Semester 3 Unit 6

A 3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, the respiratory rate is 56 breaths/min, the pulse is 102 beats/min, and there is a nonproductive cough. What does the nurse expect regarding the child's blood gas values? 1 pH of 7.32 2 Po 2 of 95 mm Hg 3 Pco 2 of 40 mm Hg 4 HCO 3 - of 26 mEq/L (26 mmol/L)

A pH of 7.32 is less than the expected range of 7.35 to 7.45; hypoxia causes hypercapnia, which results in a decrease in the pH. A Po 2 of 95 mm Hg is within the expected range of 80 to 100 mm Hg. A Pco 2 of 40 mm Hg is within the expected range of 35 to 45 mm Hg. An HCO 3 - of 26 mEq/L (26 mmol/L) is within the expected range of 21 to 28 mEq/L (21 to 28 mmol/L).

A patient is experiencing withdrawal from opioids. The nurse expects to see which assessment finding most commonly associated with acute opioid withdrawal? a. Elevated blood pressure b. Decreased pulse c. Lethargy d. Constipation

a. Elevated blood pressure

The nurse is teaching a class about the effects of alcohol. Long-term excessive use of alcohol is associated with which of these problems? (Select all that apply.) a. Coronary artery disease b. Wernicke's encephalopathy c. Polyneuritis d. Seizures e. Cirrhosis of the liver f. Korsakoff's psychosis

b. Wernicke's encephalopathy c. Polyneuritis e. Cirrhosis of the liver f. Korsakoff's psychosis

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? A. Atrial fibrillation B. Forearm laceration C. Migraine headache D. Respiratory infection

A. Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. A forearm laceration, migraine headache, or a respiratory infection does not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

(nurse sarah) Diabetic ketoacidosis, aspirin toxicity, and renal failure are examples of the causes of ___________________. A. High anion gap metabolic acidosis B. Normal anion gap metabolic acidosis C. Low anion gap metabolic acidosis D. Normal anion gap respiratory acidosis

A. High anion gap metabolic acidosis

(Nurse Sarah) A patient is experiencing respiratory acidosis due to brain trauma. Which of the following lab values correlates with this acid imbalance? A. Potassium level of 6.0 B. Potassium level of 2.5 C. Potassium level of 5.0 D. Potassium level of 3.5

A. Potassium level of 6.0

The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia. Which statements provided by a student nurse indicate the need for further learning? Select all that apply. A. "The client would show signs of twitching." B. "The client would show signs of hyporeflexia." C. "The client would show signs of paresthesias." D. "The client would show signs of muscle cramping." E. "The client would show signs of skeletal muscle weakness.

B. "The client would show signs of hyporeflexia." C. "The client would show signs of paresthesias." the neuromuscular manifestation of alkalosis with hypocalcemia is hyperreflexia, not hyporeflexia. Paresthesias is a symptom of alkalosis, which is manifested in the central nervous system not the neuromuscular system. The manifestation of alkalosis is neuromascular and can be observed through twitching, muscle cramping, and skeletal muscle weakness.

(Nurse Sarah) A patient has the following blood gases: PaCO2 25, pH 7.50, HCO3 19. Which of the following could NOT be the cause of this condition? A. Anxiety attack B. Chronic obstructive pulmonary disease (COPD) C. Fever D. Aspirin toxicity

B. Chronic obstructive pulmonary disease (COPD)

(nurse sarah) A patient has the following arterial blood gases: PaCO2 33, HCO3 15, pH 7.23. Which condition below is presenting? A. Metabolic alkalosis partially compensated B. Metabolic acidosis partially compensated C. Respiratory alkalosis not compensated D. Metabolic acidosis fully compensated

B. Metabolic acidosis partially compensated

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? A. The stockings should reach the middle of the knee. B. The stockings should be applied before getting out of bed. C. The stockings should be applied at the first sign of discomfort. D. The stockings may be substituted with loose elastic bandages

B. The stockings should be applied before getting out of bed. To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; loose elastic bandages may slip, creating uneven, ineffective pressure. Edema also may result.

Which of the following is least risky initial testing for a PE? A. Doppler US - identify DVT/Embolus B. V/Q scan C. Helical CT Angiogram D. D-Dimer

B. V/Q scan

(Nurse Sarah) Respiratory alkalosis can affect other electrolyte levels in the body. Which of the following electrolyte levels can also be affected in this condition? A. Calcium and sodium levels B. Potassium and sodium levels C. Calcium and potassium levels D. Potassium and phosphate levels

C. Calcium and potassium levels

A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed? A. Getting her involved with a rape therapy group B. Remaining available and supportive to limit destructive anger C. Exploring her feelings about men to promote future relationships D. Providing a safe environment that permits the ventilation of feelings

D. Providing a safe environment that permits the ventilation of feelings

The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and the elderly due to: a. The love they have for parents or children. b. Their limited options. c. The need to feel safe at home. d. Other relatives do not want them.

b. Their limited options.

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What withdrawal complication does the nurse anticipate that the client may experience? A. Ataxia B. Seizures C. Diarrhea D. Urticaria

B. Seizures Seizures are a serious side effect that may occur with abrupt withdrawal from barbiturates. Ataxia, diarrhea, and urticaria are not associated with barbiturate withdrawal

Match the following 1. Respiratory alkalosis 2. Metabolic acidosis 3. Metabolic alkalosis 4. Respiratory acidosis A. Compensatory response is ↑ HCO3− excretion by kidney B. Compensatory response is ↑ CO2 retention by lungs C. Compensatory response is ↑ CO2 excretion by lungs D. Compensatory response is ↑ HCO3− retention by kidney

1. A 2. C 3. B 4. D Respiratory alkalosis compensatory response is ↑ HCO3− excretion by kidney Metabolic acidosis compensatory response is ↑ CO2 excretion by lungs by rapid breathing Metabolic alkalosis compensatory response is ↑ CO2 retention by lungs by decreasing respiratory rate Respiratory acidosis compensatory response is ↑ HCO3− retention by kidney

A client who had thoracic surgery is admitted to the postanesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system? 1. Ensure the security of the connections from the client to the drainage unit. 2. Empty the drainage container and measure and record the amount once a day. 3. Verify that there is vigorous bubbling in the wet suction control compartment. 4. Check that the fluid level in the water-seal compartment increases with expiration.

1. Ensure the security of the connections from the client to the drainage unit. The system must remain airtight (closed) to prevent collapse of the lung. The system is kept closed; a record of drainage is kept by marking the outside of the container or chamber. It should bubble but not vigorously; vigorous bubbling will not increase the suction but will cause the fluid to evaporate more rapidly. The water level will fluctuate as the client inhales and exhales. The level will increase with inspiration and decrease with expiration; this is known as tidaling.

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1 Cardiac arrest 2 Carbonic acid deficit 3 Reduction in serum pH 4 Excess oxygen saturation

2 Carbonic acid deficit Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.

The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?______

880 units. If there are 20,000 units of heparin in 500 mL of D5W, then there are 40 units in each mL.20,000 ÷ 500 = 40 unitsIf 22 mL are infused per hour, then 880 units of heparin are infused each hour.40 × 22 = 880

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

A. "I should assess for low blood pressure." B. "I should assess for increased digitalis toxicity." C. "I should assess for a decreased rate of ventilation in respiratory alkalosis." The nurse should assess for low blood pressure and increased digitalis toxicity as cardiovascular manifestations of alkalosis, not respiratory manifestation. The nurse should assess for increased rate of ventilation in respiratory alkalosis. The nurse should assess for increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A. A 59-year-old who had a knee replacement B. A 60-year-old who has bacterial pneumonia C. A 68-year-old who had emergency dental surgery D. A 76-year-old who has a history of thrombocytopenia

A. A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.

What does the term "smokeless tobacco" refer to? Select all that apply. A. A substitute for cigarettes B. Tobacco products that are safe for adolescents C. Tobacco products that produce less smoke D. Tobacco products with carcinogenic chemicals E. Tobacco products placed in mouth but not ignited

A. A substitute for cigarettes D. Tobacco products with carcinogenic chemicals E. Tobacco products placed in mouth but not ignited "Smokeless tobacco" is the term used for tobacco products that are cigarette substitutes. These items are consumed by placing them in mouth, but they are not ignited. Smokeless tobacco contains carcinogenic agents that are not safe in adolescents. Tobacco products that produce less smoke are not considered smokeless.

A nurse is caring for several clients who are going through withdrawal from alcohol. What is the primary reason for the ingestion of alcohol by clients with a history of alcohol abuse? A. Are dependent on it B. Lack the motivation to stop C.Have no other coping mechanism D. Enjoy the associated socialization

A. Are dependent on it Alcohol causes both physical and psychological dependence; the individual needs and depends on the alcohol to function. The theory that alcoholics have no other coping mechanism is a myth that often is associated with alcoholism; the individual needs to learn how to use other coping mechanisms more consistently and effectively. People with alcoholism commonly drink alone or feel alone in a crowd.

A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial action by the nurse? A. Arranging for a staff member to watch the children so the mother and nurse can talk B. Calling a facility where the mother and her children will be safe until the crisis is resolved C. Determining whether the mother is ambivalent about this decision before making permanent plans D. Suggesting that the mother and her husband return for couples counseling so the marriage can be saved

A. Arranging for a staff member to watch the children so the mother and nurse can talk This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determination of the client's ambivalence may be made, and couples counseling may be recommended eventually, all three actions are premature if a thorough assessment of the situation has not been made.

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? A. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min B. Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min C. Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min D. Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min

A. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid

A nurse knows that individuals who are alcoholics use alcohol for what reason? A. Blunt reality B. Precipitate euphoria C. Promote social interaction D. Stimulate the central nervous systems.

A. Blunt reality Alcohol, by depressing the central nervous system and distorting or altering reality, reduces anxiety. Alcohol depresses the central nervous system; it may cause lability of mood, impaired judgment, and aggressive actions rather than euphoria. Although alcohol is used as a social lubricant, alcoholics frequently drink in isolation. Also, alcohol can lead to inappropriate and aggressive behavior that may impair social interaction. Alcohol depresses the central nervous system; amphetamines and cocaine are stimulant

An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? A. Breathe into cupped hands. B. Pant using rapid, shallow breaths C. Use a rapid deep-breathing pattern D. Hold the breath for as long as possible.

A. Breathe into cupped hands. Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis A. Metabolic acidosisThe low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

(Nurse Sarah) A patient is post-opt from knee surgery. The patient has been receiving Morphine 4 mg IV every 2 hours. You notice the patient is exhibiting a respiratory rate of 8 and is extremely drowsy. Which of the following conditions is the patient at risk for? A. Respiratory acidosis B. Respiratory alkalosis C. Hypokalemia D. Metabolic acidosis

A. Respiratory acidosis

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine? A. Risk for self-injury B. Potential for seizure C. Danger of dehydration D. Probability of injuring others

A. Risk for self-injury The greatest risk in cocaine withdrawal is risk for self-injury. The risk for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. People in cocaine withdrawal, although irritable, are more apt to hurt themselves than others.

A pregnant woman continues consuming alcohol during pregnancy. Which teratogenic effects might be seen in the fetus or neonate? Select all that apply. A. Stillbirth B. Ebstein anomaly C. Neural tube defects D. Spontaneous abortion E. Intellectual disabilities

A. Stillbirth D. Spontaneous abortion E. Intellectual disabilities Prolonged fetal exposure to alcohol may cause a stillbirth. A spontaneous abortion may occur if the pregnant woman consumes alcohol in excess amounts. Intellectual disabilities may be seen in the neonate if it is exposed to alcohol in the fetal stage. Ebstein anomaly is caused by lithium exposure during pregnancy. Neural tube defects may be due to exposure to antiseizure drugs during pregnancy.

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? A. Tachycardia B. Hypotension C. Respiratory arrest D. Central nervous system depression

A. Tachycardia Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.

A nurse is assessing a toddler and the dynamics of the child's family, in which abuse is suspected. What behaviors are expected? Select all that apply. A. The child cringes when approached. B. The child has unexplained healed injuries. C. The parents are overly affectionate toward the child. D. The child lies still while surveying the environment. E. The parents give detailed accounts of the child's injuries.

A. The child cringes when approached. B. The child has unexplained healed injuries. D. The child lies still while surveying the environment. The child cringes when approached because past experiences with adults have resulted in pain rather than comfort. Evidence of past injuries may exist, but the parents do not discuss it, because this would be an admission of child abuse. Abused children are always on the alert for potential abuse. Lying motionless is an attempt to avoid attention; also, in the past the abused child's attempts to resist abuse have often precipitated more abuse. Abusive parents are unable to provide any emotional support and will not exhibit overly affectionate behavior. Because abusive parents try to hide the fact of abuse, explanations about injuries are usually fabricated, inconsistent, and vague.

What is the planned effect of naloxone when it is administered for a heroin overdose? A. To compete with opioids for occupancy of opioid receptors B. To prevent excessive withdrawal symptoms as heroin wears off C. To accelerate metabolism of heroin and stimulate respiratory centers D. To stimulate cortical sites that control consciousness and cardiovascular function

A. To compete with opioids for occupancy of opioid receptors Naloxone is used to treat opioid-induced apnea. It competes with the opioid for central nervous system receptor sites and thus acts as an opioid antagonist. Preventing excessive withdrawal symptoms as heroin wears off is not the specific action of this drug. Naloxone does not accelerate the metabolism of heroin. Stimulating cortical sites that control consciousness and cardiovascular function is not the action of naloxone. One adverse reaction of naloxone is cardiovascular irritability.

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon? A. Tolerance B. Habituation C. Physical addiction DPsychological dependence

A. Tolerance Tolerance is a phenomenon that occurs in addicted individuals in which increasing amounts of the drug of addiction are needed to satisfy need; the client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.

A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client? A. Verbalizes that a substance abuse problem exists B. Discusses the effect of drug use on self and others C. Explores the use of substances and problematic behaviors D. Expresses negative feelings about the current life situation

A. Verbalizes that a substance abuse problem exists The client must first acknowledge that a substance abuse problem exists and is creating chaos; verbalizing that a problem exists indicates that the client is not in denial and is taking the first step toward change. Once a problem is identified, the numerous ways in which drug use has controlled the client's life and the resulting lifestyle problems can be explored, and the nurse can help the client express and process negative feelings.

Which of the following are physical signs that a child was abused physically A. Withdrawing behavior in class B. Cigarette burns on arms C. Acting out sexual interactions when playing D. poor hygiene and dirty clothes

B. Cigarette burns on arms

A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? A. Administering an antiviral agent B. Clustering care to conserve energy C. Offering oral fluids to promote hydration D. Providing an antitussive agent whenever necessary

B. Clustering care to conserve energy Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Intravenous fluids are given during the acute phase to prevent dehydration. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.

A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse? A. "Inhalants can cause a mild state of intoxication." B. "Huffing paint can damage your lungs, kidneys, and liver." C. "Withdrawal problems will start if you continue huffing paint." D. "Limiting the type of inhalant used decreases respiratory irritation.

B. "Huffing paint can damage your lungs, kidneys, and liver." Inhaled toxins become systemic and cause damage to major organs such as the lungs, liver, and kidneys. Inhalants tend to produce euphoria, not just a mild state of intoxication. Huffing paint will not produce major withdrawal symptoms. All toxic substances that are inhaled become systemic and cause damage to major organs such as the lungs, liver, and kidneys

A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category? A. An opioid B. A stimulant C. A barbiturate D. A hallucinogen

B. A stimulant Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with the amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.

To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? A. A change in the respiratory rate B. A tingling sensation in the hands C. Periodic changes in the fetal heart rate D. A pulse oximetry reading of less than 98%

B. A tingling sensation in the hands The presence of a tingling sensation in the hands indicates respiratory alkalosis due to a decrease in carbon dioxide. A change in respiratory rate is incorrect because although such a change may contribute to respiratory alkalosis, it is not evidence of an increase in pH. In the presence of maternal respiratory alkalosis, chemical changes in maternal erythrocytes facilitate oxygen release to the fetus, which assists in maintaining a normal fetal heart rate. A pulse oximetry reading of 98% is incorrect because this is a normal finding.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? A. Increase in serotonin B. Deficiency of thiamine C. Reduction in iron intake D. Malabsorption of riboflavin

B. Deficiency of thiamine Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism

A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz (4167 g). The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply. A. Stranger anxiety B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions E. Adequate personal hygiene

B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment. The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.

A client receiving warfarin (Coumadin) therapy reports use of the herb feverfew. The nurse observes the client for evidence of: A. Liver toxicity B. Increased coagulation C. Renal dysfunction D. Increased bleeding potential

B. Increased bleeding potential. Caution patient about certain herbs/dietary supplements bc they may increase the risk of bleeding such as bilberry, black cohosh, chamomile, chondroitin sulfate, DHEA, feverfew, garlic, ginger, ginkgo biloba, ginseng, goldenseal, grapeseed extract, green tea, horse chestnut seed extract, melatonin, niacin, omega-3 fatty acids, psyllium, red yeast rice extract, saw palmetto, soy, turmeric.

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. A. Limiting fluid intake B. Instilling saline nose drops C. Maintaining contact precautions D. Suctioning mucus with a bulb syringe E. Administering warm humidified oxygen

B. Instilling saline nose drops C. Maintaining contact precautions D. Suctioning mucus with a bulb syringe Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? A. Poached eggs B. Spinach salad C. Sweet potatoes D. Cheese sandwich

B. Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

(Nurse Sarah) A patient is experiencing respiratory alkalosis. What is the most classic sign and symptom of this condition? A. Bradypnea B. Tachypnea C. Bradycardia D. None of the options are correct

B. Tachypnea

An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: a. A decrease in family interaction so that there are fewer opportunities for abuse to occur. b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. c. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. d. A triad of treatment modalities, including medication, counseling, and role-playing opportunities.

B. The perpetrator will recognize destructive patterns of behavior and learn alternate responses.

(nurse sarah) A patient has the following arterial blood gases: HCO3 38, pH 7.50, PaCO2 50. Which of the following signs may this patient exhibit as a compensatory mechanism? A. Hyperventilation (tachypnea) B. Hypoventilation (bradypnea) C. Increased potassium level (hyperkalemia) D. Constipation

B: Hypoventilation (bradypnea)

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last several days.

C. "I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic acidosis? A. Type B chronic obstructive pulmonary disease (COPD) and pneumonia B. Acute meningococcal meningitis C. A pancreatic fistula that is draining D. Severe hyperaldosteronism

C. A pancreatic fistula that is draining The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss. Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion. Meningitis can stimulate hyperventilation, which causes respiratory alkalosis. Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

Which of the following is a cause of respiratory acidosis? A. Pulmonary emboli B. Asthma C. Chronic obstructive pulmonary disease (COPD) D. Hyperventilation

C. Chronic obstructive pulmonary disease (COPD)

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? A. Confronting the client about substance abuse B. Avoiding calling attention to the client's drug abuse C. Determining the amount and time of last use of the substance D. Realizing that this client will need more pain medication than a nonabuser

C. Determining the amount and time of last use of the substance Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists, but this is not the priority. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would, but this is not the priority.

The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? A. Ambulating the client to promote circulation B. Inserting two small-bore intravenous catheters C. Determining whether the client feels safe at home D. Ensuring that the client has her glasses to ambulate

C. Determining whether the client feels safe at home Bruising on the backs of both shoulders and both wrists indicates potential abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding. A client in preterm labor should have a large-bore intravenous catheter. Ambulation is not appropriate for a client in preterm labor, and bed rest should be maintained. Reporting should not be delayed

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? A. Excessive fluid intake B. Inadequate chest expansion C. Extension of cancerous lesions D. Irritation from the bronchoscopy

C. Extension of cancerous lesions Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space.

An older adult presents with a fx arm, multiple bruises, which action should the RN do first A. Notify elder protective services B. Make a referral for a nursing home assessment C. Have the family member stay in the waiting room when the RN assesses the patient D. Ask the patient how injury occurred and watch the family's response

C. Have the family member stay in the waiting room when the RN assesses the patient

A client with a history of gambling is experiencing legal difficulties for embezzling money and has been required to obtain counseling. During an intake interview the client says, "I never would have done this if I'd been paid what I am worth." What factor will create the greatest difficulty in helping this client develop insight? A. Feelings of boredom and emptiness B. Grandiosity related to personal abilities C. Projection of reasons for difficulties onto others D. Anger toward those who are in authority positions

C. Projection of reasons for difficulties onto others The development of insight is impeded by the client's unwillingness or inability to face his own contribution to a problem. Feelings of boredom and emptiness will not impede the development of insight. Such feelings are common in clients with borderline personality disorders. Grandiosity will not impede the development of insight. It is often a cover for feelings of inadequacy, which are threatening to the client; these feelings usually disappear with insight. Anger will not impede the development of insight. It is not the anger itself but instead how the anger contributes to interpersonal difficulty that the client must recognize.

When assessing a client with pleural effusion, what does the nurse expect to identify? A. Moist crackles at the posterior of the lungs B. Deviation of the trachea toward the involved side C. Reduced or absent breath sounds at the base of the lung D. Increased resonance with percussion of the involved area

C. Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.

(Nurse Sarah) A patient attempted to commit suicide by ingesting a bottle of Aspirin. Which of the following conditions is this patient at risk for? A. Hyperkalemia B. Hypercalcemia C. Respiratory alkalosis D. Respiratory acidosis

C. Respiratory alkalosis

A client is responding within 5 minutes of receiving naloxone to combat respiratory depression from an overdose of heroin. Why will a nurse continue to closely monitor this client's status? A. The drug may cause peripheral neuropathy. B. Naloxone and heroin can cause cardiac depression when combined. C. Symptoms of the heroin overdose may return after the naloxone is metabolized. D. Hyperexcitability and amnesia may cause the client to thrash about and become abusive

C. Symptoms of the heroin overdose may return after the naloxone is metabolized. When naloxone is metabolized and its effects are diminished, the respiratory distress caused by the original drug overdose returns. A combination of these drugs does not cause cardiac depression. There are no reports of peripheral neuropathy or hyperexcitability and amnesia with naloxone.

A 6-year-old child with a leg fracture of suspicious origin is brought into the emergency department by the mother and the mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, a nurse anticipates that the healthcare provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool? A. The exact location and extent of the fracture will be pinpointed. B. Three separate x-ray films of the leg and hip should be ordered, making it more cost-effective. C. The skeletal history of the current fracture and any previous healing or healed fractures are identified. D. It is the first step toward a complete assessment before computed tomography and magnetic resonance imaging are done.

C. The skeletal history of the current fracture and any previous healing or healed fractures are identified. Abusive parents may "shop" for hospitals that do not have a previous record of their child; the skeletal survey will provide a revealing injury history if abuse has occurred. Pinpointing the exact location of a fracture is necessary to plan appropriate treatment and can be done with a single x-ray film of the area; a skeletal survey is more extensive and helpful when abuse is suspected. Cost-effectiveness is not the primary concern if abuse is suspected. Computed tomography and magnetic resonance imaging are not required unless internal injuries are suspected.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? A. Bradycardia B. Flushed face C. Unilateral chest pain D. Decreased blood pressure

C. Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittentsuction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute.The nurse would expect the patient to have which of the following arterial blood gas values? a) pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L b) pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L c) pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d) pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L.

Compensated metabolic alkalosis should show alkalosis pH and HCO3- (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2 is acidic (normal 35 to 45 mm Hg), and HCO3- is elevated (normal = 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L is compensated respiratory acidosis.

A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse? A. "Maybe it was your husband's fault, too." B. "I can't agree with that—no one should be beaten." C. "Tell me why you believe that you deserve to be beaten." D. "You say that it was your fault—help me understand that."

D. "You say that it was your fault—help me understand that." Paraphrasing and clarifying are interviewing techniques that promote communication between the nurse and client and help the client hear and explore her words and gain insight into her behavior. "Maybe it was your husband's fault, too" is a declarative statement that is closed, will limit dialog, and is not therapeutic. When the nurse voices her opinion saying, "I can't agree with that—no one should be beaten", the nurse is shutting off communication with the client. Nurses are to be nonjudgmental and not offer an opinion, and should ask open-ended questions to facilitate communication with the client. Asking a "why" question is generally not therapeutic because most clients cannot respond to these questions with logical explanations.

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party? A. The client B. The client's spouse C. The client's primary healthcare provider D. Adult Protective Services

D. Adult Protective Services The nurse has a legal responsibility to report suspicions of abuse to the appropriate agency, which in this instance is Adult Protective Services. The client will not be able to understand the discussion. It is not the nurse's responsibility to directly challenge the spouse's behavior in this situation; the nurse may act as a client advocate by interrupting the spouse's behavior and providing immediate physical and emotional care. The nurse should then report suspicions of abuse to Adult Protective Services. Although the nurse may report suspicions about the spouse's behavior to the healthcare provider, the law requires that Adult Protective Services be notified.

A teacher's aide in a kindergarten class informs the school nurse that a male student said that his mother beat him and that he has bruises on the back and shoulders. What is the priority nursing action? A. Notifying Child Protective Services B. Reporting this information to the principal C. Calling the parents to arrange a conference D. Assessing the child for the presence of bruises

D. Assessing the child for the presence of bruises The nurse must validate the presence of physical injury and potential abuse before initiating other interventions. Child Protective Services, the school principal, and the parents should not be notified until signs of possible abuse are verified.

(nurse sarah) You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding?* A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.

D. Check the drainage system for an air leak.

A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfiram (Antabuse) as part of the alcoholism treatment regimen. What important client teaching does the nurse share regarding this drug? A. Voluntary compliance with the disulfiram regimen is very high. B.A single dose of oral disulfiram will be effective for up to 72 hours C. Disulfiram may be taken intramuscularly and will be effective for as long as 7 days. D. Foods, medications, and any topical preparation containing alcohol should be avoided.

D. Foods, medications, and any topical preparation containing alcohol should be avoided. Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction. Voluntary compliance with the use of disulfiram is often very low because of the negative physical effects experienced by the individual if alcohol is ingested. For disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.

What is the best room assignment for a 5-year-old child admitted with injuries that may be related to abuse? A. In an isolation room B. With a friendly older child C. With a child of the same age D. In a room near the nurses' desk

D. In a room near the nurses' desk A child who exhibits signs of abuse needs close supervision, especially when members of the family visit. The child requires close monitoring and should not be left alone. There is no indication that this child needs to be placed in an isolation room for the sake of infection control. An older child who exhibits signs of friendliness may be threatening to this child. Placement with a child of the same age may be desirable from a developmental level, but it does not meet the child's safety needs.

An 8-year-old girl visits the school nurse frequently with vague ailments. The nurse spends time listening to the girl, takes her temperature, and always sends her back to class. One Thursday the girl tells the nurse that she no longer wants to visit her grandfather in his home because he "hugs me too tight and touches me down there" (pointing to her genitals). She has told her mother that she does not want to spend the weekend with her grandparents, but her mother says that she has no choice. What is the most appropriate action by the nurse? A. Planning a home visit to discuss with the mother what her child has shared with the nurse B. Advising the child to tell her mother why she does not want to go to her grandfather's house C. Arranging a meeting with the principal and the mother to discuss the possibility of child molestation D. Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit

D. Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit

During a therapy group session, after several members relate traumatic incidents that happened during the week, a client says with a smile, "Things haven't gone well in my life this week either." It is most appropriate for the nurse to: A. Ask the client to share what has happened this week. B. Make a note of the incongruity of the client's message but remain silent. C. Comment, "This seems to have been a bad week for several of our members." D. Say to the client, "You say things have been bad this week, but you're smiling."

D. Say to the client, "You say things have been bad this week, but you're smiling." Say to the client, "You say things have been bad this week, but you're smiling.""You say things have been bad this week, but you're smiling" is an open-ended, nonjudgmental response that points out incongruity between the client's verbal and nonverbal communication. Asking the client to share, remaining silent but making a note of the incongruity, or noting that it has been a bad week for several of the group's members will not help the client recognize the incongruity.

The school nurse is conducting a teacher's in-service on signs that may indicate that a child is a victim of bullying. Which sign should the nurse include in the teaching session? A. The child wants to try out for the basketball team. B. The child asks for extra work to make better grades. C. The child is participating in several extracurricular activities after school. D. The child asks to go to the nurse's office frequently with vague complaints.

D. The child asks to go to the nurse's office frequently with vague complaints.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? A. To promote healing of the incision B. To decrease the incidence of urinary tract infections C. To use energy to help the client sleep better at night D. To keep blood from pooling in the legs to prevent clots

D. To keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.

pH: 7.23 PaCO2: 50 HCO3: 30 Respiratory or metabolic acidosis ? and is it compensated ?

Partially compensated respiratroy acidosis

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.

Place a sterile dressing over the site and tape it on three sides and notify the physician.

A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should: Refer the mother to the psychiatrist. Explain to the mother the results of the tests. Suggest that the mother call the psychologist. Teach the mother about the tests that were administered.

Refer the mother to the psychiatrist. It is the responsibility of the psychiatrist, who is the primary care provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered.

True or False: Patient experiencing respiratory alkalosis may have hypocalcemia and hypokalemia

TRUE Respiratory acidosis you may see sings of HYPERkalemia

(nurse sarah) A patient reports taking Diamox and has been reporting confusion, fatigue, and headaches. On assessment, you note the patient is exhibiting deep and rapid respirations. Which arterial blood gas finding below confirms the acid-base imbalance for this patient given their symptoms and medication usage? A. HCO3 12, pH 7.19, PaCO2 29 B. HCO3 23, pH 7.36, PaCO2 36 C. HCO3 10, pH 7.65, PaCO2 47 D. PaCO2 49, pH 7.55, HCO3 21

The answer is A: HCO3 12, pH 7.19, PaCO2 29 This patient is at risk for metabolic acidosis, especially since they are taking Diamox (Carbonic anhydrase inhibitors which reduces the reabsorption of bicarb). HCO3 12, pH 7.19, PaCO2 29 are the only ABGs that reflect metabolic acidosis.

(nurse sarah) A patient states they have been vomiting for the last 4 days. The patient is irritable, weak, and reporting muscle cramping and weakness. On assessment, the patient is experiencing bradypnea with a respiratory rate of 10. The patient has the following ABGs result: HCO3 36, pH 7.52, PaCO2 48. Which condition below is presenting? A. Metabolic alkalosis partially compensated B. Metabolic alkalosis fully compensated C. Metabolic acidosis partially compensated D. Metabolic acidosis not compensated

The answer is A: Metabolic alkalosis partially compensated

(nurse sarah) What of the following is NOT a cause of metabolic alkalosis? A. Hyperaldosteronism B. Usage of Diamox C. Nasogastric suctioning D. Diuretic therapy

The answer is B: Usage of Diamox

(nurse sarah) Which of the following is NOT a cause of metabolic acidosis? A. Aspirin toxicity B. Ileostomy C. Hyperaldosteronism D. Carbonic anhydrase inhibitors

The answer is C: Hyperaldosteronism

(nurse sarah) A patient is in metabolic alkalosis due to diuretic therapy. How do you expect the potassium level and bicarbonate level to be affected? A. Increased potassium level and increased bicarb level B. Decreased potassium level and decreased bicarb level C. Increased potassium level and decreased bicarb level D. Decreased potassium level and increase bicarb level

The answer is D: Decreased potassium level and increase bicarb level

Which problem is observed in children who regularly witness acts of violence in their family? Select all that apply. a. Phobias b. Low self-esteem c. Major depressive disorder d. Narcissistic personality disorder e. Posttraumatic stress disorder

a) Phobias b) Low-self esteem c) Major depressive disorder e) PTSD

A 2-year-old child was brought into the emergency department after ingesting several morphine tabletsfrom a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

a) Respiratory acidosis Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions

a. Establish trust and rapport

Perpetrators of domestic violence tend to: Select all that apply. a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea

a. Intense nausea b. Diaphoresis d. Confusion e. Dyspnea throbbing in the head and neck, nausea, copious vomiting, diaphoresis, dyspnea, hyperventilation, vertigo, blurred vision, and confusion

Thiamine (vitamin B 1) and niacin (vitamin B 3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? a. Neuronal activity b. Bowel elimination c. Efficient circulation d. Prothrombin development

a. Neuronal activity Thiamine and niacin help convert glucose for energy, and therefore influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention? a.Obtaining information about her perception of the incident b.Notifying legal authorities that a sexual assault has occurred c.Talking with the husband about his feelings concerning sexual assault d. Teaching the client how to obtain a midstream clean-catch urine specimen

a. Obtaining information about her perception of the incident In a crisis situation it is important for the individual to talk about the situation to enable her to move past shock and disbelief. Notifying the legal authorities that a sexual assault has occurred is the client's decision ( if a minor nurse must report). Although the nurse might talk with the husband, the priority is the woman not the husband. Teaching the client how to obtain a midstream clean-catch urine specimen is contraindicated because the use of water or an antiseptic solution during the procedure will wash away sperm or blood evidence.

A patient has been admitted to the emergency department after a suspected overdose of benzodiazepines mixed with alcohol. The patient is lethargic and cannot speak. The nurse expects which immediate measures to be implemented? (Select all that apply.) a. Prepare to administer naloxone (Narcan). b. Prepare to administer flumazenil. c. Monitor the patient for convulsions. d. Prepare for potential respiratory arrest. e. Apply restraints.

a. Prepare to administer naloxone (Narcan). b. Prepare to administer flumazenil. c. Monitor the patient for convulsions. d. Prepare for potential respiratory arrest.

Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Eileen is so upset."

b. "Gambling activates the reward pathways in my brain."

What is a priority nursing intervention in the care of a drug-dependent mother and infant? a. Supporting the mother's positive responses toward her infant b. Requesting that family members share responsibility for infant care c. Keeping the infant separated from the mother until the mother is drug free d. Helping the mother understand that the infant's problems are a result of her drug intake

a. Supporting the mother's positive responses toward her infant A nurse should attempt to support the mother-child relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. The client needs contact with her new infant to facilitate bonding. Helping the mother understand that the infant's problems are a result of her drug intake will make the client feel guilty and will not facilitate positive action at this point.

The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? Select all that apply. a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter e. The hospital emergency department

a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter

Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply. a. Tremors b. Dehydration c. Hyperactivity d. Muscle hypotonicity e. Prolonged sleep periods

a. Tremors c. Hyperactivity Opioid dependence in the newborn is physiologic; as the drug is cleared from the body, signs of drug withdrawal become evident. Tremors and hyperactivity are typical signs of cerebral irritability. Dehydration is a result of inadequate feeding, not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid withdrawal. Signs of opioid withdrawal include excessive activity and sleep disturbances.

(med surg book) A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for laboratory analysis. d. monitoring the patient's level of consciousness.

a. administering ordered analgesia

(pharm book ) In caring for a patient experiencing ethanol withdrawal, the nurse expects to administer which medication or medication class as treatment for this condition? a. lithium (Eskalith) b. Benzodiazepines c. buspirone (BuSpar) d. Antidepressants

b. Benzodiazepines

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? a. Constriction of the superficial vessels dilates the deep vessels. b. Constriction of the peripheral vessels increases the force of flow. c. Dilation of the superficial vessels causes constriction of collateral circulation. d. Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

b. Constriction of the peripheral vessels increases the force of flow. Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.

A patient who is taking disulfiram as part of an alcohol treatment program accidentally takes a dose of cough syrup that contains a small percentage of alcohol. The nurse expects to see which symptom as a result of acetaldehyde syndrome? a. Lethargy b. Copious vomiting c. Hypertension d. No ill effect because of the small amount of alcohol in the cough syrup

b. Copious vomiting

Maxwell is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Maxwell has been working for 36 hours straight without eating and has consumed eight double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome

b. Dehydration and caffeine overdose

The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

A patient experiencing ethanol withdrawal is beginning to show severe manifestations of delirium tremens. The nurse will plan to implement which interventions for this patient? (Select all that apply.) a. Doses of an oral benzodiazepine b. Doses of an intravenous benzodiazepine c. Restraints if the patient becomes confused, agitated, or a threat to himself or others d. Thiamine supplementation e. Oral disulfiram (Antabuse) treatment f. Monitoring in the intensive care unit

b. Doses of an intravenous benzodiazepine c. Restraints if the patient becomes confused, agitated, or a threat to himself or others d. Thiamine supplementation f. Monitoring in the intensive care unit

Secondary effects of abuse often manifest as arrested development in children due to the fact that: a. Coping is easier than emotional growth b. Energy for development is diverted to coping c. Children cannot differentiate love from abuse d. Abuse fosters a sense of belonging, even if dysfunctional

b. Energy for development is diverted to coping

Samantha is a new patient to the mental health clinic and is seeking assistance for what she describes as "severe anxiety." In addition to daily self-medicating with alcohol, Samantha describes long-term use of herbal kava. The nurse knows that kava is associated with inhibiting P450 and orders which of the following tests? a. Electrocardiogram b. Liver enzymes c. Glomerular filtration rate d. Complete blood count

b. Liver enzymes

A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low stimulus environment. d. Advocate for at least 3 months of treatment.

b. Manage the patient's withdrawal symptoms well.

The nurse is examining a patient with hypocalcemia. For which clinical findings should the nurse look during the assessment? (Select all that apply). a. Abdominal distension b. Positive Chvostek's sign c. Positive Trousseau's sign d. Muscle twitching and cramping e. Bilateral muscle weakness in quadriceps

b. Positive Chvostek's sign c. Positive Trousseau's sign d. Muscle twitching and cramping Rationale: Hypocalcemia occurs due to low serum calcium level. It increases neuromuscular excitability and can cause a positive Chvostek's sign. Chvostek's sign refers to the contraction of facial muscles when a facial nerve is tapped. Trousseau's sign refers to the carpal spasm in response to hypoxia. This sign is positive in hypocalcemia. In addition, muscle twitching and cramping can be noted. Abdominal distension is noted in case of hypokalemia, along with muscle weakness. Bilateral muscle weakness in the quadriceps is noted in the case of imbalances of serum potassium levels.

What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with the elderly.

b. The caregiver was neglected as a child.

During treatment for withdrawal from opioids, the nurse expects which medication to be ordered? a. amphetamine (Dexedrine) b. clonidine (Catapres) c. diazepam (Valium) d. disulfiram (Antabuse)

b. clonidine (Catapres)

(med surg book) When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using sequential compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

b. using sequential compression devices.

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using sequential compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

b. using sequential compression devices.

Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is: a. Risk for injury/Remains free from injury b. Ineffective denial/Accepts responsibility for behavior c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs d. Risk for suicide/Expresses feelings, plans for the future

c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs

The nurse is assessing a patient for possible substance abuse. Which assessment finding indicates possible use of amphetamines? a. Lethargy and fatigue b. Cardiovascular depression c. Talkativeness and euphoria d. Difficulty swallowing and constipation

c. Talkativeness and euphoria

Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time

c. Tolerance

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care (Select all that apply)? a.Administer antibiotics .b.Administer cough syrup. c.Encourage infant to drink 8 ounces of formula every 4 hours. d.Institute cluster care to encourage adequate rest. e.Place on noninvasive oxygen monitoring.

c.Encourage infant to drink 8 ounces of formula every 4 hours. d.Institute cluster care to encourage adequate rest. e.Place on noninvasive oxygen monitoring.

A patient has a history of opioid abuse and is hospitalized after a fall down a flight of stairs. After a visit by a friend, the nurse finds the patient unresponsive with pinpoint pupils. Which of these ordered medications will the nurse administer? a.Clonidine (Catapres) b.Methadone (Dolphine) c.Naloxone (Narcan) d.Diazepam (Valium)

c.Naloxone (Narcan) Rationale:The patient's assessment indicates an opiate overdose, and Narcan should be given to prevent respiratory arrest. The other medications may be used to decrease symptoms associated with opioid withdrawal but would not be appropriate for an overdose.

What safety-related responsibility does the nurse have in any situation of suspected of abuse? a) protect the patient from future abuse by the abuser. b) Inform the suspected abuser that the authorities have been notified. c) Arrange for counseling for all involved parties but especially the patient. d) Report suspected abuse to the proper authorities.

d) Report suspected abuse to the proper authorities.

What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

Which of the following would be a potential cause for respiratory acidosis? a. Diarrhea b. Vomiting c. Hyperventilation d. Hypo-ventilation

d. Hypo-ventilation

Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change

d. Not ready to change

(medsurg) A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

A nurse who is assigned to care for a patient who has been admitted with an opiate overdose tells the nursing supervisor, "This is a waste of my time. The patient will be back on the needle right after being discharged." The most appropriate response by the nursing supervisor is a."Your lack of professionalism will make it difficult for you to provide adequate care." b."You know we are obligated to provide appropriate care no matter how we feel." c."Since you feel so strongly, perhaps you should be assigned to care for a different patient." d."It is important to recognize these feelings and then figure out how to deal with them."

d."It is important to recognize these feelings and then figure out how to deal with them." Rationale:To provide nonjudgmental care for substance-abusing patients, nurses must examine their own values and feelings. This statement validates the nurse's feelings but recognizes the need to care for the patient in a nonjudgmental way. The response beginning, "Your lack of professionalism" is critical of the nurse and is unlikely to lead to a change in the nurse's attitude. The response beginning, "You know we are obligated to provide appropriate care" is accurate but does not encourage the nurse to examine his or her own values. The response beginning, "Since you feel so strongly" would solve the immediate problem but would not encourage self-examination.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a.Prothrombin time b.Erythrocyte count c.Fibrinogen degradation products d.Activated partial thromboplastin time

d.Activated partial thromboplastin time Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, premature separation of the placenta, and stillbirth? a.Heroin b.Alcohol c.PCP d.Cocaine

d.Cocaine Cocaine is a powerful central nervous system stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth.

Why do infants and young children quickly have respiratory distress in acute and chronic alterations of the respiratory system? a.They have a widened, shorter airway. b.There is a defect in their sucking ability. c.The gag reflex increases mucus production. d.Mucus and edema obstruct small airways.

d.Mucus and edema obstruct small airways.

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. A 65-year-old with pulmonary fibrosis B. A 24-year-old with uncontrolled type 1 diabetes C. A 45-year-old who has been vomiting for 3 days D. A 54-year-old who takes sodium bicarbonate for indigestion

A. A 65-year-old with pulmonary fibrosis The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? A. An obese client with leg trauma B. A pregnant client with acute asthma C. A client with diabetes who has cholecystitis D. A client with pneumonia who is immunocompromised

A. An obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? A. Notify the primary healthcare provider immediately B. Apply a warm, moist compress to the incision site C. Increase the intravenous fluid rate by 20 mL/hr D. Monitor vital signs more frequently

A. Notify the primary healthcare provider immediately The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? A. Pink B. Clear C. Green D. Yellow

A. Pink With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? SELECT ALL THAT APPLY. A. Place the infant in a private room B. Ensure that the infant's head is in a flexed position C. Wear mask at all times when in contact with the infant. D. Place the infant in a tent that delivers warm humidified air. E. Position the infant on the side, with the head lower than the chest. F. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

A. Place the infant in a private room F. Ensure that nurses caring for the infant with RSV do not care for other high-risk children. Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduces nosocomial transmission of RSV. A mask is unnecessary. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply. A. Planning for future safety B. Normalizing victimization C. Validating the experiences D. Promoting access to community services E. Providing housing for the victim

A. Planning for future safety C. Validating the experiences D. Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.

(Nurse Sarah) A patient on mechanical ventilation has the following blood gases: PaCO2 29, pH 7.56, HCO3 23. Which of the following conditions is the patient experiencing? A. Respiratory alkalosis not compensated B. Respiratory alkalosis partially compensated C. Respiratory alkalosis fully compensated D. Respiratory acidosis partially compensated

A. Respiratory alkalosis not compensated

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. A. Sharp chest pain B. Acute onset of dyspnea C. Pain in the residual limb D. Absence of the popliteal pulse E. Blanching of the affected extremity

A. Sharp chest pain B. Acute onset of dyspnea Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in phytonadione and that should be avoided. What should the nurse include on the list? Select all that apply. A. Spinach B. Oranges C. Broccoli D. Chicken breast E. Sweet potatoes

A. Spinach C. Broccoli

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? A. pH: 7.28; PCO 2: 28; HCO 3: 18 B. pH: 7.30; PCO 2: 54; HCO 3: 28 C. pH: 7.50; PCO 2: 49; HCO 3: 32 D. pH: 7.52; PCO 2: 26; HCO 3: 20

A. pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.

A nurse is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply. A. Apathy B. Dyspnea C. Hemoptysis D. Bronchial wheezes E. Feeling of impending doom

B. Dyspnea C. Hemoptysis E. Feeling of impending doom Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus usually are apprehensive and hyperalert, not apathetic. Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders, such as asthma.

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 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.

B. Gather supplies needed which will include 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.

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? A. Apply negative pressure while inserting the suction catheter. B. Hyperoxygenate with 100% oxygen before and after suctioning. C. Suction two to three times in succession to effectively clear the airway. D. Use rapid movements of the suction catheter to loosen secretions

B. Hyperoxygenate with 100% oxygen before and after suctioning. Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage.

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus should the nurse assess the client? Select all that apply. A. Flushed face B. Increased temperature C. Severe abdominal pain D. Decreased oxygen saturation level E. Sudden onset of shortness of breath

B. Increased temperature D. Decreased oxygen saturation level E. Sudden onset of shortness of breath When perfusion in the lung is interrupted the exchange of carbon dioxide and oxygen is impaired; as a result, the client's oxygen saturation level will decrease. Because an embolus interferes with capillary perfusion in the alveoli, the transfer of oxygen into the blood and carbon dioxide out of the blood is impaired, so the client becomes short of breath. An increase in body temperature may occur. A flushed face is not a clinical manifestation of a pulmonary embolus. Abdominal pain is related to the surgical procedure. A sudden onset of mild to severe, and often sharp, chest pain can be associated with a pulmonary embolus.

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? A. Request an order for pain medication and oxygen at 6 L/min. B. Lubricate the patient's lips and allow continued hyperventilation. C. Have the patient breathe into a paper bag to stop hyperventilating. D. Contact the physician immediately regarding this complication.

B. Lubricate the patient's lips and allow continued hyperventilation Lubricate the patient's lips and allow continued hyperventilation.Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? A. Place in a warm, dry environment. B. Maintain standard and contact precautions. C. Administer prescribed antibiotic immediately. D. Allow parents and siblings to room in with the infant

B. Maintain standard and contact precautions. RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated. ** as far as the exam goes RSV is contact and droplet precaution

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? A.Initiate strict enteric precautions B.Move the infant to a room with another child with RSV. C.Leave the infant in the present room because RSV is not contagious. D. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

B. Move the infant to a room with another child with RSV. Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing techniques and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are unnecessary.

(Nurse Sarah) Which patient is experiencing partially compensated respiratory acidosis? A. PaCO2 30, pH 7.35, HCO3 26 B. PaCO2 53, pH 7.23, HCO3 28 C. PaCO2 45, pH 7.49, HCO3 21 D. PaCO2 50, pH 7.30, HCO3 23

B. PaCO2 53, pH 7.23, HCO3 28

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? A. Administer oxygen ten (10) L via nasal cannula. B. Place the client in a high Fowler's position. C. Obtain a STAT pulse oximeter reading. D. Auscultate the client's lung sounds.

B. Place the client in a high Fowler's position. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular syste

(Nurse Sarah) A patient with COPD has the following blood gases: PCO2 59, pH 7.26, HCO3 42. Which of the following conditions is presenting? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. Respiratory acidosis

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.

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis?(Select all that apply.) A. Have you been vomiting today? B. When did your kidneys stop working? C. How long have you had diarrhea? D. Are you still feeling short of breath? E. What type of antacid did you take? F. Which weight loss diet are you using?

B. When did your kidneys stop working? C. How long have you had diarrhea? F. Which weight loss diet are you using? Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids. Shortness of breath might be related to a cause of respiratory acidosis.

Incidents of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation? A.Isolation B.Repression C.Regression D.Introjection

B.Repression Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness.

Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action? A. Auscultate the chest B. Obtain the vital signs C. Elevate the head of the bed D. Position the client on the right side

C. Elevate the head of the bed Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be done eventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? A. PO 2 value is 80 mm Hg. B. PCO 2 value is 60 mm Hg. C. HCO 3 value is 50 mEq/L (50 mmol/L). D. Serum potassium value is 4 mEq/L (4 mmol/L

C. HCO 3 value is 50 mEq/L (50 mmol/L). The HCO 3 value is elevated. The urinary system compensates by retaining H + ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis [1] [2] the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A K + level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? A. Hypocapnia B. Hyperkalemia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant? A. pH of 7.50 and Pco 2 of 34 mm Hg B. pH of 7.23 and Pco 2 of 70 mm Hg C. pH of 7.20 and HCO 3 - of 20 mEq/L (20 mmol/L) D. pH of 7.56 and HCO 3 - of 30 mEq/L (30 mmol/L)

C. pH of 7.20 and HCO 3 - of 20 mEq/L (20 mmol/L) Low blood pH and bicarbonate levels indicate metabolic acidosis, which occurs with severe dehydration because the reduced urine output causes retention of hydrogen ions. The other options include findings that indicate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis, respectively

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? A. Repression B. Manipulation C. Transference D. Displacement

D. Displacement Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on those who are less threatening. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse

What should the nurse do to prevent thrombus formation after most surgeries? A. Keep the client's bed gatched to elevate the knees. B. Have the client dangle the legs off the side of the bed. C. Have the client use an incentive spirometer every hour. D. Encourage the client to ambulate with assistance every few hours

D. Encourage the client to ambulate with assistance every few hours Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A. Airway obstruction B. Inadequate nutrition C. Prolonged gastric suction D. Excessive mechanical ventilation

D. Excessive mechanical ventilation The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis

What physiologic alteration does the nurse expect when assessing a 6-month-old infant with bronchiolitis (respiratory syncytial virus [RSV])? A. Decreased heart rate B. Intercostal retractions C. Increased breath sounds D. Prolonged expiratory phase

D. Prolonged expiratory phase Infectious and mechanical changes narrow the bronchial passages and make it difficult for air to leave the lungs. As a result of increased respiratory effort and decreased oxygen exchange, tachycardia may develop. Intercostal retractions are unlikely because of overinflation of the chest with air and shallow, rapid breathing. Breath sounds may be diminished because of swelling of the bronchiolar mucosa and filling of the lumina with mucus and exudate

What should the nurse expect when assessing a client with pleural effusion? A. Crackles or rhonchi at the posterior of the lungs B. Deviation of the trachea toward the affected side C. Increased resonance on percussion of the affected area D. Reduced or absent breath sounds at the base of the lung

D. Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at its base reduces expansion and air exchange. Crackles or rhonchi at the posterior of the lungs are not associated with pleural effusion. If tracheal deviation occurs, it is away from the affected side. Dullness is produced on percussion of the affected area.

A patient is having her first severe, acute asthma episode. It began 2 hours ago. What blood gas values should the nurse expect to see? A. pH high, PaCO2 high, HCO3- high B. pH low, PaCO2 low, HCO3- low C. pH low, PaCO2 high, HCO3- high D. pH low, PaCO2 high, HCO3- normal

D. pH low, PaCO2 high, HCO3- normal A severe acute asthma episode impairs the excretion of carbonic acid, causing respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3- normal. A high pH occurs with alkalosis, not acidosis. ANSs that include abnormal levels of HCO3- are not correct for the 2-hour time frame.

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

a. ThoracentesisRationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication.

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.

a. acid-base balance b. oxygenation status c. acidity of the blood d. bicarbonate (HCO3-) in arterial blood Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3-), and arterial oxygen saturation (SaO2) in arterial blood. The overall balance of electrolytes cannot be determined with ABGs

(med surg)A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for laboratory analysis. d. monitoring the patient's level of consciousness.

a. administering ordered analgesia.

(med surg book) The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at progressively distal points away from the patient until the tidaling stops.

a. continue to monitor the patient.

(med surg) The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.

A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

a. metabolic acidosis. The pH and HCO3 indicate that the patient has a metabolic acidosis. The other options are incorrect.

The nurse would not expect full compensation to occur for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

b) Respiratory alkalosis Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.

A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next? a.Complete a head-to-toe assessment. b.Administer an inhaled bronchodilator. c.Place the patient on high-flow oxygen. d.Obtain repeat arterial blood gases (ABGs).

c.Place the patient on high-flow oxygen. Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of O2 delivered to tissues, so high oxygen concentrations should be given. A head-to-toe assessment and repeat ABGs may be implemented later. Bronchodilators are not needed for metabolic alkalosis and there is no indication that the patient is having difficulty with airflow.

A patient has had chronic diarrhea for 3 months. He also is experiencing repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find during examination? (Select all that apply). a. Positive Chvostek's sign b. Hyperactive reflexes c. Numbness of circumoral region d. Bilateral muscle weakness e. Signs of digoxin toxicity at normal digoxin levels

d. Bilateral muscle weakness e. Signs of digoxin toxicity at normal digoxin levels Rationale: In hypokalemia, the patient experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. Signs of digoxin toxicity at normal digoxin levels are also seen. Positive Chvostek's sign, hyperactive reflexes, and numbness of the circumoral region are signs of hypocalcemia.

The primary health care provider orders the nurse to administer potassium chloride to a patient with 10 episodes of vomiting in two days. Which complication does the nurse anticipate from the potassium chloride? a. Cancer b. Seizures c. Respiratory acidosis d. Cardiac dysrhythmia

d. Cardiac dysrhythmia Rationale: Potassium chloride is an intravenous solution that should be carefully administered to a patient with severe emesis because hyperkalemia may cause fatal cardiac dysrhythmias. Patients with cancer often develop hypocalcemia. Hyponatremia or hypernatremia may cause confusion and seizures. An increased partial pressure of carbon dioxide leads to respiratory acidosis.