NU 448 Adult Health III Exam 1
NU 448 Adult Health III Exam 1
NU 448 Adult Health III Exam 1
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 an...
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 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
Response The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min.
Feedback: 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 The nurse should have a bag-valve mask in the client’s room because midazolam hydrochloride can lead to
Feedback: 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 The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes
Feedback: 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 The ABGs shown indicate the pH is low which would mean acidosis. The PaCO2 is within normal levels
Feedback: 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 =25
pH = 7.47 PaCO2 = 30 HCO3 = 22
Response Clients who have a prescription for continuous suction are at increased risk for metabolic alkalosis indicated
Feedback: 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 Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of
Feedback: 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 Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation
Feedback: 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
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