Lesson 2 homework: acid-base balance and fluid and electrolytes

how can the nurse prevent vomiting in a client who reports feeling nauseated after cataract surgery?

*a. administer the prescribed antiemetic medication* b. provide some dry crackers for the client to eat c. explain that this is expected after surgery d. teach how to breathe deeply until the nausea subsides

which *priority* nursing intervention would the nurse implement for a client on diuretic therapy who has developed metabolic alkalosis?

*a. fall prevention measures* b. monitoring electrolytes c. administering antiemetics d. adjusting the diuretic therapy

place the following nursing actions in the correct order for a client esophageal varices prescribed a blood transfusion

1. check the client's vital signs 2. establish IV access with IV normal saline 3. verify the blood product with another nurse against the client's ID bracelet 4. monitor the client's vital signs and status according to agency policy

during an 8 hour shift client drinks two 6 oz (180 mL) cups of teas and vomits 125 mL of fluid. intravenous fluids absorbed equaled the urinary output. what is the client's fluid balance during this 8 hour period?

235 mL

upon pressure application, which degree of edema would the nurse document for a 6 mm deep indentation?

3+

Which volume of solution would be prepared when the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client?

a. 150-250 mL b. 250-350 mL c. 300-500 mL *d. 500-759 mL*

at 10:00 AM the nurse hangs a 1000 mL bag of D5W with 20mEq of KCL to be administered at 80 mL/h. at noon the health care provider prescribes a stat infusion of IV antibiotic of 100 mL to be administered via piggybag over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic?

60 minutes

which percentage of total body water is found in a premature newborn?

85%

when a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take?

a. administer oral fluids *b. encourage deep breathing* c. increase the oxygen flow rate d. perform nasotracheal suctioning

the nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. which urinary finding indicates the need to notify the primary health care provider?

presence of large proteins

which blood type must a person have to be a universal recipient?

AB

which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?

respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

a high school student arrives at the local blood drive center to donate blood for the first time and as the site is being prepared for needle insertion, the student becomes agitated and starts to hyperventilate. which instruction would the nurse provide the student?

breathe the cupped hands

which hormone regulates blood levels of calcium?

parathyroid hormone (PTH)

which response would be given by a nurse providing discharge teaching to an older adult who admitted to the hospital to be treated for dehydration when the client asks what to do about itchy, dry skin?

a. "wear plenty of warm clothes to keep moisture in skin" *b. "use moisturizer on the skin daily to help reduce itching"* c. "take hot tub baths only twice a week to reduce drying of the skin" d. "expose the skin to the air to help reduce the sensation of itching"

which ion is the regulator of extracellular osmolarity?

sodium

which hormonal deficiency causes diabetes insipidus in a client?

antidiuretic hormone

which physiological alteration would be expected with a higher than normal RBC count?

a. increased blood pH b. decreased hematocrit *c. increased blood viscosity* d. decreased immune response

which hormone aids in regulating intestinal calcium and phosphorous absorption?

a. insulin b. thyroxine *c. glucocorticoids* d. parathyroid hormone

in which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride?

a. isotonic b. isometric *c. hypotonic* d. hypertonic

which factor is the likely cause of laboratory result when arterial blood gases are done on a client who is being resuscitated after cardiac arrest show a low pH?

a. ketoacidosis b. irregular heartbeat *c. lactic acid production* d. sodium bicarbonate administration

which symptom indicates that a client with inhalation anthrax is in the fulminant stage?

a. low grade fever b. dry cough *c. hypoxia* d. mild chest pain

which medication would the nurse identify as being used both cervical ripening during labor and for the prevention of gastric ulcers?

a. raloxifene b. clomiphene *c. misoprostol* d. dinoprostone

what action is the function of antidiuretic hormone (ADH)?

a. reduces blood volume *b. decreases water loss in urine* c. increases urine output d. initiates the thirst mechanism

which action is promoted by vasopressin?

a. sodium reabsorption *b. reabsorption of water* c. tubular secretion of sodium d. red blood cell production

which client problem would the nurse expect to decrease in response to the administration of serum albumin intravenously to a client with ascites?

abdominal girth

which gland is affected in aldosteronoma?

adrenal cortex

which information would the nurse reinforce when teaching a client with GERD about antacid therapy?

a. antacids should be taken 1 hour before meals b. these should be scheduled at 4-hour intervals c. antacids tablets are just as fast and effective as the liquid form *d. antacids commonly interfere with the absorption of other medication*

which clinical finding would the nurse associate with hypokalemia?

a. edema b. muscle spasms c. kussmaul respirations *d. muscle weakness*

which effect of sodium bicarbonate is the nurse trying to prevent when teaching a client about dangers of using sodium bicarbonate regularly?

a. gastric distention *b. metabolic alkalosis* c. chronic constipation d. cardiac dysrhythmias

which complication will the nurse anticipate when caring for a client in late hypovolemic shock?

a. hypokalemia *b. metabolic acidosis* c. respiratory alkalosis d. decreased pco2 levels

which complication would a nurse try to avoid by slowly administering a parenteral preparation of potassium?

cardiac arrest

which adverse effect would a nurse monitor for when caring for a client receiving furosemide to relieve edema?

hypokalemia

which food item would the nurse instruct a client whose pathology report states a urinary calculus is composed of uric acid to avoid?

liver

an arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. which disturbances would the nurse identify based on these results?

metabolic acidosis

which initial change in acid-balance will nurse expect when a client is in the progressive stage of shock?

metabolic acidosis

which arterial blood gas results are associated with diabetic ketoacidosis?

pH 7.28; PCO2 28; HCO3 18

which blood gas result would the nurse expect an adolescent with diabetic ketoacidosis to exhibits?

pH 7.30, CO2 40 mm Hg, HCO3 20 mEq/L

based on an ECG a client is suspected to have hypokalemia. which test will be used to confirm hypokalemia?

serum potassium level

which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected?

serum potassium level

which action will a nurse take first when caring for a client reporting chest pain, difficulty breathing, and feeding cold twenty minutes after an infusion of packed red blood cells begins?

stop the transfusion

while providing care for a client with a second degree left ankle sprain, the nurse raises the injured part above heart level. which statement describes the rationale behind this nursing action?

to prevent further edema

a client with esophageal varices experiences severe hematemesis, a Sengstake-Blakemore tube is inserted. which design and purpose does this tube have?

triple-lumen; for esophageal compression

which statements explains why metabolic acidosis develops with kidney failure?

*a. inability of the renal tubules to secrete hydrogen ions and converse bicarbonate* b. depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention c. inability of the renal tubules to reabsorb water dilute the acid contents of blood d. impaired glomerular filtration, causing retention of sodium and metabolic waste products

an increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?

*a. ketones* b. glucose c. lactic acid d. glutamic acid

which independent nursing action would be included in the plan of care for a client after an episode of ketoacidosis?

*a. monitoring for signs of hypoglycemia resulting from treatment* b. withholding glucose in any form until the situation is corrected c. giving fruit juices, broth, and milk as soon as the client is able to take fluids orally d. regulating insulin dosage according to the client's urinary ketone level

which electrolyte deficiency triggers the secretion of renin?

*a. sodium* b. calcium c. chloride d. potassium

which condition is a cardiovascular manifestation of alkalosis? SATA

- increased heart rate - increased digitalis toxicity

in which component of the nephron does furosemide decrease fluid reabsorption? SATA

- loop of Henle - distal tubules - proximal tubules

the nurse is caring for a client who is vomiting. when caring for this client the nurse recalls that the vomiting reflex follows a set pattern. list the steps in the order that they occur.

1. initiation of reverse peristalsis in the stomach 2. contraction of abdominal muscles 3. relaxation of the upper esophageal sphincter 4. closure of the trachea to prevent aspiration