NR 226: Exam 2 review questions ALL ANSWERS 100% CORRECT SPRING FALL-2022 LATEST SOLUTION GUARANTEED GRADE A+

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1. A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult? - funds success, pg 369, # 6 a. Int... ake and output results - only fluid balance b. Serum laboratory values – fluid, electrolyte and acid-base imbalances c. Condition of the skin –only fluid balance d. Presence of tenting – only fluid balance 2. A nurse is caring for a patient with an intestinal stoma. Which intervention is most important? – funds success, pg 387, #20 a. Cleansing the stoma with cool water – not a priority b. Spraying an air-freshening deodorant in the room - not a priority c. Selecting a bag with an appropriate-size stomal opening –the opening of the appliance must be large enough to encircle the stoma to protect the surrounding tissues from intestinal discharge without impinging on the stoma and impairing circulation d. Wearing sterile nonlatex gloves when caring for the stoma 3. A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis (DVT)? – funds success, pg 418, # 11 a. Utilization of compression stockings at night – promotes venous return for limited amount of time while sleeping only b. Deep breathing and coughing daily– prevents atelectasis and pneumonia c. Leg exercises 10 times per hour when awake – active intervention by patient that contracts the muscles of the legs. This rhythmically compresses the veins, which promotes venous return and prevents stasis. d. Elevation of the legs on 2 pillows – not good. Pressure is placed on popliteal space, which constricts blood vessels and impedes venous return 4. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? - Saunders, 8th edition, pg 116, #55 a. Metabolic acidosis – diarrhea (base out the butt), b. Metabolic alkalosis – vomiting (throw up the acid), gastric suctioning c. Respiratory acidosis - caused by hypoventilation: pneumonia, asthma, OD, airway obstruction d. Respiratory alkalosis – anxiety, acute pain, ASPIRIN OD (stimulates the brain stem respiratory control) 5. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? – Saunders, 8th edition, pg 117, #63 a. Respiratory acidosis from inadequate ventilation – caused by hypoventilation b. Respiratory alkalosis from anxiety and hyperventilation - c. Metabolic acidosis from calcium loss due to broken bones – nothing in question re: Ca+ loss d. Metabolic alkalosis from taking analgesics containing base products – pt. not taking analgesics 6. A patient is experiencing diarrhea and needs to replace potassium. Which nutrients selected by the patient indicate that additional teaching is necessary regarding nutrients high in potassium. Select all that apply. Test success, pg 288, #30 a. Beef boullion b. Orange juice c. Poached egg d. Warm tea e. Avocados- review list in your power point: banana, sweet potato, baked potato, dried apricot 7. A 750-mL tap-water enema is ordered for a patient. Which should the nurse do to best promote acceptance of the volume ordered? Test success pg. 300, # 4 a. Administer the fluid slowly, and have the patient take shallow breaths b. Place the patient in the left lateral position, and slowly administer the fluid c. Have the patient take shallow breaths, and keep the fluid at body temperature d. Keep the fluid at body temperature, and place the patient in the left lateral position Test taking strategy: “promotes acceptance “are key words. Temperature of water does not promote acceptance. It just prevents abdominal cramping. 8. A nurse collected information from several patients. Which information indicates the patient who has the highest risk for developing diarrhea? Test success, pg 301, #5 a. Is physically active – prevents constipation b. Drinks a lot of fluid – prevents constipation but doesn’t precipitate diarrhea c. Eats whole-grain bread – high fiber diet prevents constipation d. Is experiencing emotional problems – increase intestinal motility and mucus secretion 9. Sequential compression devices (SCD), are ordered for a postoperative patient. The patient asks the nurse, “Why do I have to wear these things? Which information should the nurse include in the response to the patient’s question? Select all that apply. Test Success, pg 360, #34 a. Keeps the lower extremities warm b. Helps prevent deep vein thrombosis c. Accelerates the rate of wound healing d. Promotes circulation of blood back to the heart e. Eliminates the need for leg and foot exercises after surgery 10. A patient is admitted to the post anesthesia care unit (PACU) after abdominal surgery. The patient’s vital signs are blood pressure 150/90 mm Hg, pulse 88 and bounding, respirations 24 with some crackles. Which response does the nurse conclude that the patient most likely is experiencing? Test success, pg 415, #10 a. Hypoglycemia- fatigue, dizziness, sweating, palpatations, BS < 70 b. Hyponatremia – lethargy, confusion, anorexia, N/V, seizures, sodium < 135 c. Hyperkalemia – muscle cramps, dysrhythmias, oliguria/anuria, k > 5 d. Hypervolemia – intraoperative fluids can sometimes be excessive during surgery and cause this problem [Show More]

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