NURS 1430 Exam 3 (UPDATED) – El Centro College | NURS1430 Exam 3 (UPDATED)

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NURS 1430 Exam 3 (UPDATED) – El Centro College. Question 1 0 / 3 pts The nurse monitors the patient on PPV for: You Answered   paralytic ileus becuase pressure on the abdominal contents a... ffects bowel motility   signs of cardiovascular insufficiency because pressure in the chest impedes venous return   diuresis and sodium depletion because of increasted release of atrial natriuretic peptide   respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels   Question 2 2 / 6 pts The RN is developing a plan of care for a patient requiring mechanical ventilation. The nurse identifies the RN role in developing the plan includes: select all that apply    Reposition and secure ET tube based upon facility policy     Auscultate breath sounds and respiratory effort, assesing for decreased ventilation or adventitious sounds Correct!   Develop a plan for communication with the patient who has an ET tube    Give sedatives, analgesics, and paralytic drugs as needed      Monitor ventilator settings and alarms     Question 3 2 / 6 pts Oxygen is a drug and toxicity is a risk the RN must monitor.  Identify the criteria for oxygen risks. select all that apply    PaO2 levels between 40 - 50 mmHg   Correct!   Mechanically ventilated patients receiving FIO1 at a high percentage for extended periods of time    Assess ABGs for evidence of excess O2   You Answered    Target FIO2 levels to be maintained SpO2 >88%   Correct!    Uncontrolled coughing, chest pain, and dyspnea     Question 4 0 / 2 pts The nurse is caring for a 78 year old patient that was intubated 24 hours ago for respiratory distress secondary to pneumonia. PEEP is set at 5 cmH2O.  The nurse monitors the patient's PEEP for signs of complications that include:    hemodynamic instability   You Answered    a. pulmonary infiltrates      bronchoconstriction      decreasing intracranial pressure     Question 5 4 / 6 pts The nurse is caring for a mechanically ventilated patient. The ventilator alarms is sounding. The alarms for mechanical ventilation includes: select all that apply     high FIO2 percentage      apnea      hypovolemic shock   Correct!    low pressure   Correct!    high pressure     Question 6 4 / 6 pts The nurse hears an alarm on a mechanical ventilator in a patient's room. The nurse monitors for signs of unplanned extubation which can be life threatening.  This includes: select all that apply You Answered    diminished or absent breath sounds   Correct!    acute respiratory distress   Correct!    low-pressure alarm is sounding   Correct!    patient is talking      projectile vomiting     Question 7 0 / 2 pts A 80 yr old patient has confusion and a temperature of 103.8 degrees F. Patient is a ling time diabetic with purulent drainage from the left ankle. IV infusion of NS is infusing at 125 mL/min and 3 liters have been infused since admission. Assessment findings are: 86/40, 112, 46 and shallow. CO 8 L/min; and PAWP 4 mmHg. The patient's signs and symptoms are most likely indicative of: You Answered    multiple organ dysfunction syndrome      septic shock      sepsis      systemic inflammatory response syndrome     Question 8 2 / 2 pts A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first? Correct!    Place the patient on a cardiac monitor.      Insert a urinary retention catheter.      Give sodium polystyrene sulfonate (Kayexalate).      Administer epoetin alfa (Epogen, Procrit).   Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.   Question 9 2 / 2 pts A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?    Creatinine level   Correct!    Glomerular filtration rate (GFR)      Blood urea nitrogen (BUN) level      Urine volume   GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.   Question 10 0 / 2 pts A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?    Urine output over an 8-hour period is 2500 mL.      The glomerular filtration rate is less than 30 mL/min/1.73 m2. You Answered    The blood urea nitrogen (BUN) level is 67 mg/dL.      The creatinine level is 3.0 mg/dL.   The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.   Question 11 0 / 2 pts A patient in the oliguric phase after an acute kidney injury has had a 250-mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient’s fluid restriction for the next 24 hours? You Answered s 0   950 mLThe general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).   Question 12 0 / 2 pts A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be to    push upward on the epigastric area as the patient coughs.      notify the patient’s health care provider.      encourage incentive spirometry every 2 hours during the day.   You Answered    suction the patient’s nasopharynx.   Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient’s ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient’s ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse’s first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.   Question 13 2 / 2 pts A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing:     cardiogenic shock   Correct!    neurogenic shock from systemic vasodilitation      relative hypervolemia      neurogenic shock from low blood flow   Ch 66 end of chapter questions   Question 14 2 / 6 pts The ICU nurse receives an abdominal aneurysm post-op patient from PACU with IV NS infusing at 150 mL/hr. Two hours after receiving the patient, the patient becomes restless, confused, and anxious. VS are 88/40, 120, 32, 97.8. Initial interventions include: select all that apply Correct!    ive high-flow O2 by non-rebreather mask      establish second large bore IV      draw stat blood for laboratory studies   You Answered    assess bowel sounds   Correct!    get stat ECG     Question 15 0 / 2 pts The nurse reviews the blood gas results of an emergency room patient who presented with shortness of breath and anxiety. Lung sounds are diminished bilaterally in the lower lobes. Identify the findings of the ABG. pH 7.25, Paco2 50 mmHg You Answered    respiratory alkalosis      metabolic acidosis      metabolic alkalosis      respiratory acidosis     Question 16 1 / 2 pts The nurse is verifying the ET placement of a newly intubated patient. Nursing priorities include: select all that apply Correct!    Exit mark is present on the tube   Correct!   observe for symmetric chest wall movement initially and with repositioning    confirm exit mark remain constant during repositioning   You Answered    keep O2 sat at 88% or above     Question 17 8 / 8 pts Match the following rationales for the four patients being admitted to ICU to the reasons for admission. Reason may be used more than once. Correct! Patient in Ketoacidosis                 Correct! Patient with nondisplaced skull fracture who is alert and oriented                 Correct! Patient with surgical mitral valve replacement                 Correct! Comatose patient who had an anaphylactic reaction triggering a cardiac arrest                 Prioritization of care   Question 18 2 / 2 pts A patient has on oral ET tube inserted to relieve an upper airway obstruction and to facilitate secretion removal. That is the first responsibility of the nurse immediately following placement of the tube? Correct!    place an end tidal CO2 detector on the ET tube      secure the tube to the face with adhesive tape      assess for bilateral breath sounds      suction the tube to remove secretions   First action is to test expiration for CO2 by using the end tidal CO2 detector. If no CO2 is detected, the tube is in the esophagus. Other actions may be done but not immediately after intubation.   Question 19 0 / 2 pts An ICU patient is orally intubated on a ventilator, O2 saturation at 92%, becomes restless and anxious. Select the nursing intervention to be done first to prevent unplanned extubation.    obtain order for soft wrist restraints      administer ordered sedation   You Answered    communicate with the patient to remain calm     move the patient to a quieter room away from noisy nurses station     Question 20 6 / 6 pts An elderly patient in ICU is developing early signs of delirium. The nursing interventions include: select all that apply Correct!    use clock and calendar to orient patient   Correct!   identify physiologic factors that may be contributing to the confusion and irritability    maintain NPO status until gag reflex has returned     silence all alarms and minimize conversations to decrease the environmental stimuli Correct!   sedate the patient to protect the patient from harmful behaviors   end of chapter questions Ch 66, 9th ed   Question 21 0 / 2 pts A new nurse on the renal unit receives a newly admitted patient with acute kidney injury. The nurse recognizes a priority intervention is _____________ due to sepsis being the number one cause of death in a patient with AKI.    hydration      sterile techniques   You Answered    gram negative antibiotics      aseptic techniques     Question 22 2 / 2 pts The Renal ICU nurse receives a patient from the emergency department in acute kidney injury (AKI). Priority monitoring of which electrolytes are critical in this patient?    Hypokalemia and hypernatremia   Correct!    hypokalemia and hyponatremia      hypercalcemia and hyponatremia      hyperkalemia and hypernatremia   end of chapter questions Ch 47 9th ed. [Show More]

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