MDC II Exam 2

A patient is brought into the ED with respiratory depression. The patient has a history of COPD. What acid-base imbalance is most likely? - Respiratory Acidosis. The patient likely has a build-up of CO2, causing respiratory acidosis. The nurse is evaluating the lab work of a patient who has uncontrolled metabolic acidosis. Which lab result would result from this condition? A) pH 7.4 B) PaO2 98 mm Hg C) bicarbonate 38 mEq/ L D) serum potassium 5.7 mEq/L - D) serum potassium 5.7 mEq/L. Serum potassium increases during acidosis to try to buffer the acidic conditions. The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A.Encourage oral fluids B.Keep head of bed elevated C.Oxygen therapy at 4 L/min as needed D.Bedrest with bathroom privileges only - C) Oxygen therapy at 4L/ Min as needed. Oxygen therapy is often ordered for respiratory acidosis. However, COPD patients have a difficult time off-loading carbon dioxide and giving too much oxygen can cause these patients to have a decrease in respiratory drive, leading to respiratory arrest. A client has acute alcohol intoxication. What acid-base imbalance is the client at risk for? - metabolic acidosis. A client comes into the ED with respiratory acidosis. What type of medication would the nurse likely administer? - bronchodilators A client comes into the ED with a high fever and is hyperventilating. His ABG results are pH 7.51, PaCO2 28 mm Hg, and HCO3 24 mEq/L. The nurse should identify that the client has which acid-base imbalance? - Respiratory Alkalosis. Because the client is breathing rapidly, he is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, causing the pH to increase and resulting in respiratory alkalosis. A nurse is caring for a client who has metabolic alkalosis. As the client compensates for this acid-base imbalance, which of the following mechanisms should the nurse expect the client's body to use? - Hypoventilation. Hypoventilation is the mechanism that helps clients compensate for metabolic alkalosis. A nurse is inserting an NG tube for a client who is beginning enteral feedings. What action should the nurse take to verify tube placement before administering initial feeding? - Verify tube placement with radiography Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? A."I don't like the taste of spicy foods." B."I got dentures four years ago." C."I experience occasional constipation." D."I take ibuprofen three times daily for arthritis." - D. large amounts of aspirin or NSAIDs can cause peptic ulcer disease and GI bleeding. After abdominal surgery, which question should the nurse ask the patient to determine whether peristaltic movement is returning? A."Have you passed flatus?" B."Are you hungry" C."Do you have any nausea?" D."Is your pain level manageable?" - A). Passing gas is evidence of peristaltic movement When administering a new GI medication to an older patient, the nurse anticipates what? A.A higher-than-normal dose may be needed. B.Close monitoring is needed because toxic levels may develop. C.Older adults always require a lower-than-normal dose than younger patients. Nausea and vomiting may develop rapidly and are common side effects in older adults - B.Close monitoring is needed because toxic levels may develop. A patient in the ED has been experiencing upper abdominal pain after meals for the past several months. She reports pain after napping or sleeping at night. She has been taking OTC antacids with some relief. The nurse understands that which assessment finding places the patient at risk for peptic ulcer disease? A.GERD 4 years ago B.Weight loss of 35 lbs C.Use of NSAIDs to control arthritis pain D.Recent discontinuation of prednisone (Deltasone) - C. use of NSAIDS to control arthritis pain NSAID use and H. Pylori bacteria are the most common causes of ulcers Which diagnostic results does the nurse recognize that support the diagnosis of peptic ulcer disease (PUD)? (Select all that apply.) A.Low hemoglobin (Hgb) B.Low white blood cell (WBC) level C.Low hematocrit (Hct) D.Positive for H. pylori bacteria E.Low potassium of 3.4 mEq/L - A, C, and D Low hemoglobin and low hematocrit are signs of bleeding. H. Pylori is a common cause of ulcers An EGD confirms that the patient has PUD. Three hours later, the patient is admitted to the medical unit for workup and further testing. On admission the patient reports midline epigastric tenderness and indigestion (dyspepsia). The patient is prescribed triple therapy. Which drugs does the nurse prepare to administer? A.Proton pump inhibitor (PPI) and two antibiotics B.Antibiotic and two PPIs C.Histamine antagonist, antacid, and PPI D.Antacid, PPI, and prostaglandin analogue - A. proton pump inhibitor and two antibiotics. Antibiotics can treat an H. Pylori infection and PPIs reduce acid to allow ulcers to heal Which patient statement would cause the nurse to suspect that she may have Zollinger-Ellison syndrome (ZES)? A."I can't lie flat for awhile after I've eaten." B."I feel much better after taking Zantac (ranitidine)." C."Occasionally I have pain in my left lower quadrant." D."The stomach pain hurts, but the foul-smelling diarrhea is worse." - D. "The stomach pain hurts, but the foul-smelling diarrhea is worse." Zollinger-Ellison syndrome - hypersecretion of gastric acid that produces peptic ulcers as a result of pancreatic tumors Zollinger-Ellison syndrome symptoms - -Peptic ulcers (not responding to tx) -Dyspepsia -GERD -Diarrhea, foul smelling -stomach pain As the patient prepares for discharge, the nurse provides education about behaviors that reduce symptoms and aggravate peptic ulcers. Which teaching does the nurse provide? (Select all that apply.) A.Sit upright 30 to 60 minutes after meals. B.Spices should be added to food to enhance flavor. C.Extreme vomiting should be reported to your physician. D.H. pylori can be a concern in patients with peptic ulcers. E.The goal of initial intervention is to control symptoms and prevent further complications. - A, C, D, E The nurse is caring for a patient with peptic ulcer disease (PUD). Which patient statement requires nursing teaching? A."When I eat out, I avoid spicy foods." B."I sit up for at least an hour after I eat my meals." C."My doctor said to take ibuprofen for my aches and pain." D."After I quit work, my stress level decreased substantially." - C. A."My doctor said to take ibuprofen for my aches and pain." NSAIDs can cause stomach irritation and ulcers A 68-year-old patient with a history of arthritis and hypertension is admitted reporting progressive epigastric cramping, dyspepsia, nausea, and dark, sticky stools for 3 days. Which order will the nurse question? A. Guaiac stool sample x2 B. Stool sample for bacterial testing C.IV fluids, normal saline at 125 ml/hr D. Naproxen (Naprosyn) 500 mg twice daily - D. Naproxen (Naprosyn) 500 mg twice daily Long term NSAID use causes a high risk for acute gastritis, ulcers, stomach bleeding What is the nursing priority in the management of a patient with a newly active upper GI bleed? A. Obtain vital signs. B. Notify the physician. C. Apply oxygen by nasal cannula. D. Type and cross-match the patient for blood products. - C. Apply oxygen by nasal cannula. Oxygen will assist with delivery of oxygen to the tissues. Vital signs are then needed to evaluate the severity of the patient's bleed and hypovolemic status, which can then be reported to the physician. A type and cross match, although important, can take place afterward. A 72-year-old man has recently been diagnosed with oral cancer. He has been undergoing both radiation and chemotherapy. While visiting his oncologist, he mentions to the nurse that he has lost all of his hair and that his mouth is very dry. He also states that he is certain he has a cavity, because one of his teeth is hurting. What teaching will the nurse provide to decrease the incidence of dry mouth? A. consuem eight glasses of water daily. B. See the dentist immediately to get the tooth filled. C. Brush with a combined mixture of baking soda and salt. D. Increase dietary intake of grapefruits and oranges, which are high in vitamin C. - A. Consume eight glasses of water daily. Twenty minutes later after a careful assessment of the patient, the nurse notes that the patient's SaO2 is 89% and he has crackles scattered bilaterally. The oncologist decides to admit the patient to an acute care oncology unit, and within the hour, he is transported to a hospital unit. What is the priority nursing intervention upon admission? A.Start IV normal saline for rehydration. B.Ask the oncologist for a dental consult. C.Apply oxygen at 2 L per nasal cannula. D.Perform frequent oral care with normal saline. - C.Apply oxygen at 2 L per nasal cannula. Airway is always top priority A patient is scheduled to start chemotherapy. What oral cavity problem does the nurse teach the patient that may occur? A.Stomatitis B.Candidiasis C.Xerostomia D.Oral abscess - A.Stomatitis A 23-year-old female patient reports having red, raised lesions at the base of her tongue and on the inside of her mouth for the past 3 weeks. What priority assessment question should the nurse ask? A."Do you smoke cigarettes?" B."What type of work do you do?" C."Have you seen a dentist recently?" D."Do you have a history of human papillomavirus?" - D."Do you have a history of human papillomavirus?" HPV can cause mouth lesions An older patient with poor oral hygiene was admitted after a fall in which he sustained a fractured hip. What is the priority nursing intervention? A.Initiate oral care every 4 hours. B.Implement aspiration precautions. C.Request a consult with a registered dietitian. D.Use swabs to moisten the mouth as needed. - B. Implement aspiration precautions. The nurse is caring for a patient with a long history of osteoarthritis. Which risk factors will the nurse teach the patient that may contribute to development of gastroesophageal reflux disease (GERD)? A.Weight of 130 lbs B.Walks 20 minutes once daily C.Frequently takes NSAIDs for pain D.Consumes foods with calcium supplementation - C.Frequently takes NSAIDs for pain Which nursing intervention is the priority in the care of a patient with a hiatal hernia? A.Providing nutrition education B.Promoting regular exercise C.Providing medication education D.Instructing the patient on signs and symptoms of intestinal strangulation - A.Providing nutrition education Which assessment variable requires immediate nursing intervention post esophagectomy? A. Respiratory rate of 28 B. Blood pressure of 170/88 C. Temperature of 38.1º C D. Pain assessment of 6 on a scale of 0 to 10 - A. Respiratory rate of 28 airway complications are top priority