m/a #1

The nurse is caring for the following group of clients. Select the client most likely to be diagnosed with respiratory alkalosis. - A 26-year-old female with anxiety who has been hyperventilating - A 63-year-old male with a 40-year history of smoking and chronic lung disease - A 45-year-old male with pneumothorax after a car accident - An 18-year-old female who has overdosed on narcotics

A 26-year-old female with anxiety who has been hyperventilating Explanation: Respiratory alkalosis can occur with hyperventilating and the loss of CO2.The other three clients are more at risk for respiratory acidosis as a result of retaining CO2.

A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (select all that apply.) A. "Take your heart medication with a sip of water before surgery." B. "splint the abdominal incision with a pillow when coughing and deep breathing." C. "Bed rest is recommended for the first 48 hours." D. "Anti‐embolism stockings are applied before surgery." E. "you can eat solid foods up to 4 hours before surgery."

A. CORRECT: Teach the client to take certain cardiac and other medications as prescribed with a sip of water before surgery. B. CORRECT: Teach the client how to splint with a pillow to support the incision when coughing and deep breathing postoperatively. D. CORRECT: inform the client of the application of antiembolism stockings to prevent deep‐vein thrombosis.

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include inthe plan of care? (select all that apply.) A. encourage use of the incentive spirometer every 2 hr. B. instruct the client to splint the incision when coughing and deep breathing. C. reposition the client every 2 hr. D. Administer antibiotic therapy. E. Assist with early ambulation.

A. CORRECT: Use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis. B. CORRECT: incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing, which prevents atelectasis. C. CORRECT: repositioning the client every 2 hr will mobilize secretions and allow the client to deep breathe and expand the lungs to prevent atelectasis. E. CORRECT: early ambulation expands the lungs through deep breathing and prevents atelectasis

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? A. Assess bowel sounds. B. Administer antiemetic medication. C. restart prescribed IV fluids. D. insert a prescribed nasogastric tube.

A. CORRECT: Using the nursing process, the first step is to assess the client. This enables the nurse to check for peristalsis and will guide further interventions.

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39° C (102.2° F) orally. Which of the following actions should the nurse take? A. inform the surgeon of the elevated temperature. B. Transfer the client to the preoperative unit. C. Apply ice packs to the groin. D. encourage the client to increase intake of clear liquids.

A. CORRECT: immediately notify the surgeon of the elevated temperature to determine if canceling the surgery is necessary due to an underlying infection.

A nurse is caring for a client who is receiving morphine via a patient‐controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

C. CORRECT: PCA allows the client to self‐administer pain medication on an as‐needed basis. The provider can modify the PCA settings if needed to ensurethe client achieves adequate pain relief.

nurse is teaching a client who is starting patient-controlled analgesia (PCA) following a procedure. Which of the following client statements indicates an understanding of the teaching? • A. "This method of medication can increase the chances of overdose." B. "I should self-administer the medication 1 hour before walking." ( C. "I should expect to receive smaller doses when I am sleeping." • D. "This method works by keeping my opioid levels steady."

D. "This method works by keeping my opioid levels steady."

A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A. Cabbage B. Oatmeal O c Milk D. Bananas

D. Bananas

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses. B. Apply a warm blanket. C. Assess dressings. D. Place the client in a lateral position.

D. CORRECT: The greatest risk to the client who is unresponsive or unconscious is injury from aspiration. Turning the client to the side will help keep the airway clear of secretions

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. encourage the client to void after preoperative medication administration. B. Administer antibiotics 2 hr prior to surgical incision. C. remove hair using a manual razor. D. remove nail polish on fingers and toes.

D. CORRECT: ensure the nail beds are visible for color and circulation by removing nail polish before surgery.

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Prolonged PR intervals b) Elevated ST segments c) Prolonged QT intervals d) Peaked T waves

a) Prolonged PR intervals

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L b) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L c) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L d) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L

a) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Hallucinations b) Nausea c) Confusion d) Headache

c) Confusion

A nurse is teaching a newly licensed nurse about caring for a client who has a new left arteriovenous fistula. Which of the following statements should the nurse make? A. "Check the fistula site daily for a vibration." B. "Instruct the client to restrict movement of his left arm." C. "Avoid taking a blood pressure on the client's left arm." D. "Instruct the client to sleep on his left side."

c. "avoid taking blood pressure on the client's left arm."

A nurse is caring for a post-op client following arteriovenous (AV) fistula creation in her left arm. Which of the following actions should the nurse take? A. Measure BP in the client's left arm every 4 hrs. B. Keep the client's left arm in a dependent position. C. Auscultate for bruits in the left arm every 4 hrs. D. Instruct the client to sleep on the affected side.

c. Auscultate for bruits in the left arm every 4 hrs.The client's arm should be elevated and NEVER take BP on this arm.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 -26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis

A nurse is caring for a client who has a blood potassium 5.4 meq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia

A. CORRECT: Assess for eCG changes. Potassium levels can affect the heart and result in arrhythmias.

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. CORRECT: Attempt to identify manifestations that occur along with the client's pain (nausea, fatigue, or anxiety).

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply.) A. Review the medications the client currently takes. B. Assess the AV fistula for a bruit. C. Calculate the client's hourly urine output. D. Measure the client's weight. E. Check serum electrolytes. F. Use the access site area for venipuncture.

A. CORRECT: By reviewing the medications the client currently takes, the nurse can determine which medications to withhold until after dialysis. B. CORRECT: Assessing the AV fistula for a bruit determines the patency of the fistula for dialysis. C. The client's hourly urine output can vary with the remaining kidney function and does not determine the need for dialysis. D. CORRECT: Measuring the client's weight before dialysis is essential for comparing it with the client's weight after dialysis. E. CORRECT: Checking the serum electrolytes determines the need for dialysis.F. The nurse should never use the access site area for venipuncture because compression from the tourniquet can cause loss of the vascular access.

A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees c. Reassure the client D. Instruct the client to avoid coughing

A. Cover the client's wound with a sterile, moist dressing

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium • B. Decreased potassium • C. Increased potassium O D. Increased calcium

A. Decreased calcium

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? A. Decreased muscle strength B. Decreased gastric motility C. Increased heart rate D. Increased blood pressue

A. Decreased muscle strength

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? • A. Elevated ST segments • B. Absent P waves C. Depressed ST segments D. Varying PP intervals

A. Elevated ST segments

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? ) A. Hypokalemia • B. Hypophosphatemia C. Hypercalcemia • D. Hypermagnesemia

A. Hypokalemia---- Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia---- Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? A. Implement seizure precautions B. Administer phosphate C. Initiate diuretic therapy D. Prepare the client for hemodialysis

A. Implement seizure precautions

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies

A. Use the pain scale to determine the client's pain level

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A.hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A.hyperkalemia

A nurse is caring for a client who has a high fever and is hyperventilating. His ABG results are pH 7.51, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis

B. respiratory alkalosis

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate

B. PaCO2

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing V E. Monitor the client for manifestations of shock

B. Place the client in supine position with hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves • B. Prolonged QT intervals O c. shortened OT intervals • D. Widened ORS complexes

B. Prolonged QT intervals

What is the patient experiencing:pH 7.48 PCO2 28 HCO3 24 A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

What is the patient experiencing:pH 7.49 PCO2 30 HCO3 26 A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open‐ended questions to identify the client's pain sensations.

C. CORRECT: Use a pain rating scale to help the client report the intensity of the pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (select all that apply.) A. explain to the client the purpose of having the procedure. B. inform the client of risks to having the procedure. C. ensure the client understands information about the procedure. D. Witness the client signing the informed consent form. E. determine if the client is capable of understanding the reason for the procedure.

C. CORRECT: ensure the client understands the information about the procedure. D. CORRECT: Witness the client sign the informed consent. E. CORRECT: determine if the client is capable of understanding the reason for the procedure.

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? • A. Muscle tremors • B. Positive Chvostek's sign • C. Depressed deep-tendon reflexes D. Numbness around the mouth

C. Depressed deep-tendon reflexes

A nurse is providing teaching to a client who has chronic kidney failure with an AV fistula for hemodialysis and a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching? A. Reduces blood pressure B. Inhibits clotting of fistula C. Promotes RBC production D. Stimulates growth of neutrophils

C. Promotes RBC production

A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? A. <0.5 mL/kg of urine output for 12 hr B. No urine output for 12 hr C. No urine output without renal replacement therapy for 4 to 12 weeks D. No urine output without renal replacement therapy for more than 3 months

D. No urine output without renal replacement therapy for more than 3 months

A nurse is caring for a client who has urolithiasis and requires further diagnostic testing after an initial test indicated hypercalcemia. Which of the following structures controls calcium concentration? • A. Pancreas • B. Thyroid gland C. Anterior pituitary gland • D. Parathyroid gland

D. Parathyroid gland

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? A. Sodium 152 mEq/L B. Chloride 102 mEq/L C. Magnesium 1.8 mEq/L D. Potassium 6.1 mg/L

D. Potassium 6.1 mg/L

A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10 D. Reinforce teaching with the client about how to push the button to deliver the medication

D. Reinforce teaching with the client about how to push the button to deliver the medication

A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for? A. metabolic acidosis B. increased intracranial pressure (ICP) C. muscle weakness D. cardiac irregularities

D. cardiac irregularities

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? • A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia • D. Hyperkalemia

Hyperkalemia *A client who has chronic kidney disease can have hyperkalemia, which is a potassium level greater than 5.0 mEq/L. The expected reference range for a potassium level is 3.5 to 5.0 mEq/L. Other manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle weakness

Respiratory alkalosis can be caused by a respiratory rate in excess of that which maintains normal plasma PCO2 levels. What is a common cause of respiratory alkalosis? - Hyperventilation - Kussmaul breathing - Cluster breathing - Hypoventilation

Hyperventilation

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? - Metabolic Alkalosis - Respiratory Alkalosis - Metabolic Acidosis - Respiratory Acidosis

Respiratory acidosis

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following fings should the nurse expect?

Tingling of the extremities. -Serum calcium level of 7.6 is below the expected reference range, indicating hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysryhythmias