NR 226: Exam 2 review questions and answers

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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. In... take 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........ [Show More]

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