ATI HEHI Exam 1 things I got wrong or just liked the rationales + Enstrom practice questions from in class/reviews

the nurse should expect the client who has vomited for 24 hrs to have ______ acid base disorder

metabolic alkalosis. Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

The nurse is teaching a class on pain management strategies. Which patient statement requires additional teaching? -"Persistent pain is a warning in my body that alerts the sympathetic nervous system." -"Acute pain has a quick onset and is usually isolated to one area of my body." -"My frozen-shoulder causes musculoskeletal or somatic pain." -"Nociceptive pain follows a normal and predictable pattern."

"Persistent pain is a warning in my body that alerts the sympathetic nervous system." Acute pain, not persistent (chronic) pain serves as a warning signal to alert the sympathetic nervous system. Persistent or chronic pain serves no biologic purpose. The other answer options are all correct and do not require additional teaching.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? Lactated Ringer's Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water This is a hypertonic IV solution, which will not help correct the client's sodium elevation.

0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride. Lactated Ringer's This is an isotonic IV solution, which will not help correct the client's sodium elevation. Dextrose 5% in 0.9% sodium chloride This is a hypertonic IV solution, which will not help correct the client's sodium elevation. Dextrose 10% in water This is a hypertonic IV solution, which will not help correct the client's sodium elevation.

A nurse in the ED is caring for a client who suddenly becomes unresponsive and notes ventricular asystole on their monitor. Place the actions the nurse should take in their correct order. Analyze heart rhythm with AED Perform initial round of high-quality CPR Identify cause Administer epinephrine

1 Perform initial round of high-quality CPR 2 Administer epinephrine 3 Analyze heart rhythm with AED 4 Identify cause

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A client who has diarrhea A client who is vomiting A client who is taking a thiazide diuretic A client who has salicylate intoxication

A client who has diarrhea Diarrhea can cause metabolic acidosis due to the loss of bicarbonate. Vomiting can cause metabolic alkalosis due to acid loss. Thiazide diuretics can cause metabolic alkalosis due to excretion of acid. Salicylate intoxication can cause respiratory alkalosis due to carbon dioxide loss from tachypnea.

A patient with diabetes is describing their pain as sharp, burning, pins- and-needles type sensation rated as a 6/10. The nurse recognizes this is consistent with which type of pain? a. Neuropathic b. Psychiatric c. Malingering d. Opioid tolerance

A neuropathic pain This is a recall question and requires you to recall that diabetic neuropathy is a common finding and is often described as burning or a pins-and-needles sensation. Malingering is not a form of pain, it is when the patient attempts to derive a benefit from falsely reporting pain. Ischemia can cause pain, but not the kind of pain reported by the patient - and there is no indication that the patient is experiencing ischemia. Visceral pain tends to be dull, non-localized pain arising from the organs.

Which documentation will the nurse record for a patient who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

A. Reports acute pain at the surgical site. The nurse will document that the patient reports acute pain at the surgical site. Acute pain is commonly associated with surgical procedures and lasts for a short duration. The client does not demonstrate persistent or chronic pain, nor is the pain neuropathic in nature. Acute pain that is poorly controlled and lasts longer than it should can lead to chronification of pain

A nurse is assessing a client who had abdominal surgery. The client reports pain in the abdomen at 9 on a 0 to 10 scale. What type of pain is the client experiencing? Acute Chronic Nociceptive Neuropathic

Acute Postoperative pain is acute pain and must be managed to prevent long-term/chronic pain.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? Insert an oral airway. Administer the abdominal thrust maneuver. Turn the client to the side. Perform a blind finger sweep.

Administer the abdominal thrust maneuver. The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. --> Performing a blind finger sweep creates a risk of worsening the obstruction and is contraindicated. --> Insertion of an oral airway is appropriate if the client is unconscious and the obstruction is due to the tongue obstructing the airway or from excessive secretions. Inserting an oral airway in a conscious client will cause the client to gag and will not relieve the obstruction.

On entry to the ED of a patient who fell from a roof, what is the nurse's priority action? • Place nasal cannula to administer oxygen. • Apply pressure to small bleeding wounds. • Assess airway and stabilize cervical spine. • Initiate large-bore IV to infuse normal saline.

Assess airway and stabilize cervical spine. All other actions can be implemented after the airway is secured, and the cervical spine is stabilized.

A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain? Dry palms and feet Decreased muscle tone Furrowed brow Eyes wide open

B: furrowed brow Using non-verbal signs of pain, a furrowed brow may indicate pain. Pain would likely cause diaphoresis, increased muscle tone. Eyes wide open is a normal finding.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) Bicarbonate excess Kussmaul's respirations Flushing Circumoral paresthesia Lethargy

Bicarbonate excess is a clinical manifestation for a client experiencing metabolic alkalosis. Circumoral paresthesia is a clinical manifestation for a client experiencing metabolic alkalosis. Kussmaul's respirations are a clinical manifestation for a client experiencing metabolic acidosis. Flushing is a clinical manifestation for a client experiencing respiratory acidosis. Lethargy is a clinical manifestation for a client experiencing metabolic acidosis.

Select all that apply: A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Client who has dysphagia Client who has AIDS Client who was vaccinated for pneumococcus and influenza 6 months ago Client who is postoperative and has received local anesthesia Client who has a closed head injury and is receiving mechanical ventilation Client who has myasthenia gravis

Client who has dysphagia The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration. Client who has AIDS The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. Client who has a closed head injury and is receiving mechanical ventilation Mechanical ventilation is invasive and places the client at risk for ventilator-associated pneumonia. Client who has myasthenia gravis A client who has myasthenia gravis has generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia.

A nurse is caring for a client who reports pain at 10 on a 0 to 10 scale. The nurse plans to administer morphine. Which of the following adverse effects should the nurse monitor for in the client? Confusion Hypertension Constipation Bradypnea Diarrhea

Confusion Constipation Bradypnea A client receiving morphine is at risk for confusion, sedation, respiratory depression, hypotension, constipation, nausea, vomiting and urinary retention.

You receive report on your patients. Which one would you assess first? a) A patient with rheumatoid arthritis with a left knee that is warm and swollen b) A patient with osteoarthritis who needs help cutting sausage on their breakfast tray c) A patient with gout who reports 6/10 pain from the big toe d) A patient with new-onset substernal chest pain

D - a patient with new-onset substernal chest pain. • Using the ABC approach to the initial assessment, the chest pain may indicate a threat to circulation.

What patient does that oncoming ED nurse see first when assigned to care for four patients? A. 21-year-old with a skin rash who has been waiting 2 hours to see a provider B. 30-year-old with influenza who has infusing IV fluids and is resting quietly C. 47-year-old who fell off of a curb, resulting in a sprained ankle D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior

D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior emergent condition

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? • Elevated sodium level • Decreased potassium level • Elevated magnesium level • Decreased calcium level

Decreased potassium level Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning. Hypernatremia is an imbalance of sodium in which the serum sodium level is greater than 145 mEq/L. It can occur as a result of renal failure, dehydration, Cushing's disease, or excessive intake of sodium; however, loss of gastric fluid does not increase sodium levels. [opposite = Hyponatremia is a net gain of water or loss of sodium that results in a sodium level less than 136 mEq/L. Manifestations of hyponatremia include headache, confusion, lethargy, muscle weakness, fatigue, decreased deep-tendon reflexes, and seizures.] Hypermagnesemia is an imbalance of magnesium in which the serum level is greater than 2.1 mEq/L. Hypocalcemia an electrolyte imbalance in which the serum calcium level is less than 9.0 mg/dL. Hypocalcemia is a result of renal failure, cellular damage, or other metabolic disorders.

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Potassium 3.6 mEg/L Chloride 105 mEg/L Glucose 102 mg/dL BUN 18 mg/dL Creatinine 0.7 mg/dL renal failure dehydration low protein diet syndrome of inappropriate antidiuretic hormone SIADH

Dehydration Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit. The creatinine and BUN are within the accepted reference range, which does not indicate renal failure. None of the laboratory findings supports a condition that includes a high-protein diet. SIADH is associated with hyponatremia (decreased sodium).

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? Reposition the client. Administer the medication. Determine the location of the pain. Review the effects of the pain medication.

Determine the location of the pain. The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? Decreased heart rate Constricted pupils Elevated blood pressure Reduced respiratory rate

Elevated blood pressure Nonverbal manifestations of acute pain can include hypertension, diaphoresis, grimacing, and guarding.

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?

Explain that the provider will see him and determine a course of action. This response illustrates the therapeutic communication technique of focusing the client on the usual course of action that must precede drawing any conclusions about the cause of the client's pain.

A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? Decreased pH and metabolic acidosis Decreased pH and respiratory acidosis Elevated pH and metabolic alkalosis Elevated pH and respiratory alkalosis

I still dont get this one, why is it not respiratory acidosis because the CO2 is at a greater change Decreased pH and metabolic acidosis This client would have a decreased pH and be in metabolic acidosis. Other findings would include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.

Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive. t decreases the client's level of anxiety. It facilitates the client's deep breathing. It enhances the client's ability to sleep. It reduces the client's blood pressure.

It facilitates the client's deep breathing. When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? Lethargy Hyperactive deep tendon reflexes Prolonged ST segment Hyperactive bowel sounds

Lethargy A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion. A client who has a serum calcium level below the expected reference range is more likely to have hyperactive deep tendon reflexes. The nurse should expect this client to have depressed deep tendon reflexes. Calcium plays a role in the electrical conduction of the heart by controlling depolarization and action potentials within cells. A client who has a serum calcium level below the expected reference range is more likely to have a shortened ST segment and shortened QT intervals. A client who has a serum calcium level below the expected reference range is more likely to have hyperactive bowel sounds and diarrhea. The nurse should expect this client to have constipation, anorexia, nausea, vomiting, and abdominal distention.

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

Metabolic acidosis A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis A client who has influenza has experienced excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities. A client who has metabolic acidosis has a low pH level and a low bicarbonate level with manifestations such as Kussmaul's respirations, lethargy and confusion. A client who has respiratory acidosis has a low pH and a high bicarbonate level with manifestations such as warm, flushed skin, headache and tachycardia. A client who has respiratory alkalosis has high pH and a low bicarbonate level with manifestations such as tremulousness, blurred vision and difficulty concentrating.

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? Nausea and vomiting Extreme thirst Flushed skin Fever

Nausea and vomiting~ A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level. Extreme thirst is an expected finding for a client who has hypernatremia. Flushed skin is an expected finding for a client who has hypernatremia. Fever is an expected finding for a client who has hypernatremia.

A nurse is evaluating a patient with 9/10 pain caused by a broken finger. Which of the following vital signs doesthenurseanticipate? Selectallthatapply. a. Tachycardia b. Hypertension c. Bradycardia d. Hypotension e. Tachypnea

Patients with acute pain may have abnormal vital signs including tachycardia, hypertension, and tachypnea

A nurse is planning care for a client who has fluid volume excess. Which of the following interventions should the nurse include in the plan? Select all that apply. Check the client's weight 2 times per week Place the client in a semi-Fowler's position Monitor the client's breath sounds Change the client's position every 4 hrs Assess the client for peripheral edema

Place the client in a semi-Fowler's position When generating solutions, the nurse should place the client in semi‑Fowler's or Fowler's position, and reposition every 2 hrs to reduce the risk for tissue breakdown. Monitor the client's breath sounds The nurse should monitor the client's breath sounds, because the client is at risk for pulmonary edema. Assess the client for peripheral edema The nurse should assess and monitor the client for peripheral edema.

Asking the client to rate the level of the pain is using the severity component of the PQRST mnemonic. The nurse should use the PQRST mnemonic to obtain more information about the client's pain Administer oxygen at 2 L/min Administer prescribed analgesic medication. Encourage coughing and deep breathing. Raise the head of the bed.

Raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 m Eq/mL). rationales for wrong answers are HELPFUL AF Hyperventilation, from acute pain or anxiety, can causes respiratory alkalosis. In the presence of respiratory alkalosis, the client's blood gas values meet the following criteria: a pH greater than 7.45, a PaCOz less than 35 mm Hg, and a HCO3 of 22 to 26 mEq/mL. Ketoacidosis can cause metabolic acidosis. In the presence of metabolic acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 that is normal if uncompensated (35 to 45 mm/Hg), and a HCO3 less than 22 mEq/mL. Persistent vomiting can cause metabolic alkalosis. In the presence of metabolic alkalosis, the client's blood gas values meet the following criteria: a pH greater than 7.45, a PaCO2 that is normal if uncompensated (35 to 45 mm/Hg), and a HCO3 that is greater than 26 mEq/mL.

A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST mnemonic?

Severity Asking the client to rate the level of the pain is using the severity component of the PQRST mnemonic. The nurse should use the PQRST mnemonic to obtain more information about the client's pain

Expected reference ranges Sodium: Calcium: Potassium: Magnesium: Chloride: Phosphorus:

Sodium: 136 to 145 mEq/L Calcium: 9.0 to 10.5 mg/dL Potassium: 3.5 to 5.0 mEq/L Magnesium: 1.3 to 2.1 mEq/L Chloride: 98 to 106 mEq/L Phosphorus: 3.0 to 4.5 mg/dL

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of nociceptive pain? Strained muscle Post-herpetic neuralgia Diabetic neuropathy Phantom limb pain

Strained muscle Nociceptive pain is pain that is caused by somatic origin or visceral origin. Somatic pain occurs due to damage to bone, joints, muscle, skin, or connective tissue. Visceral pain occurs due to damage to a visceral organ, such as the gastrointestinal tract or pancreas. Neuropathic pain is caused by damage to the somatosensory system. Examples of neuropathic pain can include post-herpetic neuralgia. Examples of neuropathic pain can include diabetic neuropathy. Examples of neuropathic pain can include phantom limb pain.

Nurses' Notes 1200: Client has severe right wrist pain following a fall Past medical history: Anemia, osteoporosis, and congestive heart failure Current Medications: Ferrous sulfate 325 mg po daily, alendronate 70 mg po once per week, and furosemide 40 mg po QD 18 g IV started in the client's left antecubital 0.9% sodium chloride IV infusion initiated at 150 mL/hr per provider's prescription Temperature 36.9° C (98.4° F) Apical pulse 88/min Respiratory rate 20/min Blood pressure 118/78 mm Hg Pulse oximetry 97% on room air 1315: Client requested pain medication. Rates pain as 8 on a scale of 0 to 10. Client given 4 mg of IV morphine per provider's prescription Following administration, the client became lethargic and respirations decreased to 6/min. Naloxone IV was administered per provider's prescription. Client is still lethargic at this time, but respirations have increased. Provider notified. Temperature 37.2° C (99° F) Apical pulse 76/min Respiratory rate 10/min and shallow Blood pressure 110/70 mm Hg Pulse oximetry 91% on room air what is the pt at risk for developing

The client is at risk for developing respiratory acidosis and hypervolemia

The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the following findings nurse are manifestations of fluid volume deficit? Select all that apply. Potassium level Urine specific gravity Heart rate Temperature Oxygen saturation

Urine specific gravity Heart rate Temperature When recognizing cues, the nurse should identify that concentrated urine, tachycardia, and elevated temperature are manifestations of fluid volume deficit.

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? Urine specific gravity 1.035 Hematocrit 44% BUN 19 mg/dL sodium 155 mEg/L

Urine specific gravity 1.035 A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030. A BUN of 19 mg/dL is within the expected reference range. A client experiencing fluid volume deficit would manifest an increased BUN. A sodium finding of 155 mE/L is above the expected reference range. A client experiencing fluid volume deficit would manifest a sodium level within the expected reference range

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? Hyperactive reflexes Extreme thirst Weak, irregular pulse Hyperactive bowel sounds

Weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias. The client who has hypokalemia will experience muscle weakness and hyporeflexia (depressed deep tendon reflexes) Extreme thirst is a common manifestation of elevated sodium levels Hyperactive bowel sounds are a common manifestation of elevated potassium levels

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CA). Which of the following parameters should the nurse use first in order to assess the client's pain level? pulse and blood pressure findings behavioral indicators and effect scheduled treatments and client illness a self-report pain rating scale

a self-report pain rating scale Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client's self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

After assessing four patients, which will the triage nurse identify to be seen first in the ED? • Patient with fever of 101.2°F • Patient who reports slurred speech • Patient who reports bilateral ear pain • Patient with urinary burning and frequency

• Patient who reports slurred speech its giving stroke vibes

A patient has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The patient reports that the drug is no longer controlling the pain. What does the nurse suspect? a. There is likely a history of addiction. b. Tolerance to the opioid is developing. c. Physical dependence is developing. d. Thepatientisopioid-naïve.

b. Tolerance to the opioid is developing. A patient who has been receiving the same dose of an opioid for several days and now reports that the drug is not controlling the pain is likely developing tolerance. This is not the same thing as addiction or physical dependence. Physical dependence is manifested when a drug is stopped and the patient shows withdrawal symptoms. Tolerance means the body has adapted to the drug and the patient may require an increased dose or switching to a different drug for pain control. An opioid-naïve person has not recently taken enough opioid on a regular basis to become tolerant to the effects of an opioid. Tolerance does not indicate addiction or a history of addiction.

A nurse is caring for a client who was in a motor‑vehicle accident and reports chest pain and difficulty breathing. A chest x‑ray reveals the client has a pneumothorax. Which of the following ABG results should the nurse expect? pH 7.25 PaCO2 52 mm Hg HCO3− 24 mEq/L pH 7.42 PaCO2 38 mm Hg HCO3− 23 mEq/L pH 7.30 PaCO2 36mm Hg HCO3− 18mEq/L pH 7.50 PaCO2 29 mm Hg HCO3− 26 mEq/L

pH 7.25 PaCO2 52 mm Hg HCO3− 24 mEq/L the nurse should expect the client who has a pneumothorax to have respiratory acidosis. A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis.

A nurse is teaching a group of nurses about acid-base imbalances. Match the acid-base imbalance with the ABG result. pH 7.30 PaCO 2 48 mm Hg HCO 3 − 26 mEq/L pH 7.50 PaCO 2 28 mm Hg HCO 3 − 24 mEq/L pH 7.32 PaCO 2 35 mm Hg HCO 3 - 18 mEq/L pH 7.50 PaCO 2 38 mm Hg HCO 3 − 30 mEq/L

respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis the nurse should instruct that in respiratory acidosis, the pH is less than 7.35, the PaCO 2 is greater than 45 mmHg, and the HCO 3 - is 22to 26mEq/L. The nurse should instruct that in respiratory alkalosis, the pH is greater than 7.45, the PaCO 2 is less than 35 mmHg, and the HCO 3 - is 22 to 26 mEq/L. The nurse should instruct that in metabolic acidosis, the pH is less than 7.35, the PaCO 2 is 35 to 45 mmHg, and the HCO 3 - is less than 22 mEq/L. The nurse should instruct that in metabolic alkalosis, the pH is greater than 7.45, the PaCO 2 is 35 to 45 mmHg, and the HCO 3 - is greater than 26 mEq/L.

A nurse is administering a cold therapy application to a patient. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. Hypotension b. Numbness c. Shivering d. Reduced blood viscosity

shivering Cold therapy can cause shivering. This would be an indication for discontinuing the application due to a systemic response. Cold therapy would not cause hypotension. Cold therapy can cause a localized numberness, not systemic. Cold therapy can increase blood viscosity.

Manifestations of hypokalemia

the nurse should instruct manifestations of hypokalemia include hypoactive bowel sounds and dysrhythmias. Manifestations of hyperkalemia includes tall, peaked t-waves on an ECG and hypotension. Manifestations of hypocalcemia include positive Trousseau's sign and paresthesia. Manifestations of hyponatremia with hypervolemia include a full bounding pulse and hypothermia.

example of a condition that would put pt at risk for hyperkalemia

the nurse should instruct that diabetic ketoacidosis places a client at risk for hyperkalemia. During acidosis, hydrogen enters cells and potassium is pushed out of cells, causing blood potassium levels to rise

What clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a patient with dehydration? Select all that apply. ̶ Blood pressure ̶ Deep tendon reflexes ̶ Hand-grip strength ̶ Pulse rate and quality ̶ Skin turgor ̶ Urine output

̶ Blood pressure ̶ Pulse rate and quality ̶ Urine output

What responses does the nurse expect as a result of infusing 500ml of 3% saline intravenous solution into a patient over a 1-hour time period? ̶ Plasma volume osmolarity increases; blood pressure increases ̶ Plasma volume osmolarity decreases; blood pressure increases ̶ Plasma volume osmolarity increases; blood pressure decreases ̶ Plasma volume osmolarity decreases; blood pressure decreases

̶ Plasma volume osmolarity increases; blood pressure increases 3 % intravenous saline solutions are Hypertonic solutions which causes an increase in plasma sodium and plasma osmolarity. Also it causes free water shift or osmosis from intracellular space to extracellular space , resulting in an increase in Blood pressure.

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED? • Assess breath sounds and respiratory efforts • Establish vascular access with a large-bore catheter • Remove clothing to perform a complete physical assessment • Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)

• Assess breath sounds and respiratory efforts literally assess airway was priority action unless pulseless then CAB

The nurse is preparing to administer an opioid analgesics. Which of the following is a contradiction to administering this medication? Patient reports pain of 7/10 Patients respiratory rate is 8 breaths per minute The patient's heart rate is 96 beats per minute The patient's blood pressure is 129/85

• B: Patients respiratory rate is 8 breaths per minute• Normal respiratory rate is 12-20 breaths/min• Opioid medications can cause respiratory depression.

A nurse is caring for a patient who came into the emergency department after an injury to the right arm. The nurse is assessing the patient's pain. Which question should the nurse ask first? a) "Whereisyourpain?" b) "Whatdoesitfeellike?" c) "Howdoesitchangewithtime?" d) "Howsevereisyourpain?"

• When performing a comprehensive pain assessment, it is important to first identify where the pain is located. The first question the nurse should ask is "where is your pain?"