N405 Study Guide Exam 1 Questions And Actual Answers.
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Course
N405
Institution
N405
While monitoring a client with fluid overload, which assessment findings requires immediate nursing intervention?
A. Neck Vein Distension
B. Presence of crackles in the lungs
C. Pitting edema in the feet
D. Bounding Pulse - Answer B. Presence of crackles in the lungs.
(in terms of emerg...
N405 Study Guide Exam 1 Questions
And Actual Answers.
While monitoring a client with fluid overload, which assessment findings requires immediate nursing
intervention?
A. Neck Vein Distension
B. Presence of crackles in the lungs
C. Pitting edema in the feet
D. Bounding Pulse - Answer B. Presence of crackles in the lungs.
(in terms of emergencies, remember ABC, airway, breathing, circulation)
Fluid overload may lead to pulmonary edema and heart failure. Any client with fluid overload, regardless
of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems,
pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be
indicative of pulmonary edema, which can occur very quickly and lead to death in clients with fluid
overload.
For which electrolyte imbalance will the nurse monitor a client with Clostridium difficile infection and
significant diarrhea?
A. hypocalcemia
B. hypokalemia
C. dehydration
D. hyponatremia - Answer B. Hypokalemia
Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of
potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant
diarrhea.
,A client with a history of COPD is brought to the ED with respiratory depression. What acid-base
imbalance does the nurse anticipate?
A. Metabolic Alkalosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Acidosis - Answer C. Respiratory Acidosis
Respiratory acidosis results when respiratory function is impaired and the exchange of oxygen (O2) and
carbon dioxide (CO2) is reduced. This problem causes CO2 retention, which leads to the same increase in
hydrogen ion levels and acidosis
The nurse is evaluating laboratory assessment data of a client with uncontrolled metabolic acidosis.
What finding does the nurse anticipate?
A. bicarbonate 38 mEq/L
B. PaO2 98 mmHg
C. pH 7.40
D. potassium 5.7 mEq/L - Answer D. potassium 5.7 mEq/L
Metabolic acidosis is reflected by several changes in ABG values. The pH is low (<7.35). The bicarbonate
level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because gas exchange is
adequate. The serum potassium level is often high in acidosis as the body attempts to maintain
electroneutrality during buffering.
A client with severe burns over 85% of the body is being transported to the ED. The paramedic tells the
nurse over the phone that IV access could not be established in the field. What type of IV device does
the nurse anticipate will be ordered upon the client's arrival?
A. Intraosseous catheter
B. PICC line
C. Central line
, D. Subcutaneous Infusion - Answer A. Intraosseous catheter
Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of
trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because
often clinicians are unable to access these clients' vascular systems for traditional IV therapy. If IV access
cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After
establishing IO access, efforts should continue to obtain IV access as well.
While assessing a client with Graves disease, the nurse notes that the client's temperature has risen 1° F
(1° C). What does the nurse do first?
A. Turn the lights down and shut the patient's door.
B. Call for an immediate electrocardiogram (ECG).
C. Calculate the client's apical-radial pulse deficit.
D. Administer a dose of acetaminophen. - Answer A. Turn the lights down and shut the patient's door.
(Graves disease --> Hyperthyroidism)
A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and the primary
health care provider or RRT needs to be notified. But before notifying the provider, the nurse should first
take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse
can then call for an ECG. The apical-radial pulse deficit would not be necessary, and acetaminophen is
not needed because the temperature increase is due to thyroid activity.
DIF: Applying
KEY: Thyroid disorder, Emergency care
MSC: Integrated Process: Nursing Process: Planning and Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal thyroid-
stimulating hormone levels. What actions does the nurse take? (Select all that apply.)
A. Administer levothyroxine
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