exam 2 practice Flashcards
(50 cards)
A patient has been experiencing severe diarrhea for the past 48 hours. The nurse reviews the patient’s arterial blood gas (ABG) results:
pH: 7.31 PaCO₂: 38 mmHg HCO₃⁻: 18 mEq/L Which acid-base imbalance does the nurse identify?
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
c) Metabolic acidosis (Diarrhea causes loss of bicarbonate, leading to metabolic acidosis.)
The nurse is analyzing the following ABG results:
pH: 7.47 PaCO₂: 30 mmHg HCO₃⁻: 23 mEq/L Which condition does the nurse suspect?
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
b) Respiratory alkalosis (High pH, low CO₂ indicates respiratory alkalosis, often due to hyperventilation.)
A patient in respiratory distress presents with the following ABG values:
pH: 7.30 PaCO₂: 50 mmHg HCO₃⁻: 24 mEq/L What is the most likely cause?
a) Hyperventilation
b) Hypoventilation
c) Excessive vomiting
d) Diabetic ketoacidosis
b) Hypoventilation (CO₂ retention leads to respiratory acidosis.)
The nurse is caring for a patient with diabetic ketoacidosis (DKA). Which ABG results are expected?
a) pH 7.50, PaCO₂ 28, HCO₃⁻ 32
b) pH 7.28, PaCO₂ 36, HCO₃⁻ 18
c) pH 7.42, PaCO₂ 42, HCO₃⁻ 25
d) pH 7.31, PaCO₂ 50, HCO₃⁻ 24
b) pH 7.28, PaCO₂ 36, HCO₃⁻ 18 (DKA causes metabolic acidosis.)
The nurse is reviewing interventions for a patient with metabolic alkalosis. Which interventions are appropriate?
a) Administer antiemetics
b) Encourage deep breathing exercises
c) Monitor potassium levels
d) Administer sodium bicarbonate
e) Assess for excessive vomiting
a, c, e (Administering antiemetics prevents further HCO₃⁻ loss, monitoring potassium is crucial, and vomiting can cause metabolic alkalosis.)
A patient is admitted with a history of chronic alcoholism and is experiencing withdrawal symptoms. Which assessment findings should the nurse expect?
a) Bradycardia and hypotension
b) Hyperglycemia and drowsiness
c) Tachycardia and tremors
d) Miosis and respiratory depression
c) Tachycardia and tremors (Common withdrawal symptoms.)
The nurse is monitoring a patient undergoing alcohol withdrawal. The patient is at risk for delirium tremens (DTs) within:
a) 1 hour
b) 4-12 hours
c) 24-48 hours
d) 2-3 days
d) 2-3 days (Delirium tremens occurs 2-3 days after the last drink.)
The nurse is preparing to administer medications for alcohol withdrawal. Which medication is commonly used to prevent seizures?
a) Lorazepam
b) Metoprolol
c) Haloperidol
d) Clonidine
a) Lorazepam (A benzodiazepine used to prevent seizures.)
The nurse is caring for a patient experiencing delirium tremens. Which interventions are appropriate?
a) Administer benzodiazepines
b) Monitor for hallucinations
c) Encourage the patient to walk
d) Place the patient in a quiet environment
e) Assess for autonomic instability (tachycardia, hypertension)
a, b, d, e (Benzodiazepines, monitoring for hallucinations, reducing stimuli, and checking for autonomic instability are key interventions.)
The nurse recognizes which laboratory finding as a potential indicator of chronic alcoholism?
a) Increased platelet count
b) Elevated liver enzymes
c) Decreased potassium levels
d) Increased calcium levels
b) Elevated liver enzymes (Alcoholism often leads to liver damage.)
A patient with Alzheimer’s disease is in Stage 5. What symptom does the nurse expect?
a) Loss of ability to recognize family members
b) Mild forgetfulness
c) Disorientation to time and place
d) Ability to perform ADLs independently
c) Disorientation to time and place (Stage 5 includes moderate cognitive decline.)
The nurse is providing care for a patient with severe Alzheimer’s disease. Which intervention is most appropriate?
a) Encourage reality orientation
b) Allow the patient to independently choose meals
c) Provide a structured daily routine
d) Encourage complex problem-solving
c) Provide a structured daily routine (Predictability helps reduce anxiety.)
Which medication is commonly used to manage symptoms of Alzheimer’s disease?
a) Donepezil
b) Lithium
c) Phenytoin
d) Furosemide
a) Donepezil (A cholinesterase inhibitor used in Alzheimer’s disease.)
Which interventions are appropriate for a patient with Alzheimer’s disease?
a) Provide locks on doors and windows
b) Encourage cognitive stimulation activities
c) Use open-ended questions
d) Offer cholinesterase inhibitors
e) Use physical restraints
a, b, d (Safety modifications, cognitive stimulation, and medications help manage Alzheimer’s.)
The nurse is teaching a family caregiver about Alzheimer’s disease progression. Which statement indicates understanding?
a) “My loved one will never develop language problems.”
b) “Alzheimer’s disease progresses at the same rate for everyone.”
c) “My loved one may eventually forget how to eat and walk.”
d) “Memory loss is the only symptom of Alzheimer’s disease.”
c) “My loved one may eventually forget how to eat and walk.” (Late-stage Alzheimer’s leads to loss of motor functions.)
A patient with COPD has an oxygen saturation of 89%. What is the best nursing action?
a) Increase oxygen to 6L/min
b) Keep the oxygen at 2L/min
c) Place the patient in Trendelenburg position
d) Encourage fluid restriction
b) Keep the oxygen at 2L/min (Too much O₂ can suppress respiratory drive in COPD patients.)
The nurse identifies which hallmark symptom of chronic bronchitis?
a) Pink, flushed skin
b) Pursed-lip breathing
c) Productive cough for at least three months
d) Hyperinflated alveoli
c) Productive cough for at least three months (Chronic bronchitis definition.)
Which complication is the priority concern for a patient with COPD?
a) Hypoxemia
b) Hypertension
c) Peripheral edema
d) Muscle wasting
a) Hypoxemia (O₂ deficiency is the main concern in COPD.)
The nurse provides teaching for a COPD patient on ways to improve breathing. Which techniques should be included?
a) Pursed-lip breathing
b) Diaphragmatic breathing
c) Rapid shallow breathing
d) Tripod positioning
e) Encourage high-carbohydrate diet
a, b, d (Pursed-lip breathing, diaphragmatic breathing, and tripod positioning improve oxygenation.)
The nurse is educating a patient with COPD about medication therapy. Which medication should the nurse expect to be prescribed?
a) Albuterol
b) Furosemide
c) Warfarin
d) Metformin
a) Albuterol (A bronchodilator used for COPD.)
A nurse is assessing a post-op patient. Which finding requires immediate intervention?
a) Mild pain at the incision site
b) Temperature of 99.1°F (37.3°C)
c) Urinary output of 20 mL/hr
d) Slight redness around the incision
c) Urinary output of 20 mL/hr (Indicates potential acute kidney injury)
Which intervention is most important for preventing post-op atelectasis?
a) Administering antibiotics
b) Encouraging incentive spirometry
c) Restricting fluid intake
d) Maintaining bed rest
b) Encouraging incentive spirometry
A patient reports nausea after surgery. Which action should the nurse take first?
a) Administer ondansetron as prescribed
b) Offer clear liquids
c) Place the patient in a side-lying position
d) Encourage deep breathing
c) Place the patient in a side-lying position (Prevents aspiration)
The nurse is monitoring a patient for post-op complications. Which findings are concerning?
a) Sudden chest pain and dyspnea
b) Blood pressure of 85/50 mmHg
c) Capillary refill less than 2 seconds
d) Warm, dry skin
e) Absent bowel sounds
a, b, e (Indicate pulmonary embolism, hypovolemia, and potential ileus)
