NUR 202 exam 2 questions respiratory, renal

The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1 Rationale: Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy.

What are appropriate interventions for a patient intubated on continuous sedation to prevent ventilator associated pneumonia? SATA 1. Daily sedation & weaning protocols "sedation vacations" 2. Elevate HOB 30-45 3. Oral Care with chlorohexidine 4. Hand hygiene 5. Complimentary therapy music

1 2 3 4

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1, 2, 4, 6 -Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base in the body fluids. This occurs in conditions that cause over stimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. 1. Tetany 2. Lethargyd 3. Tingling 4. Confusion 5. Numbness 6. Restlessness

1. Tetany 3. Tingling 5. Numbness 6. Restlessness (Alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the CNS. If the severity of alkalosis increases, convulsions and coma may occur.)

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 2.0 mg/dL 4. Phosphorus level of 4.0 mg/dL

2-Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause over stimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. the correct option identifies the presence of hypokalemia.

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. 1. Seizures 2. Lethargy 3. Headache 4. Weakness 5. Confusion 6. Hyperactivity

2. Lethargy 3. Headache 4. Weakness 5. Confusion

§Which ventilator change do you anticipate based on your analysis of these improving ABG values? §1. Increasing the VT to 600 mL §2. Changing the rate on the ventilator to 35 breaths/min §3. Decreasing the Fio2 to 60% §4. Changing to continuous mandatory ventilation (CMV) mode

3 So the PT does not become dependent and risk for O2 toxicity

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6 ° F (38.1 ° C). Which of the following would be a priority outcome for this client? 1. Prevention of urinary tract complications. 2. Alleviation of nausea. 3. Alleviation of pain. 4. Maintenance of fluid and electrolyte balance.

3. The priority nursing goal for this client is to alleviate the pain, which can be excruciating. Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the client's hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid and electrolyte imbalance.

§The intensivist arrives quickly and inserts a chest tube into the right anterior chest at the second intercostal space. You assess Mr. E after the chest tube insertion. Which finding is most important to report to the physician? 1. A large number of air bubbles appear in the water-seal chamber during expiration. 2. Fluctuation of red drainage in tubing when patient breathes. 3. 100 mL of blood drains into the collection chamber immediately after the chest tube insertion. 4. The client indicates that he has pain with every ventilator-assisted inspiration.

3. blood indicates that trauma could of occurred during insertion. >70-100ml/hr can significant damage. air is expected when first inserting a Chest tube to expel air.

A client with chronic renal failure has been prescribed calcium carbonate. What is the rationale for this particular medication? 1) Diminishes incidence of gastric ulcer formation 2) Alleviates constipation 3) Binds with phosphorus to lower concentration4 ) Increase tubular reabsorption of sodium

3: Clients with ARF have hyperphosphatemia. Clients are prescribed calcium-based phosphate binders to improve excretion of phosphorus.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypo-ventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased CO2 2. An increased pH and a decreased CO2 3. A decreased pH and a decreased HCO3 4. An increased pH with an increased HCO3-

4 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

if a person weighs 80kg, in order to make sure their kidney perfusion/urinary output is adequate they need to be putting out at least _____mL/hr.

40-80ml per hour

A nurse in ED is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen B. Increase the rate of IV fluids C. Administer pain medication D. Initiate cardiac monitoring

A .Apply supplemental O2 using airway, breathing, circulation -greatest risk to client is severe hypoxemia. Therefore it is supplemental O2Others aren't priority

What condition would slow in-flow of PD fluid? a. Constipation b. Anemia c. Low fiber diet d. Hypertension

A constipation

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A. Baked cod B. Ham and cheese omelet C. Fried eggs D. Baked potato E. Spinach

A. Baked cod D. Baked potato E. Spinach

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A. Calcium level of 9.5 mg/dL (2.4 mmol/L) B. Magnesium level of 4.1 mEq/L (2.1 mmol/L) C. Potassium level of 6.0 mEq/L (6.0 mmol/L) D. Sodium level of 120 mEq/L (120 mmol/L)

A. Calcium level of 9.5 mg/dL (2.4 mmol/L) RATIONALE: The client with a calcium level of 9.5 mg/dL (2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is 1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose risk for dysrhythmia, and a sodium level of 120 mEq/L (120 mmol/L) may cause serious cerebral dysfunction requiring assessments and/or interventions by the RN.

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should nurse take? (Select all that apply) A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution C. Instruct the client to take deep breath during the procedure D. Position the client laterally on the affected side before the procedure E. Apply pressure to the site after the procedure

A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution E. Apply pressure to the site after the procedure Nurse and provider both need to wear goggle and mask to reduce the risk for exposure to pleural fluid Use of antiseptic solution decreases the risk for infection which is increased due to invasive nature of procedure Application of pressure decreases the risk for bleeding at the procedure site - should instruct client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung - should position client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid

which outcome would result from metabolic acidosis? a. pH 7.40 b. Pa02 c. Bicarbonate 38 mEqL d. serum potassium 5.7 mEq/L

D. when you have metabolic acidosis it causes the K+ to shift out of the cell to replace H+ so the serum level is high.

A nurse is providing discharge teaching about improving teaching about improving gas exchange for a client who has emphysema. which of the following instructions should the nurse include in the teach? a. used pursed-lip breathing during periods of dyspnea b. limit fluid intake to 1,500 mL per day c. Practice chest breathing each day d. wear home oxygen to maintain an SaO2 of at least 94%

A. use pursed-lip breathing during periods of dyspnea. The nurse should instruct the client about using pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange.

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax (SATA) a. tracheal deviation to the left b. temperature of 38.8C (102F) c. Absent breath sounds on the right side d. Neck vein distention e. Bradypnea

ACD HR will be tachycardia

what vitamins should you hold before hemodialysis ? VIT A VIT B VIT C VIT D VIT K Folic acid Iron

Hold water soluble vitamins ◦Vit. B ◦Vit. C ◦Folic acid

A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician. b. Continue to monitor the client. c. Reinforce the occlusive dressing. d. Encourage the client to deep-breathe.

Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded. Options A, C, and D are incorrect.

A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? 1. hyperkalemia 2. hypokalemia 3. hypercalcemia 4. hypocalcemia

Answer: 1 Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes. Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.

When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt? 1. other electrolyte disturbances 2. hypertension 3. visual disturbances 4. drug toxicity

Answer: 1 Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension. Rationale 3: Visual disturbances do not occur with hypocalcemia. Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.

An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypermagnesemia? 1. hypotension, warmth, & sweating 2. nausea & vomiting 3. hyperreflexia 4. excessive urination

Answer: 1 Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating. Rationale 2: Lower levels of magnesium are associated with nausea & vomiting. Rationale 3: Lower levels of magnesium are associated & hyperreflexia. Rationale 4: Urinary changes are not noted.

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? 1. seizure 2. infection 3. neutropenic 4. high-risk fall

Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.

An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? 1. hypernatremia 2. hyponatremia 3. fluid volume excess 4. hyperkalemia

Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia. Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level.

A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances? 1. hypokalemia 2. hypernatremia 3. carbon dioxide 4. magnesium

Answer: 2 Rationale: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.

The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder? 1. calcium 2. magnesium 3. phosphorous 4. potassium

Answer: 4 Rationale 1: This pt will be less likely to develop a calcium imbalance. Rationale 2: This pt will be less likely to develop a magnesium imbalance. Rationale 3: This pt will be less likely to develop a phosphorous imbalance. Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography(ECG)

Answer: A Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias B. Encourage increased intake of phosphate antacids C. Discontinue any magnesium-contain medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.

Answer: A Rationale: The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

Which patient below is NOT at risk for developing chronic kidney disease? A. A 58 year old female with uncontrolled hypertension. B. A 69 year old male with diabetes mellitus. C. A 45 year old female with polycystic ovarian disease. D. A 78 year old female with an intrarenal injury.

C

You're assessing morning lab values on a female patient who is recovering from a myocardial infraction. Which lab value below requires you to notify the physician?* A. Potassium level 4.2 mEq/L B. Creatinine clearance 35 mL/min C. BUN 20 mg/dL D. Blood pH 7.40

C

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased Urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

Answer: C Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability

Answer: C Rationale: Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau's sign D. Loss of deep tendon reflexes

Answer: D Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia

A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply:* A. Hypervolemia B. Hypokalemia C. Increased BUN level D. Decreased Creatinine level

B C

A 36-year-old male patient is diagnosed with acute kidney injury. The patient is voiding 4 L/day of urine. What complication can arise based on the stage of AKI this patient is in? Select all that apply: A. Water intoxication B. Hypotension C. Low urine specific gravity D. Hypokalemia E. Normal GFR

B C D

ou are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? Select-all-that-apply: A. "This medication will help keep my calcium level normal." B. "I will take this medication with meals or immediately after." C. "It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication." D. "This medication will help prevent my phosphate level from increasing."

B D

client who has been diagnosed with calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time? A. Report hematuria to the physician B. Strain the urine carefully C. Administer meperidine (Demerol) every 3 hours D. Apply warm compresses to the flank area

B. Strain the urine carefully Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone.

A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow back and over the chest to support the arm B. High-Fowler's position with the arms supported on the overbed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the HOB to 15 degree

B. High-Fowler's position with the arms supported on the overbed table Should place in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillow for comfort on the overbed table.- lateral position can be a good position for sleeping but not promote max. Chest expansion- supine allows diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise expansion

A nurse is assessing a client with stridor on the left side of the chest. The nurse would suspect which of the following? A. Atelectasis B. Poor oxygen exchange C. Pneumonia D. Hemothorax

B. Poor oxygen exchange

Which is a proper nursing action for a patient in acute respiratory failure? A. Administer 100%oxygen to an intubated patient until the pathology has resolved. B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day. C. Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations. D. Administer packed red blood cells to maintain the hemoglobin level at 7g/dL or higher.

B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day.

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B. The lung may have re-expanded or there is a kink in the system.

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? A. Decreasing PEEP B. Use of permissive hypercapnia C. Increasing the tidal volume D. Use of positive pressure ventilation

B. Use of permissive hypercapnia

A nurse in the PACU unit is caring for a patient who had a regional block. The nurse knows that what qualifications are necessary for the client to be transferred back to a different unit? (SATA) A. Ability to speak B. Voluntary movement C. Score of 15 on the Glasgow coma scale D. Sensory function E. Pain of less than 5 on a scale of 1~10

B. Voluntary movement D. Sensory function

Select all the patients below that are at risk for acute intra-renal injury? A. A 45 year old male with a renal calculus. B. A 65 year old male with benign prostatic hyperplasia. C. A 25 year old female receiving chemotherapy. D. A 36 year old female with renal artery stenosis. E. A 6 year old male with acute glomerulonephritis. F. An 87 year old male who is taking an aminoglycoside medication for an infection.

C E F

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal set C. Container of sterile water D. Nonadherent pads

C. Container of sterile water Should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax-other choices don't require at bedside

A nurse is assessing a client and hears absent breath sounds on the left. The nurse would suspect which of the following? A. Atelectatsis B. Pneumonia C. Migration of endotracheal tube D. Migration of chest tube

C. Migration of endotracheal tube~indicates migration of ET tube down right mainstem bronchus Rationale: It can also indicate pneumothorax

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3 C (99.1F)

C. Persistent cough When using airway, breathing, circulation approach to client care, nurse should determine the priority finding is a persistent cough because this can Indicate tension pneumothroaxi, which is a medical emergency - pallor indicates blood loss, insertion site pain can result in shallow respiration, and temperature can indicate infection but they aren't priority

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS) A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96..

C. The patient's PaO2 remains at 45 mmHg. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic.

Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: a. Exhale slowly. b. Stay very still. c. Inhale and exhale quickly. d. Perform the Valsalva maneuver.

D - The nurse should instruct the patient to perform the Valsalva's maneuver (take a deep breathe, exhale and bear down). Then the tube would be quickly removed and an airtight dressing placed. An alternative would be to ask the patient to take a deep breathe and hold the breath while the tube is removed.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24mEq/L D. Intercostal retractions

D. Intercostal retractions should report intercostal retractions to the provider because the finding indicates increasing respiratory compromise in client who has ARDS- decreased bowel sound is expected finding- O2Sat, and CO2 are WNL

A patient has a calcium level of 7.2 mg/dL. What sign below is indicative of this lab value?(Required) A. None, this is a normal calcium level B. Shortened ST segment C. Hypoactive bowel sounds D. Prolonged QT interval on the EKG

D. Prolonged QT interval on the EKG

A patient has a potassium level of 1.5 mEq/L. Which of the following is NOT typically a sign with this condition?(Required) A. None, this is a normal potassium level. B. Decreased respirations C. Decreased deep tendon reflexes D. Tall T-waves

D. Tall T-waves

Pt's on dialysis should maintain a low-protein diet true or false?

False, generally Pts on dialysis should not restrict protein in their diets.

Elevated hct can indicate Fluid volume overload or Fluid volume deficit?

Fluid volume deficit or dehydration

A nurse is caring for a hospitalized client who received hemodialysis 1 hr ago. When evaluating the client's status after dialysis, which of the following information should the nurse assess for first? - Serum potassium level - Body weight - Serum creatinine level - Vital signs

Vital signs When using ABCs approach to client care, the nurse should determine that the priority info to asses is the client's V/S

vomiting , dehydration due to fly for 3 days. ABGS: pH 7.46 PA C02 50, HC03 33, Pa02 95 a. metabolic acidosis, uncomp b. respiratory acidosis, comp b. metabolic alkalosis, partial comp

c

a client with COPD admitted to hospital with exacerbation. ang results are pH: 7.39 PaCo2 52 HCO3 25 how would the nurse interpret. a. resp acid, uncomp b. respiratory alk, partially compensated c. resp acid, comp d. metabolic acid, comp

a.

A PT endstage kidney disease has the following labs: K+ 5.9 Na+ 152 Creatinine 6.2 mg/dL BUN 60 mg/dL which is the priority nursing intervention? a. assess heart rate and rhythm b. Implement seizure precautions. c. Assess the PTs resp. status. d. evaluate the PTs acid base balance.

a. The renal labs is expected but the most dangerous lab is the elevated potassium.

Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.

a. Do nothing, because this is an expected finding. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure.

a. Hyperactive deep-tendon reflexes

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome

a. Right pneumothorax

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

a. arterial blood gas (ABG) analysis.

calcium level of 8.0. which of the following actions should the nurse take? a. implement seizure precautions b. administer phosphate c. initiate diuretic therapy d. prepare the client for hemodialysis

a. at risk for seizures due to low serum levels of calcemia

A nurse is caring for a client who is receiving mechanical ventilation and you cannot trouble shoot the alarm what is the first thing that you? a. call respiratory b. Initiate bag-valve mask ventilation c. call IT d.

b

After dialysis, the patient's daughter asks why the dialysis nurses weigh her mother before and after the dialysis treatment. What is the nurse's best response? A."It is part of the protocol for dialysis." B."It ensures that she is getting adequate nutrition." C."It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis." D."It is essential for calculating the fluid restriction your mother will receive on non-dialysis days."

c

A nurse is review the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect.? a. Hgb 20g/dL b. Hct 34% c. BUN 25mg/dL d. Urine specific gravity 1.050

b. the nurse should identify that a client who has fluid volume excess can have a Hct level that is below exprected rage of 37% to 52%. Fluid volume excess can cause hemodilution and a decreased hematocrit level.

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

b. Endotracheal intubation and positive pressure ventilation

PT has potassium level of 3.0. The nurse should plan to monitor the client for which of the following findings? a. hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse

b. orthostatic hypotension remember with hypokalemia everything is low and slow

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern .b. partial pressure of arterial oxygen(PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg .d. respiratory rate of 32/min.

b. partial pressure of arterial oxygen(PaO2) of 45 mm Hg.

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen(PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

b. partial pressure of arterial oxygen(PaO2) of 45 mm Hg.

Which precaution will the nurse follow to ensure the function of the AV graft? A.Insert an IV and run saline at 10 mL/hr. B.Keep the patient's arm elevated on two pillows. C.Monitor blood pressure and radial pulses in both arms. D.Check for a bruit and thrill by auscultation and palpation over the site.

d

dx of MI, pH 7.36 PaC02 29 HCO3 20 Pa02 90 a. well oxygenated with uncompensated respiratory alkalosis b. hypoxemic with compensated respiratory acidosis c. well oxygenated with compensated metabolic acidosis d. hypoxemic with compensated metabolic acidosis

c. pH normal but acid side Carbon dioxide alkalosis HCO3 is acidic so it is metabolic acidosis but compensated because the CO2 is High because the lungs are trying to help.

When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs."

c. "The infection caused generalized inflammation that damaged the lungs."

A nurse is caring for a client who has received hemodialysis. The nurse should identify that which of the following findings places the client at risk for seizures? a. Hypokalemia b. A rapid increase in catecholamines c. A rapid decrease in fluid d. Hypercalcemia

c. A rapid decrease in fluid A rapid decrease in fluid can result in cerebral edema and increased intracranial pressure, placing the client at risk for seizures

Which of the following drugs is commonly used in the preoperative period for its combined effects of analgesia and sedation? a. Propofol b. Midazolam c. Diazepam d. Dexmedetomidine

d. Dexmedetomidine

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

d. Increased respiratory rate

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the healthcare provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%,although the O2 flow rate has been increased.

d. The patient's SpO2 has dropped to 90%,although the O2 flow rate has been increased.

The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports his finding? a. sodium 152 b. Chloride 102 c. magnesium 1.8 d. potassium 6.1

d. hyperkalemia, defined as a potassium level above 5.0, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's arterial oxyhemoglobin saturation (SpO2)from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patient's oropharynx. d. increase the oxygen flow rate.

d. increase the oxygen flow rate.

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? 1. Increase daily fluid intake to at least 2 to 3 L. 2. Strain urine at home regularly. 3. Eliminate dairy products from the diet. 4. Follow measures to alkalinize the urine.

1. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

In what order should the nurse plan to implement the new prescriptions? (Rank items in order from first action to last action.) Start a peripheral intravenous catheter. Give the first dose of Ciprofloxicin 400 mg/ 100 ml IV twice daily. Collect blood for Chem 7, CBC, and blood cultures x 2. Apply 2 L oxygen by nasal cannula. Collect urine sample by clean catch.

1. Apply 2 L oxygen by nasal cannula. 2.Start a peripheral intravenous catheter. 3. Collect blood for Chem 7, CBC, and blood cultures x 2. 4. Collect urine sample by clean catch. 5. Give the first dose of Ciprofloxicin 400 mg/ 100 ml IV twice daily.

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply .1. Correct bradypnea 2. Blow off carbon dioxide 3. Correct metabolic acidosis 4. Correct an acid-base imbalance 5. Cause respiratory compensation 6. Stimulate Cheyne-Stokes respirations

2. Blow off carbon dioxide 3. Correct metabolic acidosis 4. Correct an acid-base imbalance 5. Cause respiratory compensation

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

2. Respirations that are increased in rate 4. Respirations that are abnormally deep

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. bradycardia and hyperactivity 2. decreased respiratory rate and depth 3. headache, restlessness, and confusion 4. bradypnea, dizziness, and paresthesia's

3. headache, restlessness, and confusion

A registered nurse is instructing a new nursing graduate about hemodialysis. Which statement if made by the new nursing graduate would indicate an inaccurate understanding of the procedure for hemodialysis? a. Sterile dialysate must be used. b. Warming the dialysate increases the efficiency of diffusion. c. Heparin sodium is administered during dialysis. d. Dialysis cleanses the blood from accumulated waste products.

A Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis.

The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choices by the patient indicate that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Cheese sandwich, tomato soup, and cranberry juice c. Split-pea soup, whole-wheat toast, and nonfat milk d. Oatmeal with cream, half a banana, and herbal tea

A Rationale: Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the menu? a. Cream of wheat, blueberries, coffee b. Sausage and eggs, banana, orange juice. c. Bacon, cantaloupe melon, tomato juice. d. Cured pork, grits, strawberries, orange juice.

A The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium.

A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys? A. Lisinopril B. Metoprolol C. Amlodipine D. Verapamil

A Two types of drugs that can be used to treat HTN and protect the kidneys in PTs with CKD. These drugs include ACE inhibitors and ARBs.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A. A client who is 48hr postoperative following a total arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. DVT are most likely to occur 48-72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stocking and by administering anticoagulant medications- open surgical appendectomy- at low risk of PE. Greatest risk is peritonitis-open reduction external fixation- low risk- greatest risk to the client is neurovascular compromise- laparoscopic cholecystectomy is at low risk for PE- some clients develop from CO retention in the abdomen following surgery.

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Encourage use of incentive spirometer every 2 hrs B. Instruct client to splint incision when coughing and deep breathing C. Reposition every 2 hrs D. Administer antibiotic therapy E. Assist with early ambulation

A. Encourage use of incentive spirometer every 2 hrs B. Instruct client to splint incision when coughing and deep breathing C. Reposition every 2 hrs E. Assist with early ambulation Rationale: Promote lung expansion

Which is a classic finding for a patient with ARDS? A. Hypoxemia despite increased oxygen administration B. Bronchodilators ordered to relieve airway spasms C. Development of Kussmaul respirations D. Development of Cheyne-Stokes respirations

A. Hypoxemia despite increased oxygen administration

which of the following is a finding of chronic kidney disease a hypotension b hypocalemia c hypokalemia d hyponatremia

b hypocalcemia

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? a. Monitor the client. b. Notify the physician. c. Elevate the head of the bed. d. Medicate the client for nausea.

B Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified.

A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. The nurse's response is based on an understanding that the typical schedule is: a. 5 hours of treatment 2 days per week. b. 3 to 4 hours of treatment 3 days per week c. 2 to 3 hours of treatment 5 days per week d. 2 hours of treatment 6 days per week

B The typical schedule for hemodialysis is 3 to 4 hours of treatment three days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

B C D E

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify provider if there is a fluctuation of drainage in the tubing with inspection" B. " I will notify the provider if there is a continuous bubbling in the water seal chamber" C. "I will notify the provider if there is drainage of 60mL in the first hour after surgery" D. "I will notify the provider if there are several small, dark-red blood clots in the tubing

B. " I will notify the provider if there is a continuous bubbling in the water seal chamber" Continuous bubbling suggests air leak and requires notification of the providers. The nurse should check the system for external correctable leaks while waiting for instructions from provider-fluctuation of drainage in tubing with inspiration is expected finding, need cont. monitoring but not notifying- Drainage of 60mL in the first hour after surgery is expected finding- small, dark-red blood clots is expected finding

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

B. Assess for an air leak due to bubbling noted in the suction chamber.

An EKG shows a shortened QT interval. Which lab value below would be indicative of this change? A. Calcium level of 8 mg/dL B. Calcium level of 12 mg/dL C. Calcium level of 8.7 mg/dL D. Calcium level of 9.2 mg/dL

B. Calcium level of 12 mg/dL

An EKG shows a shortened QT interval. Which lab value below would be indicative of this change?(Required) A. Calcium level of 8 mg/dL B. Calcium level of 12 mg/dL C. Calcium level of 8.7 mg/dL D. Calcium level of 9.2 mg/dL

B. Calcium level of 12 mg/dL

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

B. Elevated temperature should report an elevated T to the provider because it can indicate a possible respiratory infection. Client who have emphysema are at risk for the development of pneumonia and other respiratory infections- rhonchi on inspiration, barrel-shaped chest, diminished breath sounds are expected findings

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

B. Nonrebreather mask Should use nonrebreather mask for a client who is in respiratory distress to provide highest oxygen level. A nonrebreather mask i s made up of a reservoir bad from which the client obtains the O2, a one-way valve to prevent exhaled air form entering the reservior bad, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2-O2 flow rate via nasal cannula is 1-6L/min and provides O2 at a concentration of 24% to 44%. It does not provide the highest level of O2 for client who is in respiratory distress- simple face mask delivers O2 conc. Between 40-60% and has open exhalation ports that allow RA in and exhaled air out. It doesn't provide highest level of O2 for a client who is in respiratory distress- The partial rebreather mask delivers O2 conc. 60-75%. The exhalation ports are open, which will allow RA in and exhaled air out.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with exertion

B. Productive cough with green sputum When using urgent vs. nonurgent approach to client care, priority finding is a productive cough with green sputum- it indicate infection- increased diameter is nonurgent because expected findings- clubbing is nonurgent because COPD is chronic low arterial oxygen level.- Pursed-lip is nonurgent because it is expected findings with COPD

A nurse is providing instructions about pursed-lip breathing for a client who has COPD. with emphysema. This breathing technique accomplishes which of the following? a. increase O2 intake b. Promote CO2 elimination c. uses the intercostal muscles d. strengthens the diaphragm

B. Purse lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "I will use clean technique when suctioning a client's ETT" B. "I will use a rotating motion when removing the suction catheter" C. "I will suction the oropharyngeal cavity prior to suctioning the ETT" D. "I will suction a client's ETT every 2 hours"

B. the nurse should rotate the suction catheter during withdrawal to remove secretions suctions the ETT before the oropharyngeal to prevent cross contamination

When treating hyperkalemia with kayexalate, what is important to monitor?

Bowel sounds, do not give if there is a paralytic ileus.

The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2F. Which of the following is the appropriate nursing action? a. Encourage fluids. b. Notify the physician. c. Continue to monitor vital signs. d. Monitor the site of the shunt for infection.

C The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations.

Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.

C. Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat...hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.

A nurse is caring for a patient who is having a hard time coughing up secretions. The patient describes the secretions as thick. Which type of suction would the nurse use if the client does not want suction from his nose? A. Endotracheal suction tube B. Large French suction catheter C. Yankauer suction D. Nasopharyngeal suction

C. Yankauer suction Rationale: This type of suction is for thick oral secretions. The large French suction is for nasopharyngeal and nasotracheal suction

a nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? a. instruct the client to cough b. admin oxygen via face mask c, evaluate the PT for stridor d. Keep the client in a semi-to high fowler's position

C. evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubating, the nurse should continuously evaluate the client's resp status. Stridor is a high-pitched sound during inspiration that indications laryngospasm or swelling around the glottis. Stridor reflects a narrow airway and might require emergency reintubation

PT is brought to the Ed after hit by a car he is unresponsive, shallow breathing open femur fracture has lost a lot of blood which acid-base imbalance? A. metabolic alkalosis B. respirator acidosis C. metabolic acidosis and respiratory acidosis D. metabolic alkalosis and respiratory alkalosis

C. metabolic acidosis and respiratory acidosis shallow breathing = retaining CO2 Kidneys are not being perfused and holding onto H+ and acid, lactic acid produced from the tissues not being perfused (anaerobic metabolism).

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. Upon detecting an output obstruction, which of the following actions should the nurse take first? -Irrigate the catheter w/ normal saline -Notify the provider -Check the irrigation tubing for kinks -Provide the PRN pain medication

Check the irrigation tubing for kinks The first action the nurse should take is to check the irrigation tubing for kinking or clots as these can prevent outflow of fluids

The kidneys are responsible for performing all the following functions EXCEPT? A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production

D

The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a. Check the shunt for the presence of bruit and thrill. b. Observe the site once as time permits during the shift. c. Check the results of the prothrombin times as they are determined. d. Ensure that small clamps are attached to the arteriovenous shunt dressing.

D An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours.

You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve air flow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."

D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation." This setting of PEEP (it can range between 10 to 20 mmHg of water) and it helps to open the alveoli sacs that are collapsed, especially during exhalation.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority? A. Provide a quiet environment B. Encourage use of incentive spirometry every 1 to 2 hr C. Obtain a blood sample for electrolyte study D. Administer heparin via continuous IV infusion

D. Administer heparin via continuous IV infusion Airway, breathing, circulation approach to client care- should place priority on stabilizing circulations to the lungs by administering heparin to prevent further clot formation- others aren't priority

A nurse is assessing a client postop who is responsive to verbal stimuli. What is the nurse's first action for the patient after completing a full head to toe assessment? A. Turn the client lateral B. Place pillows under the clients knees C. Get the client to shower D. Place the bed in semi Fowlers

D. Place the bed in semi Fowlers Rationale: Facilitate chest expansion. The client should be turned lateral if they are unresponsive to stimuli to decrease the risk of aspiration. Do not place anything under clients knees unless indicated, due to decreased venous return. If client becomes hypotensive or shock is suspected. elevate legs and lower the head of the bed

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor

D. Place the client on a cardiac monitor RATIONALE: Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate. Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress at this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium excess is determined.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. which of the following findings indicates that the nurse should suction the client's airway secretions'? a. unable to speak b. clients airway secretions were last suctioned 2 hr ago. c. the client coughs and expectorates a large mucous plug. d. the nurse auscultates coarse crackles in the lung fields.

D. the nurse should auscultate corase crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, then suction the client's airway. Incorrect. a client with a tracheostomy with an inflated cuff in place is unable to speak. The nurse should assess the need for suctioning every 2 hours and suction as necessary. The nurse should assess the client's airway after coughing and only suction if the client is not able to cough and expectorate secretions.

A patient has a Magnesium level of 1.3 mg/dL. Which of the following is NOT a sign or symptom of this condition?(Required) A. Hypertension B. Torsades de pointes C. Positive Trousseau's Sign D. Absent deep tendon reflexes

D: Absent deep tendon reflexes

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings

a

When admitting a patient in possible respiratory failure with a highPaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. (sleepy) b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is162/94.

a

metabolic acidosis occurs in the oliguric phase of ako as a result of impairment of a. ammonia synthesis b. excretion of sodium c. excretion of hco3 d. conservation of potassium

a

A nurse is performing an admission assessment on a client who has severe chronic kidney disease (CKD). Which of the following findings should the nurse expect for this client? - Tachypnea - Hypotension - Exophthalmos - Insomnia

Tachypnea The nurse should expect the client who has severe CKD to have tachypnea due to metabolic acidosis

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?*= A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

The answer is B. Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition?* A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

The answer is D. ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and option C describes a pneumothorax.

After dialysis , As the patient is preparing to discharge, the patient should be taught to restrict which elements in her diet? (Select all that apply.) A.Potassium B.Phosphorus C.Calcium D.protein E. vitamins

a b d

The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L c) the client's hemoglobin level is 10 g/dL d) the client's serum calcium is 7.7 mg/dL e) the client's serum sodium is 140 mEg/L f) the client's serum magnesium is 4 mEq/L g) the client's weight has increased from 60 kg to 63 kg

a b e

A nurse is reviewing the laboratory reports of a client who has acute kidney injury (AKI). Which of the following findings should the nurse expect (select all) a BUN 30 mg/dL b Urine output of 40 mL in past 3 hr c Potassium 3.6 mEqL d Serum calcium 9.8 mg/dL e Hematoctrit 30%

a b e BUN 30 mg/dL Urine output of 40 mL is past 3 hours: Oliguria w/ a urine output of 100 - 400 mL per 24 hr is expected finding Hematocrit 30%: decrease is expected Incorrect: Potassium: elevated in AKI Serum Calcium: decrease in AKI

The nurse responding to a High pressure alarm on the ventilator would assess for which condition?(SATA) a. Auscultate the lungs for Pulmonary edema b. Biting the ET Tube c. Tube displacement d. Disconnection of the tubes. e. Excessive airway secretions f. Kinked ventilator tubing

a b e f

a nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased Heart rate d. Increased Blood pressure

a. decreased muscle strength will experience muscle weakness, fatigue, paresthesia, and nausea.

Which intervention should be included in the plan of care during the immediate kidney transplant postop period. a. assess surgical incision every shift b. monitor urinary output hourly using an urimeter c. monitor NG tube every 4 hour d. encourage use of the incentive spirometer daily.

b a receipt of a kidney donor usally begins function immediately and may produce large amount of urine incision should be assessed every 2 hour incentive spirometer is at least every 2-4 hours

A nurse is providing discharge teaching to a client who has emohysema. which instruction should the nurse include? a. be sure to take cough medicine to avoid coughing b. try to drink at least 2 to 3 L for fluid per day c. try to reduce your smoking to 2 cigarettes per day d. be sure to eat 3 full meals each day

b helps to liquefy secretions coughing is important PT should eat 4-6 small meals per day to prevent the exhaustion and SOB that can result from ingesting large meals.

CKD PT has a Hgb level of 7.8 Which underlying pathology does the nurse recognize as the cause of this abnormal lab value? a. Hematuria results in blood loss. b. Fewer red blood cells are being formed. c. Dehydration causes dilutional anemia. d. Renal waste products destroy red blood cells

b Kidneys become less able to produce erythropoietin necessary for the formation of red blood cells.

DB is a known risk factor for renal failure. What are some other risk factors for CKD? a. Female gender b. HTN c. hysterectomy at age 35 d. Polycystic Kidney Disease e. African American ethnicity

b d e

Which risk factors relate to the use of Hemodialysis (SATA) a. ascites b. orthostatic hypotension c. bowel or bladder perforation d. noncompliance bc treatments require more time e. hemorrhage

b e not bowel or bladder perforation or non compliance because that's associated with peritoneal dialysis hypotension occurs in 50% of HD treatments heparin required during HD increases risk for bleeds.

After dialysis, which instruction should the nurse provide to the student nurse who is helping to provide care for the patient? A.Expect the patient's blood pressure to be higher after dialysis. B.The patient's weight will most likely be increased after dialysis. C.Expect the patient's temperature to be higher after dialysis. D.The patient's clotting studies will need to be drawn after dialysis.

c

The patient is to have hemodialysis this morning and has the following medications ordered. What decision will you make regarding administration of the medications? A.Calcium B.Multivitamin C.Atenolol (Tenormin) D.GlyBURIDE (DiaBeta)

c

A nurse is caring for a client who has chronic kidney failure and the following lab results: BUN 196 mg/dL, sodium 152 mEq/L, and potassium 7.3 mEq/L. Which of the following interventions should the nurse implement?- a. Initiate an IV infusion of 0.9% sodium chloride b. Give oral spironolactone c. Infuse reg. insulin in dextrose 10 % in water d. Administer furosemide

c. Infuse regular insulin in dextrose 10% in water. The client who has elevated potassium level should receive reg. insulin w/ dextrose 10% in water by continuous IV infusion to facilitate moving potassium out of the extracellular fluid into intracellular fluid.

PT with pneumonia who is experiencing thick oral secretions. which action should the nurse take first? a. provide chest physiotherapy b. perform oropharyngeal suction c. encourage deep-breathing and coughing d. assist the client with ambulation

c. encourage deep-breathing and coughing ABCs