Gender F. Family history (genetics) H. Congenital heat dz I. DM type 1 (powerpoint)

Pt comes in with shortness of breath and chest pain with breathing what labs do you expect to be ordered (select all that apply) A. Arterial blood gas B. Complete blood count (CBC) and basic metabolic panel (BMP) C. Hemoglobin D. Vitamin B12 levels

A. Arterial blood gas C. Hemoglobin (powerpoint) Gas exchange clinical findings: cough sputum abnormal breathing patterns adventitious breath sounds, decreased level of consciousness shortness of breath chest pain with breathing

Both central and local perfusion are impacted by blood flow from ? Select all that apply A. Arteries B. Capillaries C. Cardiac preload D. Ventricular contractions

A. Arteries B. Capillaries D. Ventricular contractions (powerpoint)

Which aspects of cognitive function are tested when a person is asked to start with 100 and count backward, subtracting 7 each time? Mark all that apply. A. Attention B. Concentration C. Thought process D. Immediate recall E.Short-term memory F. Long term memory

A. Attention B. Concentration Asking the patient to count backward from 100, subtracting 7 each time is an assessment of attention and concentration. Attention and immediate recall are tested by asking the patient to repeat a set of numbers both as stated and backward. Thought process is assessed by evaluating conversation for coherence, relevance, logic, and organization. Short-term memory is assessed by asking the patient to remember three stated items and repeat them back in 5 minutes. Long-term memory is tested by asking for information that has been in memory for at least 24 hours.

*The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation (NIPPV)

A. Augmented coughing or huff coughing (Skills) Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

Which organs should you be concerned with in a patient with impaired gas exchange (select all that apply) A. Brain B. Lungs C. Heart D. Kidneys

A. Brain B. Lungs C. Heart (powerpoints)

An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? A. Breathe into cupped hands. B. Pant using rapid, shallow breaths. C. Use a rapid deep-breathing pattern. D. Hold the breath for as long as possible.

A. Breathe into cupped hands. Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply. A. Check tubing for kinks B. Run wires under carpeting C. Post "no smoking" signs in the clients' rooms D. Place oxygen tanks flat in the carts when not in use E. Make sure that the client is familiar with the phrase "Stop, drop, and roll"

A. Check tubing for kinks C. Post "no smoking" signs in the clients' rooms E. Make sure that the client is familiar with the phrase "Stop, drop, and roll"Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.

A late sign of hypoxia A. Cyanosis B. Anxiety C. Diaphoresis D. Tachypnea

A. Cyanosis Late signs of hypoxia: Increased restlessness, stupor, dyspnea, decreased respirations, bradycardia, cyanosis

A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A. Delirium is reversible with treatment of the underlying cause. B. Delirium is progressive and has no known cure. C. Delirium affects a specific area of cognitive functioning. D. Delirium indicates the onset of a cerebrovascular accident.

A. Delirium is reversible with treatment of the underlying cause. Delirium can be reversible with treatment of the precipitating problem and control of predisposing factors. Dementia is progressive and irreversible. Focal cognitive disorders affect a single area of cognitive functioning. Memory and orientation may be affected by a cerebrovascular accident (stroke), but delirium is not a sign of a stroke.

A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When questioned about the behavior by the family, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A. Delirium. B. Dementia. C. Alzheimer's disease. D. Sundowner syndrome

A. Delirium. Delirium, which occurs over hours to a few days, is the most frequent complication of hospitalization in the elderly population. Dementia occurs over a period of months. Alzheimer's disease develops over months to years. Sundowner syndrome is most prominent in dementia and becomes worse in the evenings.

**Normal cognitive exam includes (select all that apply ) A. Express and explain realistic thoughts B. speak with smooth natural pattern C. follow multi step direction D. listen and answer question E. recall significant past events F. pattern of speech does not matter

A. Express and explain realistic thoughts B. speak with smooth natural pattern C. follow multi step direction D. listen and answer question E. recall significant past events (power points)

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? A. Fetal hypoxia B.Perineal lacerations C. Carpopedal spasms D. Maternal hypertension

A. Fetal hypoxia Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath. Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.

memory retention, higher cognitive thinking , voluntary eye movement, voluntary motor-movements, and speech production are controlled by what portion of the brain A. Frontal lobe B. Temporal lobe C. Brain stem D. Occipital lobe

A. Frontal lobe (broca's area)

atelectasis, collapsed lung, collapsed alveolar are all causes of? A. Hypoventilation B. Hypoxia C. Hyperventilation D. Cyanosis

A. Hypoventilation

Exercise and activity are included in a cardiac rehabilitation program for which purposes? (Select all that apply.) A. Increase cardiac output B. Increase serum lipids C. Increase blood pressure D. Increase blood flow to the arteries E. Increase muscle mass F. Increase flexibility

A. Increase cardiac output D. Increase blood flow to the arteries E. Increase muscle mass F. Increase flexibility A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure.

Primary prevention for impaired gas exchange (select all that apply) A. Infection control B. smoking cessation C. immunizations D. mantoux skin test E. preventing post op complications F. healthy diet G. minimize environmental pollutants

A. Infection control B. smoking cessation C. immunizations E. preventing post op complications F. healthy diet G. minimize environmental pollutants

**What part of the brain is responsible for respiratory function, vasomotor, and cardiac function A. Medulla B. Cerebral cortex C. Pons D. Parietal lobe

A. Medulla

Refers to the retention and recall of past experiences and learning A. Memory B. Perception C. Cognition D. Learning

A. Memory (*key term on objective )

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? A. No observable respiratory difficulty or shortness of breath over the last 24 hours. B. A decrease in the amount of nasal drainage and sneezing. C. No sputum production, and a decrease in coughing episodes. D. Relief of an acute asthmatic attack.

A. No observable respiratory difficulty or shortness of breath over the last 24 hours. Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.

Population at greatest risk for cognitive impairment A. Older adults B. Women with lack of social support, poor health, insomnia C. Men with hx of stroke or DM D. People with reduced mobility

A. Older adults B. Women with lack of social support, poor health, insomnia C. Men with hx of stroke or DM People with reduced mobility is a risk factor however ever they are not at the GREATEST risk

A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A. Older male adults with diabetes. B. Older female adults who are overweight. C. Young adults living in school dormitories. D. Adolescents attending summer camps

A. Older male adults with diabetes. The primary risk factor for cognitive impairment is advancing age; males with a history of stroke or diabetes are at significant risk. Older females with a history of poor health, insomnia, and lack of social support are at risk for cognitive impairment, not those who are overweight. Risk factors for young adults include substance abuse and high-risk behaviors, not crowded living conditions. Adolescents who attend summer camp are not necessarily at risk for cognitive problems; adolescents who participate in high-risk behaviors would be at risk.

A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend? A. Placing him near a cool-mist humidifier B. Bringing him to the emergency department C. Giving him an over-the-counter cough syrup D. Offering him warm tea sweetened with honey

A. Placing him near a cool-mist humidifier During a spasmodic croup attack, cool humidified air to decrease inflammation is a fast home remedy. An attempt should be made to interrupt the attack at home first rather than going to the emergency department. Cough syrup is ineffective because it does not relieve laryngeal spasm. Tea with honey is an ineffective remedy for a spasmodic croup attack, and the tea may present a risk of aspiration

The brain stem consists of (select all that apply) A. Pons B. Cerebellum C. Medulla D. Midbrain

A. Pons C. Medulla D. Midbrain

Label the following pH as Acidotic, optimal, or Alkalotic A. 7.3 B. 7.35 C. 7. 4 D. 7. 45 E. 7.46

A. acidotic B. normal C. normal D. normal E. alkalotic Acidotic: < 7.35 Optimal: 7.35-7.45 Alkalotic: > 7.45

A mental status assessment forms the basis for cognitive assessment and includes (select all that apply) A. general appearance B. behavior C. fatigue level D. cognitive functions

A. general appearance B. behavior D. cognitive functions Giddens p341

At what age are significant cognition development changes noted (select all that apply) A. infancy B. adolescent C. older age

A. infancy B. adolescent most significant changes from infancy through adolescents (giddens p. 338)

insufficient flow of oxygenated blood leading to cell injury or death A. ischemia B. hypoxia C. hypoxemia D. dyspnea

A. ischemia

***questions that help assess cognitive function (select all that apply A. orientation questions (time, place, person) B. repeat 3 words C. name an object D. ask them their what their favorite color is E. write " close your eye" and see if patient does this

A. orientation questions (time, place, person) B. repeat 3 words C. name an object D. ask them their what their favorite color is E. write " close your eye" and see if patient does this (*in class discussion )

A. pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.

***General assessment includes (question on exam 2) select all that apply A. posture and gait B. motor movements C. abdominal sounds D. dress and hygiene

A. posture and gait B. motor movements D. dress and hygiene (powerpoints)

Reticular activating system (RAS) is responsible for A. regulating arousal and sleep wake transitions B. A. relying sensory information C. memory retention D higher cognitive thinking

A. regulating arousal and sleep wake transitions

The function of the reticular formation which is located in the brain stem (select all that apply) A. relying sensory information b. influencing excitatory and inhibitory control of spinal motor neurons C. controlling vasomotor and respiratory activity D. memory retention

A. relying sensory information b. influencing excitatory and inhibitory control of spinal motor neurons C. controlling vasomotor and respiratory activity

Select the statements tat are true in regards to cognition A. represents a continuum B. is a matter of "all or none" C. does NOT change over time D. degree of impairment ranges from mild to severe

A. represents a continuum D. degree of impairment ranges from mild to severe -it does change over time -is NOT ad matter of all or none

Select all primary prevention A. smoking cessation B. blood pressure C. exercise D. weight control E. serum cholesterol levels F. cardiac diet (AHA) G. maintain normal blood pressure

A. smoking cessation C. exercise D. weight control F. cardiac diet (AHA) G. maintain normal blood pressure Secondary prevention: -blood pressure -serum cholesterol levels

Mantoux skin test A. test exposure to tuberculosis B. measures arterial blood gas C. measures hemoglobin in the blood D. test for emphysema

A. test exposure to tuberculosis (** secondary prevention for impaired gas exchange...is a screening tool)

The oxygen transport system consists of the lungs and cardiovascular system. Delivery depends on (select all that apply) A. the amount of oxygen entering the lungs (ventilation) B. Blood flow to the lungs and tissues (perfusion) C. the rate of diffusion D. hemoglobin oxygen carrying capacity

A. the amount of oxygen entering the lungs (ventilation) B. Blood flow to the lungs and tissues (perfusion) C. the rate of diffusion D. hemoglobin oxygen carrying capacity

A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

ANS: A Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? a) pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L b) pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L c) pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d) pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L

ANS: B Compensated metabolic alkalosis should show alkalosis pH and HCO3- (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2is acidic (normal 35 to 45 mm Hg), and HCO3- is elevated (normal = 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L is compensated respiratory acidosis.

Which of the following tools is the best measure to determine a patient's gas exchange and respiratory function? A. Chest x-ray B. Oxygen saturation C. Arterial blood gas (ABG) analysis D. Central venous pressure monitoring

Arterial blood gas (ABG) analysis ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining a patient's ventilatory function; however, they are not the best measure.

The nurse is caring for a patient who suddenly becomes agitated and confused. Which action should the nurse takes first? A. Notify the health care provider. B. Check pupils for reaction to light. C. Attempt to calm and reorient the patient. D. Assess oxygenation using pulse oximetry.

Assess oxygenation using pulse oximetry. Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? A. Check the client's temperature. B. Take the client's blood pressure. C. Obtain the client's pulse oximetry. D. Assess the client's respiratory status.

Assess the client's respiratory status The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.

Process to control changes in the pH by neutralizing acids A. Acid production B. Acid buffering C. Acid excretion D. Acid exchange

B. Acid buffering Acid production: generation of acid through cellular metabolism Acid excretion: removal of acid from the body

A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur? A. Acidosis B. Alkalosis C. Hyperkalemia D. Hypernatremia

B. Alkalosis Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), leading to metabolic alkalosis, an excess of base bicarbonate. Acidosis is caused by retention of hydrogen ions and a loss of base bicarbonate, which is more likely to occur with diarrhea. Hypokalemia, not hyperkalemia, will occur. With the loss of chloride ions, hyponatremia is more likely to occur.

Perception, patterned recognition, and attention falls under which level in of cognition A. impaired B. Basic C. Higher

B. Basic

*All are clinical findings for impaired CENTRAL perfusion EXCEPT: A. reduced cognition B. Cyanosis C. Anxiety D. Diaphoresis E. Increased respiratory rate

B. Cyanosis (clinical finding for impaired local perfusion) Clinical findings related to impaired central perfusion: -reduced cognition -anxiety -diaphoresis -increased respiratory rate (powerpoints)

The right ventricle pumps ___________ blood through the pulmonary circulation A. Oxygenated B. Deoxygenated

B. Deoxygenated (powerpoint)

When assessing infants and young children with impaired gas exchange what will you notice(select all that apply: A. Chest wall tenderness B. Flaring of the nostrils C. retraction of the chest on inhalation D. grunting E. Cyanosis of the lips

B. Flaring of the nostrils C. retraction of the chest on inhalation D. grunting E. Cyanosis of the lips NOTE: frequent rest periods during feeding is also related to impaired gas exchange in infants

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.

B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

*Which laboratory test would be appropriate to order when assessing perfusion (select all that apply) A. Thyroid panel B. Hemoglobin C. Cardiac enzymes D. Lipid panel

B. Hemoglobin C. Cardiac enzymes D. Lipid panel (powerpoint)

anemia, carbon monoxide poisoning , septic shock, cyanide poisoning , pneumonia, cardiomyopathy, spinal cord injury, and head trauma are causes of? A. Hypoventilation B. Hypoxia C. Hyperventilation D. Cyanosis

B. Hypoxia

*Ischemia would fall into which category pertaining to the scope of optimal perfusion A. Optimal perfusion B. Impaired perfusion C. No perfusion

B. Impaired perfusion (in class discussion)

A patient is experiencing an acid-base imbalance due to impaired lung function. Which organ do you think would compensate for the lung impairment? A. Brain B. Kidneys C. Heart D. Cardiovascular system

B. Kidneys Organs involved in acid-base balance are the lungs and kidneys

Which organs should you be concerned with in a patient with impaired acid-base balance (select all that apply) A. Brain B. Lungs C. Heart D. Kidneys

B. Lungs D. Kidneys

If difficulty in breathing occurs you will notice use of accessory muscles ...where are accessory muscles located (select all that apply) A. In between the ribs B. Neck C. Back D. Abdomen

B. Neck C. Back D. Abdomen Normal breath is done by--> intercostal muscles and the diaphragm

The interpretation of the environment and is dependent on the acuity of sensory input A. Memory B. Perception C. Cognition D. Learning

B. Perception (*key term on objective)

The flow of blood through arteries and capillaries delivering nutrients and oxygen to cells and removing cellular waste A. Gas exchange B. Perfusion C. Elimination D. Nutrition

B. Perfusion (powerpoints)

_________________ is a normal physiological process that requires the heart to generate sufficient cardiac output to transport blood through patent blood vessel for distribution in the tissues throughout the body A. Gas exchange B. Perfusion C. Elimination D. Nutrition

B. Perfusion (powerpoints)

*A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness.

B. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

The nurse thinks the patient has hypoxia what could help the nurse confirm this A. ABG levels B. Pulse oximetry reading

B. Pulse oximetry reading

Modifiable risk factors for impaired perfusion. (select all that apply) A. Age B. Smoking C. Gender D. Elevated cholesterol E. Sedentary lifesyle F. Family history G. Trauma H. DM type 1 I. DM type 2

B. Smoking D. Elevated cholesterol E. Sedentary lifesyle G. Trauma I. DM type 2 (powerpoint)

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? A. Ratio of hemoglobin and hematocrit B. Status of acid-base balance in arterial blood C. Adequacy of oxygen transport D. Presence of a pulmonary embolus

B. Status of acid-base balance in arterial blood The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus

somatic, visual and auditiory data are controlled by what portion of the brain A. Frontal lobe B. Temporal lobe C. Parietal lobe D. Occipital lobe

B. Temporal lobe

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? A. The nurse should minimize the use of tape on the skin. B. The nurse should keep the client adequately hydrated. C. The nurse should change the dressings as soon as they get wet. D. The nurse should provide rest for the client throughout the day.

B. The nurse should keep the client adequately hydrated. The best practice of the nurse to improve perfusion of the wound to promote healing for an older client after surgery is to keep the client adequately hydrated. The nurse should minimize the use of tape on the skin to protect the fragile skin of the client. The nurse should also change the dressing as soon as they get wet during the protection of fragile skin. The nurse should provide rest to the client throughout the day to conserve the energy required for healing.

What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age. B. Tobacco use. C. Drug overdose. D. Prolonged immobility.

B. Tobacco use Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use.

A patient is admitted to the emergency department with dehydration. Arterial blood gas (ABG) results reveal that the patient has metabolic acidosis. Which of the following signs or symptoms is the most likely cause of this imbalance? A.Hypoventilation B. Vomiting and diarrhea C.Serum potassium is 5.1 mEq/L. D. Arterial oxygen saturation is 91%

B. Vomiting and diarrhea Vomiting and diarrhea cause too much acid, the buffers have been overwhelmed, and body fluids have too much acid. Acid excretion is not able to keep up with acid production or intake. Hypoventilation leads to respiratory acidosis Hyperventilation leads to respiratory alkalosis. Oxygen saturations below 95% indicate that the patient may need supplemental oxygen and may contribute to imbalance; however, a low reading alone is not enough to determine the cause.

Intact cognition means an individual exhibits cognitive behaviors that are considered to be within the range of normal for _______(select all that apply) A. society acceptance B. age C. culture D. developmental milestones

B. age C. culture (giddens p. 337)

Which muscles are used during normal respiration (select all that apply) A. abdominal rectus B. diaphragm C. Trapezius D. intercostal

B. diaphragm D. intercostal muscular movements provide the physical force essential for ventilation.....the main muscle use in respiration include the diaphragm and muscle in-between the rib (intercostal) *If difficulty in breathing occurs you will notice use of accessory muscles which are muscle in the back, neck, or abdomen (powerpoints)

The process by which oxygen is transported to cells and carbon dioxide is transported from cells A. perfusion B. gas exchange C. acid base balance D. cognition

B. gas exchange

A patient who is short of breath and still able to consume food you would expect what kind of meal A. a large meal B. high caloric, high protein nutritious foods in small servings C. Pureed foods only D. foods high in vitamin C

B. high caloric, high protein nutritious foods in small servings (power points)

Early signs of hypoxia include (select all that apply ) A. decreased respirations B. tachypnea C. cyanosis D. restlessness

B. tachypnea D. restlessness Early signs: restlessness, tachycardia, tachypnea, dyspnea, increased agitation, anxiety, diaphoresis, retractions, and headache

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? a. "Have you ever had this pain before?" b. "Can you describe the pain to me?" c. "Does the pain get worse when you breathe in?" d. "Can you rate the pain on a scale of 1-10, with 10 being the worst?"

C "Does the pain get worse when you breathe in?" (Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.)

Hypoxemia occurs when oxygen saturation levels fall below A. 89% B. 91% C. 93% D. 95%

C. 93% normal levels 95-100% however, you may see decreased oxygen levels in conditions such as COPD, emphysema, asthma

Normal physiology of gas exchange includes all of the following EXCEPT A. Ventilation B. Perfusion C. Acid excretion D. Transportation

C. Acid excretion Normal physiology of gas exchange Ventilation--> Transport--> Perfusion

The process of regulating the pH, bicarbonate concentration, and partial pressure of carbon dioxide of body fluids A. Gas exchange B. Perfusion C. Acid-base balance D. Cognition

C. Acid-base balance

Sneezing, coughing, hiccuping, vomiting, sucking, and swallowing are controlled by what portion of the brain A. Frontal lobe B. Temporal lobe C. Brain stem D. Occipital lobe

C. Brain stem

The mental action or process of acquiring knowledge and understanding through through, experience, and senses A. Health Promotion B. Patient Education C. Cognition D. Functional ability

C. Cognition

An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? A. Problem that first emerges in the third decade of life B. Nonorganic disorder that occurs in the later years of life C. Cognitive problem that is a slow and relentless deterioration of the mind D. Disorder that is easily diagnosed through laboratory and psychological tests

C. Cognitive problem that is a slow and relentless deterioration of the mind Dementia of the Alzheimer type accounts for 80% of dementias in older adults; it may be due to a neurotransmitter deficiency and is characterized by a steady decline in intellectual function, including memory deficits, disorientation, and decreased cognitive ability. More than 90% of people with dementia of the Alzheimer type are older than 50 years. It is an organic, not functional, disorder. Dementia of the Alzheimer type is difficult to diagnose and often is made when other causes of the dementia have been ruled out.

A patient informs the nurse that he is having severe chest pain. He took two nitroglycerin tablets more than 1 hour ago with no relief. On further assessment the nurse notices that the patient is diaphoretic and also complains of feeling dizzy. The nurse would expect which diagnostic test or tests to be ordered: A. Vitamin B12 test B. Cardiac stress test C. Creatine kinase-myoglobin (CK-MB) and C-reactive protein (CRP) D. Complete blood count (CBC) and basic metabolic panel (BMP)

C. Creatine kinase-myoglobin (CK-MB) and C-reactive protein (CRP) Pain, diaphoresis, and dizziness are all symptoms of someone experiencing acute coronary syndrome, which likely precipitates a myocardial infarction (MI). Patients with angina pectoris often take nitroglycerin to relieve the chest pain, which accompanies impaired tissue perfusion. Because the patient's chest pain is unrelieved by the nitroglycerin, this alerts the nurse that he is experiencing unstable angina, possibly advancing to MI. Enzymes and markers such as CK, present in the myocardium, are often evaluated as a diagnostic measure for an MI because enzymes that are released from damaged cells circulate in the blood and can be detected to confirm the presence of impaired perfusion. Although vitamin B12 deficiencies can elevate homocysteine (Hcy) levels, it is more likely that Hcy levels will be measured, rather than a laboratory test for vitamin B12 levels. A cardiac stress test may be used to measure vital signs during exercise on a treadmill. A cardiac stress test is not recommended if a patient is experiencing signs of an MI. Although a CBC and BMP may be ordered to evaluate a patient's overall functioning, it would not be used as a diagnostic tool to diagnose an MI.

The nurse is caring for a 27-year-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? A. Tachycardia and pursed lip breathing B. Kussmaul respirations and hypotension C. Frequent position changes and agitation D. Cyanosis and increased capillary refill time

C. Frequent position changes and agitation

Problem solving, learning, comprehension, insight, decision making, creativity, meta cognition falls under which level in of cognition A. impaired B. Basic C. Higher

C. Higher

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with BP 90/60, apical pulse 110, and respiratory rate 8. Based upon the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance

C. Hypercapnic respiratory failure related to alveolar hypoventilation

anxiety, infections, use of drugs, fever, ASA poisoning, use of stimulants are causes of? A. Hypoventilation B. Hypoxia C. Hyper ventilation D. Cyanosis

C. Hyperventilation

Inadequate tissue oxygenation at the cellular level A. Hyperventilation B. Hypoventilation C. Hypoxia D. Anoxia

C. Hypoxia

A mother comes for a well-child visit of her 4-year-old child. Which psychosocial developmental skill is the nurse likely to notice in the child? A. Self-evaluation B. Logical thinking C. Increased curiosity D. Understand others

C. Increased curiosity The nurse will notice that the 4-year-old child is curious about his or her surroundings and wants to make new friends. School-aged children begin to define their self-concept and develop self-esteem, an overall self-evaluation. School-aged children have the ability to think in a logical manner about the here and now and to understand the relationship between things and ideas. At around the age of 12 years old, children start concentrating on more than one aspect of a situation. They start understanding the point of view of other people also.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? A. Hypocapnia B. Hyperkalemia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease

C. Myocardial infarction

*Infraction would fall into which category pertaining to the scope of optimal perfusion A. Optimal perfusion B. Impaired perfusion C. No perfusion No perfusion (tissue death) reduced cardaic output leads to impaired perfusion which leads to shock Central perfusion is generated by cardiac output or the amount of blood pumped by the heart each minute to the entire body system Local tissue perfusion is the the volume of blood that flows through to target tissues

C. No perfusion (in class discussion)

spatial information is controlled by what portion of the brain A. Frontal lobe B. Temporal lobe C. Parietal lobe D. Occipital lobe

C. Parietal lobe

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis The pH indicates acidosis [1] [2]; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? A. Subtract serial sevens from 100. B. Copy one simple geometric figure. C. State three random words mentioned earlier in the exam. D. Name two common objects when the nurse points to them

C. State three random words mentioned earlier in the exam. Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? A. The fat-forming ketoacids were broken down. B. The irregular heartbeat produced oxygen deficit. C. The decreased tissue perfusion caused lactic acid production. D. The client received too much sodium bicarbonate during resuscitation efforts.

C. The decreased tissue perfusion caused lactic acid production. Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis.

*All are clinical finding for impaired LOCAL perfusion EXCEPT: A. reduced or absent pluses B. cool or cold extremities C. diaphoresis D. discoloration of skin E. cyanosis

C. diaphoresis (clinical finding for impaired central perfusion) Clinical findings related to impaired local perfusion: -reduced or absent pluses -cool or cold extremities -discoloration of skin -cyanosis

What is essential to maintaining optimal perfusion? A. Reduced cardiac output C. maintaining cardiovascular health

C. maintaining cardiovascular health

Patient scores a 25 on the MME test... what is the nurses best response A. its ok for you to go home B. how have you been sleeping C. the physical is going to need to see you for further evaluation D. this is a normal score

C. the physical is going to need to see you for further evaluation MMSE...mini-mental state exam screens for dementia and delirium ...the lower the score the more severe the impairment (out of a total of 30) individuals who score below 27 should be referred evaluation

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A. A patient with asthma and severe shortness of breath. B. A patient undergoing a bronchoscopy for a biopsy. C. A patient with a pleural effusion requiring fluid removal. D. A patient experiencing a problem with a pneumothorax.

D. A patient experiencing a problem with a pneumothorax. When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.

*Which of the following would be documented as a normal finding of a chest exam ? A. AP (anteroposterior to lateral) diameter 2:1 B. Respirations labored at 26 breaths/min C. Breath sounds with crackles or wheezes noted D. Excursion equal bilaterally with no increase in tactile fremitus

D. Excursion equal bilaterally with no increase in tactile fremitus Normal chest exam : • AP (anteroposterior to lateral) diameter 1 : 2 • Respirations nonlabored at 12-20 breaths/min • Breath sounds vesicular without crackles or wheezes • Excursion equal bilaterally with no increase in tactile fremitus

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C. Encourage coughing and deep breathing to clear the airway. D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min.

D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

Processing of sight takes place in the A. Frontal lobe B. Temporal lobe C. Parietal lobe D. Occipital lobe

D. Occipital lobe

The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A. Keep a radio on all the time to provide sound for the patient. B. Decrease patient confusion by limiting verbal interactions. C. Limit family visits to one person for 30 minutes per day. D. Provide a quiet environment in a private room.

D. Provide a quiet environment in a private room. The patient experiencing dementia needs a quiet environment with a minimum of unfamiliar stimulation from a roommate. A patient with dementia does not need extra stimulation from having a radio on continually. The nurse should speak clearly and quietly to the patient before any procedure or assistance to decrease agitation. Family visits would be encouraged because family members are familiar to the patient and their presence increases a sense of security.

The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern that the nurse should address for this patient? A. Promoting at least 6 hours of sleep a night. B. Encouraging an oral intake of 1200 calories per day. C. Managing the patient's pain from arthritis. D. Supervising medication administration.

D. Supervising medication administration. Safety is the priority concern for the cognitively impaired patient; safely taking medication addresses safety needs for the patient. Sleep, nutrition, and management of pain are important components of the patient's care and can affect overall health, but safety is the highest priority.

Ideomotor apraxia is classified as a deficit in which cognitive area? A. Memory B. Language C. Thought process D.Visuospatial

D. Visuospatial deomotor apraxia is an abnormality affecting the visuospatial cognitive area. Apraxia is the inability to perform purposeful movements or manipulate objects despite intact sensory and motor abilities. Ideomotor apraxia is a specific type of apraxia in which there is an inability to translate an idea into action.

Which is a clinical findings for a patient with impaired perfusion A. Headache B. Diaphoresis C. Low urine output D. all of the above

D. all of the above Clinical findings: Headache Dizziness Confusion Fluid retention Murmurs Coolness and edema in extremities bounding or diminished pulses diaphoresis blood clots low urine output

Factors that can significantly impair cognitive function are all of the following EXCEPT: A. Decrease in glucose and oxygen supply B. electrolyte imbalance C. acid-base imbalance D. continuous perfusion

D. continuous perfusion optimal brain function depends on optimal perfusion and of oxygenated and nutrient rich blood. Decreases in oxygen and glucose supply as well as electrolyte and acid-base imbalances significantly impair cognitive function

A patient is having her first severe, acute asthma episode. It began 2 hours ago. What blood gas values should the nurse expect to see? A. pH high, PaCO2 high, HCO3- high B. pH low, PaCO2 low, HCO3- low C. pH low, PaCO2 high, HCO3- high D. pH low, PaCO2 high, HCO3- normal

D. pH low, PaCO2 high, HCO3- normal A severe acute asthma episode impairs the excretion of carbonic acid, causing respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3- normal. A high pH occurs with alkalosis, not acidosis. ANSs that include abnormal levels of HCO3- are not correct for the 2-hour time frame.

The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. open a window to let fresh air into the room. B. use nasal strips to assist with breathing. C. sleep in a side-lying position. D. use pillows to prop yourself up while sleeping

D. use pillows to prop yourself up while sleeping Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat.

Which of the following is an essential defining difference between delirium and dementia? A. Occurrence of sundowning syndrome B. Presence of delusions C. Incoherent speech D. Disturbance in consciousness

Disturbance in consciousness Delirium is a disorder of disturbed consciousness and altered cognition, whereas dementia is characterized by progressive deterioration in cognitive function with little or no disturbance in consciousness or perception. Sundowning, delusions, and incoherent speech occur with both conditions.

Pertaining to perfusion physical examination it is most important to asses all of the following EXCEPT? A. skin color B. capillary refill less than 3 seconds C. present peripheral pulses D. blood pressure (orthostatic) E. Apical heart rate F. lung sounds

F. lung sounds NOTE: if peripheral pulses are absent and doppler may be ordered (powerpoint)

True or False Ventilation is the movement of CO2 into the body and O2 out of the lungs

FALSE Ventilation is the movement of air/oxygen into the body and carbon dioxide out of the lungs

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? Request an order for pain medication and oxygen at 6 L/min. Lubricate the patient's lips and allow continued hyperventilation. Have the patient breathe into a paper bag to stop hyperventilating. Contact the physician immediately regarding this complication.

Lubricate the patient's lips and allow continued hyperventilation. Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

According to Piaget's theory, which period describes a child's stage of egocentrism? Sensorimotor Preoperational Formal operations Concrete operations

Preoperational During the preoperational period, children learn to think with the use of symbols and mental images. They exhibit egocentrism where they see all objects and persons as their own. The sensorimotor period occurs between birth and two years. During this period, infants develop an action pattern for dealing with the environment. The formal operations period lasts from 11 years of age into adulthood. During this period, the person is self-conscious and thinks he or she is invulnerable and tends to show risk-taking behaviors. The concrete operations period occurs between seven to 11 years of age. During this period, children are able to perform mental operations.

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