Download Nurs 487 Final Exam 2 Latest 2025 Week 11 100% Verified Exam With Answers and more Exams Nursing in PDF only on Docsity!
Anemia Is? A deficiency in the
- Number of erythrocytes (RBC) •Quantity or quality of hemoglobin •Volume of packed RBCs (hematocrit) Erythropoietin (EPO) hormone secreted by the kidney to stimulate the production of red blood cells by bone marrow (small amount is also secreted by the liver) How long is the RBC life span? 120 days The nurse is caring for a client postoperative after a thyroidectomy and the client states "I have a tingling feeling around my mouth." Which of the following data is priority for the nurse to assess? The presence of Chvostek's sign
- The client's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding. pallor paleness (pasty)
- decreased hemoglobin
Nurs 487 Final Exam 2 Latest 2025 Week 11 100%
Verified Exam With Answers
- decreased blood flow to the skin jaundice yellowing of the skin
- increased serum bilirubin pruritus itching
- increased serum and skin bile salt concentrations The nurse has administered 3% saline to a client with hyponatremia. Which of the following assessment data will require the most rapid response by the nurse? There are crackles audible throughout both lung fields.
- Crackles throughout both lungs suggest that the client may be experiencing pulmonary edema, a life- threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli. The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement? Notify the client's health care provider. The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the client will not be able to slow the respiratory rate.
- Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the client's protein status. Which assessment finding about a client who has a serum calcium level of 1.58 mmol/L is most important for the nurse to immediately report to the health care provider? The client is experiencing laryngeal stridor. Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the client's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client? Daily weight
- Daily weight is the most easily obtained and accurate means of assessing volume status. signs and symptoms of anemia
- Pallor of skin and mucous membranes
- Fatigue, lethargy, and cold intolerance
- tachypnea
- tachycardia
- narrow or widened pulse pressure
- headache
- confusion
- poor skin turgor
- blue sclera
** indicator for low hemoglobin shortness of breath Thrombocytopenia Reduction of platelets
- HIT & DIC Heparin-induced thrombocytopenia (HIT)
- life threatening state of hyper coagulability with onset 5 - 10 days after heparin exposure
- platelets are destroyed
- you will see epistaxis (nosebleed), hematuria Disseminated Intravascular Coagulation (DIC) abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs
- clotting factors become overactive
- weirdly you will see bleeding out of every part of body
- prolonged PTT Manifestation of Acute blood loss 20% (1000ml)
- no detectable signs at rest
- tachycardia with exercise
- postural hyptension
After studying about viruses, which information indicates the student has a good understanding of viruses? Viruses replicate their genetic material inside host cells. Virus replication depends totally on the ability of the virus to infect a permissive host cell, a cell that cannot resist viral invasion and replication. Viruses contain both DNA and RNA, are incapable of independent reproduction, and cannot be killed by antimicrobials. What common symptom should be assessed in individuals with immunodeficiency? Recurrent infections After which injury would healing by secondary intention occur? . Stage IV pressure ulcer The nurse identified each of the following clinical manifestations of inflammation. Which would the nurse classify as a local response?
- swelling
- heat
- pain
- redness In addition to matching ABO antigens, what else does a blood transfusion need to be matched for? Rh antigen
An immunologist is discussing endotoxin production. Which information should the immunologist include? Endotoxins are produced by Gram-negative bacteria. A nurse recalls that bacteria become resistant to antimicrobials by: mutation: Antibiotic resistance is usually a result of genetic mutations that can be transmitted directly to neighbouring micro-organisms by plasmid exchange After studying about fungi, which information indicates a correct understanding of fungi? Fungi causing deep or systemic infections: are commonly opportunistic. Mycoses fungal infections What is Shock?
- An acute widespread process of impaired tissue perfusion leads to a state of cellular and tissue hypoxia from:
- Decreased oxygen delivery
- Increased oxygen consumption
- Inadequate use of oxygen
- Shock can lead to multi organ dysfunction and death Patho of shock
Which occurs in septic shock? Increased cardiac output Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. After receiving change-of-shift report, which of the following clients should the nurse assess first? A client with septicemia who has intercostal and suprasternal retractions This client's history of septicemia and laboured breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation The nurse is caring for a client who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider? Skin cool and clammy Since clients in the early stage of septic shock have warm and dry skin, the client's cool and clammy skin indicates that shock is progressing. We have an expert-written solution to this problem! When prone positioning is used in the care of a client with acute respiratory distress syndrome (ARDS), which of the following information obtained by the nurse indicates that the positioning is effective? The client's PaO2 is 90 mm Hg, and the SaO2 is 92% The purpose of prone positioning is to improve the client's oxygenation as indicated by the PaO2 and SaO2. Which of the following information obtained by the nurse when caring for a client who has cardiogenic shock indicates that the client may be developing multiple organ dysfunction syndrome (MODS)?
The client's serum creatinine level is elevated. The elevated serum creatinine level indicates that the client has renal failure as well as heart failure. the nurse is caring for a client in the emergency department with massive trauma and possible spinal cord injury. Which of the following findings by the nurse will help confirm a diagnosis of neurogenic shock? Apical heart rate 48 beats/minute Neurogenic shock is characterized by hypotension and bradycardia. The nurse is admitting a client who is in possible respiratory failure with a high PaCO2. Which of the following assessment information will be of most concern to the nurse? The client is somnolent Increasing somnolence will decrease the client's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute, respirations 34/minute. Which of the following actions should the nurse take next? Obtain oxygen saturation using pulse oximetry. The client's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS hematology study of blood Leukocytes
include BNP and ANP and are elevated in patients with HF to promote vasodilation and diuresis due to increased stretching of the mycoardium (volume overload causing frank-starling mechanism for maximal contraction). Both activated guanylate cyclase to increased cGMP Buffering Systems •A buffer is a chemical that can bind excessive H+ or OH- without a significant change in pH. •Most important plasma-buffering systems are the carbonic acid-bicarbonate pair. Volatile •Carbonic acid (H2CO3) can be eliminated as CO2 gas and water Nonvolatile •Sulfuric, phosphoric, and other organic acids •Eliminated by the renal tubules with the regulation of bicarbonate (HCO3) carbonic acid-bicarbonate buffer
- operates in both the lung and the kidney and is a major extracellular buffer
- lungs and kidneys act to compensate for primary changes in PH Protein buffering (hemoglobin) Proteins have negative charges, so they can serve as buffers for H+
renal buffering Secretion of H+ in the urine and reabsorption of HCO3- Acidosis •Systemic increase in H+ concentration or decrease in bicarbonate (base) Alkalosis •Systemic decrease in H+ concentration or increase in bicarbonate Respiratory acidosis low pH, high CO •elevation of PaCO2 as a result of ventilation depression Respiratory alkalosis high pH, low CO •depression of PaCO2 as a result of alveolar hyperventilation Metabolic acidosis low pH, low HCO •depression of HCO3- or an increase in noncarbonic acids Metabolic alkalosis
humoral immunity specific immunity produced by B cells that produce antibodies that circulate in body fluids cell-mediated immunity type of immunity produced by T cells that attack infected or abnormal body cells Apoptosis Programmed cell death Necrosis tissue death Not normal in developed tissues; serious when many cells involved Coagulative necrosis Cell proteins are altered or denatured - coagulation liquefactive necrosis
- bacterial infections
- pus accumulates and tissue liquifies caseous necrosis
the death of tissue with a cheeselike appearance
- seen in tuberculosis Gangrenous necrosis Two types Wet: sudden loss of blood flow causes the cell death Dry: blood supply gradually reduced seen in diabetes Exudate fluid, such as pus, that leaks out of an infected wound Primary intention healing Phases
- initial phase (inflammatory)
- granulation phase (proliferative)
- Maturation phase Primary intention healing tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Secondary intention healing wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring
Multiple organ dysfunction syndrome (MODS) progression from SIRS. It is the failure of two or more organ systems in a patient who is acutely ill to such a degree that homeostasis cannot be maintained without intervention. Resp, hematology, liver, renal, brain, cardiovascular. ARDS: acute respiratory distress syndrome Cause: sepsis or trauma are main causes (also COVID pneumonia) Respiratory failure is the state in which one or both gas-exchanging functions are inadequate: Either the amount of O2 transferred to the blood is insufficient, or the amount of CO2 removed from the lungs is inadequate. Respiratory failure can be classified as hypoxemic or hypercapnic Albumin protein in blood; maintains the proper amount of water in the blood hydrostatic pressure the pressure within a blood vessel that tends to push water out of the vessel oncotic pressure The osmotic pressure in the blood vessels due only to plasma proteins (primarily albumin) --> causes water to rush back into capillaries at end.
osmotic pressure the movement of water out of or into a cell Isotonic fluids are used to? replace extracellular fluid losses and expand vascular volume quickly Hypertonic fluids are used to? shift fluid out of the cells and into intravascular space which can cause fluid overload
- lung crackles, increased BP, bounding pulses
