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Adult Health III Exam 1

- Question 1 2.5 out of 2.5 points A client with chronic obstructive pulmonary disease (COPD) arrives in the emergency department (ED) reporting shortness of breath and dyspnea on minimal exertion. Which of the following findings would be a priority for the nurse to report to the health care provider? Answers : Response Feedback: SaO2 level is 91% bibasilar lung crackles the client is sitting in the tripod position the client’s respirations have decreased to 10 breaths/min The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min. Crackles, tripod position and SaO2 of 91% are all common findings for a client with COPD. Lewis 2017, pgs. 1613-1614abck - Question 2 0 out of 2.5 points The nurse caring for a client scheduled for surgery administers prescribed intravenous (IV) midazolam hydrochloride and the client then demonstrates signs of an overdose. The nurse should collaborate with the surgical team to do which of the following actions next? Answers: administer prescribed epinephrine prepare to defibrillate the client ventilate the client with an oxygenated bag-valve mask titrate prescribed intravenous flumazenil Response Feedback: The nurse should have a bag-valve mask in the client’s room because midazolam hydrochloride can lead to respiratory acidosis if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or to receive epinephrine unless cardiac compromise developed after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the midazolam, but first the nurse should ventilate the client. Lewis 2017, pgs. 288stem, 1610stem, 1614-1615k, bcd by omission - Question 3 2.5 out of 2.5 points The nurse has attended a staff education conference about fluid balance. Which of the following statements, if made by the nurse, would indicate a correct understanding of homeostatic mechanisms in the body that regulate body fluid? Select all that apply. Answers "Clients with increased levels of aldosterone are at risk for fluid loss." : "The amount of fluid loss through exhalation has no impact on fluid balance." "I will monitor urine output to measure the kidney's effect on fluid volume balance." "Clients who have a lack of antidiuretic hormone (ADH) are at risk for fluid volume deficit (FVD)." "Thirst triggers a mechanism in the hypothalamus to maintain fluid balance." Response Feedback: The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes increased aldosterone which results in sodium and water retention. Approximately 300 ml of water is lost daily through exhalation (insensible water loss). Low levels of antidiuretic hormone (ADH) have an impact on fluid balance. The thirst center in the hypothalamus regulates oral intake by sensing intracellular dehydration. The kidneys regulate extracellular fluid (ECF) volume by selective retention and excretion of body fluids. Lewis 2017, pgs. 274-275kde - Question 4 0 out of 2.5 points The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L Answers: respiratory acidosis

metabolic alkalosis respiratory alkalosis metabolic acidosis

Response Feedback: The ABGs shown indicate the pH is low which would mean acidosis. The PaCO2 is within normal levels and the HCO3 is low indicating a metabolic disturbance. Remember the acronym ROME when interpreting ABGs. Lewis 2017, pgs. 290-291kbcd

- Question 5 0 out of 2.5 points The nurse is reviewing the arterial blood gas (ABG) results for a client who was admitted with a bowel obstruction and has nasogastric tube (NG) with continuous suction. Which of the following ABGs would indicate to the nurse the client is experiencing a complication from the NG tube? Answers: pH = 7.50 PaCO2 = 40 HCO3 = 39 pH = 7.28 PaCO2 = 41 HCO3 = 19 pH = 7.30 PaCO2 = 50 HCO3 = pH = 7.47 PaCO2 = 30 HCO3 = 22 Response Feedback: Clients who have a prescription for continuous suction are at increased risk for metabolic alkalosis indicated by pH =7.50 CO2 = 40 HCO3 = 39, due to a loss of hydrogen and chloride ions from gastric fluids. Gastric fluids are acidic. - Question 6 0 out of 2.5 points The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24- hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take? Answers: Administer prescribed antibiotics. Decrease the intravenous fluids. Assist the client to ambulate to increase their metabolic rate. Encourage the client to increase their fluid intake. Response Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. 1071-1072abkd - Question 7 0 out of 2.5 points The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following actions by the nurse would help prevent ventilator associated pneumonia (VAP)? Answers: maintaining the head of the client's bed elevated at least 10 degrees suctioning of the client's oral cavity secretions every shift practicing meticulous hand hygiene ensuring the respiratory therapist changes the ventilator circuit tubing every 4 hours Response Feedback: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. The client will need oral suctioning more frequently than every shift and at least 30-degree head of the bed elevation. It is not necessary to change the ventilator circuit tubing every 4 hours. The more frequently the circuit is broken, the greater the risk for pathogen entry. Lewis 2017, p. 1623kbcd - Question 8 0 out of 2.5 points

The nurse in the emergency department (ED) is caring for a client who reports acute dyspnea, pain and anxiety. The client’s blood pressure is 140/85 mm/Hg, pulse is 110 beats/minute and SaO2 is 85%. ABG values are; pH 7.50, PaCO2 29 mm/Hg, and HCO3 24 mm/Hg. Which of the following actions should the nurse take? Select all that apply. Answers: encourage the client to breathe slowly

obtain a medical history from the client to determine the cause of symptoms administer oxygen therapy administer prescribed pain medication prepare the client for intravenous therapy to promote compensation Response Feedback: The client is experiencing respiratory alkalosis based on the ABG levels. The pH is high and the PaCO2 is low. The nurse should administer oxygen, and pain medication and encourage the client to slow the breathing because pain can cause respiratory alkalosis and hyperventilation increases the pH levels. Obtaining as much of a medical history from the client as possible is key to treating the cause. With respiratory alkalosis, compensation is typically not possible because the client requires aggressive treatment of the hypoxemia. Lewis 2017 pgs. 288-289ck, stem, 1614-1615k

- Question 9 0 out of 2.5 points The nurse is caring for a client who is receiving positive pressure ventilation and high levels of PEEP via endotracheal intubation for acute respiratory distress syndrome (ARDS). The nurse should contact respiratory therapy for which of the following findings? Answers: The client’s temperature increased from 98.8o F. to 100.1o F in the last hour. The client’s blood pressure decreased from 110/68 mm/Hg to 89/60 mm/Hg in the last hour. The client’s FIO2 is at 65%. The client’s PaO2 is at 75%. Response Feedback: The nurse should contact respiratory therapy for the decrease in blood pressure. Client’s receiving high levels of PEEP can experience a reduction in blood return to the left side of the heart from hyperinflation of the alveoli and compression of the pulmonary capillary bed which then causes dramatic reduction in BP. The PEEP should be adjusted to correct the BP. The client’s temperature is unrelated to respiratory therapy and the FIO2 and PaO2 are within expected levels. Lewis 2017, pg. 1624Kbc, d by omission. - Question 10 2.5 out of 2.5 points A client is admitted to the intensive care unit (ICU) after a motor vehicle collision (MVC) in which the client received blunt trauma to the chest. The client is in acute respiratory failure and is intubated and minimally sedated. Which of the following should the ICU nurse monitor when caring for the client? Select all that apply. Answers ability to communicate verbally : oral intake arterial blood gases (ABGs) respiratory system vital signs (VS) Response Feedback: Clients are usually managed in the intensive care unit. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. In addition, the nurse assesses the entire respiratory system and implements strategies (eg, turning schedule, mouth care, skin care, range of motion of extremities) to prevent complications. The nurse also assesses the client's understanding of the management strategies that are used and initiates some form of communication to enable the client to express concerns and needs to the health care team. The other options are incorrect; a client in respiratory failure is intubated. The client cannot communicate verbally and cannot take in anything orally. Lewis 2017, pgs. - Question 11 0 out of 2.5 points The nurse is caring for a client who is postoperative lung surgery. The client has a shallow, monotonous respiratory pattern and is reluctant to cough. The nurse should assess the client for which of the following? Answers :

Response Feedback: increased risk for aspiration atelectasis increased oxygen saturation malnutrition The reluctance to cough is likely due to poor pain control. A shallow, monotonous respiratory pattern places the client at an increased risk of developing atelectasis. The client would not be at increased risk for increased

oxygen saturation, aspiration, or malnutrition. Lewis 2017, pgs. 1621-1622k, acd by omission, 334 k

- Question 12 2.5 out of 2.5 points The nurse is caring for a client who is receiving long-term mechanical ventilation. The client becomes frustrated when trying to communicate with the nurse. Which of the following would be an appropriate action by the nurse? Answers : Response Feedback: Ask the healthcare provider to wean the client off the mechanical ventilator to allow the client to talk. Assure the client that everything will be all right and tell the client to calm down. Ask a family member to interpret what the client is trying to communicate. Provide a picture board or alphabet board for the client to communicate. Providing the client with alternative methods of communication may provide the client with control and become less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. In a client with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the client's wishes. Making them responsible for interpreting the client's gestures may frustrate the family. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met. Lewis 2017, pgs. 1556k abc by omission - Question 13 0 out of 2.5 points The nurse is explaining how to provide postural drainage to a client. Which of the following interventions would be appropriate when providing postural drainage? Answers: applying percussion firmly to bare skin sitting in an upright position performing the procedure directly after meals using pillows to help position the client Response Feedback: Postural drainage is usually performed two to four times per day. The client uses gravity to facilitate postural draining, which may require the use of pillows. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal. Lewis 2017, pgs. 1616-1617k, 570abck - Question 14 2.5 out of 2.5 points The nurse receives report about the following four clients with asthma. Which client should the nurse see first? Answers: A 16-year-old who is speaking in short sentences, with crackles on expiration, is sitting upright, and has an oxygen saturation of 93%. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds and has an oxygen saturation of 92%. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. Response Feedback: The 12-month-old is exhibiting signs of severe asthma and should be seen first. The child no longer has wheezes and now has diminished breath sounds. All the clients are exhibiting mild to moderate signs of asthma and do not take priority over the 12-month-old client. Lewis 2017, pgs. 545-546abk, 1612k, 1613- 1614 ad - Question 15 2.5 out of 2.5 points The nurse in the emergency department is caring for a client experiencing acute respiratory failure who is restless and has decreased cardiac output. Which of the following interventions would be a priority by the nurse?

Answers: Connect the client to a cardiac monitor. Provide airway suctioning. Administer a prescribed bronchodilator. Prepare to intubate the client. Response A client with decreased cardiac output who is already experiencing ARF indicates severe acute respiratory

Feedback: distress syndrome (ARDS) and requires intubation to maintain the PaO2 at acceptable levels. The client will need cardiac monitoring and bronchodilators and probably suctioning once intubated, but those are not the priority. Lewis 2017, p. 1624 kacd by omission, 1615 stem

- Question 16 2.5 out of 2.5 points The nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values for a client diagnosed with respiratory failure and notes the client's pH 7.58, PaCO2 20, PaO2 75, HCO3 28, and SaO2 92%. Which of the following interventions should be a priority for the nurse? Answers: contacting the client’s family to come sit with the client and explaining that the client's ABG's are within normal limits (WNL) completing a spiritual assessment and providing appropriate clergy support for the client preparing the client for endotracheal intubation and mechanical ventilation immediately starting an infusion of dextrose 50% in water solution (D50W) Response Feedback: This client is experiencing respiratory alkalosis related to respiratory failure. The pH level is elevated in hyperventilation; the client’s hyperventilation will “blow off” more CO2, leading to lower pCO2 levels. Decreased pCO2 is caused by hyperventilation. With rapid breathing SO2 can be increased with deep or rapid breathing. Acute airway management is indicated to improve tissue oxygenation. Airway support meets the client’s physiologic need for a clear airway. Spiritual support is a higher level (self-actualization) on Maslow’s hierarchy. Providing IV management for circulatory support is a basic physiologic need; however, airway management is priority. Lewis 2017, pgs. 288-290 k, bcd by omission, 1614-1615 k - Question 17 2.5 out of 2.5 points The nurse received change of shift report about assigned clients. Which of the following clients should the nurse assess first? Answers: The client with serum potassium level 5.0 mEq/L who is reporting abdominal cramping. The client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The client with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates. The client with serum sodium level 145 mEq/L who reports dry mouth and is asking for water. Response Feedback: The client with low magnesium needs to be seen first because hypomagnesemia can lead to cardiac dysrhythmias. The client with a high phosphorus is just barely high and has manifestations that are expected and not life threatening. The client with a high normal potassium level is experiencing expected symptoms of abdominal cramping and also does not have life-threatening symptoms. Finally, the client whose sodium is 145 is within normal limits and so would not be the priority. Lewis 2017, p. 286 k, 279b,280-281a, 285d - Question 18 2.5 out of 2.5 points The nurse provided discharge teaching for a client with mild chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following statements by the client would indicate a correct understanding of the teaching? Answers: "I will lie in the supine position to facilitate air entry when practicing deep breathing." "I should practice using diaphragmatic breathing in the sitting position." "I will practice chest breathing." "I should use pursed lip breathing as a last resort." Response Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration and should not only be used as a last resort. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing. Lewis 2017, p. 568- - Question 19 2.5 out of

2.5 points A nurse is caring for a client in the emergency department (ED) who had a radiograph (x-ray) that reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which of the following interventions should the nurse include in the client's plan of care?

Answers: suction the client's airway secretions strict fluid intake and fluid replacement restriction prepare the client for surgery immediately sedate and intubate the client Response Feedback: As with rib fracture, treatment of flail chest is usually supportive. Management includes ventilatory support, clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Clients should have adequate fluid intake and replacement to mobilize secretions and underlining pulmonary contusion. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the fail segment. Lewis 2017, pgs. 521-522kbcd, 1610 k

- Question 20 1.66667 out of 2.5 points The nurse administered prescribed IV morphine to a client who was 18 hours postoperative and reported feeling anxious and having incisional pain. The client’s respiratory rate was 25 breaths/min, and the arterial blood gas (ABG) results were pH 7.50, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3 23 mEq/L. The nurse should expect which of the following changes in the client’s condition? Select all that apply. Answers decreased pH level : decreased respirations decreased PaCO2 level decreased HCO3 level decreased pain Response Feedback: After receiving pain medication (morphine) the client should experience decreased pain, respirations, pH level and an increase in the PaCO2 level. The HCO3 level is already within normal levels and would not expect to change. The client is experiencing respiratory alkalosis. Lewis 2017, pgs 289-291kde Vallerand 2017, pgs 866-870k - Question 21 0 out of 2.5 points The nurse is caring for a client whose calcium level is 5.8 mg/dL and when the nurse was obtaining the client’s blood pressure the client experienced carpal spasms. Which of the following actions would be a priority for the nurse to take? Answers: Implement seizure precautions. Assist the client to breathe into a paper bag. Use the client’s ankle to obtain a blood pressure. Obtain a prescription for a muscle relaxer. Response Feedback: The nurse should recognize the client’s symptoms as Trousseau’s sign and that the client is at risk for ineffective breathing patterns. Assisting the client to breathe into a paper bag can promote CO2 retention to help alleviate hypocalcemia s/s of muscle spasms until an IV of calcium gluconate can be administered to correct the low calcium level. The nurse should implement seizure precautions once the client’s breathing is under control, but seizure precautions would not be the priority. A muscle relaxer and obtaining the blood pressure on the ankle is not necessary or part of the treatment for hypocalcemia. Lewis 2017, pgs. 284-285kd, ac by omission. - Question 22 0 out of 2.5 points The nurse is caring for a client who was admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2. mEq/L. Which of the following actions, if prescribed by the health care provider, should the nurse take first? Answers : Response Feedback:

Place the client on a cardiac monitor. A d m i n i s t e r r e g u l a r i n s u l i n i n t r a v e n o u s l y (IV) at 20 units/hr. Obtain urine glucose and ketone levels. Administer intravenous (IV) potassium supplements. Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be

administered without cardiac monitoring, since insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient’s care. Lewis 2017, pgs. 282-283akcd

- Question 23 0 out of 2.5 points The nurse is evaluating the appropriateness of a physician’s prescription for continuous positive airway pressure (CPAP) with the delivery of oxygenation. The nurse should expect the prescription to be for which of the following clients? Answers: The client diagnosed with pneumonia who requires 100% oxygen and refuses to have endotracheal intubation. The client with muscular dystrophy who is experiencing symptoms of acute respiratory failure (ARF). The client who experienced near drowning with an SaO2 level of 89% and has crackles in all lung fields. The client in hypovolemic shock who is experiencing symptoms of acute respiratory distress syndrome (ARDS). Response Feedback: Continuous positive airway pressure (CPAP), a form of non-invasive positive pressure ventilation (NIPPV), is used with oxygen therapy to reverse or prevent micro-atelectasis, allowing a lower percentage of oxygen to be used. NIPPV is most useful in managing chronic respiratory failure in clients with chest wall and neuromuscular disease, like muscular dystrophy. Clients who require high oxygen requirements, who have excessive secretions of are hemodynamically unstable are not good candidates for NIPPV. Lewis 1617abkd, 1610 k - Question 24 0 out of 2.5 points The nurse is providing discharge instructions for a client who experienced respiratory acidosis from severe chronic obstructive pulmonary disease (COPD). Which of the following information would help prevent future episodes of respiratory acidosis? Answers: “You should avoid using home oxygen when you are resting and sleeping.” “Paradoxic breathing should be used when you are exercising.” “Using pursed-lip breathing can help slow your respiratory rate.” “When you feel out of breath you should use diaphragmatic breathing.” Response Feedback: The client should be taught to use pursed-lip breathing to slow the respiratory rate and work of breathing which will help prevent respiratory acidosis. Diaphragmatic breathing for clients with COPD can actually increase the work of breathing and exacerbate dyspnea especially clients with severe COPD. During paradoxic breathing the chest and abdomen move outward with exhalation and inward with inspiration which is the opposite of how they should move. This movement during breathing does not help a client with COPD decrease the work of breathing. Oxygen use should not be avoided. Client’s with COPD who use long-term O2 have increased survival. Oxygen should be used during exercise and sleep especially and evaluated on an individual bases for necessity. Lewis 2017, pgs. 568-570akd, 288 k, 1614 b - Question 25 0.83333 out of 2.5 points The nurse is assessing a client with end stage kidney disease (ESKD). The client's serum laboratory results indicate hypocalcemia and hyperphosphatemia. Which of the following findings should the nurse anticipate? Select all that apply. Answers: Trousseau's sign decreased clotting time drowsiness and lethargy constipation cardiac arrhythmia's fractures Response Feedback: Hypocalcemia is a deficit that causes nerve fibers irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include cardia arrhythmias, diarrhea, increased clotting times, anxiety and

irritability. The calcium/phosphorus imbalance leads to brittle bones and pathologic fractures. Lewis 2017, pgs. 284- 258 kkcdek

- Question 26 0 out of 2.5 points

The parents of a child with asthma ask the nurse how a prescribed inhaled beta-agonist works. Which of the following would be the best response by the nurse? Answers : Response Feedback: "Beta agonists relax smooth muscles in the airway, which then dilate rapidly." "Beta agonists increase airway inflammation and hyper-responsiveness." "The medication is given to stop your child's wheezing." "Beta agonists reduce mucosal edema in the airway, thereby increasing the diameter." The action of a beta agonist is to relax smooth airway muscle, resulting in bronchodilation. When inhaled, it exerts action directly on the airway. While it is true that albuterol may 'stop the wheezing' this is not the best selection and does not answer the parent's question. Beta agonists do not reduce edema or inflammation. Vallerand 2017, pgs. 120-

- Question 27 0 out of 2.5 points The nurse is caring for a client experiencing acute metabolic alkalosis from gastroenteritis and notes the client’s pulse is 110 beats/min, and on telemetry the client has flattened T waves and presence of U waves. Which of the following information should the nurse explain to the client? Answers : Response Feedback: “You are experiencing symptoms of kidney failure and will need peritoneal dialysis.” “Your body is going into hypovolemic shock and requires rapid intravenous fluid replacement.” “Your body is showing signs of decreased potassium and will require potassium replacement therapy.” “You are experiencing low blood sugar and will need to receive intravenous glucose.” Gastroenteritis is accompanied by diarrhea and vomiting which can result in decreased potassium levels and cause metabolic alkalosis. Flattened T waves, presence of a U wave, and rapid pulse are all manifestations of hypokalemia. The client will require potassium replacement therapy. A client experiencing metabolic alkalosis would more likely have a high blood sugar not low. A client with acute kidney failure would have an increased potassium level with peaked T waves. The client may be hypovolemic from gastroenteritis, however there is not enough information in the stem to determine that the client is experiencing shock. Lewis 2017, pgs. 944 stem, 282k, 289-291k, 1072b, 1589c, 1591c - Question 28 0 out of 2.5 points The nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas values: pH 6.88, HCO3 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which of the following actions should the nurse take? Answers: Obtain a prescription and administer 50 mL of 20% glucose and 20 units of regular insulin. Administer 50 mL of prescribed sodium bicarbonate intravenously. Apply the prescribed oxygen by mask or nasal cannula. Apply a paper bag over the client's nose and mouth. Response Feedback: The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped, and the client can breathe again, the fastest way to return to acid-base balance is to administer oxygen. Sodium bicarbonate should not be administered because the client’s arterial bicarbonate level is normal. Applying a paper bag over the client’s nose and mouth would worsen the acidosis. Glucose and regular insulin would not be appropriate to administer to the client. Lewis 2017, p. 290, 1615k - Question 29 0 out of 2.5 points The nurse is evaluating the arterial blood gas (ABG) results for a client experiencing acute respiratory distress syndrome who has received prone positioning. Which of the following would indicate the prone positioning was successful?

Answers : pH is 7.34 and PaCO2 is 33 mm Hg HCO3 level changed from 25 mEq/L to 35 mEq/L pH is 7.45 and HCO3 is 26 PaO2 level changed from 60 mm Hg to 85 mm Hg

Response Feedback: The nurse should check the client’s PaO2 level for an increase to show that the client’s perfusion/ventilation is better matched. The prone positioning allows for fluid filled alveoli that were in the dependent area, when the client was supine, to drain to the anterior portion of the lungs, which become the dependent lungs when in the prone position. This helps to improve ventilation of better-perfused lung areas. The changes in the HCO3 level indicate the HCO3 has increased which would not indicate the position helped with ventilation. The other two distractors do not provide enough information to know if there is an improvement. Lewis 2017, p. 290 kbcd, 1624- 1625 k

- Question 30 2.5 out of 2.5 points The nurse is preparing to assist with weaning an assigned client from the mechanical ventilator. Which of the following should be a priority for the nurse to assess prior to weaning the client from the ventilator? Answers: electrocardiogram (ECG) results bilateral lung sounds fluid intake for the last 24 hours baseline arterial blood gas (ABG) levels Response Feedback: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. ABG levels will indicate if the client is maintaining adequate ventilation and perfusion. Lung sounds are important, but not critical indicators that ventilation and perfusion are adequate. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. Lewis 2017, pgs. 289-290k, 1582akcd - Question 31 0 out of 2.5 points The nurse caring for a client experiencing acute hypoxemic respiratory failure due to V/Q mismatch is evaluating the client’s plan of care. Which of the following interventions would be appropriate for the client’s care plan? Answers: Provide oxygen via noninvasive positive pressure ventilation (NIPPV). Initiate 24% to 32% oxygen via face mask. Initiate invasive positive pressure ventilation (PPV) via endotracheal tube for SaO2 below 90%. Provide high flow supplemental oxygen via nasal cannula. Response Feedback: The nurse should understand that acute hypoxemic respiratory failure due to V/Q mismatch requires low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen. This helps improve the PaO2 and SaO2 levels. Without knowing the client’s baseline SaO2 an intervention to initiate PPV vie ET tube for SaO2 would be inappropriate. NIPPV is typically the treatment of choice for hypoxemia secondary to an intrapulmonary shunt, not V/Q mismatch. Lewis 2017, pgs. 1615- - Question 32 0 out of 2.5 points (Extra Credit) Order: Ceftin oral suspension 30 mg/kg bid is prescribed for a child who weighs 66 pounds. How many mg of Ceftin should the nurse administer per day? Write only the number not the units. 66/2.2=30| 30mg/30kg=900mg bid| 900mg x 2 = 1800? - Question 33 0 out of 2.5 points The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L Answers: respiratory alkalosis metabolic alkalosis metabolic acidosis respiratory acidosis

Response Feedback:

- 2.5 points The ABGs shown indicate the pH is high which would mean alkalosis. The PaCO2 is low which is the opposite of the pH and indicates that the respiratory system is the primary problem. The HCO3 is within normal levels. Remember the acronym ROME when interpreting ABGs. Lewis 2017, pgs 290-291abcK Question 34 ??? 0 out of

The nurse is caring for a group of assigned clients. The nurse should prepare to administer prescribed bicarbonate intravenously to the client with which of the following clinical manifestations? Answers: pH 7.28, HCO3– 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma attack pH 7.31, HCO3– 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract infection (UTI) and diabetes mellitus, type 2 (DM-2) pH 7.30, HCO3– 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis and emphysema pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea Response Feedback: The only client who has lower than normal bicarbonate levels is the client with diarrhea. This deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to help return this client’s acid-base balance to normal. Giving bicarbonate to any of the other clients listed would be adding too much base and would risk the development of alkalosis. Lewis 2017, pgs. 290-291kbcd

- Question 35 2.5 out of 2.5 points The nurse is caring for a client who is in acute respiratory failure (ARF) from exacerbated chronic obstructive pulmonary disease (COPD). The client is intubated with an endotracheal (ET) tube and placed on mechanical ventilation. Which of the following actions would be a priority for the nurse to take following intubation? Answers: Arrange for a chest radiograph (x-ray). Auscultate the lungs for presence of bilateral breath sounds. Monitor the client for signs of aspiration. Reposition the client every hour. Response Feedback: When a client is intubated with a endotracheal tube for mechanical ventilation, the nurse should immediately assess for chest expansion symmetry and auscultate breath sounds bilaterally. The client will have a chest radiograph to confirm placement, but that is not the immediate priority. Repositioning the client and assessing for aspiration are important to prevent complications but is not the immediate priority. Lewis 2017, p.1570kbcd - Question 36 2.5 out of 2.5 points The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is being mechanically ventilated. The nurse evaluates that adequate gas exchange occurs based on which of the following? Answers: diffusion of gas in the shunted blood adequate ventilation-perfusion ratio perfusion/diffusion ratio shunting of blood in the lungs Response Feedback: Adequate gas exchange depends on an adequate ventilation–perfusion (adV/adQ) ratio. There is no perfusion/diffusion ratio; diffusion refers to the process by which oxygen and carbon dioxide are exchanged Shunting occurs when perfusion exceeds ventilation, the blood bypasses the alveoli without gas exchange. Lewis 2017, pgs. 1610-1611k, acd by omission - Question 37 2.5 out of 2.5 points The nurse reviews the nursing care plan of a client with pneumonia and notes documentation of a nursing diagnosis of Activity intolerance. The nurse should implement which of the following in the client’s plan of care? Answers: encourage deep, rapid breathing during activity maintain bedrest except for meals, assist client out of bed schedule activities before giving prescribed respiratory medications or treatments obtain vital signs and oxygen saturation periodically during activity Response Feedback: The nurse monitors vital signs, including oxygen saturation, before, during, and after activity to gauge client response. Activities should be planned after giving the client respiratory medications or treatments to increase

activity tolerance. The client should use pursed-lip and diaphragmati c breathing to lower oxygen consumption during activity. Finally, the environment should be conducive to rest because the client is easily fatigued. Lewis 2017, pgs. 506 abkd

- Question 38 0 out of 2.5 points The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is mechanically ventilated with positive end-expiratory pressure (PEEP). Which of the following should alert the nurse that the client is having complications from PEEP? Select all that apply. Answers: hypopnea decreased urine output diminished lung sounds tachycardia hypertension Response Feedback: PEEP is indicated in clients with ARDS. PEEP provides positive pressure at the end of expiration to keep the alveoli open. This positive pressure can increase the intrathoracic pressure. When intrathoracic pressure increases, the client will have a decrease in preload, which can decrease cardiac output. When there is a decrease in cardiac output, the client can have tachycardia, hypotension, and decreased perfusion to the kidneys. With increased intrathoracic pressure, barotrauma or pneumothorax can occur. A client on mechanical ventilation should have equal and bilateral breath sounds, diminished breath sounds may indicate a pneumothorax. Lewis 2017, pg. 1577Kbe - Question 39 0 out of 2.5 points The nurse is evaluating the client who is receiving assist-control ventilation via mechanical ventilation for acute respiratory failure. Which of the following findings would indicate the client is tolerating the mode of ventilation? Answers: The client’s work of breathing has increased. The client is initiating spontaneous breaths. The client is breathing faster than the preset rate. The client is self-regulating the volume of each breath. Response Feedback: The assist-control ventilation mode allows the client to initiate spontaneous breathes and then delivers the preset Vt. This allows the client to have some control over ventilation while still getting some assistance if the client does not spontaneously breath as often as the preset frequency is set for. The WOB should not increase, this means the client may be getting tired and needs more assistance. Breathing faster than the preset rate can occur when the client is overventilated and results in hyperventilation. Self-regulating the volume of each breath is consistent with pressure support ventilation mode. Lewis 2017, pgs. 1575-1576abck - Question 40 0 out of 2.5 points The nurse is assessing a client who experienced metabolic alkalosis from food poisoning and received intermittent parenteral fluid therapy. Which of the following findings would indicate that the fluid therapy was successful? Answers: pH level has decreased and PaCO2 level has increased pH level has decreased and HCO3 level has increased pH and HCO3 levels have decreased pH and PaCO2 levels have increased Response Feedback: The client experiencing metabolic alkalosis would have high pH and HCO3 levels, so if the IV fluids were successful the pH and HCO3 levels should have decreased. If the pH or HCO3 increased the client’s metabolic alkalosis would be worsening. The PaCO2 would be normal or increased with metabolic alkalosis, so if the fluids were successful the level should not increase more. Lewis 2017, pgs. 290-291kbcd, 288stem and k. - Question 41 2.5 out of 2.5 points (Extra Credit) A patient is prescribed Shebahcillin 250 mg PO bid. Available is Shebacillin 100 mg in 10 mL. How many mL to administer? Write only the number not the units. 250/100 = 2.50*10= 25

- Question 42 0 out of 2.5 points The nurse is preparing to suction a client with an endotracheal (ET) tube. Which of the following should be the nurse's first step in the suctioning process? Answers: Turn on the suction source between 80 and 120 mm/hg.

Response Feedback: Assess the client's lung sounds and SaO2 via pulse oximeter. Explain the procedure to the client before beginning and offer reassurance during suctioning. Perform hand hygiene and put on nonsterile gloves, goggles, gown, and mask. Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the client's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step and turning on the suction source is the fourth step. Lewis 2017 pgs. 1571-1572abkd

- Question 43 2.5 out of 2.5 points The nurse is educating the parents of a child diagnosed with cystic fibrosis. Which of the following prescribed interventions should the nurse include in the teaching? Answers: chest physiotherapy (CPT), postural drainage, and digestive enzymes dietary modification involving a low-protein, high-fat, low-carbohydrate diet passive range of motion (PROM) limited to upper extremities preparation for renal dialysis and strict intake and output Response Feedback: Children with cystic fibrosis require daily, ongoing pulmonary hygiene including chest percussion and inhaled Pulmonase in order to clear the tenacious secretions in the lungs. For appropriate growth, fat-soluble vitamin supplements are needed, as well as dosing with pancreatic enzymes at all feedings/meals. The information in the distractors is not appropriate for the child with cystic fibrosis. Lewis 2017, pgs. 578-579k abc by omission, 1610k - Question 44 0 out of 2.5 points The nurse is evaluating the care plans for a group of assigned clients who have acute respiratory failure with a new nursing diagnoses of ineffective airway clearance related to excessive secretions. Which of the following clients requires immediate revision of the care plan? Answers : Response Feedback: The client taking in 1,200 to 1,500 L/day of oral fluids. The client who cannot perform huff coughing. The client whose SaO2 decreased from 96% on 2 L nasal canula to 93%. The client receiving non-invasive positive pressure ventilation. The client receiving non-invasive positive pressure ventilation needs immediate revision of the care plan because it is not appropriate for clients who have excessive secretions. The clients in the distractors do not require immediate revisions, but they do require revisions. Huff coughing can help clients expectorate secretions and if the client is unable to perform huff coughing there are other therapeutic cough techniques that can be used. The client with excessive secretions should be able to take in 2 to 3 L/day of oral fluids otherwise should receive IV hydration to help thin the secretions. An SaO2 decreasing from 96% to 93% is not an emergency unless the client had other signs of hypoxia. Lewis 2017, p. 1616-1617kbcd - Question 45 2.5 out of 2.5 points The nurse is caring for a client who arrived in the emergency department (ED) with reports of nonproductive cough, fever, and fatigue. Which of the following assessment findings would require immediate action by the nurse? Answers : (^) Response Feedback:

tachypnea P a O 2 4 5 m m H g s h a l l o w r e s p i r a t i o n s P a C O 2 33 mm Hg The client is reporting symptoms that are consistent with the manifestations of pneumonia and a PaO2 of 45 mm Hg indicates acute respiratory failure (ARF) and requires immediate oxygen therapy and airway maintenance. The PaCO2 is slightly below normal and should be addressed but does not require immediate

action over the PaO2. Shallow respirations and tachypnea would be expected for a client with a fever and other manifestations of pneumonia. Lewis 2017, pgs. 1615stem, 290kb, 1613 cd

- Question 46 0 out of 2.5 points The nurse received report from the previous shift for a client who was intubated for acute respiratory failure (ARF) less than one hour ago. Which of the following test results would be a priority for the nurse to follow-up? Answers : Response Feedback: complete blood count (CBC) electrocardiogram (ECG) mixed venous O2 saturation (SvO2) end-tidal CO2 (ETCO2) After a client is intubated the ETCO2 should be evaluated because this confirms proper tube placement within the airway immediately after intubation. A CBC, ECG and SvO2 are also done after intubation but would not be a priority over correct tube placement. Lewis 2017, p. 1614 - Question 47 2.5 out of 2.5 points The nurse is caring for a client with acute respiratory failure (ARF) who has a prescription for postural drainage with percussion and vibration twice daily. Which of the following interventions would be appropriate for the nurse to implement? Answers: Perform percussion before assisting the client into the drainage position. Administer prescribed albuterol before the client receives the therapy. Maintain the client in the lateral position for 20 minutes during the procedure. Schedule the procedure for 2 hours after the client eats. Response Feedback: Bronchodilators are administered before chest physiotherapy to help open up the airways for the drainage to occur. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Clients remain in each postural drainage position for 5 minutes. Percussion is done while the client is in the postural drainage position. - Question 48 0 out of 2.5 points The nurse is caring for a client with right sided pneumonia (PN) and helps position the client in the left Sims position. The nurse should evaluate the client’s response to the position by doing which of the following? Answers : Response Feedback: Compare the client’s PaO2 level with the previous level. Compare the client’s pH and HCO3 levels with the baseline levels. Ask the client to perform coughing and deep breathing. Assessing the client’s pain level. Clients with unilateral lung disease should be positioned with the healthy lung in a dependent position. This helps to mobilize the secretions which makes it easier to expectorate. The client’s PaO2 level compared to the previous level would give the nurse a good indication if the client’s ventilation has increased. Lewis 2017, pgs. 1610-1611k, 1624-1625k, acd by omission - Question 49 2.5 out of 2.5 points The nurse is providing telephone triage and is speaking with the spouse of a client with asthma who has a prescription for a short-acting inhaled beta-agonist to utilize as needed. The spouse states, "My spouse’s personal best peak flow reading is 290 L/minute and today the reading is 220 L/minute." Which of the following would be an appropriate response by the nurse? Answers: "Your spouse should use the prescribed beta-agonist inhaler." "Your spouse’s asthma is under good control." "A prescription for intravenous corticosteroids is most likely necessary."