NURS 231 BIOD 331 FINAL EXAM WITH
VERIFIED QUESTIONS AND DETAILED
ANSWERS|| GUARANTEED PASS || LATEST
VERSION!!!
Which of the following respresents acute respiratory failure?
a) pH 7.56, pCO2 28, paO2 70, HCO3 25, SaO2 91%
b) pH 7.22, pCO2 59, paO2 59, HCO3 28, SaO2 84% - ANSWER-b) pH 7.22,
pCO2 59, paO2 59, HCO3 28, SaO2 84%
*pt is in resp acidosis with some metabolic compensation with severe
hypoxemia.
*Pt meets the criteria for resp failure bc PaO2 <60 OR PaCO2 >45 & SaO2
<90%
What assessment findings other than resp symptoms would the nurse expect for
pt in acute rep failure (think resp acidosis & hypoxemia) - ANSWER--
tachycardia
-dysrhythmias likely
-hypotension
-altered/decreased LOC
-muscle weakness, hyporeflexia
*bc hyperkalemia & hypercalcemia cause weak & floppy muscles; CO2
vasodilator & CNS depressant
,Pt was admitted w ARDS & is being mechanically ventilated w ET tube. Resp
therapist increase PEEP to 10 since pt was still in resp acidosis. Then bedside
alarm goes off & you see HR has increase to 125 and BP dropped to 88/58.
What are the 2 possible causes? - ANSWER-Decreased CO from either:
1) reduction in SV from increased thoracic pressure
2) barotrauma leading to (tension) pneumothorax
If mechanically vented pts bedside alarm goes off & nurse sees pts HR
increased & BP dropped, what manifestations indicate whether it was caused by
a tension pneumothorax or a reduction in SV from thoracic pressure?
*2 causes of decreased CO are tension pneumothorax and decreased SV -
ANSWER-Tension pneumothorax:
-high pressure alarm
-rapidly declining SpO2
-rapidly declining BP
-unequal chest expansion
-absent breath sounds on one side
Reduction in SV:
-no alarm bc no effect on vent pressure
-stable SpO2
-equal chest expansion & breath sounds
*no matter the cause tho, nurse's initial action for pt w sudden drop BP is the
take pt off ven & manually ambubag & call for help
What is the priority action for nurse taking care of pt that's bedside alarm is
going off showing a sudden drop in BP and increased HR?
a) could be a tension pneumothorax, listen to lung sounds & chest expansion
b) could be reduction in SV, check HR & skin color
,c) could be either, make sure to lower HOB & apply O2
d) it doesn't matter the cause, just take pt off the vent & manually ambubag -
ANSWER-d) it doesn't matter the cause, just take pt off the vent & manually
ambubag
Match the following cranial nerves to the assessment:
a) CN I
b) CN II
c) CN III, IV, VI
d) CN V
e) CN VII
f) CN VIII
g) CN IX, X
h) CN XI
i) CN XII
___= tongue movement
___=hearing and equilibrium
___= vision
___= movement of trapezius and sternomastoid
___= smell___= taste and fascial muscles
___= eye movement
___= chewing and face sensation - ANSWER-__i__= tongue movement
(hypoglossal)
__f__=hearing and equilibrium (acoustic)
__b__= vision (optic)
__h__= movement of trapezius and sternomastoid (spinal accessory muscles)
__a__= smell (olfactory)
__e__= taste and fascial muscles (fascial)
, __c__= eye movement (occulomotor, trochlear, abducens)
__d__= chewing and face sensation (trigeminal)
__g__=talking and swallowing (glossopharyngeal and vagus)
What condition is the whole bodies response due to poor cellular oxygenation? -
ANSWER-Hypoperfusion; shock
*can be fatal
Match the classification of shock
1) ____ not enough blood volume (tank is low) ex: hemorrhage or severe
dehydration
2) ___ LV so weak that doesn't eject enough blood to support perfusion (pump
problem) ex: acute MI
3) ___ vasodilation; relative hypovolemia ex: sepsis
4) ____ constriction around heart doesn't allow blood to get out ex: cardiac
tamponade, tension pneumothorax
a) cardiogenic
b) distributive
c) hypovolemic
d) obstructive - ANSWER-1) c) hypovolemic
2) a) cardiogenic
3) b) distributive
4) d) obstructive
Match the following types of shock with what causes it
1) hemorrhage
2) cardiac tamponade