Unit 6 Exam
After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? "I will avoid crossing my legs." "Pillows placed under my knees will help avoid clots." "Staying on bed rest as long as possible is best for me." "Three times every day I will massage my lower legs to get blood moving."
"I will avoid crossing my legs." Clients should avoid crossing the legs to prevent the constriction of blood flow in the lower leg, which can lead to deep vein thrombosis (DVT). When dislodged, DVT can become a pulmonary embolus. Pillows should not be placed under the knees because this constricts blood flow to and from the lower leg and increases risk for DVT. Activity, rather than staying immobile in bed, helps encourage blood flow. The lower legs should not be massaged because this action could dislodge a DVT that has formed.
Which information would the nurse include in parental education about bullying? Select all that apply. One, some, or all responses may be correct. A cyberbully can remain anonymous. Bullying usually takes place at school. A cyberbully attack can reach a wider audience. The school-age child is at greatest risk for cyberbullying. The child is at greatest risk for bullying in middle school.
A cyberbully can remain anonymous. Bullying usually takes place at school. A cyberbully attack can reach a wider audience. Cyberbullying involves an electronic medium that is used to harm or bother another. Cyberbullying attacks can be more harmful because it can reach a wider audience and the attacker can remain anonymous. Bullying usually takes place in school hallways or playgrounds. The risk for bullying is greater in elementary and middle school than high school. Cyberbullying occurs more frequently in high school.
When a client with a suspected pulmonary embolism is scheduled for a spiral computed tomography (CT) scan, which action would the nurse take before the procedure? Check the client's blood glucose levels. Obtain informed consent from the client. Assess if the client is allergic to shellfish. Instruct the client to remove dentures.
Assess if the client is allergic to shellfish. Before preparing the client for the test, the nurse would assess if the client is allergic to shellfish because the contrast used in the test is iodine based. Blood glucose level will not affect the spiral CT testing. Informed consent is not needed for spiral CT. Dentures may remain in place for spiral CT.
For a client who has an addiction problem, which client communication shows progress in the working stage of the nurse-client relationship? Select all that apply. One, some, or all responses may be correct. Describes how others have caused the addiction Identifies personal strengths and weaknesses Expresses uncertainty about meeting with the nurse Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
Identifies personal strengths and weaknesses Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress By sharing strengths and weaknesses the client demonstrates a willingness to work with the nurse to address personal issues. When the client is willing to address cause and effect of issues of personal behavior and how behavior affects others, the working phase of a therapeutic relationship is underway. Projection (how others have caused the addiction) is a defense that prevents taking responsibility for the addiction. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.
VS Temp 99.4 Pulse 155 RR 40 ABG pH 7.30 PCO2 33 HCO3 17 lethargic, irritable, dry mucous membranes, dark amber urine, inelastic tissue A 3-month-old infant with a 3-day history of diarrhea has an arterial blood gas drawn. Which acid-base imbalance would the nurse suspect? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis The pH indicates acidosis, not alkalosis; the HCO 3 - level is further from the expected range than is the Pco 2 level, indicating a metabolic, not respiratory, origin (losses from diarrhea).
Which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence? Select all that apply. One, some, or all responses may be correct. "Tell me about your struggles." "Everything is going to be okay." "Get out of the house right away." "You'll feel better after you leave." "Why do you stay when he hits you?" "Why did you return to him after the abuse?"
"Tell me about your struggles," is therapeutic communication, as it encourages a client to describe their perception. Talking about feelings can help clients clarify their thoughts. "Everything is going to be okay" is falsely reassuring and underrates the client's feelings; it would be better to clarify the client's message. "Get out of the house right away" gives premature advice and assumes that the nurse knows best; it would be better to encourage the client to problem-solve. "You'll feel better after you leave" minimizes the client's feelings and indicates that the nurse is unable to empathize; the nurse would attempt to empathize and explore. "Why do you stay when he hits you?" is a value judgment that prevents problem-solving. The nurse would instead make observations. "Why did you return to him after the abuse?" implies criticism and may make the client defensive. The nurse would ask open-ended questions to avoid this.
Which action would the nurse include in the plan for care for a 6-month-old infant with respiratory syncytial virus (RSV) who is in respiratory distress? Begin a clear fluid diet. Maintain droplet and contact precautions. Administer prescribed antibiotic immediately. Allow parents and siblings to room in with the infant.
Maintain droplet and contact precautions. RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Droplet and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive a normal diet as long as the respiratory rate is below 60 breaths per minute. Antibiotics are not effective against RSV, and their use is contraindicated. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant.
What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser. Ability to discuss the addiction with significant others. State an intention to stop using illegal substances. Abstain from the use of mood-altering substances. Substitute a less addicting drug for the present drug.
Abstain from the use of mood-altering substances. Abstinence is a highly desirable long-term goal/outcome. It is a better outcome than short-term goal because lapses are common in the short term. The remaining options would be considered short-term goals.
Cocaine exerts which of the following effects on a client? Stimulation after 15 to 20 minutes Stimulation and euphoria Immediate imbalance of emotions Paranoia
Stimulation and euphoria Cocaine exerts two main effects on the body, both anesthetic and stimulant.
The nurse is caring for a child admitted with suspicious injuries. Which question would the nurse ask to obtain further information about possible child abuse? "What behaviors cause you to get into trouble?" "What problems do you have when at school?" "What is it about your parents that upsets you the most?" "What happens when you do something wrong?"
"What happens when you do something wrong?" The nurse would ask the child what happens when the child does something wrong. This provides information about punishment and physical and/or verbal abuse that may be taking place. Asking the child what behaviors cause the child to get into trouble allows the child to understand what actions are inappropriate to perform. Problems the child may have at school may reflect poor coping skills or bullying, but not child abuse. Asking the child what upsets him or her the most about their parents may elicit responses about strict rules but not necessarily evidence of child abuse.
A teaching need is revealed when a client taking disulfiram (Antabuse) states: "I usually treat heartburn with antacids." "I take ibuprofen or acetaminophen for headache." CORRECT "Most over-the-counter cough syrups are safe for me to use." "I have had to give up using aftershave lotion."
"Most over-the-counter cough syrups are safe for me to use." The client taking disulfiram has to avoid hidden sources of alcohol. Many cough syrups contain alcohol. The remaining statements are correct.
The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery A 76-year-old who has a history of thrombocytopenia
A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
A client with which diagnosis will be at risk for development of a pulmonary embolism? Atrial fibrillation Forearm laceration Migraine headache Respiratory infection
Atrial fibrillation Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headache. Respiratory infections do not increase pulmonary embolism risk.
Which intervention would the nurse provide a 3-month-old infant hospitalized with respiratory syncytial virus (RSV)? Administering an antiviral agent Clustering care to conserve energy Administering a bronchodilator every four hours Providing an antitussive agent whenever necessary
Clustering care to conserve energy Providing an antitussive agent whenever necessary Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Bronchodilators are not routinely indicated for RSV. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.
Which factors may cause an adolescent to develop a smoking addiction? Select all that apply. One, some, or all responses may be correct. Peer pressure Academic success Involvement in sports Imitating adult behavior of smoking Imitating lifestyles portrayed in movies and advertisements
Peer pressure Imitating adult behavior of smoking Imitating lifestyles portrayed in movies and advertisements Factors that influence an adolescent to smoke include peer pressure and imitating adult behavior of smoking and lifestyles portrayed in movies. Succeeding in academics and being involved in sports are not factors that cause an adolescent to begin smoking.
Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal? Tremors Seizures Blackouts. Hallucinations
Tremors Tremors are an early sign of alcohol withdrawal. The remaining options are not events considered early signs of alcohol withdrawal
The nurse should anticipate that which patient will need to be treated with insertion of a chest tube? A patient with a pleural effusion requiring fluid removal A patient undergoing a bronchoscopy for a biopsy A patient experiencing a problem with a pneumothorax A patient with asthma and severe shortness of breath
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.
The nurse is caring for a patient with severe metabolic alkalosis. Which intervention is the highest priority? Ensure the upper side rails of the patient's bed are up. Administer intravenous NaHCO3 as ordered. Teach the family about metabolic alkalosis. Measure the urine output and skin turgor.
Ensure the upper side rails of the patient's bed are up. 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 NaHCO3 to a patient with metabolic alkalosis should be questioned because it would make the alkalosis worse. Urine output and skin turgor are part of the assessment for extracellular fluid volume (ECV) deficit, but this is not a high priority in this situation.
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? Humidified cool air and adequate hydration Postural drainage and oxygen by hood Bronchodilators and cough suppressants Corticosteroids and broad-spectrum antibiotics
Humidified cool air and adequate hydration Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
Which arterial blood gas finding would be expected of a child with an acute asthma exacerbation? High oxygen level Increased alkalinity Decreased bicarbonate Increased carbon dioxide level
Increased carbon dioxide level Gas exchange is limited because of narrowing and swelling of the bronchi; the carbon dioxide level increases. The oxygen level will be decreased, not increased. The pH will decrease; the child is in respiratory acidosis, not alkalosis. The bicarbonate level will be increased to compensate for acidosis.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? Cyanosis Bradycardia Mental confusion Distended neck veins
Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).
A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive. What nursing intervention should be implemented to best assure the safety of the client and the milieu? Taking him to the gym on the psychiatric unit Obtaining an order for seclusion and close observation Assigning a psychiatric technician to "talk him down" Obtaining a prescription for a benzodiazepine Administering naltrexone as needed per hospital protocol
Obtaining an order for seclusion and close observation Obtaining a prescription for a benzodiazepine Aggressive, violent behavior is often seen with PCP ingestion. The client will respond best to a safe, low-stimulus environment such as that provided by seclusion until the effects of the drug wear off as well as the calming effect of a benzodiazepine. Talking down is never advised because of the client's unpredictable violent potential. Naltrexone is an opiate antagonist
When suspicion of child abuse is confirmed, which intervention is the priority? Promoting bonding with the child Staying with the parents while they visit Protecting the total well-being of the child Teaching methods of discipline to the parents
Protecting the total well-being of the child Protection of the child's total well-being is placed above the parents' rights or wishes. Protecting the child, not promotion of parental attachment, is the priority. Supervision may be necessary, but it is only part of maintaining the child's well-being. Teaching methods of discipline may be included in the long-term plan of care.
A patient is having the arterial blood gas (ABG) measured. What should the nurse identify as the parameters to be evaluated by this test? Presence of a pulmonary embolus Ratio of hemoglobin and hematocrit Status of acid-base balance in arterial blood Adequacy of oxygen transport
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.
Which clinical manifestations indicate a possible pulmonary embolism in a client after a total hip replacement? Select all that apply. One, some, or all responses may be correct. Sudden chest pain Flushing of the face Elevation of temperature Abrupt onset of shortness of breath Hip pain rating increased from 2 to 8
Sudden chest pain Abrupt onset of shortness of breath Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.
What is the most significant modifiable risk factor for the development of impaired gas exchange? Tobacco use Drug overdose Age Prolonged immobility
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.
Which example of indirect bullying would the nurse use when teaching a parent about bullying? Hitting Pushing Exclusion Verbal attack
exclusion Exclusion is an example of indirect bullying. Direct bullying includes hitting, pushing, and a verbal attack.
After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? "Lately I can only breathe well if I sit up." "During the night I sometimes get the chills." "I get a sharp, stabbing pain when I take a deep breath." "I'm coughing up large amounts of thicker mucus for the past several days."
"I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up large amounts of thicker mucus for the past several days" may indicate a pulmonary infection.
Which patient should the nurse closely monitor for the risk factors of metabolic acidosis? A patient diagnosed with acute meningococcal meningitis A patient with a pancreatic fistula that is draining A patient with severe hyperaldosteronism A patient with Type B chronic obstructive pulmonary disease (COPD) and pneumonia
A patient with 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.
The public health nurse is developing a program geared toward primary prevention of domestic violence. Which information would the nurse include in the program for those at high risk? Select all that apply. One, some, or all responses may be correct. Coping skills Social support Care for victims Stress reduction Screening programs
Coping skills Social support Stress reduction Primary prevention of domestic violence would include programs that prevent abuse from occurring. These would include working with high-risk people to improve coping skills and provide social support and stress reduction techniques. Secondary prevention provides intervention early in abusive relationships including caring for victims and screening programs for at-risk individuals.
Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the most rapid action by the nurse? Oxygen saturation of 93% Blood pressure of 160/94 mm Hg Decreased right side breath sounds Ecchymosis at the site of the thoracentesis
Decreased right side breath sounds After thoracentesis the breath sounds should be audible on the affected side and decreased breath sounds may indicate pneumothorax. The nurse would immediately notify the health care provider and expect actions such as a chest x-ray and possible insertion of a chest tube. The oxygen saturation of 93% is slightly below normal, but would not be surprising in a client who has a history of lung disease. Hypotension after thoracentesis may indicate bleeding or that too much pleural fluid has been removed at once, but mild hypertension may occur due to anxiety or pain. Ecchymosis at the thoracentesis site would be monitored, but would be expected after thoracentesis.
What are some primary prevention activities a nurse can perform related to substance abuse? (Select all that apply.) Education to prevent substance abuse .Focusing on relapse prevention Identification of risk factors for abuse Referral to a self-help group for stress relief and meditation Medical detoxification
Education to prevent substance abuse Identification of risk factors for abuse Referral to a self-help group for stress relief and meditation Primary prevention actions are those taken in order to prevent a problem from occurring. Primary prevention involves reducing stress to prevent addiction. Secondary prevention includes screening and early detection for prompt treatment. Referral to a support group might be considered secondary prevention if a patient has screened positive for substance abuse and has agreed to start attending a group. Tertiary prevention includes rehabilitative strategies.
After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. The nurse concludes that which condition is the most likely cause of the pleural effusion? Excessive fluid intake Inadequate chest expansion Extension of cancerous lesions Irritation from the bronchoscopy
Extension of cancerous lesions Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space.
When evaluating the concept of gas exchange, how should the nurse best describe the movement of oxygen and carbon dioxide? Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.
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.
A married woman reports intermittent episodes of being beaten by her husband. Which behavior is typical of the honeymoon stage in the cycle of domestic violence? Husband has a few extra drinks with coworkers Wife spends extra time cleaning the house Husband brings flowers and shows kindness Wife stays at work late to avoid the husband
Husband brings flowers and shows kindness After an abusive episode, there is often a " honeymoon" period because the tensions of the abuser have been released. The abuser is kind and expresses remorse. During the tension-building phase, abusers may try to reduce tension by using alcohol or drugs, whereas the victim will try to please the abuser. The wife may unconsciously be trying to provoke an incident by staying at work. Some experts believe that this is the victim's way of releasing tension, so that the honeymoon phase can begin.
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? Administer a PRN (as necessary) dose of an intranasal glucocorticoid. Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). Encourage coughing and deep breathing to clear the airway.
Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 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 diminish 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.
Which collaborative action would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.24, PaCO 2 60 mm Hg (7.98 kPa), HCO 3 20 mEq/L (20 mmol/L), PaO 2 54 mm Hg (7.18 kPa), and O 2 saturation 88% (0.88)? Oxygen at 6 L/minute by nasal cannula Nebulized albuterol treatment Intubation and mechanical ventilation Sodium bicarbonate intravenously
Intubation and mechanical ventilation The client's low pH, high PaCO 2, low HCO 3, low PaO 2, and low oxygen saturation indicate respiratory failure and the need for mechanical ventilation. The client has respiratory acidosis due to poor ventilation and CO 2 retention and lactic (metabolic) acidosis secondary to hypoxemia. Oxygen at 6 L/minute will not be adequate to resolve hypoxemia. Nebulized albuterol would improve ventilation, but not enough to resolve the respiratory acidosis. Sodium bicarbonate would help correct pH and HCO 3, but would not correct hypoxemia.
When arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH, which factor is the likely cause of the laboratory result? Ketoacidosis Irregular heartbeat Lactic acid production Sodium bicarbonate administration
Lactic acid production Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Sodium bicarbonate causes alkalosis, not acidosis.
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance would the nurse identify based on these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis, not alkalosis. The CO 2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.
The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level
Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.
The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 45 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 which diagnosis? Hypocapnia Hyperkalemia Metabolic alkalosis Respiratory acidosis
Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 45 mm Hg is within the expected value of 35 mm Hg to 45 mm Hg; no hypocapnia is present. The client's serum potassium level is within the expected level of 3.5 mEq/L to 5 mEq/L (3.5-5 mmol/L). With respiratory acidosis the pH will be less than 7.35 and the Pco 2 will be elevated.
The nurse is administering oral glucocorticoids to a patient with asthma. What finding indicates a therapeutic response to the medication? No observable respiratory difficulty or shortness of breath over the last 24 hours A decrease in the amount of nasal drainage and sneezing No sputum production, and a decrease in coughing episodes Relief of an acute asthmatic attack
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 (β2 agonist) are used to relieve bronchospasm in an acute episode.
A client has a 4 year history of using cocaine intranasally. When brought to the hospital in an unconscious state, what nursing measure should be included in the client's plan of care? Induction of vomiting Administration of ammonium chloride Monitoring of opiate withdrawal symptoms Observation for tachycardia and seizures
Observation for tachycardia and seizures Tachycardia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose. None of the other options are associated with the nursing care required of cocaine stimulation.
Which arterial blood gas report is indicative of diabetic ketoacidosis? Pco 2: 49, HCO 3: 32, pH: 7.50 Pco 2: 26, HCO 3: 20, pH: 7.52 Pco 2: 54, HCO 3: 28, pH: 7.30 Pco 2: 28, HCO 3: 18, pH: 7.28
Pco 2: 28, HCO 3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased Pco 2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased Pco 2 value indicates compensatory hypoventilation. Increased pH and decreased Pco 2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased Pco 2 values reflect hypoventilation and respiratory acidosis.
Which rationale best explains how an addiction to alcohol occurs? Person eventually requires alcohol for functioning Person lacks the motivation or will to stop drinking Person has developed very few coping mechanisms Person enjoys the social aspects of drinking alcohol
Person eventually requires alcohol for functioning Alcohol causes both physical and psychological dependence; the individual needs and depends on the alcohol to function. Dependency and addiction override motivation and will. The theory that alcoholics have no other coping mechanism is a myth that often is associated with alcoholism; the individual needs to learn how to use other coping mechanisms more consistently and effectively. People with alcoholism commonly drink alone or feel alone in a crowd.
A client is diagnosed with pleural effusion. Which assessment finding would the nurse expect to identify? Moist crackles at the posterior of the lungs Deviation of the trachea toward the involved side Reduced or absent breath sounds at the base of the lung Increased resonance with percussion of the involved area
Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.
Which sign indicates a child is a victim of bullying and would be included in a teaching session for teachers? The child wants to try out for the basketball team. The child asks for extra work to make better grades. The child is participating in several extracurricular activities after school. The child asks to go to the nurse's office frequently with vague complaints.
The child asks to go to the nurse's office frequently with vague complaints. Signs that may indicate a child is being bullied are similar to signs of other types of stress, including nonspecific ailments or complaints. Spending inordinate amounts of time in the school nurse's office with vague complaints is a sign that should be included in the teaching session. Withdrawal and deteriorating school performance are often signs of bullying. The child's wanting to participate on the basketball team, asking for extra work, and participating in extracurricular activities are not signs of withdrawal or deterioration in school performance.
A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? (Select all that apply.) The patient states, "I now realize that the drinking has affected by family life." The patient states, "I have been attending one meeting a day." The patient states, "I am glad that I did not drag others into my drinking." The patient states, "I don't think my body will recover from the drinking." The patient states, "I will watch the game at my friend's house instead of at the bar."
The patient states, "I now realize that the drinking has affected by family life." The patient states, "I have been attending one meeting a day." The patient states, "I will watch the game at my friend's house instead of at the bar." A patient who realizes that changing his environment will decrease temptation shows that he is motivated and willing to try to change. A patient who is able to see the effect the abuse is having on his life has a key component of motivation. A patient who is attending meetings of Alcoholics Anonymous (AA) is motivated toward recovery.
Which questions should the nurse ask when assessing for risk factors for metabolic acidosis? (Select all that apply.) Have you been vomiting today? What type of antacid did you take? Are you still feeling short of breath? When did your kidneys stop working? How long have you had diarrhea? 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.
A patient is experiencing their first severe, acute asthma episode. The episode began 2 hours ago. What blood gas values should the nurse expect? pH high, PaCO2 high, HCO3− high pH high, PaCO2 low, HCO3− low pH low, PaCO2 high, HCO3− normal pH low, PaCO2 high, HCO3− high
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.
A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Which statements are more likely to come from a parent who engages in child abuse? Select all that apply. One, some, or all responses may be correct. "Trial and error is a way for kids to learn about accidents and dangers." "Every time I turn around the kid is falling over something." "This child is adventurous and doesn't understand about getting hurt." "The kid didn't have a problem using the stairs without my help before this." "Little kids are always on the go, and I just can't keep running after him." "We live in a two-story house; do you have any ideas to keep him off the stairs?"
"Trial and error is a way for kids to learn about accidents and dangers." "Every time I turn around the kid is falling over something." "This child is adventurous and doesn't understand about getting hurt." "The kid didn't have a problem using the stairs without my help before this." "Little kids are always on the go, and I just can't keep running after him." Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. Statements 1 to 5 suggest a combination of a poor understanding and blaming. When the parents ask for help and suggestions, this indicates a knowledge deficit but also a readiness to learn and to correct problems. Admitting to knowledge deficit and seeking corrective action are not behaviors that abusive parents usually display.
When the concerned parents come to visit their son who was admitted for drug addiction, the son angrily shouts at them to go away. Which intervention is the most therapeutic after the parents leave? Insisting that the client call his parents and apologize Confronting the client about his behavior and verbal response Explaining why the visit was important to his parents Suggesting that the client go to the gym to work off the anger
Confronting the client about his behavior and verbal response Avoidance is characteristic of the addicted individual, so confronting the client about the behavior prevents him from avoiding responsibility. This approach may also help the client develop some self-awareness. Insisting that he calls and apologizes is giving unsolicited advice; the client would be given positive feedback if he initiates this action on his own. The focus should be on the client, not the parents. A visit to the gym provides an outlet for the anger; this could be suggested if he can't verbalize his feelings. If he goes to the gym, the nurse would initiate a follow-up discussion after his anger has decreased.
Which statement most accurately describes women who are involved in a situation of domestic violence? These women do not have financial resources or job skills for self-support. Most women try to leave about six times before they are successful. Many of the women freely make their own choices to stay with the abuser. These women don't recognize how irrational it is to stay in an abusive situation.
Most women try to leave about six times before they are successful. Nurses who work with victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to leave abusive relationships. Some women do not have financial resources or high-paying job skills, but domestic abuse occurs across all socioeconomic levels. Women do have freedom of choice, but many factors (e.g., fear of reprisal, finance, social obligations, family influences, dependent children, lack of support systems) hinder free choice. These women may be intellectually aware of the dangers, but for a variety of reasons they are unable to successfully extricate themselves.
A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which intervention(s)? (Select all that apply.) Observing for stress reaction Observing for delirium tremens Converting narcotic use from an illicit to a legally controlled drug Encouraging involvement in Narcotics Anonymous A motivational interview
Observing for stress reaction Encouraging involvement in Narcotics Anonymous A motivational interview The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.
Which arterial blood gas result for a client who is receiving mechanical ventilation using the pressure support ventilation mode indicates that the client is hyperventilating? pH 7.28 Bicarbonate (HCO 3) 24 mEq/L (24 mmol/L) Partial pressure of oxygen (PaO 2) 60 mm Hg (7.98 kPa) Partial pressure of carbon dioxide (PaCO 2) 30 mm Hg (3.99 kPa)
Partial pressure of carbon dioxide (PaCO 2) 30 mm Hg (3.99 kPa) The normal PaCO 2 is 35 to 45 mm Hg. Hyperventilation leads to elimination of carbon dioxide, lowering of PaCO 2, and causing respiratory alkalosis. A pH of 7.28 would indicate acidosis. An HCO 3 of 24 is in the normal range of 21 to 27 mEq/L and would not be consistent with hyperventilation. PaO 2 is not directly affected by respiratory rate or depth, and the of PaO 2 of 60 could occur with normal rate and depth of ventilation or with either hypoventilation or hyperventilation.
Which is the professional nurse's legal responsibility regarding child abuse? Honor the request of the parents not to report the suspected abuse. Report any suspected abuse to local law enforcement authorities. Return the child to the legal parent even if he or she is suspected of abuse. Provide the parents with a copy of the child's medical record.
Report any suspected abuse to local law enforcement authorities. Nurses and primary health care providers are legally responsible for reporting suspected or actual abuse. Child protective services may obtain a court order to grant temporary guardianship if it is found that the child is in immediate danger. The other answer options do not fulfil the nurse's duty to report suspected child abuse.
A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is an appropriate response by the nurse? (Select all that apply.) "You will not become physically addicted, but you may develop a physiological addiction." "You will likely experience euphoria from the medication." "You will likely become dependent on this medication and require other medications to control your pain." "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic."
"Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." Tolerance is an increasing need for a substance or a lack of effect when a certain dose is given over time. Withdrawal is a syndrome of symptoms that result from stopping the use of a substance. Dependency and psychological addiction do not usually occur with patients that are in pain, because the pain receptors are not being artificially stimulated.
Which is the best response the nurse would make to a male client who is denying addiction to alcohol but says that it is his nagging wife causing him to drink? "I don't think that your wife is the problem." "Everyone is responsible for his own actions." "Perhaps you should have marriage counseling." "Why do you think that your wife is the cause of your problems?"
"Everyone is responsible for his own actions." The nurse would say, "Everyone is responsible for his own actions." This comment encourages the client to accept responsibility and does not support denial or rationalization as a defense mechanism. Although the comment, "I don't think that your wife is the problem," may be true, it may also close off communication; with a decrease in communication, the nurse cannot be effective in helping break through the denial. Although suggesting marriage counseling may be appropriate, it does not address the issue of denial. The question, "Why do you think that your wife is the cause of your problems?" enables the client to continue to avoid responsibility for his own behavior, and the use of "why" is nontherapeutic.
Which statement by the mother supports a suspicion of child abuse for a 3-year-old girl admitted to the hospital with many poorly explained injuries? "When I get angry, I take her for a walk." "I have no problems with any of my other children." "When she misbehaves, I send her to her room." "I just ignore her when she has a tantrum at home."
"I have no problems with any of my other children." Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt an investigation of possible physical abuse. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to her room alone is an acceptable penalty for misbehavior. Ignoring a child is one method to extinguish an undesirable behavior, such as a tantrum.
Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct. Floss twice daily to prevent the need for dental work. Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes. Use enemas to prevent straining during bowel movements.
Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes. The goal of self-care for clients on anticoagulation therapy is to prevent bleeding. Clients should avoid eating hot food or liquid, which can burn the mouth, disrupt the mucous membrane, and encourage bleeding. Clients should use an electric shaver instead of a straight-bladed razor to avoid cuts. Clients should be instructed to apply ice to any areas of trauma, such as bumps and scrapes, to slow blood flow and minimize bleeding. Clients on anticoagulation therapy should not floss because this can cause the gums to bleed; however, they should be encouraged to brush their teeth with a soft tooth brush and make sure their dentist knows they are on anticoagulants. Stool softeners, rather than enemas, should be used to prevent straining because enemas can cause rectal bleeding.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? Client reports stools are black. Oxygen saturation is 93%. Respiratory rate is 25 breaths per minute. Client has an ecchymosis on the ankle.
Client reports stools are black. Because anticoagulant use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the health care provider and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. A slightly elevated respiratory rate in a client with a pulmonary embolus is a compensatory mechanism to prevent hypoxemia. Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.
The nurse is caring for a newborn whose mother is suspected of having a drug addiction. Which would the nurse do to most accurately confirm that the newborn may be at risk for withdrawal? Examine the mother's arms for needle marks. Monitor the newborn closely for the first 48 hours. Check the mother's medication record for the previous 24 hours. Collect the newborn's urine by applying a collection bag to obtain a sample for testing.
Collect the newborn's urine by applying a collection bag to obtain a sample for testing. Collecting the newborn's urine by applying a collection bag to obtain a sample for testing is the most reliable method of confirming the presence of opiates or other illicit substances. Examining the mother's arms for needle marks will not reveal the amount of drugs the mother has used or determine the last time the drug was taken. The priority is to determine whether the newborn is at risk for withdrawal before clinical signs occur. It is the mother's drug habit that is important, not the prescribed medications she received the previous day.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse provide for the infant? Select all that apply. One, some, or all responses may be correct. Limiting fluid intake Instilling saline nose drops Maintaining droplet precautions Nasal suctioning to remove mucus Administering inhaled bronchodilators
Instilling saline nose drops Maintaining droplet precautions Nasal suctioning to remove mucus Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. Research has shown that bronchodilators are not effective in the treatment of bronchiolitis.
The nurse is assessing a patient diagnosed with diabetic ketoacidosis. The 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.
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? The partial pressure of oxygen (PO 2) value is 80 mm Hg. The partial pressure of carbon dioxide (PCO 2) value is 60 mm Hg. The bicarbonate (HCO 3) value is 50 mEq/L (50 mmol/L). Serum potassium value is 4 mEq/L (4 mmol/L).
The bicarbonate (HCO 3) value is 50 mEq/L (50 mmol/L). The HCO 3 value is elevated. The urinary system compensates by retaining hydrogen (H +) ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21-28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A potassium (K +) level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5-5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.
The parents inform the nurse that their preschooler's teachers often complain about the child's bullying behavior in school. The parents were surprised by the feedback because the child is well behaved at home. Which would the nurse conclude to be the probable cause of this discrepancy? The parents are lying about the child being well behaved. The parents are inconsistent in their disciplining methods. The child's parents do not spend enough time with the child. The child is scared of the parents and displaces anger on others.
The child is scared of the parents and displaces anger on others. If the child is scared of the parents, the child will displace the anger that is experienced on others, especially peers and authority figures. The child is likely well behaved at home out of fear, but not out of respect for the parents. The parents are not lying about the child being well behaved at home if the child does behave in a disciplined manner out of fear. The parents may be very strict but not lack consistency in this scenario. Not spending enough time with the child does not result in aggressive behavior but may increase feelings of loneliness.
The nurse is assessing a patient using the CAGE questionnaire. Which statement(s) by the patient should make the nurse suspect possible alcoholism? (Select all that apply.) The patient states, "I go to meetings once or twice a week but continue to drink." The patient states, "I can quit whenever I want to." The patient states, "I am going to try to cut down on drinking. I have been partying too much." The patient says to the nurse, "I am ashamed of how much I have been drinking lately." The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." The patient states, "My wife keeps nagging me about my drinking."
The patient states, "I am going to try to cut down on drinking. I have been partying too much." The patient says to the nurse, "I am ashamed of how much I have been drinking lately." The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." The patient states, "My wife keeps nagging me about my drinking." The patient may need help admitting that there is a problem. The CAGE questionnaire is designed to objectively assist in assessing problems related to alcohol use. A patient who states that he is going to meetings of Alcoholics Anonymous (AA) is admitting he has a problem, even if he still drinks. A patient who feels he can quit whenever he wants to may be in denial of the problem.
In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. There are no physical symptoms associated with fetal alcohol syndrome (FAS) so it may be harder to diagnose. Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. The pattern of growth restriction persists after birth. There are classic physical symptoms associated with the clinical diagnosis of fetal alcohol syndrome (FAS), which are easily recognizable. Some learning problems do not become evident until the child is in school. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.
An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to: prevent respiratory syncytial virus (RSV) infection. make isolation of infant unnecessary. prevent secondary bacterial infection. decrease toxicity of antiviral agents.
prevent respiratory syncytial virus (RSV) infection. Synagis is a monoclonal antibody specific for respiratory syncytial virus (RSV). Monthly administration is expected to prevent infection with RSV. The goal of this drug is prevention of RSV. It will not affect the need to isolate the child if RSV develops. The antibody is specific to RSV, not bacterial infection. This will have no effect on antiviral agents.
