Module 5 & 6 Quizzes
Match the etiology to the correct acid-base imbalance: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis 1. Hyperventilation 2. Renal failure 3. COPD 4. Vomiting
A 2 B 4 C 1 D 3
At home, which of the following is the safest exercise for the nurse to recommend for the client when recovering from a CABG? A. Jogging in place B. Swimming for 15 minutes C. Walking on a treadmill D. Using a rowing machine
ANS: Walking on the treadmill is provides the least amount of stress on the heart. Swimming can be good, but doing in for 15 minutes with a lot of arm movement could be fatiguing and strenuous.
The client has the following ABGs. Which system will compensate to return the pH to its normal level? pH 7.30 pCO2 42 mmHg HCO3- 20 mmHg A. Respiratory B. Renal
ANS: A
The nurse is caring for the following clients. Which client will the nurse see first? A. The 33-year-old who has a head injury after a motor vehicle accident with a Glasgow Coma Score of 8. B. The 44-year-old who reports left-sided weakness and is scheduled for an MRI. C. The 68-year-old who came in two days ago for a stroke who has right-sided paralysis. D. The 25-year-old with a concussion who is complaining that someone is waking them up every 4 hours.
ANS: A
A nurse is caring for a client waiting to go to surgery for a hemorrhagic stroke. Which client action will indicate a need for the nurse to intervene? A. The client lays down flat to take a nap. B. The client waits to sign their surgical consent form until after the surgeon explains the procedure. C. The client asks the unlicensed assistive personnel to turn off the room lights. D. The client family member closes the room door.
ANS: A A client with a hemorrhagic stroke should have the head of the bed elevated to reduce intracranial pressure.
A nurse is assessing a client who is experiencing an ischemic stroke to determine the appropriateness of alteplase (tPA) administration. Which finding will be a priority for the nurse to report to the healthcare provider? A. The client reports having a robotic hysterectomy two weeks ago. B. The client takes low dose oral progesterone daily for birth control. C. The client has an allergy to ace inhibitors. D. The client's blood pressure is 136/ 82mmHg. Next
ANS: A A recent surgical procedure needs to be reported to the healthcare provider as it is a contraindication to tPA administration.
When a client with a cuffed ET (endotracheal tube) reports shortness of breath, the nurse would collaborate with Respiratory Therapy to assess what? A. assesses for a cuff leak. B. gives the ordered pain medication. C. elevate the head of the bed. D. increase the level of O2 delivery.
ANS: A Assessing for air coming through the mouth and not the tube indicates a leak in the ET tube. Air or Water depending on the type of tube should be added back to the cuff by the Respiratory Therapist.
The client has the following ABGs. Which is the priority nursing intervention? pH 7.30 PaO2 123 mmHg PaCO2 55 mmHg HCO3 28 mEq/L Oz sat 100% A. Notify Respiratory Therapy that the client is not tolerating the spontaneous breathing trial. B. Give the client metoclopromide IV as ordered.
ANS: A Respiratory acidosis with partial compensation - treat with interventions that blow off PaCO2, coughing, moving, incentive spirometer, increasing RR, increasing TV. It is also an indication that the client is not taking good breaths and is not being successful breathing their own. This is not a metabolic problem. Trying to fix the metabolic problem can worsen the pH and hurt the patient.
Client's ventilator PEEP (positive end-expiratory pressure) was increased from 5 mmHg to 12 mmHg. The nurse would assess for which of the following? SELECT ALL THAT APPLY A. Improved lung sounds B. Blood pressure dropping C. Decreased need for FiO2 D. Rising PaCO2
ANS: A, B, C (A) The PEEP leaves more air/pressure into the alveoli and should improve lung sounds. (B) The increase in PEEP puts a strain on the heart and decreases venous return to the heart. The BP needs to be watched closely for dropping, and if so, the nurse needs to contact the healthcare provider. (C) As the alveoli are opened, there should be a decreased need for Fraction of inspired oxygen (FiO2) i.e. FiO2 100% down to FiO2 of 30% would be a great improvement.
A client has an intracranial pressure (ICP) of 32 mmHg, and a Cerebral Perfusion Pressure (CPP) of 45 mmHg. Which actions will the nurse complete? SELECT ALL THAT APPLY A. Give mannitol IV push B. Document Glasgow Coma Scale score C. Initiate a norepinephrine infusion D. Make client nothing by mouth (NPO) E. Administer nitroprusside IV
ANS: A, B, C, D (A) Hypertonic solutions would be indicated to pull fluid from the tissues into the vascular space. (B) This documentation communicates to everyone on the team the neurologic condition of the client. (C) The CPP needs to be greater than 60 mmHg, so we need a pressor to increase BP. (D) This would prevent aspiration as the client is having a neurologic change.
Which of the following actions will the nurse implement when caring for a client who has an intracranial pressure (ICP) monitor? SELECT ALL THAT APPLY A. Zeroes the transducer at the tragus. B. Maintain spinal precautions C. Limits the number of times the system is opened. D. Uses strict aseptic technique to change dressings. E. Keep the HOB < 30 degrees
ANS: A, B, C, D (A) Zeroing at the midbrain (the tragus - the flap on the external ear) is needed for accurate ICP readings. (B) If a client has a head injury that requires ICP monitoring, the client should have a C-Collar on and maintain spinal precautions. (C) The less times the ICP catheter is accessed, the less chance of displacement and infection. (D) This will help prevent infection.
The client has the below lab values. Which clients would best fit with these values? SELECT ALL THAT APPLY pH 7.32 PaO2 88 mmHg CO2 48 HCO3- 26 PaCO2 48 mmHg HCO3 26 mEq/L O2 sat 96% A. Post surgical client not coughing. B. Client with chronic obstructive airway disease. C. Client with infection. D. Client with an opioid overdose. E. Client with vomiting.
ANS: A, B, D Client has respiratory acidosis with no compensation. This would be true for opioid overdose that depresses the respiratory drive and retain PaCO2, for post-surgical clients, and for chronic obstructive airway diseases like COPD.
A client who was admitted with a head injury is now having trouble staying awake. Which actions are appropriate for the nurse to implement? SELECT ALL THAT APPLY A. Obtain a Glasgow Coma Scale (GCS) level. B. Monitor for seizures. C. Give intravenous morphine for pain. D. Assess the ability to swallow. E. Check for breathing difficulties.
ANS: A, B, D, E (A) This would be utilized to have an objective way to note progress, either better or worse in the neurologic assessment. (B) This would be a sign of increased intracranial pressure (ICP). (D) We should assess the ability to swallow to prevent aspiration. (E) Assessing for maintaining airway is a priority.
The client presents with this lab. Which nursing interventions would be appropriate? SELECT ALL THAT APPLY pH 7.32 PaO2 80 mmHg PaCO2 60 mmHg HCO3 27 mEq/L O2 sat 95% A. Have client use an incentive spirometer 10 times every hour. B. Turn, cough, deep breathe. C. Place oxygen on patient. D. Give 1 amp Sodium Bicarbonate IV. E. Get client up and walk.
ANS: A, B, E The problem is a respiratory acidosis with partial compensation. The main problem is the client is not blowing off enough CO2. Coughing, deep breathing, incentive spirometry, and getting the patient up and moving all would help lower the PaCO2.
At 9 AM a client is placed on a T-piece (blow-by) for weaning from the mechanical ventilator. The nurse assesses for what changes to know that the client is not tolerating the change? SELECT ALL THAT APPLY A. O2 sats < 94% B. Tidal Volumes increasing C. Use of accessory muscles D. RR > 20 E. Calm demeanor
ANS: A, C, D (A) O2 sats > 94% indicate a PaO2 above 80mmHg and 80-100 mmHg is normal. Anything lower than this except for COPD clients would indicate worsening. (C) This would indicate an increased workload and indicate client may exhaust themselves. (D) Increase RR greater than 20 indicates working too hard and not tolerating this.
Which education will the nurse include when teaching a client who is being dismissed after a transient ischemic attack about how to prevent an ischemic stroke? SELECT ALL THAT APPLY A. Avoid smoking and secondhand smoke. B. Do not use garlic when seasoning your foods. C. Exercise for 30 minutes at least five times a week. D. Take your nicardipine daily for hypertension as prescribed.
ANS: A, C, D (A) Smoking or frequent exposure to secondhand smoke increases the risk of stroke, so should be avoided. (C) Daily exercise is an important way to decrease the risk of stroke. (D) Calcium channel blockers such as nicardipine are helpful to lower blood pressure through vasodilation which is beneficial in preventing strokes
As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would do which of the following? SELECT ALL THAT APPLY A. Administer furosemide IV as ordered. B. Monitor vital signs every 30 to 45 minutes until stable. C. Get cultures prior to antibiotics as ordered. D. Provide antianxiety medication to calm the client down. E. Collaborate to provide high flow oxygen as ordered.
ANS: A, C, E (A) This would help with the fluid overload of the client. (C) It is important to find the underlying cause of the ARDS and treat with a broad spectrum antibiotic until the results come back. (E) With all the fluid, the client will need high flow oxygen and maybe a ventilator to keep the alveoli from collapsing.
The client comes in with shortness of air and dyspnea and subcutaneous emphysema. When assessing the client, the nurse notes decreased breath sounds on the right lower lobe. Which action will be appropriate for the nurse to perform? A. Advocate for a chest x-ray. B. Call for a stat intubation. C. Prepare for setting up a chest tube drainage system. D. Start the IV Propofol infusion. E. Place oxygen on the client.
ANS: A, C, E The client presents as if he/she has a pneumothorax, so giving oxygen and asking for a chest X-Ray and setting up a chest tube drainage system would be appropriate. It is not indicated to intubate the client. We would not start IV Propofol unless the client was already intubated because it may stop their breathing.
A client who was extubated 2 hours ago states, "I feel restless." The chart readings are recorded prior to extubation and after extubation. What would be the priority intervention for the nurse to perform? Readings prior to extubation HR 88 bpm RR 18 breaths/minute BP 138/78 mmHg PaCO2 45 mmHg PaO2 80 mmHg Readings after extubation HR 104 bpm RR 26 breaths/minute BP 140/80 mmHg PaCO2 62 mmHg PaO2 48 mmHg A. Obtain a complete blood count (CBC). B. Assist with reintubation. C. Administer a nebulized bronchodilator. D. Assist with tracheotomy procedure.
ANS: B Collaborating with Respiratory Therapy to give a breathing treatment would be good but the readings require a more urgent and invasive intervention. This may be done earlier in the process. Right now, assisting with reintubation is the priority. The client has signs that the respiratory drives are failing. The O2 is lower than 50 mmHg and the CO2 is higher than 60 mmHg. This requires an emergent intervention.
All patients have been extubated from mechanical ventilation during their hospital stay. Which patient should the nurse see first? A. O2 sats 92%, complains of the time the doctor took to examine him/her B. RR 22, using accessory muscles, confusion C. Pt complaining of difficulty breathing while walking D. Pt coughing up clear mucous with every deep breath
ANS: B Elevated RR, using extra effort, and confusion shows a patient that is hypoxic and needs to be seen first.
A client with Broca's aphasia after a stroke is tearful when trying to communicate with family and medical staff. Which action will the nurse complete first? A. Finish the client's sentences about what they are feeling. B. Sit down at the bedside and take time to listen to the client describe how they are feeling. C. Call speech therapy to assess the client's needs. D. Administer the first dose of a newly prescribed antidepressant.
ANS: B Sitting down at the client's bedside will demonstrate that you have time to listen and allow the client to take the time they need to search for the words they need to share their feelings. It is important to encourage verbal communication to help them rebuild nerve pathways.
The client has a chest tube to -20 cm suction via the chest tube drainage system. The healthcare provider calls to order to place the chest tube to water seal, which nursing assessment would the nurse advocate for staying on suction? A. The cough is now productive. B. Bubbling in the water seal chamber. C. The drainage changed to serous. D. Lung sounds heard bilaterally.
ANS: B The bubbling in the water seal chamber indicates a air leak, and the nurse would advocate for the suction to continue. The others are expected findings. Sanguineous to change to serous drainage means bleeding is stopping. Lungs are expanding, and has a more forceful productive cough.
A nurse is caring for a client who has a CPP reading of 45 mmHg. Which medication(s) will the nurse advocate for when calling the healthcare provider? A. Epinephrine IV push B. Dopamine, Norepinephrine, and Phenylephrine infusions C. Lidocaine, Procainamide, Amiodarone infusions D. Nitroglycerin, Nitroprusside, Labetalol infusions
ANS: B These will raise the BP and the CPP (MAP-ICP = CPP).
The client is extremely anxious about an upcoming exam. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.48 PaO2 77 mmHg PaCO2 30 mmHg HCO3 24 mEq/L O2 Sat 92% A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
ANS: B This is correct. pH is base, PaCO2 is 30 - This is my respiratory system, my acid system. Do I have too much or too little acid? Too little, this makes it a base. HCO3 is normal. Client needs more O2, but will not correct the pH as oxygen has nothing to do with correcting pH.
In the nursing care of a client recently intubated and placed on mechanical ventilation, the nursing action that would take highest priority is A. Suctioning the client every hour B. monitoring End Tidal CO2 continuously C. monitoring temperature every 4 hours. D. turning the client every 3 hours.
ANS: B This is the priority assessment to assure placement of the tube into the lungs, CO2 readings should be 35-40 mmHg on an End Tidal CO2 monitor.
A nurse is monitoring a client after a fall. Which assessment finding(s) will the nurse notice as an indication to transfer the client to an ICU? A. Pupils that react to light and accommodates briskly. B. A weak and thready pulse with cool, clammy skin. C. Some blood noted on the forehead bandage. D. A headache which improves after pain medication administration.
ANS: B This would indicate rising ICP.
The nurse monitoring a client with acute respiratory distress syndrome (ARDS) would notify the healthcare provider with which of the following assessments? SELECT ALL THAT APPLY A. an enlarged heart. B. atelectasis. C. decreasing PaO2. D. elevated WBC. E. pulmonary edema.
ANS: B, C, D, E (B) Diminished lung sounds and poor gas exchange would indicate worsening ARDS. (C) This would indicate worsening and should be identified early. (D) Signs of infection could be the source of ARDS or the ARDS could cause a complication such as infection. (E) This would indicate that fluid third spacing to the lung tissue and would be worsening.
A client is admitted to the floor for a coronary artery bypass graft (CABG) surgery scheduled for tomorrow. Which education should the nurse include in the plan of care? SELECT ALL THAT APPLY A. Explain the IV infusions the client will have after surgery B. Discuss with the client that they will come back on a breathing machine C. Show the client how to splint with the heart pillow when coughing and deep breathing D. Teach client how to use the incentive spirometer 10 times every hour E. Tour of the unit where the client will go to after surgery.
ANS: B, C, D, E Touring the unit and explaining that the client will be on a ventilator is important as that can be a scary feeling after surgery. Teaching how to use an incentive spirometer and splint when coughing and deep breathing will help reinforce this for after surgery. These will lend a sense of familiarity to the client and help them reorient and learn easier. The IV infusions are variable. By the time the client may be aware of infusions, they may be weaned off. It will be addressed at the time after surgery, no way to predict exactly which ones will be there at any given time.
A client has a coronary artery bypass graft (CABG) X 4, returns on a ventilator to the SICU with IV Propofol, nitroglycerin, and norepinephrine. The blood pressure is 140/70 mmHg, HR is 112, and client is beginning to arouse. Which actions should the nurse take? SELECT ALL THAT APPLY A. Increase the norepinephrine IV infusion B. Decrease the norepinephrine IV infusion C. Decrease the nitroglycerin IV infusion D. Increase the Propofol IV infusion E. Increase the rate on the ventilator F. Decrease the Propofol IV infusion G. Increase the nitroglycerin IV infusion
ANS: B, D, G Increasing sedation would be correct and then increasing the nitroglycerin and decreasing the norepinephrine IV infusions. We would do one at a time, but the nurse would do it quickly to have the SBP 90-120 mmHg for the first few hours to reduce the strain on the new graft sites. There is no indication to raise or lower the respiratory rate.
A client's ventilator alarm begins to sound an alarm. The nurse enters the room and notes that the "low expired minute volume" alarm is sounding. After quickly determining that the client is in no acute distress, the nurse would A. add more water to the humidifier. B. look for a kink in the tubing. C. look for a leak or disconnection in the system. D. suction the client.
ANS: C
The client comes to SICU on a nitroprusside IV infusion for the first 2 hours after CABG X 5 to keep the SBP < 120 mmHg. The nurse assesses the vital signs, which action would be the priority? HR 110 bpm BP 122/64 mmHg RR 18 per min O2 sats 91% A. Call respiratory therapy to increase the oxygen B. Administer IV Amiodarone. C. Increase the Nitroprusside. D. Advocate for a order to treat pain.
ANS: C The parameter that is worrisome is the BP being too high. Increase the Nitroprusside would be the priority.
A nurse is reviewing a set of current vital signs documented in the electronic health record for a client who was admitted for a severe headache after a traumatic brain injury (TBI). Which evidence based protocol actions will the nurse complete? SELECT ALL THAT APPLY 1 hour ago T 98.8 F P 76 BP 126/62 mmHg RR 12 Current T 99.4 F P 56 BP 178/42 mmHg RR 24 A. Administer the nitroglycerin IV infusion B. Lower the head of the bed. C. Assess level of consciousness. D. Hang the 7% Sodium Chloride. E. Notify the Healthcare Provider.
ANS: C, D, E (C) Checking the client first would be a high priority to see if the patient can support their own airway. (D) The vital signs indicate an increase in intracranial pressure (ICP), so a hypertonic solution would be indicated. (E) Changes in neurological status should be reported to the provider.
A client comes to the SICU after a coronary artery bypass graft, on the ventilator, and 3 chest tubes connected to one chest tube drainage system. The first hour the client has out 100 mL, second hour the client has out 90 mL, the third hour the client has out 125 mL. Which actions would be appropriate for the nurse before calling the healthcare provider? SELECT ALL THAT APPLY A. Collaborate with respiratory therapy B. Draw an arterial blood gas C. Check the urine output D. Check a blood pressure E. Examine the chest tube sites
ANS: C, D, E Check a blood pressure for low perfusion due to blood loss, assess the chest tube sites for signs of bleeding, and check urine output dropping for signs of dehydration.
The nurse who works on the neurological floor is caring for the following clients. Which client will the nurse see first? A. The client who had a surgical aneurysm repair after a hemorrhagic stroke three days ago who is scheduled for a follow-up MRI today. B. The client who is being transferred to the medical surgical unit today after improvement of symptoms following a transient ischemic attack. C. The client who is experiencing impulsivity after a stroke who has a sitter at the bedside. D. The client who received intravenous alteplase two days ago after an ischemic stroke who is reporting a severe headache.
ANS: D A severe headache can be a symptom of increased ICP or a hemorrhagic stroke, so this client needs to be assess right away.
A patient is on mechanical ventilation. The nurse advocates for which intervention as a priority for his/her patient: A. Provide oral care with hydrogen peroxide every 4 hours B. Stop all sedation immediately C. Raise the Head of the bed to 20 degrees D. Call for a patient to be started on lansoprozole
ANS: D Reducing stomach acid with help prevent aspiration
A post-CABG patient has a heart rate of 74. What is the target heart range for this patient during exercise? A. 70-90 B. 110-120 C. 100-110 D. 90-100
ANS: D Target heart rate should be about 20-25 beats above the baseline.
A nurse is caring for a client who has an intracranial pressure reading of 33 mmHg. Which medication will the nurse advocate for when calling the healthcare provider? A. Labetalol B. Naloxone C. Furosemide D. Mannitol
ANS: D This is a hypertonic solution that will lower the ICP.
A nurse is assessing a client who has a history of a transient ischemic attack. Which finding will the nurse identify as the most concerning? A. Client states they have a coworker who takes frequent breaks to smoke outside. B. Client's current blood pressure is 136/86 mmHg. C. The client states that their daily fasting blood sugars have been in the 100 to 110 g/dL range. D. The client states they have not been taking the prescribed atorvastatin because they cannot afford the medication.
ANS: D This is the most important finding because untreated hyperlipidemia is a risk factor for stroke and this client has not been taking their medication. Additionally, if they are unable to fill this prescription, finding out if they are not taking other prescribed medications like aspirin or an antihypertensive is very important.