Practice q Flashcards
(42 cards)
What clinical manifestation should the nurse expect to find in a patient with Addison’s disease?
Dark pigmentation of the mucous membrane.
What type of IV solution should the nurse infuse for a client with DKA?
Normal Saline.
What signs of compensation should the nurse expect in a client with DKA?
Kussmaul’s respiration.
Which actions are most effective when monitoring a patient with DI?
Serum sodium level and urine specific gravity.
When assessing a patient with SIADH, which lab values would the nurse expect to identify?
Urine specific gravity > 1.030 and sodium of 120.
For a client with SIADH and serum sodium of 114, what is the most appropriate action by the nurse?
Restrict client fluid intake to at least 900 mL/hour.
what is the priority intervention for a patient with HHNS?
volume resuscitation
Which statement by a patient about Addisonian crisis indicates understanding?
I will avoid emotional distress
To rule out DVT, what medication should you anticipate to be ordered for a patient experiencing dyspnea and chest pain on inspiration?
Heparin
What does fluctuations in the water seal chamber of a closed drainage system indicate?
The system is working properly
When suctioning the airway of a client with a tracheostomy, how should the catheter be inserted?
Insert catheter until coughing or resistance is felt
For a patient with a PE whose oxygen saturation changed from 94% to 88%, what management is required?
Supplemental oxygen
What should be started for a patient with persistent vomiting for 3 days and increasing weakness?
IV therapy with Ringer’s solution and an ABG analysis
What strategies should nursing staff develop to prevent VAP?
Checking gastric residual Q4, elevating HOB 30 - 45, maintaining sterile technique, suctioning, maintaining adequate pressure in the cuff of ET tube
What indicates complications for a client who is brought to the ER following an overdose on sedatives?
Hypoventilation and respiratory acidosis
Which position would NOT be tolerated in a client with acute respiratory failure?
Supine with bed flat
What do the ABG levels of a client with pneumonia and a history of obstructive pulmonary disease reflect?
Hypoxemia
Which client is at the greatest risk of developing ARDS?
22 year old who received 10 units of blood after MVA
In a plan of care for ARDS with an order for prone positioning, what is the highest priority nursing concern?
Management and protection of airway
What is the most proper interpretation for a client with left-sided chest trauma, increased dyspnea, and tracheal deviation to the right?
Tension pneumothorax
How can correct placement of an endotracheal tube be confirmed?
Chest x-ray
What are possible causes for a high inspiratory pressure alarm on mechanical ventilators?
Coughing, attempting to talk, kinks in the ventilator tube, need for suctioning
What acid-base disturbance is a client at risk for if their respirations decrease to 4 after receiving morphine?
Respiratory acidosis
What ABG abnormality may occur for a client with a spontaneous RR of 22?
Respiratory alkalosis
