Week 12 Sherpath Flashcards by Monica Galvan-Valencia

Which findings would prompt the nurse to perform a focused cardiopulmonary assessment?

Select all that apply.

Medical history of a cardiovascular problem

Medical history of a respiratory problem

Signs and symptoms of decreased oxygenation

Signs and symptoms of activity intolerance

Signs and symptoms of increased peripheral perfusion

Medical history of a cardiovascular problem

Medical history of a respiratory problem

Signs and symptoms of decreased oxygenation

Signs and symptoms of activity intolerance

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Which questions would the nurse include during the patient interview of a focused respiratory health assessment?

Select all that apply.

Have you ever smoked?

Have you had recent weight gain?

Do you use oxygen at home?

Do you have difficulty clearing secretions?

Do you have a cough? For how long?

Have you ever smoked?

Do you use oxygen at home?

Do you have difficulty clearing secretions?

Do you have a cough? For how long?

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Which peripheral vascular assessment would the nurse perform when admitting a patient with impaired cardiac function?

Auscultating breath sounds

Auscultating an apical pulse

Inspecting skin color in the extremities

Measuring the chest for expansion

Inspecting skin color in the extremities

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Which set of values would the nurse review to determine whether heart muscle injury has occurred?

Complete blood count (CBC) with differential

Lipid panel

Basic metabolic panel

Cardiac enzymes

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Which information would the nurse expect to obtain from a chest x-ray prescribed for a patient with a cough and shortness of breath?

Select all that apply.

Hypoxia from diminished lung function

Areas of increased lung tissue density

Impaired electrical activity in the heart

Size of the heart

Atherosclerosis in heart blood vessels

Areas of increased lung tissue density

Size of the heart

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Which health problem risk would be evaluated by obtaining a lipid panel?

Cardiac injury

Atherosclerosis

Fluid around heart

Blood electrolyte imbalances

Atherosclerosis

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Match the pulmonary function test (PFT) with the measured element.

Air volume expelled with lungs maximally inflated

Air volume expelled in 1 second from start of FVC

Air volume left in lungs after forced expiration

Air volume left in lungs after normal expiration

Maximal flow rate in the middle of FVC maneuver

Answer choices

Functional residual capacity (FRC)

Residual volume (RV)

Forced vital capacity (FVC)

Forced expiratory flow (FEF)

Forced expiratory volume in 1 second (FEV1)

Air volume expelled with lungs maximally inflated
Forced vital capacity (FVC)

Air volume expelled in 1 second from start of FVC
Forced expiratory volume in 1 second (FEV1)

Air volume left in lungs after forced expiration
Residual volume (RV)

Air volume left in lungs after normal expiration
Functional residual capacity (FRC)

Maximal flow rate in the middle of FVC maneuver
Forced expiratory flow (FEF)

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Which cues would the nurse expect to find in a patient with an inability to effectively pump blood to the tissues?

Select all that apply.

Dyspnea with exertion

Fatigue

Lower extremity edema

Crushing chest pain

Nausea and vomiting

Dyspnea with exertion

Fatigue

Lower extremity edema

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Which condition would the nurse suspect in a postsurgical patient who is experiencing dyspnea with decreased breath sounds?

Chronic obstructive pulmonary disease (COPD)

Asthma

Atelectasis

Heart failure

Atelectasis

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Which cues would the nurse expect in a patient with hypoxic myocardial tissue?

Select all that apply.

Fever

Dyspnea

Vomiting

Chest pain

Diaphoresis

Dyspnea

Vomiting

Chest pain

Diaphoresis

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Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder?

Sputum characteristics

Pulse oximetry

Capillary refill

Respiratory rate

Sputum characteristics

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Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment?

Select all that apply.

Are you having chest pain?

Have you had recent weight gain?

What type of work do you do?

How many pillows do you sleep with?

Do you ever experience dizziness?

Are you having chest pain?

Have you had recent weight gain?

How many pillows do you sleep with?

Do you ever experience dizziness?

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Which questions would the nurse include as part of a focused respiratory health assessment?

Have you ever been exposed to hazardous materials at work?

Have you had recent weight gain?

Have you ever lost consciousness?

Do you take medications to prevent blood clots?

Have you ever been exposed to hazardous materials at work?

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Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction?

Select all that apply.

They are released when death of cardiac cells occurs.

Elevated serum levels suggest cardiac damage.

There are “good” and “bad” types of cardiac enzymes.

Alterations in enzyme types may indicate infection.

Abnormally low levels are seen with decreased oxygenation.

They are released when death of cardiac cells occurs.

Elevated serum levels suggest cardiac damage.

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The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding?

Hyperlipidemia

Hypoxia

Infection

Hemodilution

Hypoxia

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When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition?

Hemodilution

Hypoxia

Infection

Hyperlipidemia

Hemodilution

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Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?

Elevated levels increase the risk for atherosclerosis.

Abnormal levels can cause cardiac arrhythmias.

Reduced levels can result in decreased oxygen levels.

Normal levels suggest healing of muscle tissue.

Abnormal levels can cause cardiac arrhythmias.

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Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?

Select all that apply.

Inspection

Palpation

Auscultation

Reflexes

Vital signs

Inspection

Palpation

Auscultation

Vital signs

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Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia?

Dyspnea

Elevated arterial carbon dioxide level

Irregular heart rhythm

Chest pain

Dyspnea

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Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia?

Select all that apply.

Chest pain

Dyspnea

Abnormal cardiac enzymes levels

Irregular heartbeat

Decreased breath sounds

Abnormal cardiac enzymes levels

Irregular heartbeat

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Which postoperative complication can be prevented by regularly performing deep-breathing exercises?

Thrombus formation

Bronchospasm

Alveolar enlargement

Atelectasis

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Which delivery system would the nurse use when the health care provider prescribes a common low-flow system to deliver continuous oxygen at 2 L/min for a patient with pneumonia?

Nonrebreather mask

Bilevel positive airway pressure (BiPAP)

Nasal cannula

Ambu bag

Nasal cannula

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Which alterations of oxygenation and perfusion may require supplemental oxygen therapy?

Select all that apply.

Increased respiratory rate

Decreased heart rate

Low oxygen saturation

Cyanosis

Elevated hemoglobin

Increased respiratory rate

Low oxygen saturation

Cyanosis

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Match the type of oxygen mask to its description.

No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧

Reservoir bag present; room air is inspired with O2 delivered

Reservoir bag present; one-way valve prevents entry of exhaled air

No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials

Answer choices

Nonrebreather mask

Simple face mask

Partial rebreather mask

Venturi mask

No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧
Simple face mask

Reservoir bag present; room air is inspired with O2 delivered
Partial rebreather mask

Reservoir bag present; one-way valve prevents entry of exhaled air
Nonrebreather mask

No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Venturi mask

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Which device would the nurse apply to a patient who has arrived unconscious and in respiratory arrest (is not breathing)? Venturi mask Ambu bag Nasal cannula Continuous positive airway pressure (CPAP) device

Ambu bag

Match the artificial airway tube with the correct situation. Inserted in the patient’s nose to facilitate ease of suctioning Inserted in mouth; maintains airway and breathing without ventilatory help Inserted through the mouth for positive pressure mechanical ventilation Inserted through trachea; provides ventilation when upper airway obstructed Answer choices Tracheostomy tube Endotracheal tube Oropharyngeal tube Nasopharyngeal tube

Inserted in the patient’s nose to facilitate ease of suctioning Nasopharyngeal tube Inserted in mouth; maintains airway and breathing without ventilatory help Oropharyngeal tube Inserted through the mouth for positive pressure mechanical ventilation Endotracheal tube Inserted through trachea; provides ventilation when upper airway obstructed Tracheostomy tube

Which guidelines would the nurse recall when inserting a nasopharyngeal tube? Select all that apply. The airway is inserted into the mouth over the tongue. The length is measured from the tragus to the nostril plus 1 inch. The airway is removed and changed at least every 24 hours. Gentle to moderate force is applied when resistance is encountered. The airway is lubricated before attempting insertion and inserted gently.

The length is measured from the tragus to the nostril plus 1 inch. The airway is removed and changed at least every 24 hours. The airway is lubricated before attempting insertion and inserted gently.

Which situations would indicate a need for the nurse to consider insertion of a pharyngeal airway? Select all that apply. Decreased level of consciousness Inability to breathe effectively Frequent suctioning needs Loss of muscle tone Requires mechanical ventilation

Decreased level of consciousness Frequent suctioning needs Loss of muscle tone

Which type of tube would a patient receiving general anesthesia require to maintain oxygenation? Nasopharyngeal Tracheostomy Oropharyngeal Endotracheal

Endotracheal

For which purpose would a chest tube be inserted in a patient injured in a car crash? Provides oxygenation when respirations are impaired Allows for removal of excessive airway secretions Drains blood and fluid to promote full lung expansion Keeps the airway open when there is airway damage

Drains blood and fluid to promote full lung expansion

Match the type of chest physiotherapy to its description. Therapeutic positioning that facilitates gravity drainage from the lungs Combines controlled coughing with deep breathing to maintain lung expansion Helps a patient reach a set inhalation volume Answer choices Coughing/deep breathing Postural drainage Incentive spirometry

Therapeutic positioning that facilitates gravity drainage from the lungs Postural drainage Combines controlled coughing with deep breathing to maintain lung expansion Coughing/deep breathing Helps a patient reach a set inhalation volume Incentive spirometry

Which actions are the nurse’s responsibilities during a chest tube insertion procedure? Select all that apply. Explaining the procedure to the patient Positioning the patient Ensuring that the drainage system is working properly Administering a prescribed bronchodilator Initiating oxygen therapy immediately before tube insertion

Positioning the patient Ensuring that the drainage system is working properly

Match the pulmonary drug classification with the key principle of use. Increase the diameter of the bronchi Improve airway clearance Decrease inflammation Decrease the thickness of secretions Answer choices Corticosteroids Anticholinergics Mucolytics Inhaled bronchodilators

Increase the diameter of the bronchi Inhaled bronchodilators Improve airway clearance Anticholinergics Decrease inflammation Corticosteroids Decrease the thickness of secretions Mucolytics

Which finding indicates that the prescribed inhaled bronchodilator administered to a patient with chronic obstructive pulmonary disease (COPD) has been effective? Decreased secretions Decreased wheezing Increased heart rate Decreased body temperature

Decreased wheezing

Which action describes the primary rationale for administering a corticosteroid (methylprednisolone) to a patient with a pulmonary disease? Treats the underlying infection Decreases inflammation Increases the diameter of the bronchi Decreases the thickness of airway secretions

Decreases inflammation

Which patient changes would the nurse expect when medications used to treat pulmonary disease are effective? Select all that apply. Decreased symptoms Fewer exacerbations Increased exercise tolerance Improved overall health status Reduced laboratory testing requirement

Decreased symptoms Fewer exacerbations Increased exercise tolerance Improved overall health status

Match the drug classification with the key assessment associated with evaluation of treatment. Blood pressure. Daily weights, intake and output Heart rate and rhythm Bleeding Answer choices Antiarrhythmics Diuretics Anticoagulants Antihypertensives

Blood pressure. Antihypertensives Daily weights, intake and output Diuretics Heart rate and rhythm Antiarrhythmics Bleeding Anticoagulants

Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)? Select all that apply. High oxygen levels can be toxic. Use oxygen therapy only as absolutely needed. Limit oxygen concentration to low-flow. Do not smoke while using oxygen. Avoid humidified oxygen.

High oxygen levels can be toxic. Limit oxygen concentration to low-flow. Do not smoke while using oxygen.

Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy? Select all that apply. Increased level of daily function Slowed progression of the disease Improved mental status Increased activity tolerance Decreased inflammation of the alveoli

Increased level of daily function Improved mental status Increased activity tolerance

Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia? Teaching deep breathing exercises Seeking readmission to the hospital for oxygen therapy Suggesting counseling to overcome the unreasonable fear Requesting a prescription for a high-flow nasal cannula

Requesting a prescription for a high-flow nasal cannula

Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube? Select all that apply. Obturator Inner cannula Bag-valve-mask (BVM) device Blood pressure equipment Tracheostomy care kit

Obturator Inner cannula Bag-valve-mask (BVM) device Tracheostomy care kit

Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube? “There will be a small incision made to help you breathe” “This will help facilitate clearing secretions from your mouth and throat.” “This will remain in place only as long as you are under general anesthesia.” “Your nares will be lubricated to ease insertion.”

“This will help facilitate clearing secretions from your mouth and throat.”

Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider? Excessive secretions Reddened incision Respiratory infection Subcutaneous emphysema

Subcutaneous emphysema

Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary? It facilitates gravity drainage of secretions. It prevents atelectasis. It removes mucus from the respiratory tract. It drains fluid from the pleural space.

It prevents atelectasis.

Which type of chest physiotherapy involves percussion? Aerobic exercise Postural drainage Incentive spirometry Coughing/deep breathing

Postural drainage

The nurse would instruct a patient to hold each breath for ____ seconds when explaining coughing/deep breathing chest physiotherapy? Record your answer as two whole numbers separated by a hyphen. Use numbers only.

3-5

Which route would the nurse use when administering medication to a patient with non–life-threatening lower airway inflammation? Subcutaneous Nasal Intravenous Inhalation

Inhalation

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing? Decreases inflammation Increases the diameter of the bronchi Decreases the thickness of secretions Protects against disease

Increases the diameter of the bronchi

Which medications would the nurse expect to be added to the patient’s drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital? Select all that apply. Corticosteroids Antibiotics Vaccines Anticholinergics Mucolytics

Corticosteroids Antibiotics Anticholinergics

Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication? It promotes increased urine flow. Low doses prevent blood clot formation. It is needed to reduce high blood pressure. It suppresses abnormal rhythms of the heart.

It suppresses abnormal rhythms of the heart.

Which interventions would the nurse implement when providing care for a patient prescribed a diuretic? Select all that apply. Applying antiembolic stockings Monitoring daily weight Monitoring intake and output Elevating the head of the bed to the semi-Fowler position Monitoring for bleeding tendencies

Monitoring daily weight Monitoring intake and output

Which benefit is important for the nurse to include when educating a patient about antihypertensive medications? Control an irregular heart rate Reduce the risk for stroke Reduce the risk for blood clots Control swelling of the feet

Reduce the risk for stroke

Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease? Select all that apply. Diuretics Anticoagulants Antiarrhythmics Calcium channel blockers Bronchodilators

Diuretics Anticoagulants Antiarrhythmics Calcium channel blockers

Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy? Expect bleeding and bruising while taking the medication. Limit intake of green, leafy vegetables. Monitor blood pressure daily. Take daily weights at the same time every day.

Limit intake of green, leafy vegetables.

Which patient health history finding would alert the nurse to the possibility of a fluid volume imbalance? Weight loss of 5 kg over the past month Weight gain of 2 kg since yesterday morning Loss of appetite for the past few weeks Occasional headaches

Weight gain of 2 kg since yesterday morning

Which laboratory results would a nurse expect when caring for a patient with vomiting and diarrhea who has developed rapid onset isotonic fluid volume deficit (FVD)? Select all that apply. Elevated red blood cell (RBC) levels Increased blood urea nitrogen (BUN) and creatinine levels Low serum osmolality Decreased urine specific gravity Decreased urine osmolality

Elevated red blood cell (RBC) levels Increased blood urea nitrogen (BUN) and creatinine levels

Which datum would support the presence of fluid volume excess (FVE) in a patient with associated risk factors? Weak, thready pulse Weight loss of 1 kg since yesterday Poor skin turgor Crackles auscultated in lung bases

Crackles auscultated in lung bases

Match each laboratory test with the information it provides. Indicator of overall renal function Helps determine hydration status, useful in managing fluid requirements Measure of the oxygen-carrying capacity of the blood Measure of the concentration of solutes in the urine Answer choices Serum osmolality Red blood cell (RBC), hemoglobin, hematocrit Urine osmolality Blood urea nitrogen, creatinine

Indicator of overall renal function Blood urea nitrogen, creatinine Helps determine hydration status, useful in managing fluid requirements Serum osmolality Measure of the oxygen-carrying capacity of the blood Red blood cell (RBC), hemoglobin, hematocrit Measure of the concentration of solutes in the urine Urine osmolality

Which level on the dehydration scale would a nurse use to describe a patient with a weight loss of 8% of total body weight secondary to vomiting and diarrhea? Mild dehydration Moderate dehydration Severe dehydration Life-threatening dehydration

Severe dehydration

Which patients would a nurse conclude are experiencing fluid volume deficit (FVD)? Select all that apply. An 86-year-old woman with a fever who has dry mucous membranes and decreased urination A 50-year-old man with mild hypertension and flat neck veins while seated who has lost 8% total body weight over a year’s time An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel A 75-year-old woman with orthostatic hypotension and tachycardia after an increase in her blood pressure medication dosage A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor

An 86-year-old woman with a fever who has dry mucous membranes and decreased urination An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor

Which sign or symptom in a patient with fluid volume deficit would be a result of decreased interstitial fluid? Decreased skin turgor Weak, thready pulse Lightheadedness Sunken fontanel in an infant

Decreased skin turgor

Which manifestation, specifically caused by an increase in interstitial fluids, would a nurse expect when caring for a patient who has developed fluid volume excess (FVE)? Confusion Dependent edema Bounding peripheral pulses Jugular vein distension

Dependent edema

Which degree of fluid volume excess (FVE) would a nurse document for an adult patient with a 5% weight gain over the last 24 hours because of fluid retention? Mild FVE Moderate FVE Irreversible FVE Severe FVE

Moderate FVE

Which laboratory results would a nurse expect in a patient who has developed a hypertonic fluid volume deficit? Select all that apply. Decreased urine specific gravity Decreased hematocrit levels Increased blood urea nitrogen (BUN) and creatinine levels Low red blood cell (RBC) count Elevated serum osmolality

Increased blood urea nitrogen (BUN) and creatinine levels Elevated serum osmolality

Which questions would be appropriate for the nurse to ask to obtain fluid balance information? Select all that apply. “What types of fiber-containing food do you eat during a typical day?” “Have you lost or gained weight recently?” “Do you have a history of renal disease or diabetes mellitus?” “Have you noticed swelling of your hands and feet?” “Do you have any food allergies?”

“Have you lost or gained weight recently?” “Do you have a history of renal disease or diabetes mellitus?” “Have you noticed swelling of your hands and feet?”

Which patient assessments would suggest a significant fluid volume deficit (FVD) in an acutely ill patient brought into the urgent treatment center? Select all that apply. Hypertension Elevated serum blood urea nitrogen (BUN) and creatinine -levels Rapid, weak, thready pulse Weight loss of 0.5 kg over the past 2 days Dry, cracked lips and furrows on the tongue

Elevated serum blood urea nitrogen (BUN) and creatinine -levels Rapid, weak, thready pulse Dry, cracked lips and furrows on the tongue

Which amount of fluid would the nurse calculate has been lost by a patient with a fluid volume deficit reporting a 10 kg loss of total body weight in the last 48 hours as a result of vomiting and diarrhea? 1 liter of fluid 5 liters of fluid 10 liters of fluid 15 liters of fluid

10 liters of fluid

Which specific clinical findings would be expected by a nurse caring for an adult patient with isotonic fluid volume deficit (FVD)? Select all that apply. Hypotension Flat neck veins when supine Confusion Low urine output Slow, thready pulse

Hypotension Flat neck veins when supine Low urine output

Which rationale would explain the neurologic signs and symptoms caused by hypertonic fluid volume deficit? Decreased serum osmolality causes water to shift out of brain cells by osmosis. Decreased intracellular osmolality causes water to shift into the brain cells by osmosis. Increased intracellular osmolality causes sodium to shift into the brain cells by osmosis. Increased serum osmolality causes water to shift out of brain cells by osmosis.

Increased serum osmolality causes water to shift out of brain cells by osmosis.

Which sign or symptom suggests that a patient is experiencing hypertonic fluid volume deficit (FVD)? Hypotension Oliguria Confusion Dry mucous membranes

Confusion

Which type of fluid imbalance would a nurse suspect when the morning patient assessment reveals bounding peripheral pulses and jugular venous distention? Increased interstitial fluids Increased circulating volume Increased intracellular volume Increased transcellular volume

Increased circulating volume

A patient who received hypotonic intravenous (IV) fluids has developed the signs and symptoms of hypotonic fluid volume excess (FVE). Which neurologic signs or symptoms are consistent with this fluid imbalance? Select all that apply. Seizures Paralysis Tingling sensations in the lower extremities Confusion Facial numbness

Seizures Confusion

Which explanation would a nurse give to a student regarding the primary cause of edema resulting from fluid volume excess? Increased capillary permeability Obstruction of lymphatic drainage Decreased circulating plasma proteins Increased hydrostatic pressure

Increased hydrostatic pressure

Which descriptions would a nurse provide when educating a patient about edema? Select all that apply. Edema is caused by excessive fluid in the interstitial space. Edema develops when fluid moves into the intravascular space faster than it is absorbed. Dependent edema occurs in the sacral area of patients on bedrest. Edema causes tissue to become quite fragile. Increased circulating plasma proteins are a major cause of edema.

Edema is caused by excessive fluid in the interstitial space. Dependent edema occurs in the sacral area of patients on bedrest. Edema causes tissue to become quite fragile.

Match the signs and symptoms to their underlying cause. Increased interstitial fluid volume Increased circulating fluid volume Pulmonary edema Answers Choices Shortness of breath, cough Edema of the ankles and feet Bounding peripheral pulses and hypertension

Increased interstitial fluid volume Edema of the ankles and feet Increased circulating fluid volume Bounding peripheral pulses and hypertension Pulmonary edema Shortness of breath, cough

Which assessments would the nurse closely monitor as indicators of changes in a patient’s fluid volume status? Select all that apply. Vital signs Pain level Daily weights Bowel sounds Intake and output

Vital signs Daily weights Intake and output

Which substances would the nurse include in a patient’s fluid intake tally at the end of 24 hours? Select all that apply. Intravenous fluids A dish of cherry-flavored gelatin A piece of toast Supplemental enteral feedings A small piece of chicken

Intravenous fluids A dish of cherry-flavored gelatin Supplemental enteral feedings

Which measurements would the nurse include in a patient’s fluid output tally at the end of the day? Select all that apply. Urine in a urinary catheter collection bag A soft, formed stool Emesis caused by a vomiting episode A large volume enema Free water flushes for enteral feedings

Urine in a urinary catheter collection bag Emesis caused by a vomiting episode

Which items are commonly used as measuring tools for urine output? Select all that apply. Urine hat Diaper Urinal Indwelling catheter Wound dressing

Urine hat Diaper Urinal Indwelling catheter

Which factors would a nurse consider when planning fluid intake for a patient on a 1200 mL fluid restriction plan? Select all that apply. Meals Medications Solid foods on menu plan Intravenous (IV) fluid intake Between-meal fluids

Meals Medications Intravenous (IV) fluid intake Between-meal fluids

A patient has been placed on fluid restriction for management of fluid volume excess. Which actions would the nurse take to ensure the alert, adult patient is responsible and comfortable meeting the fluid restriction goals? Keep water and other beverages away from the bedside and only distribute them to the patient on a schedule. Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day. Provide two-thirds of the fluid volume during the day and restrict the remaining one-third to be given with medications. Assess and document all fluids consumed by the patient using an oral intake log kept at the bedside.

Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day.

Which action would the nurse take after noting that at 1:00 p.m. a patient on a fluid restriction has consumed 800 mL of the daily allotted 1200 mL? Hold all fluid intake except for what is needed for administering medications and begin distributing remaining allotment at the evening meal. Fill a water pitcher with 400 mL of water to be budgeted for medications and drinking for the remainder of the day. Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day. Give the patient 200 mL of fluid now and plan on giving the remaining 200 mL with the evening meal.

Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day.

Which related actions would be included when carrying out the nursing intervention “Provide water and a variety of fluids based on patient preferences” for a patient who requires oral fluid replacement? Select all that apply. Distribute fluid intake equally throughout the 24-hour day. Encourage intake of caffeinated beverages. Keep a pitcher of fresh water at the bedside at all times. Determine which beverages the patient prefers. Remove water and beverages during hours of sleep

Keep a pitcher of fresh water at the bedside at all times. Determine which beverages the patient prefers.

Which questions would the nurse consider when choosing the intravenous (IV) site for a patient with a prescription to start IV fluids? Select all that apply. What is the condition of the patient’s veins? What is the patient’s age? How long is the patient to receive IV therapy? What is the patient’s diagnosis? Will family members be staying in the patient’s room?

What is the condition of the patient’s veins? What is the patient’s age? How long is the patient to receive IV therapy? What is the patient’s diagnosis?

Which complication would a nurse need to monitor for when assigned a patient receiving 0.9% normal saline intravenously? Hypovolemia Hypernatremia Cellular dehydration Water intoxication

Hypernatremia

Match each intravenous (IV) fluid name to its corresponding category. Hypotonic crystalloid Isotonic crystalloid Hypertonic crystalloid Answer choices 0.45% normal saline (0.45% NS) 5% dextrose and 0.9% normal saline (D5 0.9 NS) 5% dextrose and water (D5W)

Hypotonic crystalloid 0.45% normal saline (0.45% NS) Isotonic crystalloid 5% dextrose and water (D5W) Hypertonic crystalloid 5% dextrose and 0.9% normal saline (D5 0.9 NS)

A patient receiving an intravenous (IV) crystalloid infusion reports that the IV site hurts. The nurse notes redness, swelling, and warmth at the IV site. Which complications would the nurse consider as a result of these signs and symptoms? Select all that apply. Collapsed vein Phlebitis Extravasation Catheter-related infection Infiltration

Phlebitis Catheter-related infection

Which major uses of a central venous catheter (CVC) would a nurse recognize? Select all that apply. Long-term intravenous (IV) therapies Short-term single IV therapy Short-term intensive therapies Administering hypertonic solutions Administering nonirritating IV medications

Long-term intravenous (IV) therapies Short-term intensive therapies Administering hypertonic solutions

Which patients are candidates for blood or blood product administration? Select all that apply. A patient with missing clotting factors A patient with drug-related destruction of red blood cells A patient who is severely dehydrated A patient with abdominal bleeding from trauma A patient who has had recent major surgery

A patient with missing clotting factors A patient with drug-related destruction of red blood cells A patient with abdominal bleeding from trauma A patient who has had recent major surgery

Which individuals are responsible for checking and verifying blood prior to administration? Select all that apply. Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient’s bedside before initiating -transfusion Shift nurse in charge Primary health care provider

Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient’s bedside before initiating -transfusion

The nurse must ensure that a blood product is infused within _4___ hours after leaving the blood bank? Use numbers only.

Which data reflect the priority assessments that a nurse would monitor when concerned that a patient may be developing a fluid volume imbalance? Select all that apply. The patient’s self-report of pain The patient’s pulse and blood pressure The patient’s weight changes over the past day The patient’s cranial nerve status The patient’s intake and output balance over the past 48 hours

The patient’s pulse and blood pressure The patient’s weight changes over the past day The patient’s intake and output balance over the past 48 hours

Which substances would a nurse need to include in the fluid intake tally? Select all that apply. Small volume enemas Nasogastric (NG) tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications

Nasogastric (NG) tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications

Which patient-related data would require entry of fluid output information on the electronic health record (EHR)? Select all that apply. The patient has a nasogastric (NG) tube attached to wall suction. The patient is receiving bladder irrigations. The patient has an indwelling urinary catheter in place. The patient has a surgical wound drain on his abdomen. The patient had a large volume enema this morning.

The patient has a nasogastric (NG) tube attached to wall suction. The patient has an indwelling urinary catheter in place. The patient has a surgical wound drain on his abdomen.

Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs after receiving a “force fluids” prescription for a fluid volume deficit? Select all that apply. Ensuring the pitcher of water at the patient - bedside is refilled as required Providing coffee and sodas at frequent intervals in addition to water Providing ways to record intake of fluids to meet required levels Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day

Ensuring the pitcher of water at the patient - bedside is refilled as required Providing ways to record intake of fluids to meet required levels Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day

Which factors would be included by the nurse when developing a 24-hour fluid budget for a patient with a 1000 mL fluid restriction? Select all that apply. Medications Intravenous (IV) fluids Solid foods consumed Between-meal fluid sipping Breakfast, lunch, and dinner

Medications Intravenous (IV) fluids Between-meal fluid sipping Breakfast, lunch, and dinner

Which plan would a nurse suggest for the remainder of the 24-hour period for a patient on a 1000 mL per day fluid restriction who has consumed 700 mL as of 3:00 p.m.? Allow the patient to consume another 300 mL right away and nothing more by mouth for the remainder of the 24-hour period. Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep. Remove all water and beverages from the room and allow the patient to consume 300 mL before going to sleep. Give the patient 150 mL at 3:00 p.m. and the remaining 150 mL before the patient goes to sleep.

Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep.

The nurse suspects that a patient receiving an intravenous (IV) infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. For which reason would this IV solution cause this complication? It is an isotonic solution. It is a colloid solution. It is a hypotonic solution. It is a hypertonic solution.

It is a hypertonic solution.

Which intravenous (IV) site in infants is most commonly used? The vein at the top of the foot The vein at the bend of the elbow The vein in the middle of the scalp The jugular vein in the neck

The vein in the middle of the scalp

Which actions related to intravenous (IV) fluid administration are the responsibility of the registered nurse? Select all that apply. Verify that the fluid is appropriate for the patient. Evaluate the effectiveness of IV therapy. Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration. Directly obtain the patient’s vital signs.

Verify that the fluid is appropriate for the patient. Evaluate the effectiveness of IV therapy. Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration.

Which complications would a nurse need to monitor for when caring for a patient receiving a hypertonic intravenous (IV) fluid? Select all that apply. Hypovolemia Cellular dehydration Circulatory overload Water intoxication Air embolism

Cellular dehydration Circulatory overload Air embolism

Which intravenous (IV) solution would a nurse use to prime the IV tubing when preparing to administer a blood product? 5% dextrose and water 0.45% normal saline 5% dextrose in 0.9% normal saline 0.9% normal saline

0.9% normal saline

Which procedural step failure would a nurse recognize as the most common cause of adverse blood transfusion events? Incomplete documentation during the verification process Failure to obtain informed consent prior to blood administration Blood exceeds the 4-hour time limit after leaving the blood bank Inappropriate identification prior to blood administration

Inappropriate identification prior to blood administration

During which time period would the nurse ensure extra vigilance when administering a blood product? As the transfusion is started and within the first 15 minutes Directly after the unit of blood has infused 1 to 2 hours after the transfusion has completed Approximately 2 hours after starting a transfusion

As the transfusion is started and within the first 15 minutes

Which signs or symptoms of an adverse reaction would a nurse monitor for in a patient who is receiving a unit of blood? Select all that apply. Itching Hypotension Dyspnea Fever Pale, cool skin

Itching Hypotension Dyspnea Fever

Which intervention would the nurse independently implement for a patient experiencing respiratory acidosis? Increasing the rate of IV fluid administration Encouraging deep breathing exercises Encouraging breathing into a paper bag. Administering a prescribed narcotic

Encouraging deep breathing exercises

Which nursing intervention is appropriate for all patients experiencing an acid-base imbalance? Encouraging deep breathing exercises Monitoring the arterial blood gas (ABG) analysis Restricting fluids Administering oxygen per prescription

Monitoring the arterial blood gas (ABG) analysis

Which nursing intervention would the nurse anticipate for a patient experiencing respiratory acidosis with chronic obstructive pulmonary disease (COPD)? Administering an antipyretic Administering breathing treatments Increasing the patient’s oral fluid intake Having the patient breathe into a paper bag

Administering breathing treatments

Which interventions would the nurse anticipate when caring for a patient experiencing metabolic acidosis? Select all that apply. Administering insulin Administering potassium Implementing seizure precautions Administering sodium bicarbonate Having mechanical ventilation available

Administering insulin Administering potassium Administering sodium bicarbonate Having mechanical ventilation available

Which intervention would the nurse anticipate when caring for a patient experiencing metabolic alkalosis? Administering insulin Treating hyperkalemia Implementing seizure precautions Administering sodium bicarbonate

Implementing seizure precautions

Which intervention is appropriate for a patient experiencing metabolic acidosis? Implementing seizure precautions Administering glucose Limiting ingestion of bicarbonate products Having mechanical ventilation available

Having mechanical ventilation available

Which intervention would the nurse include in the plan of care for a patient experiencing respiratory alkalosis? Restricting fluids Administering bicarbonate Administering antihypertensives Having the patient breathe into a paper bag

Having the patient breathe into a paper bag

Which members of the health care team would the nurse include when planning a collaborative care conference about the acute phase of any acid-base imbalance? Select all that apply. Unlicensed assistive personnel Physical therapist Health care provider Respiratory therapist Occupational therapist

Health care provider Respiratory therapist

Which interventions would the nurse independently implement for a patient experiencing respiratory acidosis? Select all that apply. Increasing the rate of IV fluid administration Encouraging deep breathing exercises Monitoring breath sounds Providing emotional support Administering a prescribed narcotic

Encouraging deep breathing exercises Monitoring breath sounds Providing emotional support

Which interventions would the nurse anticipate when caring for a patient experiencing metabolic alkalosis? Select all that apply. Administering potassium Administering insulin Implementing seizure precautions Administering sodium bicarbonate Administering diuretics

Administering potassium Implementing seizure precautions

The nurse is caring for a patient admitted with metabolic alkalosis. Which intervention would the nurse anticipate when providing care to this patient? Preparing for mechanical ventilation Administering the prescribed sodium bicarbonate Implementing seizure precautions Holding foods rich in potassium

Implementing seizure precautions

Which intervention would the nurse anticipate when caring for a patient experiencing metabolic acidosis? Administering antibiotics Implementing seizure precautions Providing incentive spirometry Providing mechanical ventilation

Providing mechanical ventilation

Which solutions by the nurse are appropriate when caring for a patient with known hyponatremia? Select all that apply. Administer potassium supplements. Increase oral fluid intake. Instruct the patient to avoid sports drinks and drink mostly water. Assist the patient to adhere to fluid restriction requirements. Monitor intake and output.

Assist the patient to adhere to fluid restriction requirements. Monitor intake and output.

Which nursing action is appropriate for a patient experiencing continued hypokalemia despite a week of treatment? Instruct the patient not to take a diuretic until potassium levels are normal. Instruct the patient to avoid salt substitutes. Report laboratory values to the health care provider. Instruct the patient to take potassium supplements with water only.

Report laboratory values to the health care provider.

Match the method of potassium replacement with the appropriate nursing action. Administer with juice Teach the use of salt substitutes Never administer by push or bolus Answer choices Oral Intravenous Dietary

Administer with juice Oral Teach the use of salt substitutes Dietary Never administer by push or bolus Intravenous

Which patients would benefit from administration of a calcium supplement? Select all that apply. A 20-year-old young adult with no health problems A 55-year-old woman who has been through menopause A 79-year-old male patient who resides in a nursing - home A 35-year-old male marathon runner A 72-year-old female patient who does not take any supplements

A 55-year-old woman who has been through menopause A 79-year-old male patient who resides in a nursing - home A 72-year-old female patient who does not take any supplements

Which foods would the nurse instruct the patient with hypercalcemia to avoid? Select all that apply. Milk Yogurt Spinach Dried fruit Sardines

Milk Yogurt Spinach Sardines

Match the electrolyte imbalance with the appropriate nursing intervention. Monitor intake and output and restrict intake of processed foods. Monitor electrocardiogram (ECG) and restrict intake of bananas and potatoes. Encourage oral fluid intake and physical activity. Assess deep tendon reflexes. Answer choices Hyperkalemia Hypercalcemia Hyperphosphatemia Hypermagnesemia

Monitor intake and output and restrict intake of processed foods. Hyperphosphatemia Monitor electrocardiogram (ECG) and restrict intake of bananas and potatoes. Hyperkalemia Encourage oral fluid intake and physical activity. Hypercalcemia Assess deep tendon reflexes. Hypermagnesemia

Which foods would the nurse teach patients to avoid when diagnosed with hyperkalemia? Select all that apply. Broccoli Cheese Cabbage Bananas Milk

Broccoli Cabbage Bananas

Which electrolytes would a nurse monitoring cardiac telemetry recognize as critical to proper cardiac functioning? Select all that apply. Sodium Calcium Magnesium Phosphates Potassium

Magnesium Phosphates Potassium

Which primary purpose of cardiac monitoring would the nurse include in a teaching session for patients with electrolyte imbalances? To prevent worsening of their imbalance To be able to monitor when an imbalance is improved To carefully monitor fluid status To monitor for cardiac dysrhythmias

To monitor for cardiac dysrhythmias

Which statement regarding cardiac telemetry monitoring is accurate? The nurse attaches the patient to a portable monitor and requests the patient to remain immobile. The nurse attaches electrodes, which are connected to a portable monitor allowing for patient movement, to the patient’s chest. A monitor must remain at the patient’s bedside, and the nurse must check the rhythm when assessing the patient. The patient has periodic electrocardiograms (ECGs) performed, and the results are sent to the physician

The nurse attaches electrodes, which are connected to a portable monitor allowing for patient movement, to the patient’s chest.

Which level of potassium is considered a medical emergency that requires immediate monitoring with cardiac telemetry? 2.1 mEq/L 3.5 mEq/L 4.1 mEq/L 5.1 mEq/L

2.1 mEq/L

Which statement describes the purpose of dialysis? Corrects electrolyte deficits Corrects dehydration Provides fluid and electrolyte balance Replaces lost electrolytes

Provides fluid and electrolyte balance

Which concepts would a nurse include when teaching a patient requiring dialysis for an electrolyte imbalance? Select all that apply. Dialysis may be needed as a result of decreased renal - function. Dialysis is always long term. Dialysis replaces lost potassium. Blood is drawn from the body and processed through -a series of filters to remove wastes. Dialysis helps remove excess fluid and electrolytes.

Dialysis may be needed as a result of decreased renal - function. Blood is drawn from the body and processed through -a series of filters to remove wastes. Dialysis helps remove excess fluid and electrolytes.

For which reason are patients diagnosed with impaired renal function prescribed dialysis for the treatment of electrolyte imbalances? Dialysis is required because of the effect of electrolytes on the patient’s cardiac activity. The kidneys are unable to excrete increased electrolytes. People with impaired renal function do not need to restrict electrolyte intake. People with impaired renal function always have fluid volume deficit.

The kidneys are unable to excrete increased electrolytes.

Which intervention would a nurse anticipate for a patient with a blood pressure of 80/40 mm Hg who is scheduled for dialysis later in the day? Renewed potassium supplement dosage Intravenous (IV) fluid administration Cancellation of dialysis Increased oral fluid intake

Intravenous (IV) fluid administration

Which patient conditions would benefit from electrocardiogram (ECG) monitoring because of an electrolyte imbalance? Select all that apply. Hyponatremia Hypokalemia Hypophosphatemia Hypocalcemia Hypomagnesemia

Hypokalemia Hypocalcemia Hypomagnesemia

Which action would be taken by a nurse who is administering intravenous (IV) potassium to a patient who is experiencing acute hypokalemia? Administering over a short period of time Administering the dose by IV push Administering the solution slowly Administering to replenish fluid and electrolyte loss

Administering the solution slowly

Which parameter would a nurse monitor when providing care to a patient prescribed intravenous (IV) normal saline (NS) for a prolonged period? Hyponatremia Fluid volume excess Hyperkalemia Hypokalemia

Fluid volume excess

Which foods would a nurse teach the patient to avoid when prescribed a low sodium diet for hypernatremia? Select all that apply. Canned soup Fresh vegetables Sports drinks Apples Table salt

Canned soup Sports drinks Table salt

Which food item would a nurse who is providing education to a patient with hypermagnesemia teach the patient to avoid? Table salt Dairy products Green, leafy vegetables Canned or processed food

Green, leafy vegetables

Which instruction would a nurse give to a patient experiencing hypermagnesemia? Avoid taking antacids. Increase green, leafy vegetables. Reduce the amount of sodium intake. Increase fluid intake

Avoid taking antacids.

Which patient electrolyte level would require the nurse to prepare for cardiac monitoring? A magnesium level of 52.2 mEq/L A potassium level of 2.4 mEq/L A calcium level of 4.22 mEq/L A sodium level of 139 mEq/L

A potassium level of 2.4 mEq/L

Which electrolytes are critical for proper cardiac functioning and would be included in a teaching session on cardiac telemetry? Select all that apply. Sodium Phosphate Magnesium Calcium Potassium

Phosphate Magnesium Calcium Potassium

Which advantage of cardiac telemetry would the nurse include when teaching a patient with an electrolyte imbalance? Allows the patient’s cardiac activity to be monitored remotely without affecting the patient’s mobility Provides ongoing assessment of the - patient’s electrolyte levels Provides documentation for causes of cardiac dysrhythmias Indicates which nursing interventions are needed to correct specific electrolyte abnormalities

Allows the patient’s cardiac activity to be monitored remotely without affecting the patient’s mobility

Which nursing actions would be implemented prior to a patient receiving a dialysis treatment? Select all that apply. Obtaining vital signs Increasing oral fluid intake Assessing laboratory data Providing instruction about what the patient should - expect Restricting oral intake 4 hours prior to the treatment

Obtaining vital signs Assessing laboratory data Providing instruction about what the patient should - expect

Which observation would the nurse expect after dialysis in a patient with a serum potassium level of 7.0 mEq/L? There will be no change in the patient’s potassium level. The serum potassium concentration will increase. The serum potassium concentration will decrease. What will happen to the serum potassium cannot be determined.

The serum potassium concentration will decrease

Which patient statement indicates understanding after a nurse completes education for a patient prescribed to receive dialysis to treat an electrolyte imbalance? “Dialysis will improve my kidney function.” “Dialysis will correct any fluid imbalances in the body.” “Dialysis can correct my dangerously low electrolyte levels.” “Dialysis removes excess wastes and electrolytes from my body.”

“Dialysis removes excess wastes and electrolytes from my body.”

Which questions would the nurse ask when conducting a health history assessment for a patient with a potassium imbalance? Select all that apply. “Do you have lactose intolerance?” “Do you take a diuretic, such as furosemide?” “Are you experiencing swelling in your feet?” “Do you use a salt substitute on your food?” “Do you eat canned meats or vegetables often?

“Do you take a diuretic, such as furosemide?” “Do you use a salt substitute on your food?”

Which assessment finding would support the diagnosis of hypocalcemia? Trousseau sign Lethargy Shallow respirations Stupor

Trousseau sign

Which test would the nurse anticipate for a patient with hyperkalemia? Urine specific gravity Serum calcium Electrocardiogram (ECG) Urine osmolality

Electrocardiogram (ECG)

Which action would a nurse take when assessing for Trousseau sign? Tap the skin over the facial nerve. Have the patient exhale with a closed mouth and a pinched nose. Cut the blood supply off with a blood pressure (BP) cuff. Measure the BP of a patient standing and lying down.

Cut the blood supply off with a blood pressure (BP) cuff.

Match the physical assessment with the data indicating an electrolyte imbalance. Spasm of the facial muscles when facial nerve is tapped Spasm of the hand and wrist muscles after blood pressure cuff is inflated Foot kicks wildly when patellar tendon is tapped Answer Choices Chvostek sign Trousseau sign Deep tendon reflex

Spasm of the facial muscles when facial nerve is tapped Chvostek sign Spasm of the hand and wrist muscles after blood pressure cuff is inflated Trousseau sign Foot kicks wildly when patellar tendon is tapped Deep tendon reflex

Which cues would the nurse anticipate when assessing a patient with a serum sodium level of 152 mEq/L? Select all that apply. Hyperactive deep tendon reflexes Confusion Thirst Lethargy Seizures

Confusion Thirst Lethargy Seizures

Which cues would a nurse expect in a patient with a serum potassium concentration of 3.1 mEq/L? Select all that apply. Confusion Postural hypotension Cardiac dysrhythmia Decreased bowel sounds Hyperactive deep tendon reflexes

Postural hypotension Cardiac dysrhythmia Decreased bowel sounds

Which cue would a nurse expect in a patient with severe hypocalcemia? Stupor Personality changes Laryngospasm Constipation

Laryngospasm

Which relevant cues would the nurse expect to observe when assessing a patient with hypomagnesemia? Select all that apply. Diaphoresis Seizures Cardiac dysrhythmia Nystagmus Tremors

Seizures Cardiac dysrhythmia Nystagmus Tremors

Which laboratory test would the nurse anticipate for an alert patient who presents to the emergency department with severe bilateral lower extremity weakness, shallow respirations, and normal heart rate and rhythm? Serum potassium Urine specific gravity Serum sodium Serum calcium

Serum potassium

Which neurologic assessment, performed by tapping the side of the face, would the nurse perform for a patient with risk factors for hypocalcemia? Level of consciousness exam Trousseau sign Electrocardiogram Chvostek sign

Chvostek sign

Which specific questions would a nurse include in the assessment interview for a patient with hypermagnesemia? Select all that apply. “What type of laxatives do you use?” “Have you had diarrhea recently?” “Do you use over-the-counter antacids?” “Do you have lactose intolerance?” “Do you take a prescribed diuretic?”

“What type of laxatives do you use?” “Do you use over-the-counter antacids?”

Which cues would a nurse assess a patient for based on a serum phosphate concentration of 3.1 mEq/L? Select all that apply. Tetany Hyperreflexia Decreased deep tendon reflexes Muscle cramps Shallow respirations

Tetany Hyperreflexia Muscle cramps

Which clinical manifestation would a nurse monitor for when providing care to a patient whose serum potassium level is 5.4 mEq/L? Bradycardia Hyperactive deep tendon reflexes Lethargy Emesis

Bradycardia

Which cue in a patient with end-stage renal disease would a nurse recognize as an indication of hyperphosphatemia? Decreased blood pressure Anorexia Irritated and itchy eyes Confusion

Irritated and itchy eyes

Place the steps the nurse uses to analyze arterial blood gas (ABG) levels in the correct order. Evaluate the PaO2 and O2 saturation levels. Evaluate whether or not compensation is occurring. Evaluate the PaCO2 and HCO3– to determine if the imbalance is respiratory or metabolic. Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range.

Evaluate the PaO2 and O2 saturation levels. Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range. Evaluate the PaCO2 and HCO3– to determine if the imbalance is respiratory or metabolic. Evaluate whether or not compensation is occurring.

Match the arterial blood gas (ABG) parameters to their normal values. 7.35–7.45 35–45 mm Hg 80–100 mm Hg 22–26 mEq/L Answer Choices pH PaCO2 PaO2 HCO3–

7.35–7.45 pH 35–45 mm Hg PaCO2 80–100 mm Hg PaO2 22–26 mEq/L HCO3–

Which information would the nurse require regardless of the type of acid-base imbalance? Urine output Arterial blood gas (ABG) analysis Skin turgor Bowel sounds

Arterial blood gas (ABG) analysis

Which PaO2 value range indicates moderate hypoxemia? 20 to 40 mm Hg 40 to 60 mm Hg 60 to 80 mm Hg 80 to 100 mm Hg

40 to 60 mm Hg

Match the clinical manifestation for respiratory acidosis to the corresponding system. Cardiovascular Neurologic Respiratory Answer choices Dyspnea Headache Tachycardia

Cardiovascular Tachycardia Neurologic Headache Respiratory Dyspnea

Which acid-base imbalance manifests with tachypnea and lightheadedness? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory alkalosis

Which neurologic cues are associated with metabolic acidosis? Select all that apply. Nausea Confusion Lethargy Tachycardia Anorexia

Confusion Lethargy

Which acid-base imbalance may be associated with progression to seizures? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

Metabolic alkalosis

Which conclusion would the nurse make when the ABG results for a patient suspected of having an acid-base imbalance reveal a decreased pH, increased PaCO2, and normal HCO3–? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis

Which actions would the nurse perform when analyzing ABG values for a patient suspected of having an acid-base imbalance? Select all that apply. Examining oxygenation status Evaluating the pH Assessing PaCO2 and HCO3– Monitoring potassium Determining compensation

Examining oxygenation status Evaluating the pH Assessing PaCO2 and HCO3– Determining compensation

Which acid-base imbalance would the nurse suspect when providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3– 20 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Metabolic acidosis

Which assessments would the nurse perform in all patients experiencing an acid-base imbalance? Select all that apply. Skin turgor Urine output Bowel sounds ABG analysis Vital signs

ABG analysis Vital signs

Which cardiovascular findings would the nurse anticipate in a patient with respiratory acidosis? Select all that apply. Tachycardia Dysrhythmia Hypotension Dyspnea Confusion

Tachycardia Dysrhythmia

Which clinical manifestation would the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis? Dyspnea Tachypnea Hypertension Hypotension

Tachypnea

Which assessment finding would cause the nurse to suspect that a patient is experiencing metabolic acidosis? Dyspnea Kussmaul respirations Polyuria Muscle twitching

Kussmaul respirations

Which acid-base imbalance would the nurse suspect in a patient presenting with muscle twitching and tetany who experiences a seizure 10 minutes after hospital admission? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

Metabolic alkalosis

Week 12 Sherpath Flashcards

(176 cards)