Question

Please help me with the correct answers and also the rationales for the correct answers for number 2,5,6,11,17,23,24,25.

324 Quiz 1 Version A 1. Following insertion of a central line, a client begins to have difficulty breathing. The clien, becomes progressively cyanotic and becomes unresponsive. The care team suspects an am embolus that should prompt the nurse to immediately A. Administer a thrombolytic B Place the client on the left side with the clients head down C. Have the client bear down and perform a Valsalva maneuver. D. Auscultate the clients heart sounds 2. A client has a nursing diagnosis of fluid volume deficit. Which vital signs, if decreased, supports this nursing diagnosis? A. Temperature B. Respiratory rate Heart rate D. Blood pressure 3. A nurse is caring for a client suspected of having a pulmonary embolus. The clients arterial blood gas (ABG) results indicate respiratory alkalosis. Which findings support this diagnosis A PH 7.54 Paco 2 25 B. PH 7.39 Paco2 39 C. PH 7.50 Paco 2 40 D. PH 7.32 Paco 2 48 4. A client asks the nurse why hyperemesis has caused metabolic alkalosis. Which if the flowing statements by the nurse is most correct? A. Vomiting causes too much over the counter (OCT) medication to be ingested, causing metabolic alkalosis. B. Vomiting causes loss of hydrochloric acid from the stomach causing metabolic alkalosis C. Vomiting causes loss of substance that are base in PH level causing metabolic alkalosis D. Vomiting causes hyperventilation which results in acid being exhaled in the form of carbon dioxide. 5. Which should a nurse plan when assessing and monitoring an older adult clients fluid status?(SELECT ALL THAT APPLY) (A) Monitory vital signs 8 Auscultate heart and lung sounds © Assess for presence of edema Assess level of consciousness E Maintain accurate intake and output 266 CHAPTER VANNES

Answer 1

2.The typical signs and symptoms of fluid volume deficit are

• A fall in blood pressure
• Patient may experience decreased urine output
• Feeling of increased thirst to replace fluid
• Skin ,lips, oral mucosa turns dry due to no fluid to maintain moisturizer
• When there is more than 15 to 20% loss patient starts experiencing weight loss

Ans:D.Blood pressure

5.Fluid status can be generally assessed with the help of vital signs(blood pressure ) maintaining intake and output chart gives a brief status on how much fluid is taken in and excreted out enables to identify fluid volume excess,which may cause edema,fluid accumulation in the lower extremities, alteration in mental status when electrolytes are lost.

Ans:Monitor vital signs

Assess for presence of edema

Assess level of consciousness

Monitor intake and output

6.When there is kidney insult the first thing which happens is either retention or excretion of sodium.In most of the cases in acute renal failure The level of sodium remains in the normal range.The most important concern here is the increase in potassium level which can affect the heart,decrease in calcium and phosphate level.

Ans:C.Hyperkalemia

11.Increased level of bicarbonate level can cause metabolic alkalosis. Antacid decreases the level of acidic nature and increases alkalinity hence metabolic alkalosis

Ans:Metabolic alkalosis