EXAM 4 - PRACTICE QUESTIONS

Which patient is at most risk for hypomagnesemia? A. A 55 year old chronic alcoholic B. A 57 year old with hyperthroidism C. A patient reporting overuse of anatacids and laxatives D. A 25 year old suffering from hypoglycemia

A. A 55 year old chronic alcoholic The correct answer is a 55 year old who is a chronic alcoholic. Patients who suffer from alcoholism have an increased secretion of magnesium and usually do not eat a proper diet, therefore, they are at risk for lower magnesium levels.

A patient is post-opt from gallbladder surgery and is ordered a clear liquid diet. Which of the selection can the patient have? A. Apple Juice B. Vanilla Custard C. Fudge Popsicle D. Creamy Chicken Soup

A. Apple Juice Clear liquids are foods that are transparent to light and are liquid at body temperature. Apple juice meets these requirements.

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: A. Apples B. Carrots C. Spinach D. Avocado

A. Apples Rationale: A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3 1/2 oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium. Test-Taking Strategy: Note the strategic words LOWEST IN POTASSIUM. Recalling the potassium content of the foods identified in the options will direct you to option A. Review the foods that are high and low in potassium content if you had difficulty with this question.

A patient is to be started on enteral feedings. What important step should the nurse take before the patient is started on enteral feedings? A. Assess patient allergies to lactose B. Assess the patient's understanding about enteral feedings C. Evaluate the families perception of the enteral feedings D. Make sure the patient stays nothing by mouth while enteral feedings are being administered

A. Assess patient allergies to lactose The most important step in this question is for the nurse to make sure the patient is not allergic or intolerant to lactose. The nutritionist will evaluate the patient and determine what type of enteral feedings will be started. However, as the patient's nurse it is your responsibility to make sure the patient doesn't receive something they are allergic or intolerant to (especially since you will be the one administering the enteral feeding). Lactose is a major ingredient of enteral feedings. If the patient is allergic to lactose, another ingredient can be substituted in its place.

A patient has a low magnesium level. Which food of the selection below is the highest in magnesium? A. Avocado B. Liver C. Mushrooms D. Rhubarb

A. Avocado Out of the selection Avocado is the only item highest in magnesium.

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A. Baked cod B. Ham and cheese omelet C. Fried eggs D. Baked potato E. Spinach

A. Baked cod D. Baked potato E. Spinach Normal serum potassium is 3.5 to 5.5 mEq/L. A client who has a potassium of 3.2 mEq/L would benefit from a diet high in potassium. Baked cod, baked potato, and spinach are all food selections high in potassium. A ham and cheese omelet is high in sodium. Fried eggs are high in cholesterol. A whole grain muffin is high in grains.

A patient receiving dialysis should avoid what type of foods? A. Canned soups, cold cut sandwiches, and Chinese take-out B. Fresh fruits and vegetable, poultry, and beans C. Steamed broccoli, broiled mackerel, and artificial sweeteners D. Microwaved sweet potatoes, boiled cabbage, and artichokes

A. Canned soups, cold cut sandwiches, and Chinese take-out Patients who are receiving dialysis have renal disease and therefore should follow a sodium restricted diet. Canned soups, cold cut sandwiches, and Chinese take-out are all high in sodium.

A patient asks you what vitamin is best for eye sight. Your response is: A. Vitamin B12 B. Vitamin B6 C. Vitamin C D. Vitamin A

D. Vitamin A Vitamin A maintains eye sight. Foods rich in vitamin A are liver, egg yolks, green/orange vegetables & fruits.

A patient who has a colostomy is complaining about having excess gas. You ask the patient to tell you what he has ate in the past 48 hours. Which food would you suspect is causing the patient excessive gas? A. Cherries, Radishes, and Watermelon B. Caraway seeds, tomato soup, and eggs C. Chicken, grapes, and raspberries D. Squash, Spinach, and Pickles

A. Cherries, Radishes, and Watermelon Cherries, Radishes, and Watermelon are gas causing foods and should be decreased in consummation if a patient is experiencing excess gas.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50-year-old with pneumonia, diaphoresis, and high fevers B. 62-year-old with congestive heart failure taking loop diuretics C. 39-year-old with diarrhea and vomiting D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

A. 50-year-old with pneumonia, diaphoresis, and high fevers Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl D. A client with dehydration who has a serum sodium level of 128 mEq/L

A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience a low chloride level, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dl is elevated. Normal serum phosphate is 2.8 to 4.5 mg/dl. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium is 135 to 145 mEq/L.

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? A. A client with a colostomy B. A client with congestive heart failure C. A client with decreased kidney function D. A client receiving frequent wound irrigations

A. A client with a colostomy Rationale: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options B, C, and D retain fluid. The only condition that can cause a deficit is the condition noted in option A. If you had difficulty with this question, review the causes of deficient fluid volume.

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? A. Absent patellar reflex B. Diarrhea C. Premature ventricular contractions D. Increase in blood pressure

A. Absent patellar reflex An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of A. Acute renal failure. B. Malabsorption syndrome. C. Nasogastric drainage. D. Laxative abuse

A. Acute renal failure. A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndrome, nasogastric drainage, and laxative abuse may result in a low serum potassium level, because output may be greater than input. Diarrhea results in malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L.

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? A. Alcoholism B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A. Alcoholism Rationale: THe normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. Test-Taking Strategy: First you must determine that the client is experiencing hypophosphatemia. From this point, you must know the causes of hypophosphatemia. If you had difficulty with this question, review the causative factors associated with hypophosphatemia.

Which patient is at more risk for an electrolyte imbalance? A. An 8 month old with a fever of 102.3 'F and diarrhea B. A 55 year old diabetic with nausea and vomiting C. A 5 year old with RSV D. A healthy 87 year old with intermittent episodes of gout

A. An 8 month old with a fever of 102.3 'F and diarrhea The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.

A patient just had a Wound Vac ® placed on her abdomen from abdominal surgery. Which foods would help promote wound healing? A. Citrus fruit and tomatoes B. Liver, beef, and fish C. Corn, poultry, and grains D. Peanuts, beans, and pork

A. Citrus fruit and tomatoes Foods high in vitamin C help promote the production of collagen which is vital for wound healing. Citrus fruits and tomatoes are high in vitamin C.A. Citrus fruit and tomatoes

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A. Deep tendon reflexes decreasing from +2 to +1 B. Bicarbonate rising from 20 mEq/L to 22 mEq/L C. Urine pH less than 6 D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

A. Deep tendon reflexes decreasing from +2 to +1 A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.

A patient has a stage 4 pressure ulcer on their sacral area. What type of foods would the patient most benefit from? A. Dried beans, eggs, meats B. Liver, spinach, corn C. Oats, fruits, and vegetables D. Peanuts, tomatoes, and cabbage

A. Dried beans, eggs, meats A patient with a stage 4 pressure ulcer needs a high protein diet to promote wound healing. Dried beans, eggs, and meats are the highest protein foods of the selection.

A patient with anemia would benefit from which diet? A. Legumes, organ meat, and dark green leafy vegetables B. Nuts and seeds, fruits, and soy products C. Vegetables, fish, and pasta D. Grains, berries, and organic vegetables

A. Legumes, organ meat, and dark green leafy vegetables A patient with anemia needs food high in iron, therefore, legumes, organ meat, and dark green leafy vegetables are the best choice.

The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. A. Peas B. Oranges C. Cauliflower D. Peanut butter E. Canned white tuna

A. Peas C. Cauliflower D. Peanut butter E. Canned white tuna Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. Common food sources of magnesium include avocado, canned white tuna, cauliflower, green leafy vegetables such as spinach and broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, and yogurt. Bacon is high in sodium. Oranges are high in potassium. Test-Taking Strategy: Focus on the subject, foods high in magnesium. Read each food item and recall that bacon is high in sodium and oranges are high in potassium. Review the food items high in magnesium if you had difficulty with this question.

A patient is admitted for diverticulitis. The patient has been on a full liquid diet and has been tolerating it well. Now the MD has ordered the patient a new diet. You would expect to find what type of food on the patient's lunch tray? A. Piece of white bread, skinless white potatoes, and white rice. B. Glass of whole milk, broccoli, and cabbage C. Peanut butter sandwich, glass of milk, and strawberries D. French fries, chicken salad, and apple pie

A. Piece of white bread, skinless white potatoes, and white rice. Patients with diverticulitis should be started on a low-residue diet after full liquids have been tolerated. A piece of white bread, skinless white potatoes, and white rice are considered low-residue foods.

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. C. Weigh the client weekly, first thing in the morning. D. Change the IV tubing every three (3) days. E. Monitor intake and output every shift

A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. E. Monitor intake and output every shift A. (correct) TPN is a hypertonic solution that has enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion.B. (correct) TPN contains 50% dextrose solution; therefore, the client is monitored to ensure that the pancreas is adapting to the high glucose levels.C. (incorrect) The client is weighed daily, not weekly, to monitor for fluid overload.D. (incorrect) The IV tubing is changed with every bag because the high glucose level can cause bacterial growth.E. (correct) Intake and output are monitored to observe for fluid balance. TEST-TAKING HINT: Options C and E refer to the same factor--namely, fluid level. The test taker should then determine if the time factors are appropriate. Weekly weighing is not appropriate so C can be eliminated.

A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A. Prolonged bed rest B. Renal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A. Prolonged bed rest Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. Test-Taking Strategy: Note the strategic words MOST LIKELY. First, you must determine that the client is experiencing hypocalcemia. This should assist in eliminating option D. Next, you must recall the causative factors associated with hypocalcemia to direct you to option A. If you had difficulty with the question, review the causative factors associated with hypocalcemia.

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A. Provide passive ROM exercises and encourage fluid intake B. Teach the client to increase intake of whole grains and nuts C. Place a tracheostomy tray at the bedside D. Administer calcium gluconate IM as ordered

A. Provide passive ROM exercises and encourage fluid intake A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: A. The skin B. Urinary output C. Wound drainage D. The gastrointestinal tract

A. The skin Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Test-Taking Strategy: Note that the subject of the question is insensible fluid loss. Use the process of elimination, noting that options B, C, and D are comparative or alike. In options B, C, and D, these types of losses can be measured for accurate output. Fluid loss through the skin cannot be measured accurately, only approximated. If you had difficulty with this question, review the difference between sensible and insensible fluid loss.

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect? A. Third spacing B. This is normal and expected after a burn and it is benign C. Document this finding as non-pitting abdominal edema. D. Intravascular compartment syndrome

A. Third spacing The answer is A. You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values.

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A. Twitching B. Negative Trousseau's sign C. Hypoactive bowel sounds D. Hypoactive deep tendon reflexes

A. Twitching Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and ansiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Test-Taking Strategy: Use the process of elimination, noting that options B, C, and D are comparative or alike in that they reflect a hypoactivity. The option that is different is option A. Review the assessment signs and symptoms noted in hypocalcemia if you had difficulty with this question.

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? A. U waves B. Absent P waves C. Elevated T waves D. Elevated ST segment

A. U waves Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia. Test-Taking Strategy: From the information in the question, you need to determine that the client is experiencing hypokalemia. From this point, you must know the electrocardiographic changes that are expected when hypokalemia exists. If you had difficulty with this question, review the electrocardiographic changes that occur in hypokalemia.

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A. D5.45 NS at 50 ml/hr B. 0.9 NS at an open rate C. D5W at 125 ml/hr D. 0.45 NS at open rate

B. 0.9 NS at an open rate A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A. A client with osteoporosis taking vitamin D and calcium supplements B. A client who is alcoholic receiving total parenteral nutrition C. A client with chronic renal failure awaiting the first dialysis run D. A client with hypoparathyroidism secondary to thyroid surgery

B. A client who is alcoholic receiving total parenteral nutrition A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving TPN are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.

Which patient below would have a potassium level of 5.5? A. A 76 year old who reports taking lasix four times a day B. A patient with Addison's disease C. A 55 year old woman who have been vomiting for 3 days consistently D. A patient with liver failure

B. A patient with Addison's disease A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient? A. Restrict fluid intake and monitor daily weights B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output C. Administer hypotonic IV fluid and administer sodium tablets. D. No interventions are expected

B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells.

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L? A. Pretzels B. Baked chicken C. Chicken bouillon D. Baked potato E. Baked ham

B. Baked chicken D. Baked potato Normal serum sodium is between 135 and 145 mEq/L. A sodium level of 158 mEq/L is elevated and a low sodium diet should be prescribed. A peanut butter sandwich, pretzels, chicken bouillon, and baked ham are all foods high in sodium content. Baked chicken and baked potato are low-sodium food choices.

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. A. Eggs B. Broccoli C. Organ meats D. Nuts E. Canned salmon

B. Broccoli D. Nuts E. Canned salmon Fish, eggs, and organ meats are high in phosphorus. Broccoli, nuts, and canned salmon are high in calcium. Clients with lung or breast cancer often have elevated calcium levels due to tumor-induced hyperparathyroidism.

The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first? A. Start a new IV in the right hand. B. Discontinue the intravenous line. C. Complete an incident record. D. Place a warm washrag over the site.

B. Discontinue the intravenous line. A. (incorrect) A new IV will be started in the right hand after the IV is discontinued. B. (correct) The client has signs of phlebitis and the IV must be removed to prevent further complications. C. (incorrect) Depending on the health-care facility, this may or may not be done, but client care comes before documentation. D. (incorrect) A warm washrag placed on an IV site sometimes provides comfort to the client. If this is done, it should be done for 20 minutes four (4) times a day. TEST-TAKING HINT: The question is asking for a first action, which means all of the options may be actions the nurse would implement, but only one is priority. In general, priority actions are to stop the problem, continue treatment, treat the problem, and then document.

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A. Request a physical therapy consult from the physician B. Ensure the client is safe from falls and check the most recent potassium level C. Allow uninterrupted rest periods throughout the day D. Encourage the client to increase intake of dairy products and green leafy vegetables.

B. Ensure the client is safe from falls and check the most recent potassium level In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A. Deficient fluid volume related to decreased fluid intake B. Excess fluid volume related to increased water retention C. Deficient fluid volume related to excessive fluid loss D. Risk for injury related to fluid volume loss

B. Excess fluid volume related to increased water retention The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

A patient is diagnosed with Congestive Heart Failure and must follow a specific diet. Which spices are okay for the patient to use daily? A. Onion Salt & Garlic Powder B. Ginger & Bay Leaves C. Sea Salt & Pepper D. Garlic Sodium & Nutmeg

B. Ginger & Bay Leaves Patients with CHF should avoid excessive sodium. All of the options expect one contain at least one sodium spice, therefore, Ginger & Bay Leaves are okay to use.

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

B. Hypocalcemia Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A. Withhold furosemide (Lasix) B. Notify the physician C. Administer the prescribed potassium supplement D. Instruct the client on foods high in potassium

B. Notify the physician The priority intervention for a client who had gallbladder surgery, has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum potassium of 3.0 mEq/L would be to notify the physician that the potassium level is low. After notifying the physician, the furosemide (Lasix) may be withheld and potassium supplement should be administered as prescribed and may even be increased after talking with the physician. The client may also be instructed on foods high in potassium. These are all appropriate interventions but not the priority.

You are taking care of a patient with severe COPD. What type of diet would best suit this patient's needs? A. Cut apples, fresh broccoli, and grilled chicken B. Pureed sweet potatoes, ground turkey & gravy with mash potatoes C. Green beans, boiled carrots, and steamed fish D. Fried chicken, French fries, and pudding

B. Pureed sweet potatoes, ground turkey & gravy with A patient who has COPD will have difficulty breathing and the slightest activities can cause shortness of breath. Therefore, the patient would need something that is very easy to eat and requires minimal chewing. The best option here is pureed sweet potatoes, ground turkey & gravy with mash potatoes.

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen C. Encourage the client to increase the intake of bananas D. Initiate seizure precautions

B. Question the results and redraw the specimen A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

A patient's potassium level is 6.0. Which food should the patient avoid? A. 6.0 is a normal potassium level so the patient can eat whatever they want without an effect B. Raisins C. Rice D. Egg yolks

B. Raisins Normal potassium levels are 3.5-5.0. Therefore a potassium level of 6.0 is considered high so the patient should avoid foods high in potassium. In this case, raisins are the highest in potassium.

A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: A. Has renal failure. B. Requires nasogastric suction. C. Has a history of Addison's disease. D. Is taking a potassium-sparing diuretic.

B. Requires nasogastric suction. Rationale: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia. Test-Taking Strategy: Use the process of elimination. Note that the subject of the question is a potassium deficit. Option B is the only option that identifies a loss of body fluid. If you had difficulty with this question, review the causes of hypokalemia.

The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? A. Change the IV fluid from 0.9% NS to D5W. B. Restrict the client's sodium in the diet. C. Monitor blood glucose levels. D. Prepare the client for hemodialysis.

B. Restrict the client's sodium in the diet. A. (incorrect) The nursing plan of care does not include changing the health care provider's orders. B. (correct) Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume. C. (incorrect) High blood glucose levels result in viscous blood and cause the kidneys to try and fix the problem by excreting the glucose through increasing the urine output, which results in fluid volume deficits. D. (incorrect) If the FVE is the result of renal failure, then hemodialysis may be ordered, but this information was not provided in the stem of the question. TEST-TAKING HINT: Option A is not a nursing prerogative. The test taker should not read into the question.

A patient is suffering from a broken jaw. Which foods would be most beneficial for this patient? A. Carrots, fried chicken, and cereal B. Soup, pudding, and ice cream C. Rice, watermelon, and smoked fish D. Tacos, peanuts, and fresh broccoli

B. Soup, pudding, and ice cream A patient with a broken jaw needs foods that require no chewing. Soup, pudding, and ice cream meet these qualifications.

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? A. Increase intake of dairy products and nuts B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals C. Reduce intake of chocolate, meats, and whole grains D. Avoid calcium supplements

B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A. Notify the health care provider immediately. B. Tap the cheek about two (2) centimeters anterior to the ear lobe. C. Check the serum calcium and magnesium levels. D. Prepare to administer calcium gluconate IVP.

B. Tap the cheek about two (2) centimeters anterior to the ear lobe. A. (incorrect) The health care provider may need to be notified, but the nurse should perform assessment first.B. (correct) These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency.C. (incorrect) A positive Chvostek's sign can indicate a low calcium or magnesium level, but serum lab levels may have been drawn hours previously or may not be available.D. (incorrect) If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment. TEST-TAKING HINT: Assessment is the first step in the nursing process and is an appropriate option to select if the test taker has difficulty when trying to decide between two options.

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? A. The client with renal failure B. The client who is taking diuretics C. The client with hyperaldosteronism D. The client who is taking corticosteroids

B. The client who is taking diuretics Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia. Test-Taking Strategy: Use the process of elimination. First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to option B. Review the normal serum sodium level and the causes of hyponatremia if you had difficulty with this question.

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A. The client taking diuretics B. The client with renal failure C. The client with an ileostomy D. The client who requires gastrointestinal suctioning

B. The client with renal failure Rationale: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. Test-Taking Strategy: Use the process of elimination and focus on the subject, excess fluid volume. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options A, C, and D lose fluid. The only condition that can cause an excess is the condition noted in option B. If you had difficulty with this question, review the causes of excess fluid volume.

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? A. "The fluid is an adverse reaction to chemotherapy." B. "A decrease in activity has allowed extra fluid to accumulate in the tissues." C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." B. "Most older adults get confused in the hospital." C. "The sodium level is low, and the confusion will resolve as the levels normalize." D. "The sodium level is high and the behavior is a result of dehydration."

C. "The sodium level is low, and the confusion will resolve as the levels normalize." Normal serum level is 135 to 145 C. "The sodium level is low, and the confusion will resolve as the levels normalize."mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A. 500 mL B. 1000 mL C. 2000 mL D. 4400 mL

C. 2000 mL First, determine how many pounds the client has lost:180 - 175.6 = 4.4 pounds lost Then, based on the fact that 1 liter of fluid weighs 2.2 pounds, determine how many liters of fluid have been lost.4.4 / 2.2 = 2 liters lost Then, because the question asks for the answer in milliliters, convert 2 liters into milliliters.2 x 1000 = 2000 mL TEST-TAKING HINT: The test taker must be able to work basic math problems. This problem has several steps. Sometimes it is helpful to write out what is occurring at each step, such as 4.4 divided by 2.2 kg per pound. This can help the test taker realize if a step has been overlooked.

The nurse evaluates which of the following clients to have hypermagnesemia? A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L

C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L Normal serum magnesium is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.

The patient is on a low potassium diet that includes food such as applesauce, green beans, cabbage, lettuce, grapes, and raspberries. What type of patient would you expect to be on this type of diet? A. A patient with heart disease B. A patient with osteoporosis C. A patient with Addison's disease D. A patient who recently had gastric bypass surgery

C. A patient with Addison's disease Patient's with Addison disease secrete too much potassium so they need to be on a low potassium diet.

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss B. Flat neck and hand veins C. An increase in blood pressure D. A decreased central venous pressure (CVP)

C. An increase in blood pressure Rationale: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options A, B, and D identify signs noted in deficient fluid volume. Test-Taking Strategy: Use the process of elimination and knowledge regarding the assessment findings in excess fluid volume. Note that options A, B, and D are similar or alike in that each of these signs reflects a decrease. Option C reflects an increase. If you had difficulty with this question, review the assessment findings noted in excess fluid volume.

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician

C. Assess for signs of fluid overload A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

A patient is started on the diuretic Spironolactone. Which foods should the patient be careful to avoid eating too much of? A. Eggs B. Green leafy vegetables C. Bananas D. Hot Dogs

C. Bananas Spironolactone is known as a potassium-sparing diuretic medication (meaning it keeps potassium) therefore a patient would need to watch how much potassium they eat. Bananas are high in potassium.

A patient is on a lacto-ovo vegetarian diet. What type of foods can the patient eat? A. Fish, milk, and poached eggs B. Chicken, cheese, and grilled eggplant C. Boiled eggs and chocolate milk D. Oysters, yogurt, and turkey

C. Boiled eggs and chocolate milk Patients on a lacto-ovo vegetarian diet eat eggs and dairy products but avoid meat, poultry, and seafood.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor: A. Urine output. B. Blood pressure. C. Bowel movements. D. ECG for tall, peaked T waves.

C. Bowel movements. Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin B. Encourage the client to increase fluid intake C. Call the physician D. Report the urine output E. Report indications of nausea

C. Call the physician D. Report the urine output E. Report indications of nausea Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. B. Anemia. C. Dehydration. D. Renal failure.

C. Dehydration. A. (incorrect) Clients who are overhydrated or have fluid volume excess would experience dilutional values of sodium (135-145 mEq/L) and red blood cells (44% to 52%). The levels would be lower than normal, not higher.B. (incorrect) Anemia is a low red blood cell count for a variety of reasons.C. (correct) Dehydration results in concentrated serum that causes lab values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.D. (incorrect) In renal failure, the kidneys cannot excrete, and this results in too much fluid in the body.TEST-TAKING HINT: The test taker must decide first if the values are high or low and then determine what is happening with body fluids in each process. Overhydration and renal failure result in the same fluid shift, so these two options (A and D) could be excluded.

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A. Prominent U waves B. Prolonged PR interval C. Depressed ST segment D. Widened QRS complexes

C. Depressed ST segment Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options B and D would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. Test-Taking Strategy: First, you must determine that the client is experiencing hypomagnesemia. Next, identify the electrocardiographic changes that occur in this condition. If you had difficulty with this question, review the normal magnesium level and the electrocardiographic changes that occur in hypomagnesemia and hypermagnesemia.

A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? A. Dry skin B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C. Hyperactive bowel sounds Rationale: Hyperactive bowel sounds indicate hyponatremia. Options A, B, and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. Test-Taking Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to option C. If you had difficulty with this question, review the assessment signs associated with hyponatremia and hypernatremia.

A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment? A. Flat neck and hand veins B. Furrowed dry tongue C. Increased blood pressure and crackles throughout the lungs D. Bradycardia and pitting edema in lower extremities

C. Increased blood pressure and crackles throughout the lungs The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia.

A patient with gout should follow what type of diet? A. High-calcium diet B. Potassium-modified diet C. Low-purine diet D. Renal Diet

C. Low-purine diet Patients with gout suffer from elevated uric acid levels which can cause a gout attack. Therefore, they need to restrict from eating foods high in purine. These foods usually include: anchovies, herring, mackerel, sardines, scallops, glandular meats, wild game, goose, and sweetbreads.

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

C. Metabolic alkalosis Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority? A. Set-up bedside suction B. Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions D. None of the above are correct

C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse? A. Assess a client for metabolic acidosis B. Evaluate the blood gases of a client with respiratory alkalosis C. Obtain a glucose level on a client admitted with diabetes mellitus D. Perform a neurological assessment on a client suspected of having hypocalcemia

C. Obtain a glucose level on a client admitted with diabetes mellitus A licensed practical nurse may obtain a finger-stick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological assessment on a client suspected of hypocalcemia.

The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A. The pump keeps sounding an alarm that the high pressure has been reached. B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL. C. On auscultation, crackles and rales in all lung fields are noted. D. Client has negative pedal edema and an increasing level of consciousness

C. On auscultation, crackles and rales in all lung fields are noted. A. (incorrect) The pump is alerting the nurse that there is resistance distal to the pump; this does not require notifying the health care provider.B. (incorrect) The client has an 1800 mL intake and total output of 1500 mL. The body has an insensible loss of approximately 400 mL per day through the skin, respirations, and other body functions. This would not warrant notifying the health care provider.C. (correct) Crackles and rales in all lung fields indicate that the body is not able to process the amounts of fluids being infused. This should be brought to the health care provider's attention.D. (incorrect) Negative pedal edema and an increasing level of consciousness indicate that the client is not experiencing a problem. TEST-TAKING HINT: The question requires the test taker to distinguish nursing problems from client problems. Option A is a nursing problem and options B and D are expected results, so the health care provider does not need to be notified. Only one option, C, contains abnormal or life-threatening information.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? A. PH of 7.43, PCO2 of 36, HCO3 of 26 B. PH of 7.41, PCO2 of 49, HCO3 of 30 C. PH of 7.33, PCO2 of 35, HCO3 of 17 D. PH of 7.25, PCO2 of 56, HCO3 of 28

C. PH of 7.33, PCO2 of 35, HCO3 of 17 A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-Fowler's position D. Assist the client to breathe into a paper bag

C. Place client in high-Fowler's position The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain B. Depressed deep tendon reflexes C. Positive Chvostek's sign D. Nausea

C. Positive Chvostek's sign Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.

After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A. Magnesium level of 2.2 B. Potassium level of 5.6 C. Potassium level of 2.2 D. Phoshorus level of 2.0

C. Potassium level of 2.2 Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings.

A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? A. Widened T wave B. Prominent U wave C. Prolonged QT interval D. Shortened ST segment

C. Prolonged QT interval Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. Test-Taking Strategy: Use knowledge regarding the electrocardiographic changes that occur in a calcium imbalance to answer the question. Remember that hypocalcemia causes a prolonged ST or QT interval. If you had difficulty with this question, review the electrocardiographic changes that occur in these conditions.

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A. Serum calcium. B. Serum phosphorus. C. Serum potassium. D. Serum sodium.

C. Serum potassium. A. (incorrect) Serum calcium is decreased in conditions such as osteoporosis or post-thyroid surgery, but not in vomiting and diarrhea. B. (incorrect) Serum phosphorus levels are altered in acute and chronic renal failure or diabetic ketoacidosis, among other conditions, but not with acute fluid losses from the gastrointestinal tract. C. (correct) Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias. D. (incorrect) The body is not at risk from losing sodium from these sources as it is with potassium. TEST-TAKING HINT: The nurse must recognize basic fluids and electrolytes in the body and the implications of excess or loss. The body holds onto sodium and releases potassium.

A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? A. Tap water B. Sterile water C. Sodium chloride D. Distilled water

C. Sodium chloride Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (isotonic) should be used rather than water for gastrointestinal irrigations. Test-Taking Strategy: Use the process of elimination. Eliminate options A, B, and D because they are comparative or alike (sterile water, tap water, and distilled water). Also, recalling that the serum sodium level identified in the question indicates hyponatremia will direct you to option C. If you had difficulty with this question, review the care of the client experiencing hyponatremia.

A patient was recently admitted for a Deep Vein Thrombosis and was started on Coumadin. During your education with the patient you would instruct the patient to avoid what food? A. Bananas B. Lettuce C. Spinach D. Processed meats

C. Spinach Coumadin prevents clotting of the blood. Due to the high amount of vitamin k (vitamin k plays a role in clotting) in green leafy vegetable, these foods should be limited.

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A. A client with osteoporosis and a calcium level of 10.6 mg/dl B. A client with renal failure and a magnesium level of 2.5 mEq/L C. A client with bulimia and a potassium level of 3.6 mEq/L D. A client with dehydration and a sodium level of 149 mEq/L

D. A client with dehydration and a sodium level of 149 mEq/L Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dl is normal. Normal serum calcium is 9 to 11 mg/dl. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal. Normal serum potassium is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated.

Which patient is at most risk for fluid volume deficient? A. A patient who has been vomiting and having diarrhea for 2 days. B. A patient with continous nasogastric suction. C. A patient with an abdominal wound vac at intermittent suction. D. All of the above are correct.

D. All of the above are correct. As the nursing administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A. Assess for depressed deep tendon reflexes B. Call the physician to report calcium level C. Place an intravenous catheter in anticipation of administering calcium gluconate D. Check to see if a serum albumin level is available

D. Check to see if a serum albumin level is available A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? A. Sodium is essential to maintain intracellular fluid water balance B. Magnesium is essential to the function of muscle, red blood cells, and nervous system C. Less calcium is excreted with aging D. Chloride is lost in hydrochloride acid

D. Chloride is lost in hydrochloride acid Sodium is essential to maintain extracellular fluid water balance. Phosphate is the major anion in intracellular fluid water balance that is essential in the function of muscle, red blood cells, and nervous system. A person tends to excrete more calcium with age. Chloride is lost through hydrochloride acid.

A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A. Lung congestion B. Decreased hematocrit C. Increased blood pressure D. Decreased central venous pressure (CVP)

D. Decreased central venous pressure (CVP) Rationale: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options A, B, and C are seen in a client with excess fluid volume. Test-Taking Strategy: Use the process of elimination and focus on the subject, deficient fluid volume. Eliminate options A and C first. Lung congestion is noted in excess fluid volume, as is increased blood pressure. From the remaining options, recall that central venous pressure reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore, pressure (volume) would be decreased in a deficient fluid volume. If you had difficulty with this question, review the assessment findings noted in deficient fluid volume.

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? A. Call the physician and report the change in client's condition B. Turn the client's O2 up to 4 liters nasal cannula C. Encourage the client to sit down and to take deep breaths D. Encourage the client to rest and to use pursed-lip breathing technique

D. Encourage the client to rest and to use pursed-lip breathing technique Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following? A. Hypokalemia B. Hypernatremia C. Hypermagnesemia D. Hypocalcemia

D. Hypocalcemia Normal serum calcium is 9 to 11 mg/dl. A client who has hypocalcemia would experience muscle cramps, numbness, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypothyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? A. Sodium B. Phosphorus C. Calcium D. Magnesium

D. Magnesium Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.

You have a patient who just had a stroke and has garbled speech. What type of diet do you expect the patient to be prescribed after a speech evaluation? A. Soft diet B. Full liquid diet C. Mechanically altered diet with thin liquids D. Mechanically altered diet with nectar thick liquids

D. Mechanically altered diet with nectar thick liquids When a patient has a stroke they are at risk for aspiration due to the decrease ability to swallow. Many times a stroke with affect speech as well the patient's ability to utilize the swallowing muscles. Generally, when garbled speech is noted in a stroke victim this is a sign there is a problem with the patient's ability to use their swallowing muscles. A mechanically altered diet with nectar thick liquid will usually be prescribed. However, a speech evaluation will determine what is needed.

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A. Bisacodyl (Dulcolax) suppository B. Fiber supplements C. Docusate sodium D. Milk of magnesia

D. Milk of magnesia Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? A. Encourage the client to increase fluid intake B. Administer the dose as ordered C. Draw a potassium level and administer the dose if the level is low or normal D. Notify the physician of the urine output and hold the dose

D. Notify the physician of the urine output and hold the dose Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician order.

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.

D. Place on seizure precautions. A. (incorrect) The client probably will be placed on fluid restriction. Fluids should not be encouraged for a client with a low sodium level (135-145 mEq/L).B. (incorrect) Hypertonic solutions of saline are 3% to 5%, not 10%, because of the extreme nature of hypertonic solutions. Hypertonic solutions of saline may be used but very cautiously because if the sodium levels are increased too rapidly, a massive fluid shift can occur in the body, resulting in neurological damage and heart failure.C. (incorrect) THe antidiuretic hormone (vasopressin) would cause water retention in the body and increase the problem.D. (correct) Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure. TEST-TAKING HINTS: The test taker must memorize certain common lab values and understand how deviations in the electrolytes affect the body.

A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? A. Obtaining a controlled IV infusion pump B. Monitoring urine output during administration C. Diluting in appropriate amount of normal saline D. Preparing the medication for bolus administration

D. Preparing the medication for bolus administration' Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. Test-Taking Strategy: Use the process of elimination and knowledge regarding the administration of potassium chloride intravenously. Noting the strategic word UNPREPARED in the question and BOLUS in option D will direct you to the correct option. Review the administration of potassium chloride if you had difficulty with this question.

A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? A. Peas B. Cauliflower C. Low-fat yogurt D. Processed oat cereals

D. Processed oat cereals Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content. Test-Taking Strategy: First, you must determine that the client has hypernatremia. Next, note the strategic word AVOID in the question. Eliminate options A and B first because these are vegetables. From the remaining options, note the word PROCESSED in option D. Processed foods tend to be higher in sodium content. Review foods high in sodium content if you had difficulty with this question.

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? A. Monitor intake and output B. Encourage client to increase activity C. Institute deep breathing exercises every hour D. Provide reassurance to the client and administer sedatives

D. Provide reassurance to the client and administer sedatives A client who is anxious and upset, gets lightheaded, and has tingling in the fingers is in respiratory alkalosis. The arterial blood gases include a pH of 7.48, PaCO2 of 29, and HCO3 of 24. Administering sedatives will assist the client to slow breathe and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? A. ST depression B. Inverted T wave C. Prominent U wave D. Tall peaked T waves

D. Tall peaked T waves Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. Test-Taking Strategy: From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. If you had difficulty with this question, review the normal serum potassium level and the electrocardiographic changes that occur in hyperkalemia.

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? A. The client with colitis B. The client with Cushing's syndrome C. The client who has been overusing laxatives D. The client who has sustained a traumatic burn

D. The client who has sustained a traumatic burn Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate option A and C first because they are similar or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Remember that Cushing's syndrome presents a risk for hypokalemia and that Addison's disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia.

You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true? A. The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure B. This is known as Trousseau's Sign and is present in patients with hypercalcemia C. This is known as Chvostek's Sign D. This is known as Trousseau's Sign and is present in patients with hypocalcemia

D. This is known as Trousseau's Sign and is present in patients with hypocalcemia The correct answer is "this is known as Trousseau's Sign and is present in patients with hypocalcemia". Patient's with hypokalemia may present with a positive Trousseau's and Chvostek sign.