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Foundations Nursing
set 16
| Question | Answer |
|---|---|
| A patient is admitted with an acid-base imbalance. The patient’s current assessment data includes hypotension and dysrhythmia. Which is the priority nursing diagnosis that the nurse should include in the plan of care? | decreased cardiac output |
| Which nursing diagnoses should the nurse include in the plan of care for a patient who is experiencing acid-base imbalance, hypoxemia, hypotension, restlessness, anxiety, and decreased oxygen saturation? | acute confusion decreased cardiac output impaired gas exchange |
| postop-ab surgery, presents to med-surge PACU. nurse’s assessment reveals: shallow, irregular 12 breaths/min. Lung sounds clear but decreased bilaterally. ABG post-extubation: pH 7.29, PCO2 46 mm Hg, O2 sat 88%. Which diagnosis is priority for patient? | ineffective breathing pattern |
| The nurse is completing a patient’s shift assessment and notes that the patient is lethargic, but restless and agitated. Which nursing diagnosis should the nurse include to the plan of care based on this data? | acute confusion |
| nurse diagnosis of Decreased Cardiac Output for patient admitted w/metabolic acidosis. goal is: the patient’s blood pressure will return to baseline or WNL within 24 hours of admission. Which NOC outcome should the nurse include in the plan of care? | tissue perfusion:vital signs |
| The nurse is planning care for a patient who is experiencing metabolic alkalosis and formulates the nursing diagnosis Acute Confusion. Which NOC outcomes are appropriate for the nurse to include in the plan of care? | cognition information processing memory |
| older patient reports fatigue, decreased energy, difficulty breathing. diagnosis is respiratory acidosis with metabolic compensation. The nurse formulates a nursing diagnosis of Fatigue. Which goal statement should the nurse include in the plan of care? | patient will verbalize feelings of increased energy within 24 hours of admission |
| patient’s ABG analysis is as follows: pH – 7.2; PaCO2 – 60 mm Hg; PaO2 – 73 mm Hg; HCO3− – 25 mEq/L. The nurse identifies the nursing diagnostic statement of Impaired Gas Exchange r/t COPD AEB ABG results. | patient's pH value will return to a level between 7.35 and 7.45 within 12 hours |
| Which intervention should the nurse include in the plan of care for a patient who is experiencing respiratory alkalosis? | breathing into a paper bag |
| Which nursing action is appropriate when providing care to a patient who is experiencing metabolic alkalosis? | initiating seizure precautions |
| nurse is planning a collaborative care conference for a patient diagnosed with an acid-base imbalance. Which members of the healthcare team should the nurse include during the acute phase of any acid-base imbalance? | Primary care provider (PCP) Respiratory therapist (RT) |
| Which interventions should the nurse implement for a patient who is experiencing respiratory acidosis? | Encourage deep breathing exercises Monitor breath sounds Provide emotional support |
| providing care to patient, following vehicle accident. steering wheel hit patient’s chest, trapped patient in car until rescue workers arrived. patient is now complaining of dyspnea. which acid-base imbalance does nurse identify the patient to be at risk? | Respiratory acidosis |
| child patient who fell at school, is receiving treatment for fractured arm. patient crying, complaining of pain. nurse reviews patient’s lab results, indicates elevated pH, decreased PaCO2. Which condition is patient experiencing based on current data? | Respiratory alkalosis |
| Which patients should the nurse identify as being at risk for respiratory acidosis secondary to impaired gas exchange? | 1. A patient experiencing an asthma attack 2. A patient diagnosed with scoliosis 3. A patient who is two hours postoperative for thoracic surgery |
| The nurse is caring for a patient with pulmonary edema. The nurse knows this patient is at risk for respiratory acidosis as a result of which factor? | Impaired gas exchange |
| The nurse admits a patient who is unresponsive. Which conditions in the medical history should the nurse identify as placing the patient at risk for metabolic acidosis? | 1. Type I diabetes 2. Sepsis |
| Lab values for patient include: pH - 7.31, PaO2 - 59.2 mm Hg, PaCO2 - 38.6 mm Hg, HCO3 – 17.5 mEq/L, and O2 saturation - 88%. The patient is awake, lethargic, taking rapid, deep breaths. Which data in medical history could be cause for current findings? | Diabetes mellitus |
| A patient is admitted with dehydration and lethargy. Which data should the nurse identify as supporting the diagnosis of metabolic alkalosis? | 1. Increased pH 2. Increased bicarbonate |
| The nurse is caring for a patient with an admitting diagnosis of metabolic acidosis. Which change in the patient’s respiratory pattern indicates to the nurse that compensation is occurring? | Kussmaul respirations |
| The nurse is assessing a patient who is diagnosed with respiratory acidosis. Which cardiovascular finding does the nurse anticipate when assessing the cardiovascular system? | Tachycardia - Dysrhythmia |
| Which clinical manifestation does the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis? | Tachypnea |
| Which assessment finding causes the nurse to suspect that a patient is experiencing metabolic acidosis? | Kussmaul respirations |
| A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect? | Metabolic alkalosis |
| The nurse is evaluating the ABG results for a patient who is suspected of having an acid-base imbalance. The ABG analysis indicates a decreased pH, an increased PaCO2, and a normal HCO3-. Which conclusion by the nurse is accurate? | Respiratory acidosis |
| Which nursing actions should the nurse perform when analyzing an ABG during the assessment process for a patient who is suspected of having an acid-base imbalance? | - Examining oxygenation status - evaluating the pH - Assessing PaCO2 and HCO3- - Determining compensation |
| The nurse is providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L. Which should the nurse document in the medical record regarding this ABG? | Metabolic Acidosis |
| Which should the nurse assess for in all patients who are experiencing an acid-base imbalance? | - ABG analysis - Vital signs |
| Which instruction to nursing assistive personnel (NAP) reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving intravenous (IV) fluids by gravity drip? | Let me know when you notice that the IV bag contains less than 100 mL. |
| The provider has ordered that a patient be 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? | Calculate the hourly volume of normal saline the patient should receive. |
| The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? | 25 drops/minute |
| The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order? | Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order |
| Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? | Using a volume-control device for the infusion |
Created by:
colby.caswell