Exam 4

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Nursing
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1

Which of the following pH values would indicate the client is in a acidotic state?

-7.45

-7.32

-7.41

-7.48

7.32

2

Which of the following pH values would indicate the client is in a alkalotic state?

-7.32

-7.41

-7.49

-7.28

7.49

3

Which of the following would be a low value for bicarbonate (HCO3-)?

-17

-36

-35

-22

17

4

Which of the following would be a normal value for pCO2?

-22

-47

-80

-36

36

5

The client has received an overdose of a narcotic. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.32 pCO2 48 HCO3- 26

-respiratory acidosis

-respiratory alkalosis

-metabolic acidosis

-metabolic alkalosis

respiratory acidosis

6

The client is extremely anxious about an upcoming exam. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.48 pCO2 30 HCO3- 24

-respiratory acidosis

-respiratory alkalosis

-metabolic acidosis

-metabolic alkalosis

respiratory alkalosis

7

The client has been consuming a large amount of antacids. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.48 pCO 2 36 HCO3- 30

-respiratory acidosis

-respiratory alkalosis

-metabolic acidosis

-metabolic alkalosis

metabolic alkalosis

8

The client is a diabetic whose blood sugar is 550. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.32 pCO2 42 HCO3- 18

-respiratory acidosis

-respiratory alkalosis

-metabolic acidosis

-metabolic alkalosis

metabolic acidosis

9

The client has the following ABGs. Which system will compensate to return the pH to its normal level? pH 7.30 pCO2 42 HCO3- 20

-respiratory

-renal

respiratory

10

The client has the following ABGs. Which system will compensate to return the pH to its normal level? pH 7.30 pCO2 47 HCO3- 25

-respiratory

-renal

renal

11

The client has the following ABGs. Which system will compensate to return the pH to its normal level? pH 7.30 pCO2 55 HCO3 25

-respiratory

-renal

renal

12

What is a cause of metabolic acidosis?

renal failure

13

What is a cause of metabolic alkalosis?

vomiting

14

What is a cause of respiratory alkalosis?

Hyperventilation

15

What is a cause of respiratory acidosis?

COPD

16

What are the core questions on the CAGE alcohol screening tool?

-Have you ever felt you ought to Cut downon your drinking?

-Have people Annoyed you by criticizing your drinking?

-Have you felt bad or Guilty about your drinking?

-Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)

17

What is the best nursing approach to a client that is addicted to a substance?

-have a nonjudgmental attitude

-begin with 'how' or 'describe your' rather than 'why'

18

What is the most important question to ask a client newly admitted to a treatment center?

What did you take and when was the last time you took it?

19

Denial

-the person refuses to admit that they have an addiction

"I don't have a problem, I can stop anytime I want to."

20

Projection

-the person will not see their failings in themselves but will point them out in another

'It's all his fault that I drink"

"Can you believe that he drinks that much everyday. I don't drink that much."

21

Rationalization

-person gives reasons or excuses for drinking/using

"I only do this to help me relax after a stressful day."

22

What are the five general categories that abused substances fall into?

-CNS depressants

-stimulants

-opioids

-hallucinogens

-cannibus

23

What are the s/s of alcohol withdrawal and when can you expect to see them?

-begins 4-12 hrs after last drink (or when BAL drops below usual) - mild to moderate

-(mild) elevated HR and temp, slightly elevated BP, A&O X3, mild anxiety, restless, hand tremors, impaired appetite, nausea

-(moderate) HR 100-120, elevated BP & temp, uncomfortable sweating, intermittent confusion, AH & VH, painful anxiety and motor restlessness, anorexia, n/v, dry heaves.

-severe withdrawal begins 2-3 days after last drink

-(severe) HR 120-140, elevated temp and BP, disorientation/confusion, AH/VH, agitation, restless, panic states, seizures, rejecting all food/fluid

24

How do you treat alcohol wlithdrawal?

  • institutes safety measures
  • quiet environment (promote sleep/rest)
  • orient client as needed
  • keep hydrated and provide food as tol
  • seizure precautions
  • benzodiazepines (sub for alcohol)
  • anticonvulsants/antipsychotics may be used for specific Sx
25

What are the s/s of withdrawal of stimulants (cocaine, amphetamines)

  • overdose can lead to cardiac arrhythmias and collapse
  • depression (may last for months)
  • high drug craving
  • severe fatigue
  • sleep disturbances
  • poor concentration
  • severe anxiety
  • social withdrawal
26

How would you treat stimulant withdrawal?

  • monitor VS and assess Sx
  • assess mental status
  • promote sleep/rest
  • provide support and offer reassurance to pt
  • antidepressants
  • discuss tx options and resources when pt is open to it
27

What are the withdrawal s/s of opioid abuse? (oxycontin, lortab, morphine, heroine)

  • Sx appear 6-8 hrs after last dose, peak in 2-3 days and subside in 7-10 days)
  • (mild) yawning, rhinorrhea/sweating, restlessness/craving, dysphoria & anxiety
  • (moderate) dilated pupils, bone/muscle aches, 'goose flesh', hot/cold flashes, irritability, anxiety, craving
  • (severe) n/v, stomach cramps, diarrhea, wt loss, insomnia, muscle twitching, increased BP, pulse, RR, increased anxiety, & dysphoria
28

What assessments are important when assessing for hypovolemic shock?

  • blood pressure
  • heart rate
  • respiratory rate
  • skin color
  • urinary output
  • mental status
29

The SIMV mode of positive pressure ventilation does what?

machine-assisted breaths are delivered in between a patient's spontaneous breaths

The synchronized intermittent mandatory ventilation (SIMV) mode is only used with a patient who has spontaneous breathing. With SIMV, mandatory machine-assisted breaths are delivered in between the patient's spontaneous breaths. With SIMV, there is a preset breathing rate and a preset tidal volume or pressure.

30

The use of positive end-expiratory pressure (PEEP) is indicated to increase what?

alveolar volume

Positive end-expiratory pressure (PEEP) is used to hold open alveoli that are at risk for collapse. It is also used to increase alveolar volume and subsequently decrease intrapulmonary shunting. Increasing the area available for gas exchange should improve arterial oxygen levels, and allow FiO2 (oxygen concentration) to be decreased. PEEP can also enhance pulmonary compliance and decrease the work of breathing.

31

When implementing open tracheal suctioning, which actions do you perform with suctioning?

  • Hyperoxygenate Mr. Bennett by adjusting the ventilator to deliver FiO2 1.0 before and after suctioning
  • Determine Mr. Bennett's oxygen saturation level before and after suctioning
32

What interventions are recommended to prevent ventilator-associated pneumonia (VAP)?

  • Standard Precautions
  • Head of bed elevation at 30-45 degrees
  • Subglottal suctioning
  • Frequent oral care
33

What indicates that a pt is ready to be extubated?

  • A respiratory rate less than 24 breaths per minute is desirable for weaning.
  • A vital capacity greater than 10-15 mL/kg is considered adequate for weaning
  • Synchronous and stable breathing pattern
34

What are the s/s of pulmonary embolus?

severe chest pain an dyspnea developing suddenly

35

What are the s/s of tuberculosis?

malaise, wt loss, low-grade fever, night sweats

36

What are the s/s of lung cancer?

persistent productive cough, dyspnea, wt loss, anemia

37

What are the s/s of chronic bronchitits?

constant productive cough with thick purulent secretions that are more severe in the morning.

38

What are the s/s of bronchopneumonia?

productive cough with yellow-green sputum.

39

What are the s/s of asthma?

wheezing with a tight feeling in the chest.

40

The client experienced neurologic changes from a transient ischemic attack. Family mambers exhibit an understanding of this condition if they discuss with the nurse that associated deficits from this pathology will be gone within what timeframe?

  1. Several hours
  2. Several weeks
  3. 36-48 hours
  4. Over 2-3 months

Clients who experience a TIA should have resolution of symptoms within several minutes or within a maximum of 24 hours

41

In reviewing the client's plan of care, the home care nurse has identified interventions that relate to the client's hemiparesis after the event of an embolic stroke. The nurse would expect to see what documentation by the support staff who had cared for this client within the past month?

  1. The use of a walker for mobility in the home.
  2. Full active range of motion for all extremities.
  3. Full active or passive range of motion for all extremities.
  4. Demonstrates use of picture aids for communication.

The client with hemiparesis, or weakness on one side of the body, needs exercise for both sides of the body. Active range of motion will be done on the unaffected side and passive range of motion will be done on the affected side to maintain or improve joint or muscle function