NSG3313 Adult Health 1 Final Exam Review Questions |
Answers | Rationale | With Complete Solutions
0500 labs for your patient include a critically high glucose of
795. What is your first action?
A. Notify the doctor
B. Administer 10 units of sliding scale lispro
C. Assess the patient
D. Push half an ampule of D50 Correct Answer C. Assess the
patient
0600 labs result at 0800, what is your priority concern to
address?
A. K+ is 2.8
B. Ca++ is 8.6
C. Mg+ is 1.8
D. Na+ is 145 Correct Answer A. K+ is 2.8
17 yr old male presents to ED with altered levels of
consciousness and lethargy. What do we check 1st?
A. HR
,B. BP
C. ABG
D. Blood Sugar Correct Answer D. Blood Sugar
5% NaCl should have what precaution when administering?
A. Flow rate should be slow
B. Used in Pt's with pulmonary edema
C. Give large volumes quickly
D. Infused via gravity Correct Answer A. Flow rate should be
slow
Rationale:
5%NaCl is a hypertonic solution. If you run too fast can result in
pulmonary edema. Hypertonic - fluid is pulled back into the
vasculature, commonly used for cerebral edema. Pt must be in
ICU.
81 yo pt. presents unarousable and a blood sugar of 712. What
do we suspect is the cause?
A. DKA
B. UTI
C. Respiratory failure
D. HHS Correct Answer D. HHS
Rationale:
HHS:
•Illness or emotional stress
•Type II
•Elderly
A 62 yo female pt. reports a feeling of pressure after they
urinate, what is your next action?
A. Notify the Doctor
B. Perform a bladder scan
C. Palpate below the umbilicus area
D. Check their kidney function Correct Answer C. Palpate
below the umbilicus area
A client experiencing a severe anxiety attack and
hyperventilating presents to the emergency department. The
nurse would expect the client's pH value to be
A. 7.45
B. 7.35
C. 7.3
D. 7.5 Correct Answer D. 7.5
Rationale: The patient is experiencing respiratory alkalosis.
Respiratory alkalosis is a clinical condition in which the arterial
pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis
is always caused by hyperventilation, which causes excessive
"blowing off" of CO2 and, hence, a decrease in the plasma
carbonic acid concentration. Causes include extreme anxiety,
, hypoxemia, early phase of salicylate intoxication, gram-negative
bacteremia, and inappropriate ventilator settings.
A client is being screened for a new job, their Mantoux test has
an induration of 6mm. What is the next action?
A. Isolate the client
B. Obtain a chest X-ray
C. Place the client in a negative pressure room
D. Administer a TDAP booster Correct Answer B. Obtain a
chest X-ray
Rationale:
Tuberculosis (TB):
- Closely associated with poverty, malnutrition, overcrowding,
sub-standard housing, and inadequate health care
- Spread by airborne transmission
- Blood tests- QuantiFERON- TB Gold & T-SPOT
Mantoux/PPD Test:
- 0-4 mm not significant
- >5mm= significant, need chest x-ray
- Usually seen in the upper lobes
A client is being treated in the ICU 24 hours after having a
radical neck dissection completed. The client's serum calcium
concentration is 7.6 mg/dL (1.9 mmol/L). Which physical
examination finding is consistent with this electrolyte
imbalance?
A. Presence of Trousseau sign
B. Muscle weakness
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