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Adult Health lll Exam 1 Question s With Answers Correctly
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1. The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L a. respiratory alkalosis b. metabolic acidosis c. metabolic alkalosis d. respiratory acidosis Feedback: The ABGs shown indicate the pH is high which would mean alkalosis. The PaCO2 is low which is the opposite of the pH and indicates that the respiratory system is the primary problem. The HCO3 is within normal levels. Remember the acronym ROME when interpreting ABGs.Lewis 2017, pgs 290-291abcK 2. The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take? a. Encourage the client to increase their fluid intake. b. Decrease the intravenous fluids. c. Administer prescribed antibiotics. d. Assist the client to ambulate to increase their metabolic rate. Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. 1071-1072abkd 3. The plan of care for a client with a low potassium level includes providing information about the effects of medications and the dietary intake of foods high in potassium. Which of the following information should the nurse use to evaluate if the outcome for the plan was met? a. laboratory data b. physical assessment c. health history d. client statements Feedback: The interventions are aimed at increasing the potassium level of the client, and achievement would be measured by evaluating laboratory data. Potassium levels cannot be measured by physical assessment, health history information, or client statements. Lewis 2017, pgs. 282- 4. The nurse caring for a client experiencing acute hypoxemic respiratory failure due to V/Q mismatch is evaluating the client’s plan of care. Which of the following interventions would be appropriate for the client’s care plan? a. Initiate 24% to 32% oxygen via face mask. b. Provide high flow supplemental oxygen via nasal cannula. c. Provide oxygen via noninvasive positive pressure ventilation (NIPPV). d. Initiate invasive positive pressure ventilation (PPV) via endotracheal tube for SaO2 below 90%.
Feedback: The nurse should understand that acute hypoxemic respiratory failure due to V/Q mismatch requires low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen. This helps improve the PaO2 and SaO2 levels. Without knowing the client’s baseline SaO2 an intervention to initiate PPV vie ET tube for SaO2 would be inappropriate. NIPPV is typically the treatment of choice for hypoxemia secondary to an intrapulmonary shunt, not V/Q mismatch.Lewis 2017, pgs. 1615-
5. The nurse is caring for a client with right sided pneumonia (PN) and helps position the client in the left Sims position. The nurse should evaluate the client’s response to the position by doing which of the following? a. Compare the client’s PaO2 level with the previous level. b. Assessing the client’s pain level. c. Ask the client to perform coughing and deep breathing. d. Compare the client’s pH and HCO3 levels with the baseline levels. Feedback: Clients with unilateral lung disease should be positioned with the healthy lung in a dependent position. This helps to mobilize the secretions which makes it easier to expectorate. The client’s PaO level compared to the previous level would give the nurse a good indication if the client’s ventilation has increased. Lewis 2017, pgs. 1610-1611k, 1624-1625k, acd by omission 6. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is mechanically ventilated with positive end-expiratory pressure (PEEP). Which of the following should alert the nurse that the client is having complications from PEEP? Select all that apply. a. tachycardia b. hypopnea c. decreased urine output d. diminished lung sounds e. hypertension Feedback: PEEP is indicated in clients with ARDS. PEEP provides positive pressure at the end of expiration to keep the alveoli open. This positive pressure can increase the intrathoracic pressure. When intrathoracic pressure increases, the client will have a decrease in preload, which can decrease cardiac output. When there is a decrease in cardiac output, the client can have tachycardia, hypotension, and decreased perfusion to the kidneys. With increased intrathoracic pressure, barotrauma or pneumothorax can occur. A client on mechanical ventilation should have equal and bilateral breath sounds, diminished breath sounds may indicate a pneumothorax.Lewis 2017, pg. 1577Kbe 7. The nurse received report from the previous shift for a client who was intubated for acute respiratory failure (ARF) less than one hour ago. Which of the following test results would be a priority for the nurse to follow-up? a. end-tidal CO2 (ETCO2) b. complete blood count (CBC) c. electrocardiogram (ECG) d. mixed venous O2 saturation (SvO2) Feedback : After a client is intubated the ETCO2 should be evaluated because this confirms proper tube placement within the airway immediately after intubation. A CBC, ECG and SvO2 are also done after intubation but would not be a priority over correct tube placement.Lewis 2017, p. 1614
d. "Your spouse’s asthma is under good control." Feedback: The peak flow measurement is in the mild zone (75-80%) of the client's personal best. The asthma is not currently well-controlled and the client should start using the short-acting bronchodilator. Lewis 2017, pgs. 543stem, 546abkd, 1610, 1618k
12. The nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas values: pH 6.88, HCO3 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which of the following actions should the nurse take? a. Apply a paper bag over the client's nose and mouth. b. Apply the prescribed oxygen by mask or nasal cannula. c. Administer 50 mL of prescribed sodium bicarbonate intravenously. d. Obtain a prescription and administer 50 mL of 20% glucose and 20 units of regular insulin. Feedback: The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return to acid-base balance is to administer oxygen. Sodium bicarbonate should not be administered because the client’s arterial bicarbonate level is normal. Applying a paper bag over the client’s nose and mouth would worsen the acidosis. Glucose and regular insulin would not be appropriate to administer to the client.Lewis 2017, p. 290, 1615k 13. The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following actions by the nurse would help prevent ventilator associated pneumonia (VAP)? a. practicing meticulous hand hygiene b. maintaining the head of the client's bed elevated at least 10 degrees c. suctioning of the client's oral cavity secretions every shift d. ensuring the respiratory therapist changes the ventilator circuit tubing every 4 hours Feedback: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. The client will need oral suctioning more frequently than every shift and at least 30-degree head of the bed elevation. It is not necessary to change the ventilator circuit tubing every 4 hours. The more frequently the circuit is broken, the greater the risk for pathogen entry. Lewis 2017, p. 1623 14. The nurse is caring for a client experiencing acute respiratory failure (ARF) from acute bronchitis. Which of the following medication prescriptions should the nurse question? a. methylprednisolone via nebulization b. albuterol via nebulization c. furosemide via IV d. azithromycin via IV Feedback: The nurse should question the methylprednisolone via nebulization. This is a corticosteroid and when they are inhaled, they require 4 to 5 days for optimum therapeutic effects. This would not be appropriate for a client experiencing ARF. The other medications and routes are appropriate for this client. Lewis 2017, p. 1618abcK
15. The nurse is assessing a client with end stage kidney disease (ESKD). The client's serum laboratory results indicate hypocalcemia and hyperphosphatemia. Which of the following findings should the nurse anticipate? Select all that apply. a. Trousseau's sign b. cardiac arrhythmia's c. constipation d. decreased clotting time e. drowsiness and lethargy f. fractures Feedback: Hypocalcemia is a deficit that causes nerve fibers irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include cardia arrhythmias, diarrhea, increased clotting times, anxiety and irritability. The calcium/phosphorus imbalance leads to brittle bones and pathologic fractures. Lewis 2017, pgs. 284- 16. The nurse is assessing a client who reports shortness of breath (SOB) and notes diminished breath sounds in the right lower lobe. A chest radiograph (x-ray) reveals a large right pleural effusion with significant atelectasis. The nurse should anticipate which of the following procedures to be prescribed for this client? a. thoracentesis b. bronchoscopy c. ventilation/perfusion (V/Q) scan d. repeat chest radiograph (x-ray) Feedback: Thoracentesis is an uncomplicated procedure done at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated. Lewis 2017 pgs. 527-528stem and k, bcd by omission, 1610-1611c 17. The nurse provided discharge teaching for a client with mild chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I should practice using diaphragmatic breathing in the sitting position." b. "I will lie in the supine position to facilitate air entry when practicing deep breathing." c. "I should use pursed lip breathing as a last resort." d. "I will practice chest breathing." Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration and should not only be used as a last resort. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing. Lewis 2017, p. 568- 18. The nurse is providing discharge instructions for a client who experienced respiratory acidosis from severe chronic obstructive pulmonary disease (COPD). Which of the following information would help prevent future episodes of respiratory acidosis? a. “Using pursed-lip breathing can help slow your respiratory rate.” b. “When you feel out of breath you should use diaphragmatic breathing.”
Feedback: Complications that can occur from mechanical ventilation includes barotrauma which can lead to pneumothorax which requires the PEEP to be decreased. Suctioning the client is unrelated to pneumothorax. Increasing the tidal volume and RR would only exacerbate the problem. Decreasing the FIO2 would not assist in correcting the complication of pneumothorax. Lewis 2017, pgs. 1616, 1623
22. The nurse is evaluating the arterial blood gas (ABG) results for a client experiencing acute respiratory distress syndrome who has received prone positioning. Which of the following would indicate the prone positioning was successful? a. PaO2 level changed from 60 mm Hg to 85 mm Hg b. pH is 7.34 and PaCO2 is 33 mm Hg c. HCO3 level changed from 25 mEq/L to 35 mEq/L d. pH is 7.45 and HCO3 is 26 Feedback: The nurse should check the client’s PaO2 level for an increase to show that the client’s perfusion/ventilation is better matched. The prone positioning allows for fluid filled alveoli that were in the dependent area, when the client was supine, to drain to the anterior portion of the lungs, which become the dependent lungs when in the prone position. This helps to improve ventilation of better- perfused lung areas. The changes in the HCO3 level indicate the HCO3 has increased which would not indicate the position helped with ventilation. The other two distractors do not provide enough information to know if there is an improvement. Lewis 2017, p. 290kbcd, 1624-1625k 23. The nurse is caring for a client who received long-term prescribed aminoglycoside antibiotic therapy for an infection. The nurse notes the client's potassium level is 5.4 mEq/L and the client's electrocardiogram (ECG) shows peaked T-waves. Which of the following actions should the nurse take? a. Notify the healthcare provider and request a prescription for polystyrene sulfonate. b. Notify the healthcare provider and request a prescription for a hypotonic IV solution. c. Encourage the client to increase intake of potassium rich foods. d. Monitor skin turgor and presence of edema every shift. Feedback: Hyperkalemia, a common complication of acute kidney injury, is life-threatening if immediate action is not taken to reverse it. The administration of polystyrene sulfonate reduces serum potassium levels. Increasing potassium will increase the problem of hyperkalemia. Giving a hypotonic solution is treatment for hypernatremia not hyperkalemia.Lewis 2017, pgs. 280-282abkd 24. The nurse is reviewing the arterial blood gas (ABG) results for a client who was admitted with a bowel obstruction and has nasogastric tube (NG) with continuous suction. Which of the following ABGs would indicate to the nurse the client is experiencing a complication from the NG tube? a. pH = 7.47 PaCO2 = 30 HCO3 = 22 b. pH = 7.30 PaCO2 = 50 HCO3 = c. pH = 7.28 PaCO2 = 41 HCO3 = 19 d. pH = 7.50 PaCO2 = 40 HCO3 = 39 Feedback: Clients who have a prescription for continuous suction are at increased risk for metabolic alkalosis indicated by pH =7.50 CO2 = 40 HCO3 = 39, due to a loss of hydrogen and chloride ions from gastric fluids. Gastric fluids are acidic. 25. The nurse administered prescribed IV morphine to a client who was 18 hours postoperative and reported feeling anxious and having incisional pain. The client’s respiratory rate was 25
breaths/min, and the arterial blood gas (ABG) results were pH 7.50, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3 23 mEq/L. The nurse should expect which of the following changes in the client’s condition? Select all that apply. a. decreased pain b. decreased respirations c. decreased pH level d. decreased HCO3 level e. decreased PaCO2 level Feedback: After receiving pain medication (morphine) the client should experience decreased pain, respirations, pH level and an increase in the PaCO2 level. The HCO3 level is already within normal levels and would not expect to change. The client is experiencing respiratory alkalosis. Lewis 2017, pgs 289- 291kdeVallerand 2017, pgs 866-870k
26. The nurse has attended a staff education conference about fluid balance. Which of the following statements, if made by the nurse, would indicate a correct understanding of homeostatic mechanisms in the body that regulate body fluid? Select all that apply. a. "I will monitor urine output to measure the kidney's effect on fluid volume balance." b. "Clients who have a lack of antidiuretic hormone (ADH) are at risk for fluid volume deficit (FVD)." c. "Thirst triggers a mechanism in the hypothalamus to maintain fluid balance." d. "Clients with increased levels of aldosterone are at risk for fluid loss." e. "The amount of fluid loss through exhalation has no impact on fluid balance." Feedback: The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes increased aldosterone which results in sodium and water retention. Approximately 300 ml of water is lost daily through exhalation (insensible water loss). Low levels of antidiuretic hormone (ADH) have an impact on fluid balance. The thirst center in the hypothalamus regulates oral intake by sensing intracellular dehydration. The kidneys regulate extracellular fluid (ECF) volume by selective retention and excretion of body fluids. Lewis 2017, pgs. 274- 27. The nurse is assessing a client who experienced metabolic alkalosis from food poisoning and received intermittent parenteral fluid therapy. Which of the following findings would indicate that the fluid therapy was successful? a. pH and HCO3 levels have decreased b. pH and PaCO2 levels have increased c. pH level has decreased and HCO3 level has increased d. pH level has decreased and PaCO2 level has increased Feedback: The client experiencing metabolic alkalosis would have high pH and HCO3 levels, so if the IV fluids were successful the pH and HCO3 levels should have decreased. If the pH or HCO3 increased the client’s metabolic alkalosis would be worsening. The PaCO2 would be normal or increased with metabolic alkalosis, so if the fluids were successful the level should not increase more.Lewis 2017, pgs. 290-291, 288. 28. The nurse reviews the nursing care plan of a client with pneumonia and notes documentation of a nursing diagnosis of Activity intolerance. The nurse should implement which of the following in the client’s plan of care? a. obtain vital signs and oxygen saturation periodically during activity b. encourage deep, rapid breathing during activity
Feedback: The action of a beta agonist is to relax smooth airway muscle, resulting in bronchodilation. When inhaled, it exerts action directly on the airway. While it is true that albuterol may 'stop the wheezing' this is not the best selection and does not answer the parent's question. Beta agonists do not reduce edema or inflammation. Vallerand 2017, pgs. 120-
32. The nurse is caring for a client who is postoperative lung surgery. The client has a shallow, monotonous respiratory pattern and is reluctant to cough. The nurse should assess the client for which of the following? a. atelectasis b. increased oxygen saturation c. increased risk for aspiration d. malnutrition Feedback: The reluctance to cough is likely due to poor pain control. A shallow, monotonous respiratory pattern places the client at an increased risk of developing atelectasis. The client would not be at increased risk for increased oxygen saturation, aspiration, or malnutrition. Lewis 2017, pgs. 1621- 1622k, acd by omission, 334k 33. The nurse is caring for a group of assigned clients. The nurse should prepare to administer prescribed bicarbonate intravenously to the client with which of the following clinical manifestations? a. pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea b. pH 7.28, HCO3– 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma attack c. pH 7.30, HCO3– 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis and emphysema d. pH 7.31, HCO3– 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract infection (UTI) and diabetes mellitus, type 2 (DM-2) Feedback: The only client who has lower than normal bicarbonate levels is the client with diarrhea. This deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to help return this client’s acid-base balance to normal. Giving bicarbonate to any of the other clients listed would be adding too much base and would risk the development of alkalosis. Lewis 2017, pgs. 290-291kbcd 34. The nurse is caring for a client in the emergency room who reports increased urination, and appetite, headache and blurred vision. The client’s ABG results are; pH 7.30, PaCO2 35 mm/Hg, and HCO3 19 mm/Hg. Which of the following would be the best action for the nurse to take? a. Administer prescribed intravenous fluids and insulin. b. Check the client’s vital signs and oxygen saturation level. c. Assess the client for signs of infection. d. Administer prescribed intravenous corticosteroids. Feedback: The client is experiencing signs and symptoms of diabetic ketoacidosis which causes metabolic acidosis; low pH level and HCO3 level. The nurse should administer IV fluids and insulin to correct the increased blood sugar. The vital signs should be monitored, and it is possible the client could have an infection, but those would not be the best actions by the nurse. A corticosteroid would only increase the client’s blood sugar and would not be an appropriate action. Lewis 2017, pgs. 1142- 1143stem, 1144kb, cd by omission, 289stem and k.
35. The nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values for a client diagnosed with respiratory failure and notes the client's pH 7.58, PaCO2 20, PaO 75, HCO3 28, and SaO2 92%. Which of the following interventions should be a priority for the nurse? a. preparing the client for endotracheal intubation and mechanical ventilation b. contacting the client’s family to come sit with the client and explaining that the client's ABG's are within normal limits (WNL) c. immediately starting an infusion of dextrose 50% in water solution (D50W) Feedback: This client is experiencing respiratory alkalosis related to respiratory failure. The pH level is elevated in hyperventilation; the client’s hyperventilation will “blow off” more CO2, leading to lower pCO2 levels. Decreased pCO2 is caused by hyperventilation. With rapid breathing SO2 can be increased with deep or rapid breathing. Acute airway management is indicated to improve tissue oxygenation. Airway support meets the client’s physiologic need for a clear airway. Spiritual support is a higher level (self-actualization) on Maslow’s hierarchy. Providing IV management for circulatory support is a basic physiologic need; however, airway management is priority. Lewis 2017, pgs. 288-290k, bcd by omission, 1614-1615k 36. The nurse in the emergency department (ED) is caring for a client who reports acute dyspnea, pain and anxiety. The client’s blood pressure is 140/85 mm/Hg, pulse is 110 beats/minute and SaO2 is 85%. ABG values are; pH 7.50, PaCO2 29 mm/Hg, and HCO3 24 mm/Hg. Which of the following actions should the nurse take? Select all that apply. a. administer oxygen therapy b. encourage the client to breathe slowly c. prepare the client for intravenous therapy to promote compensation d. administer prescribed pain medication e. obtain a medical history from the client to determine the cause of symptoms Feedback: The client is experiencing respiratory alkalosis based on the ABG levels. The pH is high and the PaCO2 is low. The nurse should administer oxygen, and pain medication and encourage the client to slow the breathing because pain can cause respiratory alkalosis and hyperventilation increases the pH levels. Obtaining as much of a medical history from the client as possible is key to treating the cause. With respiratory alkalosis, compensation is typically not possible because the client requires aggressive treatment of the hypoxemia. Lewis 2017 pgs. 288-289ck, stem, 1614-1615k 37. The nurse is developing the plan of care for a client with acute respiratory failure (ARF) that is being mechanically ventilated. The nurse understands that suctioning can prevent which of the following complications? a. alveolar hypoventilation b. dead space ventilation c. Incorrect answer: d. ventilation/perfusion mismatching e. intrapulmonary shunting Feedback: Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation/perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated and can occur with mucous plugs, obstruction in the distal airway, pneumonia, atelectasis. Lewis 2017, p. 1610-1611abkd
Feedback: The nurse should recognize the client’s symptoms as Trousseau’s sign and that the client is at risk for ineffective breathing patterns. Assisting the client to breath into a paper bag can promote CO retention until an IV of calcium gluconate can be administered to correct the low calcium level. The nurse should implement seizure precautions once the client’s breathing is under control, but seizure precautions would not be the priority. A muscle relaxer and obtaining the blood pressure on the ankle is not necessary or part of the treatment for hypocalcemia. Lewis 2017, pgs. 284-285kd, ac by omission.
42. The nurse receives report about the following four clients. Which client should the nurse see first? a. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds and has an oxygen saturation of 92%. b. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. c. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. d. A 16-year-old who is speaking in short sentences, with crackles on expiration, is sitting upright, and has an oxygen saturation of 93%. Feedback: The 12-month-old is exhibiting signs of severe asthma and should be seen first. The child no longer has wheezes and now has diminished breath sounds. All the clients are exhibiting mild to moderate signs of asthma and do not take priority over the 12-month-old client. Lewis 2017, pgs. 545- 546abk, 1612k, 1613-1614ad 43. The nurse is caring for a client who is receiving long-term mechanical ventilation. The client becomes frustrated when trying to communicate with the nurse. Which of the following would be an appropriate action by the nurse? a. Provide a picture board or alphabet board for the client to communicate. b. Assure the client that everything will be all right and tell the client to calm down. c. Ask a family member to interpret what the client is trying to communicate. d. Ask the healthcare provider to wean the client off the mechanical ventilator to allow the client to talk. Feedback: Providing the client with alternative methods of communication may provide the client with control and become less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. In a client with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the client's wishes. Making them responsible for interpreting the client's gestures may frustrate the family. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met. Lewis 2017, pgs. 1556k abc by omission 44. The nurse in the emergency department is caring for a client experiencing acute respiratory failure who is restless and has decreased cardiac output. Which of the following interventions would be a priority by the nurse? a. Prepare to intubate the client. b. Provide airway suctioning. c. Administer a prescribed bronchodilator. d. Connect the client to a cardiac monitor. Feedback: A client with decreased cardiac output who is already experiencing ARF indicates severe acute respiratory distress syndrome (ARDS) and requires intubation to maintain the PaO2 at acceptable
levels. The client will need cardiac monitoring and bronchodilators and probably suctioning once intubated, but those are not the priority.Lewis 2017, p. 1624kacd by omission, 1615stem
45. The nurse is caring for a client who is in acute respiratory failure (ARF) from exacerbated chronic obstructive pulmonary disease (COPD). The client is intubated with an endotracheal (ET) tube and placed on mechanical ventilation. Which of the following actions would be a priority for the nurse to take following intubation? a. Auscultate the lungs for presence of bilateral breath sounds. b. Arrange for a chest radiograph (x-ray). c. Monitor the client for signs of aspiration. d. Reposition the client every hour. Feedback: When a client is intubated with a endotracheal tube for mechanical ventilation, the nurse should immediately assess for chest expansion symmetry and auscultate breath sounds bilaterally. The client will have a chest radiograph to confirm placement, but that is not the immediate priority. Repositioning the client and assessing for aspiration are important to prevent complications, but 46. The nurse is caring for a client who was admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2.9 mEq/L. Which of the following actions, if prescribed by the health care provider, should the nurse take first? a. Place the client on a cardiac monitor. b. Administer regular insulin intravenously (IV) at 20 units/hr. c. Administer intravenous (IV) potassium supplements. d. Obtain urine glucose and ketone levels. Feedback: Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring, since insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient’s care. Lewis 2017, pgs. 282-283akcd 47. The nurse received change of shift report about assigned clients. Which of the following clients should the nurse assess first? a. The client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. b. The client with serum potassium level 5.0 mEq/L who is reporting abdominal cramping. c. The client with serum sodium level 145 mEq/L who reports dry mouth and is asking for water. d. The client with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium- phosphate precipitates. Feedback: The client with low magnesium needs to be seen first because hypomagnesemia can lead to cardiac dysrhythmias. The client with a high phosphorus is just barely high and has manifestations that are expected and not life threatening. The client with a high normal potassium level is experiencing expected symptoms of abdominal cramping and also does not have life-threatening symptoms. Finally, the client whose sodium is 145 is within normal limits and so would not be the priority. Lewis 2017, p. 286k, 279b,280-281a, 285d 48. A client is admitted to the intensive care unit (ICU) after a motor vehicle collision (MVC) in which the client received blunt trauma to the chest. The client is in acute respiratory failure and is
51. A client with chronic obstructive pulmonary disease (COPD) arrives in the emergency department (ED) reporting shortness of breath and dyspnea on minimal exertion. Which of the following findings would be a priority for the nurse to report to the health care provider? a. the client’s respirations have decreased to 10 breaths/min b. bibasilar lung crackles c. the client is sitting in the tripod position d. SaO2 level is 91% Feedback: The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min. Crackles, tripod position and SaO2 of 91% are all common findings for a client with COPD. Lewis 2017, pgs. 1613-1614abck 52. The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis Feedback: The ABGs shown indicate the pH is low which would mean acidosis. The PaCO2 is within normal levels and the HCO3 is low indicating a metabolic disturbance. Remember the acronym ROME when interpreting ABGs.Lewis 2017, pgs 290-291kbcd 53. The nurse is caring for a client experiencing symptoms of acute respiratory distress syndrome (ARDS) from a pulmonary embolism (PE). Which of the following actions should the nurse take? a. Assess the client’s breathing pattern. b. Place the client in a supine position. c. Administer prescribed bronchodilators. d. Increase the client’s prescribed oxygen. Feedback: Monitoring the client’s breathing pattern gathers more information about the client’s symptoms of ARDS. There is no reason to put the client in a supine position. Bronchodilators would not be given without further assessment first. Most likely the client will need to be intubated to treat the symptoms of ARDS so increasing the oxygen without assessing the client first would not be appropriate. Lewis 2017, pgs. 531bd, c by omission, 1624k, 1615k 54. The nurse is explaining how to provide postural drainage to a client. Which of the following interventions would be appropriate when providing postural drainage? a. using pillows to help position the client b. sitting in an upright position c. performing the procedure directly after meals d. applying percussion firmly to bare skin Feedback: Postural drainage is usually performed two to four times per day. The client uses gravity to facilitate postural draining, which may require the use of pillows. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal. Lewis 2017, pgs. 1616-1617k, 570abck
55. The nurse is evaluating the client who is receiving assist-control ventilation via mechanical ventilation for acute respiratory failure. Which of the following findings would indicate the client is tolerating the mode of ventilation? a. The client’s work of breathing has increased. b. The client is breathing faster than the preset rate. c. The client is self-regulating the volume of each breath. d. The client is initiating spontaneous breaths. Feedback: The assist-control ventilation mode allows the client to initiate spontaneous breathes and then delivers the preset Vt. This allows the client to have some control over ventilation while still getting some assistance if the client does not spontaneously breath as often as the preset frequency is set for. The WOB should not increase, this means the client may be getting tired and needs more assistance. Breathing faster than the preset rate can occur when the client is overventilated and results in hyperventilation. Self- regulating the volume of each breath is consistent with pressure support ventilation mode. Lewis 2017, pgs. 1575-1576abck 56. The nurse is preparing to suction a client with an endotracheal (ET) tube. Which of the following should be the nurse's first step in the suctioning process? a. Assess the client's lung sounds and SaO2 via pulse oximeter. b. Explain the procedure to the client before beginning and offer reassurance during suctioning. c. Turn on the suction source between 80 and 120 mm/hg. d. Perform hand hygiene and put on nonsterile gloves, goggles, gown, and mask. Feedback: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the client's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.Lewis 2017 pgs. 1571-1572abkd 57. The nurse is teaching a client being treated with bronchodilators for symptoms of acute respiratory failure. Which of the following information should the nurse include? a. “Sometimes this medication can make breathing feel more difficult, so be sure to tell me if you feel short of breath again.” b. “You may feel lightheaded from the medication decreasing your heart rate and blood pressure, so make sure you ask for help to get out of bed.” c. “This medication can cause your potassium to increase, so if you feel like you have palpitations you need to report it immediately.” d. “Your blood sugar can decrease from this medication, so if you feel nauseas or a headache you need to tell me.” Feedback: Bronchodilators can sometimes cause a worsening of hypoxemia from redistributing the inspired gas to areas of decreased perfusion. If the client experiences dyspnea or SOB it should be reported immediately. Bronchodilators tend to increase heart rate and BP, decrease potassium and increase blood sugar. Therefore, the distractors are incorrect. Lewis 2017, p. 1618akcVallerand 2017, pgs. 120- 121cd 58. The nurse is preparing to assist with weaning an assigned client from the mechanical ventilator. Which of the following should be a priority for the nurse to assess prior to weaning the client from the ventilator? a. baseline arterial blood gas (ABG) levels b. fluid intake for the last 24 hours
