CH 16

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray?

Milk carton

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

Monitor ionized calcium level.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Monitor the IV sites for redness, swelling, or tenderness.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na* 154 mEq/L (154 mmol/L)

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

Notify the patients health care provider.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

Oral digoxin (Lanoxin) 0.25 mg daily

Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately?

Presence of the Chvosteks sign

During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

Risk for injury: Seizures

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

Check the patients blood pressure.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

Administer the prescribed normal saline bolus and insulin.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which aetion?

Ask the health care provider to order a basic metabolic panel.

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

Assign the patient to a room near the nurses station.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Auscultate the patients breath sounds.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

Daily alcohol intake

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved?

Decreased peripheral edema

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Edema

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

Encourage fluid intake up to 4000 mL every day.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGS) indicate respiratory alkalosis. Which action should the nurse take first?

Give the patient the PRN IV morphine sulfate 4 mg.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

Gradually decreasing level of consciousness (LOC)

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

I will drink apple juice instead of orange juice for breakfast.

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

Increase fluids if your mouth feels dry.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Infuse 5% dextrose in water at 125 mL/hr.

IV potassium chloride (KCI) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCI at a rate of 10 mEq/hour.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

Lung sounds

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Mental status

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PACO, 37 mm Hg, and HCO; 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Serum sodium level of 120 mg/dL

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?

The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

The patient is experiencing laryngeal stridor.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

There are crackles audible throughout both lung fields.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Use the push-pause method to flush the CVAD after giving medications.

After receiving change-of-shift report, which patient should the nurse assess first?

has a dry mouth and Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Blood pressure is 90/40 mm Hg

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO, 32 mm Hg, and HCO; 25 mEq/L?

Respiratory alkalosis

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Serum calcium is 18 mg/dL.