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NURS 1220 Test 2 With Correct Answers
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NURS 1220 Test 2 With CorrectAnswers
Which nursing intervention would be included in the plan of care for a
patient who is in metabolic alkalosis because of overuse of diuretics? Select
all that apply.
- Monitoring electrolyte levels
- Administering prescribed diuretics
- Administering IV fluids
- Placing the patient on fall precautions
- Administering prescribed antiemetics - ANSWER Monitoring electrolyte
levels
Administering IV fluids
Placing the patient on fall precautions
rationale: For a patient with metabolic alkalosis because of diuretic therapy,
the patient's diuretics should be stopped, the nurse should administer IV
fluids and monitor electrolyte levels, and the patient should be placed on fall
precautions because hypotension and muscle cramping are common with
metabolic alkalosis. Antiemetics are used if metabolic alkalosis is caused by
vomiting.
Which organ plays a major role in maintaining pH balance in the body? Select
all that apply.
, - Lungs
- Brain
- Pancreas
- Kidneys
- Small intestines - ANSWER Lungs
Kidneys
rationale: Blood pH represents a delicate balance between hydrogen ions
(acid) and bicarbonate anions (base), which is largely controlled by the lungs
and kidneys. The lungs adjust the blood pH by releasing or retaining
hydrogen ions (acid), and the kidneys adjust the blood pH by releasing or
retaining bicarbonate anions (base). The liver plays a role in metabolism,
immunity, and clotting. The pancreas releases insulin for glucose metabolism
and enzymes for digestion. The brain plays a secondary role in maintaining
ph balance by sensing the need for alterations in acid or base levels and
sends appropriate signals to the kidneys and lungs. The small intestine is not
involved with regulating blood pH.
Which assessment finding if present in the patient would prompt the nurse
to suspect right-sided heart failure secondary to endocarditis? Select all that
apply.
- Distended neck veins
- Weight gain
- Peripheral edema
- Shortness of breath
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