Possible Exam II Questions: Evolve

To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? A: A change in the respiratory rate B: A tingling sensation in the hands C: Periodic changes in heart rate D: A pulse ox reading of 93%

B

The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply. A:"The client's Chvostek sign would be negative." B:"The client's Trousseau sign would be positive." C:"The client would be suffering from paresthesias." D:"The client would show signs of anxiety and irritability." E:"The client's central nervous system should have a decrease activity in case alkalosis."

B, C, D

An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance? A: Retention of potassium in the cells B: Loss of fluid by way of the kidneys C: Loss of chloride ions through vomiting D: Reduction of blood supply to body cells

C

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. What should the nurse suggest to the client? A: Use a humidifier in the bedroom B: Sleep with two or more pillows. C: Cough regularly even if the cough does not produce sputum. D: Cough and deep breathe each night before going to sleep

A

The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply. A:"I should assess for low blood pressure." B: "I should assess for increased digitalis toxicity." C: "I should assess for a decreased rate of ventilation in respiratory alkalosis." D: "I should assess for an increased depth of ventilation in respiratory alkalosis." E: "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."

A, B, C

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? A: Change the client's diet to bland B: Obtain a stool specimen for occult blood. C: Prepare for insertion of a nasogastric tube D: Monitor recent laboratory reports for hemoglobin levels.

C

One of the nurses in a group of student nurses on a team-building hike was bitten by a snake. What is the priority nursing intervention in this situation?

Moving the victim to safe area away from the snake and encouraging rest