Acid Base- 2
B Option B: Prioritization. Potassium level should be monitored regularly because potassium depletion is expected when a client is taking HCTZ.
For a client taking HCTZ, which blood test result would the nurse monitor? A. Sodium level B. Potassium level C. Calcium level D. Chloride level
D Option D: Prioritization. Chronic renal disease and pulmonary disease are risk factors for acid-base imbalances in the older adult. Option A: Although antacid abuse is a risk factor for metabolic alkalosis, occasional antacid use will not cause imbalances.
A 56-year-old male is newly admitted to the medical unit. Which factor alerts the nurse that this client has a risk for acid-base imbalances? A. The client takes antacids for occasional indigestion. B. The client gets short of breath with extreme exertion. C. The client has a history of myocardial infarction 1 year ago. D. The client has chronic renal insufficiency
D Option D: Prioritization, supervision. Repeated nausea and vomiting can lead to an acid deficit and metabolic alkalosis. Options A, B, and C: The other options are vital and still need to be assessed, but are not related to acid-base problems.
A client going through intense chemotherapy treatment is admitted to the unit. Which of these would the nurse instruct the nursing assistant to report to prevent an acid-base imbalance? A. Hair loss during the morning bath B. Complaints of pain associated with exertion C. Failure to eat all the food on the breakfast tray. D. Prolonged episodes of nausea and vomiting
C Option C: Delegation, supervision. Additional fluid intake can be reinforced by the nursing assistance once it is part of the care plan. Options A, B, and D: Administering IV fluids, developing plans, and educating families demand further education and skills that are within the field of practice of an RN.
A client is admitted to the unit with the diagnosis of Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be charged to a nursing assistant? A. Administer intravenous (IV) fluids as prescribed by the physician B. Develop a plan for added fluid intake over 24 hours C. Provide straws and offer fluids between meals D. Educate family members to assist the client with fluid intake
B Option B: Prioritization. Neck veins are usually distended when the client is in the supine position. These veins flatten as the client moves to sitting position. Options A, C, and D: These responses are characteristic of the nursing diagnosis of Excess Fluid Volume.
A client is admitted to the unit with the nursing diagnosis of Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? A. Shallow respirations with crackles on auscultation B. Flattened neck veins when the client is in the supine position C. Full and bounding pedal and posttibial pulses D. Pitting edema located in the feet, ankles, and calves
D Option D: Supervision, prioritization. Nasogastric suctioning can result in a decrease in acid components and a metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. Options A and B: These responses are incorrect. Option C: This response may be right, but it does not discuss all the components of the question.
A group of nursing students is assigned to care for a client with a nasogastric tube connected to a wall suction. One student asks why the client's respiratory rate has decreased. Choose the best response. A. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps fix the problem." B. "The client is hypoventilating because of anxiety, and we will have to stay observant for the development of respiratory acidosis." C. "It's common for clients with uncomfortable equipment such as nasogastric tubes to have a lower rate of breathing." D. "The client may have a metabolic alkalosis due to the nasogastric suctioning, and the decreased respiratory rate is a compensatory mechanism."
D Option D: Prioritization. Due to an excessive water retention, SIADH causes a relative sodium deficit.
A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte irregularity will the nurse be certain to monitor? A. Hyperkalemia B. Hypokalemia C. Hypernatremia D. Hyponatremia
A Option A: Prioritization, supervision. The client is blowing off carbon dioxide and is most likely hyperventilating. A sudden drop of carbon dioxide will result in an increase in pH and cause respiratory alkalosis.
An anxious client is rushed to your unit. The vital signs measurements include a respiratory rate of 39 breaths/min. Which acid-base imbalance should the nurse suspect? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
B Option B: Prioritization. The blood gas component tied to respiratory acidosis is carbon dioxide. Increasing the ventilator rate will blow off more carbon dioxide and decrease the acidosis. Change in the oxygen setting may improve oxygenation but will affect respiratory acidosis.
Mechanical ventilation is provided to a client with respiratory failure. The blood gas results reveal respiratory acidosis. Which change in ventilator setting should you expect to correct this problem? A. Decrease in the ventilator rate from 10 to 6 breaths/min B. Increase in the ventilator rate from 6 to 10 breaths/min C. Decrease in the oxygen concentration from 40% to 30% D. Increase in the oxygen concentration from 40% to 30%
C Option C: Prioritization. Facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear is a positive Chvostek sign. It is a neurologic manifestation of hypocalcemia. Option D: The LPN is experienced and holds the skills to carefully and accurately measure vital signs.
The assigned LPN of the unit reports to you that a client's blood pressure and heart rate have decreased, and when her face is assessed, one side twitches. What is the most appropriate thing to do as a nurse? A. Assess the client's pupillary reaction to light B. Obtain a neurologic exam request for the client C. Review the client's morning calcium level D. Retake the client's blood pressure and heart rate
A Option A: Prioritization. Bilateral moist crackles signify fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. Options B, C, and D: The other orders are important but are not urgent.
The client with a diagnosis of Fluid Volume Deficit is assessed by the physician. The assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? A. Administer furosemide (Lasix) 40 mg IV push B. Maintain accurate intake and output record C. Limit fluids to 1500 mL/day D. Weigh the client every morning
B Option B: Delegation, supervision. The normal range for potassium is 3.5 to 5 mEq/L. The client's potassium level is high. Kayexalate eliminates potassium from the body through the gastrointestinal system. Option C: Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. Option D: The beginning nursing student does not have the skill to assess ECG strips.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse? A. Give potassium 10 mEq orally B. Give sodium polystyrene sulfonate (Kayexelate) 15 g orally C. Give spironolactone (Aldactone) 25 mg orally D. Assess electrocardiogram (ECG) strip for tall T waves
B Option B: Prioritization. The nurse should immediately check the client's potassium level for hypokalemia. Common ECG changes with hypokalemia include ST depression, inverted T waves, and prominent U waves. Heart block may also transpire to clients with hypokalemia.
The monitor watcher from the telemetry units informs the assigned nurse that the client developed prominent U waves. Which laboratory value should the nurse monitor? A. Sodium level B. Potassium level C. Calcium level D. Magnesium level
D Option D: Assignment, delegation, supervision. The nursing assistant can provide oral care to the client. This is within the scope of practice of nursing assistants. Options A, B, and D: Administering IV fluids as well as assessing and monitoring clients demand the additional education and skills of the RN.
The newly hired nurse is assigned by the charge nurse to care for a client with acute renal failure and hypernatremia. Which action can the nurse assign to the nursing assistant? (Select all that apply.) A. Administer 0.45% saline by IV line B. Assess daily weights for trends C. Check for indications of dehydration D. Render oral care every 3 to 4 hours
B Option B: Delegation, supervision. A well-trained and educated nursing assistant is knowledgeable in measuring vital signs and recording intake and output. Option A: Performing fingerstick glucose checks and assessing clients demands further education and skill, as possessed by licensed nurses.
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? (Select all that apply.)1. Assess for indicators of fluid imbalance 2. Review fingerstick glucose results every hour 3. Measure vital signs every 15 minutes 4. Document intake and output every hour A. 1 and 2 B. 3 and 4 C. 1 and 3 D. 2 and 4
C Answer: C. Serum magnesium level of 0.8 mEq/LOption C: Prioritization. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias. Options A, B, and D: All of these values are also outside of the normal range, but the magnesium level is furthest from the normal values.
The nurse just received the client's morning laboratory results. Which of these results is of most concern? A. Serum sodium level of 134 mEq/L B. Serum potassium level of 5.2 mEq/L C. Serum magnesium level of 0.8 mEq/L D. Serum calcium level of mg/dL
A Option A: Delegation, supervision. A low level of phosphorus manifests generalized muscle weakness that may lead to acute muscle breakdown (rhabdomyolysis). Options B, C, and D: All other statements are true but they do not answer the nursing assistant's question.
The nursing assistant is assigned to a client with a chronically low phosphorus level. What is the best response of the nurse when asked why the client needs so much assistance with ADLs? A. "The client's skeletal muscles are weak because of the low phosphorus." B. "The client will do more for himself when his phosphorus level is normal." C. "The client's low phosphorus is probably due to malnutrition." D. "The client is just worn out from not getting enough rest."
D Option D: Prioritization. HCTZ is under thiazide diuretics. It should not be taken at night because it will cause the client to awaken and go to the toilet to urinate. Weight gain and increased edema should not transpire while the client is using this drug, so this should be reported to the prescriber. Option A: This type of diuretic causes potassium depletion, so the nurse should educate the client about eating foods rich in potassium.
The physician prescribed hydrochlorothiazide (HCTZ, Microzide) 10 mg orally for the client to take every day. What should you be sure to include in a teaching plan for this drug? (Select all that apply.)1. "Take this prescription in the morning." 2. "You should anticipate your urine output to increase." 3. "Notify your prescriber if you notice weight gain or increased swelling." 4. "This medication should be taken in 2 divided doses when you get up and when you go to bed." 5. "Eat foods with extra sodium every day." A. 4 and 5 B. 3, 4, and 5 C. 2, 3, and 4 D. 1, 2, and 3
D Option D: Delegation, supervision. A drop in respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. Options A, B, and C: All the other findings are vital and should also be reported to the RN, but the respiratory rate requires immediate attention.
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately? A. Decrease in pain level from 6 to 2 (on a scale of 10) B. Heart rate of 90 to 100 beats/min C. Request by the client that the room door be closed D. Respiratory rate of 8 to 10 breaths/min
D Option D: Assignment. The client with COPD, although ventilator dependent, is in the most stable condition among the clients in this group. Options A and C: Clients experiencing acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. Option B: The client with diabetic ketoacidosis is a new admission and will require an in-depth admission assessment.
Which client should the charge nurse designate to the step-down unit nurse pulled to the intensive care unit for the day? A. A 36-year-old man on a ventilator with narcotic overdose and respiratory alkalosis B. A 58-year-old newly admitted female client with diabetic ketoacidosis receiving an insulin drip C. A 64-year-old smoker on a ventilator with acute respiratory failure and respiratory acidosis D. A 76-year-old COPD client with normal blood gas values who is ventilator dependent
