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
... [Show More] (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
Feedback:
The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min.
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
Feedback:
The nurse should have a bag-valve mask in the client’s room because midazolam hydrochloride can lead to
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
Feedback:
The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes
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 [Show Less]