Med Sure 2 Final part 1

When concerned about a patient's GI fluid losses, which parameter would the nurse assess to determine fluid loss? Select all that apply. One, some, or all responses may be correct. A. Weight B. Skin turgor C. Urine output D. Blood pressure E. Blood urea nitrogen (BUN)

A B C D E

Which body substance will the nurse include in the documentation for a patient's measurable output? Select all that apply. One, some, or all responses may be correct. A. Feces B. Urine C. Emesis D. Perspiration E. Chest tube drainage

A B C E

Which cell is involved in the general inflammation process? Select all that apply. One, some, or all responses may be correct. A. Eosinophils B. Neutrophils C. Basophils D. Natural killer cells E. Macrophages F. Cytotoxic T-cells

A B C E

A patient diagnosed with dehydration asks, "Why is my urine so dark?" Which response would the nurse provide? A. "Your kidneys are concentrating your urine to maintain fluid balance." B. "It is likely that you have a urinary tract infection." C. "One of your medications may be causing the dark color." D. "Your urine is dilute because of the IV fluids you are receiving."

A

After reviewing four assigned patients' health records, which patient would the nurse prioritize as having the highest risk for a fluid imbalance? A. Patient A B. Patient B C. Patient C D. Patient D

A

Which change common in older adults has a neurologic cause? A. Decreased thirst reflex B. Increased urine output C. Increased muscle mass D. Decreased sweat production

A

Which mechanism causes acidosis in a patient in diabetic ketoacidosis? A. Overproduction of hydrogen ions B. Underelimination of hydrogen ions C. Overelimination of bicarbonate ions D. Underproduction of bicarbonate ions

A

Which parameter would the nurse assess to determine perfusion adequacy in a postoperative patient? A. Urine output B. Blood volume C. Blood pressure D. Glomerular filtration rate

A

Which situation causes isotonic dehydration? A. More sodium than water is lost from the body. B. A decrease in circulating blood volume causes poor tissue perfusion. C. Water and sodium are lost from the body in proportionately equal amounts. D. A shift of fluid from plasma to interstitial space occurs without a loss of water.

A

Which type of medication is administered to adjust a patient's fluid balance? A. Diuretic B. Anticoagulant C. Mood stabilizer D. Opioid analgesic

A

An older-adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. Which medication would the nurse expect to administer? Select all that apply. One, some, or all responses may be correct. A. Diuretics B. 0.9% saline C. Antipsychotics D. Calcium channel blockers E. 5% dextrose in 0.45% sodium chloride

A B E

Which assessment finding indicates that a patient is dehydrated? Select all that apply. One, some, or all responses may be correct. A. Fever B. Hypertension C. Poor skin turgor D. Pulmonary crackles E. Low blood pressure F. Concentrated urine

A C E F

Which condition or symptom is likely responsible for this acid-base imbalance: pH 7.32; partial pressure of arterial oxygen (PaO 2) 82 mm Hg; partial pressure of arterial carbon dioxide (PaCO 2) 33 mm Hg; and bicarbonate (HCO 3 -) 18 mEq/L? Select all that apply. One, some, or all responses may be correct. A. Liverfailure B. Anxiety C. Dehydration D. Constipation E. Prolonged vomiting F. Respiratory rate of 8 breaths/min

A C F

Which condition may result in metabolic acidosis? Select all that apply. One, some, or all responses may be correct. A. Starvation B. Blood transfusion C. Prolonged vomiting D. Prolonged diarrhea E. Nasogastric suctioning F. Total parenteral nutrition

A D

Which electrolyte imbalance would the nurse anticipate for a patient with dehydration? Select all that apply. One, some, or all responses may be correct. A. Hyperkalemia B. Hypocalcemia C. Hypochloremia D. Hypernatremia E. Hypermagnesemia

A D

Which factor affects the amount and distribution of body fluids? Select all that apply. One, some, or all responses may be correct. A. Age B. Poverty C. Activity D. Sex E. Body fat F. Cognition

A D E

Which cell in a human body is a non-self cell? Select all that apply. One, some, or all responses may be correct. A. Cancer cell B. B-lymphocyte C. T-lymphocyte D. Natural killer cell E. Infected body cell

A E

After reviewing a patient's chart, about which laboratory value would the nurse need to call the health care provider? A. pH B. Partial pressure of arterial oxygen (PaO 2) C. Partial pressure of arterial carbon dioxide (PaCO 2) D. Bicarbonate (HCO 3 -)

B

An older adult who is prescribed diuretics and laxatives and has a history of diabetes mellitus is brought to the emergency department in an unconscious state. Which condition would the nurse suspect? A. Hyperkalemia B. Dehydration C. Fluid overload D. Water intoxication

B

For a patient prescribed furosemide as part of treatment plan for cirrhosis and excess fluid volume, which patient goal would the nurse establish for this patient? A. Adds salt in diet B. 10-lb weight loss C. Potassium level 3.0 mEq/L D. Intake greater than output

B

The nurse is preparing to administer a tetanus booster to a patient after the patient experiences an injury. Which type of immunity is the nurse providing this patient? A. Natural active B. Artificial active C. Natural passive D. Artificial passive

B

When a patient reports disturbed deep sleep because of frequent cramping in the calves, which electrolyte would the nurse review in the patient's health record? A. Sodium B. Calcium C. Potassium D. Magnesium

B

Which antibody level would the nurse expect to be elevated in a patient after an anaphylactic reaction? A. Immunoglobin A (IgA) B. Immunoglobin E (IgE) C. Immunoglobin G (IgG) D. Immunoglobin M (IgM)

B

Which arterial blood gas reading would be expected in a patient who has had chronic obstructive pulmonary disease (COPD) for the last 15 years? A. pH 7.33, PaO 2 65 mm Hg, PaCO 2 41 mm Hg, and HCO 3 - 19 mEq/L B. pH 7.36, PaO 2 63 mm Hg, PaCO 2 52 mm Hg, and HCO 3 - 32 mEq/L C. pH 7.48, PaO 2 82 mm Hg, PaCO 2 32 mm Hg, and HCO 3 - 25 mEq/L D. pH 7.36, PaO 2 72 mm Hg, PaCO 2 30 mm Hg, and HCO 3 - 18 mEq/L

B

Which aspect of the patient's history is a likely cause of hyperkalemia? A. Cirrhosis B. Kidney failure C. Heart failure D. Hyperaldosteronism

B

Which assessment is the best indicator of perfusion after a surgical procedure? A. Heart rate B. Urine output C. Blood pressure D. Pulse oximetry

B

Which electrolyte imbalance triggers aldosterone secretion to maintain fluid balance within the body? A. Decreased serum potassium levels B. Decreased sodium levels in the extracellular fluid (ECF) C. Increased serum glucose levels D. Increased calcium levels in the extracellular fluid (ECF)

B

Which fluid volume is the expected insensible water loss for a healthy adult each day? A. 250 to 500 mL B. 500 to 1000 mL C. 1000 to 1250 mL D. 1250 to 1750 mL

B

Which term would the nurse use to document the presence of excess tissue fluid? A. Ascites B. Edema C. Turgor D. Filtration

B

Which condition places a patient at risk for developing metabolic alkalosis? Select all that apply. One, some, or all responses may be correct. A. Fever B. Diarrhea C. Blood transfusion D. Hypovolemic shock E. Nasogastric suctioning F. Total parenteral nutrition

C E F

A laboratory report for a patient shows the following results: pH 7.32; bicarbonate 24 mEq/L; partial pressure of arterial oxygen (PaO 2) 77 mm Hg; and partial pressure of arterial carbon dioxide (PaCO 2) 48 mm Hg. These findings are consistent with which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C

A patient states, "This angiotensin-converting enzyme (ACE) inhibitor medication makes me urinate all the time. I didn't think it was a water pill." Which response would the nurse make? A. "You are probably not taking your medication as prescribed." B. "This medication is a diuretic. I will print literature for you to review." C. "This medication causes greater excretion of water and sodium in your urine." D. "You must not be following your dietary restrictions. How much sodium are you eating?"

C

Which intervention would the nurse expect the health care provider to prescribe for a patient with multiple fluid and electrolyte deficits secondary to a GI virus? Select all that apply. One, some, or all responses may be correct. A. Give antihypertensives. B. Initiate fluid restrictions. C. Apply continuous oxygen. D. Administer loop diuretics E. Start an IV solution of Ringer's lactate.

E

Which action takes place during the third stage of inflammation if there is permanent tissue damage that cannot be replaced? Select all that apply. One, some, or all responses may be correct. A. Fluid leaks B. Edema occurs C. Exudate forms D. Scar tissue develops E. New blood vessels grow

D E

Which patient goal would the nurse establish when providing care for a patient admitted with hypocalcemia secondary to Crohn disease and severe diarrhea? A. Negative Chvostek sign B. Hyperactive bowel sounds C. Prolonged QT and ST intervals D. Blood pressure 90/50 to 94/54 mm Hg

A

which effect causes edema in a patient's dependent areas? a. large intercellular spaces b. filtration of fluid in the cells c. changes in normal hydrostatic pressure d. equilibrium in solute concentration on each side of the cell

C

Which mechanism in the body compensates for a low pH? A. Increases respiratory rate B. Decreases respiratory rate C. Retains carbon dioxide D. Decreases release of bicarbonate

A

Which nursing intervention takes priority for a patient admitted with severe metabolic acidosis? A. Initiate cardiac monitoring. B. Perform medication reconciliation. C. Obtain a diet history for the past 3 days. D. Assess the patient's strength in the extremities.

A

Which patient condition would likely cause increased renin secretion? A. Sodium 130 mEq/L B. Partial pressure of arterial oxygen (PaO 2) 98% on room air C. Blood pressure 130/82 mm Hg D. Heart rate of 88 beats/min

A

Which change in patient assessment over 2 days reflects that the administered diuretic is effective? A. Weight decrease from 168 lb to 162 lb B. Respiratory rate decrease from 24 breaths/min to 20 breaths/min C. Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr D. Blood pressure decrease from 138/88 mm Hg to 126/78 mm Hg

A

Which change is associated with aging? A. Loss of skin elasticity B. Adrenal hypertrophy C. Increased thirst reflex D. Increased muscle mass

A

Which daily dietary sodium limit would the nurse suggest for the patient with chronic fluid overload? A. 2 to 3 g B. 4 to 5 g C. 5 to 6 g D. 6 to 7 g

A

Which intervention may be considered to promote gas exchange and prevent respiratory acidosis in a patient with a constricting chest injury? A. Ventilatory assistance B. Placement of a nasogastric tube C. 100% oxygen via rebreather mask D. Continuous IV bicarbonate infusion

A

A patient has dry skin, a heart rate of 115 beats/min, a respiratory rate of 28 breaths/min, and weight loss of 1 lb in 1 day. Which condition would the nurse suspect? A. Dehydration B. Hyperkalemia C. Fluid overload D. Hyponatremia

A

A patient presents to the urgent care center after being exposed to hepatitis A. Which type of immunity would the nurse expect the patient to have? A. Natural active B. Artificial active C. Natural passive D. Artificial passive

A

A patient with emphysema is in acute respiratory distress and is becoming more confused. Respirations remain rapid but are shallower. The most recent blood gas results are pH 7.29, partial pressure of arterial oxygen (PaO 2) 62 mm Hg, partial pressure of arterial carbon dioxide (PaCO 2) 56 mm Hg, and bicarbonate (HCO 3 -) 25 mEq/L. Which intervention would the nurse take? A. Call the Rapid Response Team. B. Place the patient in a semi-Fowler position. C. Administer the prescribed diuretic. D. Evaluate the patient's need for sedation to assist with breathing.

A

How does the nurse respond when a patient voices concern about infection after noticing a small area of redness around an IV insertion site? A. "Redness is a hallmark of inflammation, and inflammation is not always accompanied by infection." B. "Redness is an expected side effect of having an IV. It's nothing to worry about." C. "Redness is a hallmark of a blood infection. We will start antibiotics immediately." D. "Redness is not associated with infection. Instead, it is associated with irritation of the skin by the cannula."

A

Kussmaul respiration would be seen as a compensatory mechanism with which situation? A. Aspirin overdose B. Use of hydrochlorothiazide C. Administration of sodium bicarbonate D. Patient receiving mechanical ventilation

A

The nurse is developing a plan of care to prevent infection for an older adult admitted for an exacerbation of chronic obstructive pulmonary disease (COPD). Which finding would lead the nurse to suspect an infection is beginning? A. Changes in level of consciousness B. Increased production of antibodies C. Elevated white blood cell (WBC) count D. Body temperature greater than 101°F (38.3°C)

A

The nurse recalls that which type of leukocyte releases histamine and heparin in areas of tissue damage? A. Basophil B. Eosinophil C. Neutrophil D. Plasma cell

A

What information needs to be included when comparing an inflammatory response with antibody-mediated immunity (AMI) and cell-mediated immunity (CMI) responses? Select all that apply. One, some, or all responses may be correct. A. It is an immediate response; AMI and CMI are delayed responses. B. It is a short-term response; AMI and CMI are long-term responses. C. It is a specific response to invasion or injury; AMI and CMI are nonspecific responses. D. It is a full-body response to invasion or injury; AMI and CMI are localized responses. E. It recognizes organisms upon repeated exposure; AMI and CMI do not recognize them.

A B

Which condition can cause metabolic acidosis? Select all that apply. One, some, or all responses may be correct. A. Diarrhea B. Liver failure C. Kidney failure D. Prolonged vomiting E. Nasogastric suctioning

A B C

Which substance is released in the first stage of inflammation? Select all that apply. One, some, or all responses may be correct. A. Kinins B. Serotonin C. Histamine D. Chemotaxins E. Cyclooxygenase

A B C

For the patient with increased fluid volume secondary to heart failure, which intervention would the nurse include in the patient's plan of care? Select all that apply. One, some, or all responses may be correct. A. Daily weights B. Skin pressure relief C. Fluid restriction D. Diuretic therapy E. Low-sodium diet

A B C D E

A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. Which intervention would the nurse implement as part of fall precautions? Select all that apply. One, some, or all responses may be correct. A. Activate the bed alarm. B. Orient the patient frequently. C. Assess for orthostatic hypotension. D. Loosely apply upper extremity wrist restraints. E. Maintain a calm, dim room to reduce confusion. F. Place the bed in the lowest position with brakes locked.

A B C F

The nurse is providing care to a patient who is experiencing severe nausea, vomiting, and diarrhea. Which condition is the patient at risk for developing? Select all that apply. One, some, or all responses may be correct. A. Dehydration B. Hypertension C. Hypokalemia D. Hypercalcemia E. Hypernatremia

A C E

Which organ plays a major role in maintaining pH balance in the body? Select all that apply. One, some, or all responses may be correct. A. Lungs B. Brain C. Pancreas D. Kidneys E. Small intestines

A D

Which nursing assessment would be included in the plan of care for a patient with chronic respiratory acidosis? Select all that apply. One, some, or all responses may be correct. A. Assessing the color of nail beds B. Listening for crackles at lung bases C. Checking respiratory status once per shift D. Checking for the use of accessory muscles E. Assessing for cyanosis of mucous membranes

A D E

Which type of white blood cell acts by limiting inflammation and may result in infection if the number of these cells decreases? A. Basophils B. Eosinophils C. Neutrophils D. Macrophages

C

Which clinical manifestation would the nurse likely assess in a patient with metabolic alkalosis? Select all that apply. One, some, or all responses may be correct. A. Decrease in heart rate B. Numbness around the mouth C. Increase in handgrip strength D. Presence of Kussmaul respiration E. Hyperactivity of deep tendon reflexes

B E

Which patient is at highest risk for infection because of compromised immunity? A. Patient A B. Patient B C. Patient C D. Patient D

C

A patient has had a total urine output of 200 mL in the past 24 hours. Which action would the nurse take first? A. Insert an indwelling urinary catheter. B. Notify the primary health care provider. C. Encourage the patient to drink more fluids. D. Plan to measure daily weights.

B

The nurse is providing care to a female patient who experienced an adverse reaction to a prescribed drug. The patient states, "My husband was on the same dose, and he didn't have any issues." Which response would the nurse make? A. "You are probably allergic to the prescribed drug." B. "Women have less total body water, which causes differences in drug responses." C. "There is no reason as to why certain people experience reactions to drugs." D. "Men have less muscle mass, which why your husband didn't have the same reaction."

B

Which intervention would the nurse plan to prevent skin breakdown for a patient with edema? A. Monitoring the urine output B. Changing position every 1 to 2 hours C. Administering diuretic drug therapy D. Limiting the intake of fluids and sodium

B

Which assessment finding indicates impaired tissue perfusion? Select all that apply. One, some, or all responses may be correct. A. High urine output B. Low blood volume C. Low blood oxygen D. High blood sodium E. High blood pressure

B C

Which change happens to the immune system as a person ages? Select all that apply. One, some, or all responses may be correct. A. Increased febrile response B. Decreased neutrophil function C. Decreased leukocytes when sick D. Increased macrophage production E. Decreased circulating T-lymphocytes

B C E

Which item will the nurse include when documenting a patient's fluid intake? Select all that apply. One, some, or all responses may be correct. A. Emesis B. Enemas C. Oral fluids D. Solid foods E. Irrigation fluids

B C E

Which body fluid is a source of insensible water loss? Select all that apply. One, some, or all responses may be correct. A. Urine B. Feces C. Emesis D. Respiration E. Perspiration

B D E

Which serum electrolyte value would lead the nurse to monitor the patient for dehydration? A. Chloride 92 mEq/L B. Calcium 9.5 mg/dL C. Sodium 150 mEq/L D. Potassium 3.5 mEq/L

C

Which statement explains vascular dehydration? A. Too much fluid loss B. Too little fluid intake C. Fluid shift from plasma to interstitial space D. Fluid shift from interstitial space to plasma

C

Which type of immunity occurs when antibodies pass from a mother to her fetus? A. Natural active immunity B. Artificial active immunity C. Natural passive immunity D. Artificial passive immunity

C

A patient with a history of hypertension asks the nurse what dietary changes are needed to control the blood pressure. Which item in the diet would the nurse recommend reducing? A. Iron B. Calcium C. Sodium D. Phosphorous

C

A postoperative patient has the following arterial blood gas (ABG) results: pH 7.30; partial pressure of arterial carbon dioxide (PaCO 2) 60 mm Hg; partial pressure of arterial oxygen (PaO 2) 80 mm Hg; bicarbonate 24 mEq/L; and oxygen (O 2) saturation 96%. Which action would the nurse take? A. Administer oxygen by nasal cannula. B. Inform the charge nurse that no changes in therapy are needed. C. Encourage the patient to do deep breathing, and assist with repositioning. D. Request a prescription for sodium bicarbonate from the health care provider.

C

Based on the information from the health record of a 65-year-old patient admitted with dehydration secondary to influenza A, which finding indicates a need for the nurse to take immediate action? A. Heart rate B. Oxygenation C. Urine Output D. Serum glucose

C

After administering IV magnesium sulfate (MgSO 4) to a patient with hypomagnesemia, which assessment would the nurse perform to determine the effectiveness of the medication? A. Urinary output B. Peripheral pulses C. Deep tendon reflexes D. Serum albumin levels

D

A patient admitted to the emergency department is in acute respiratory distress syndrome and has an arterial blood gas drawn. Which finding would explain the laboratory value of a pH of 7.31? A. Acidosis in response to the presence of excessive ketoacids B. Alkalosis in response to the excessive loss of hydrogen ions C. Alkalosis in response to the excessive retention of bicarbonate D. Acidosis in response to the excessive retention of carbon dioxide

D

After a motor vehicle crash, the nurse is consoling a patient in the emergency department who is hysterical and hyperventilating after being notified of the death of a family member. Which acid-base imbalance is this patient likely to develop? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D

A 77-year-old woman is brought to the emergency department after she has had diarrhea for 3 days. The patient reports that she is not she has had diarrhea for 3 days. The patient reports that she is not eating or drinking well, but she is taking her diuretics for congestive heart failure. Her laboratory results include a potassium level of 7.0 mEq/L. Which goal would the health team set for this patient? A. Maintaining proper diuresis and urine output B. Elevating serum potassium levels to a safe range C. Decreasing cardiac contractility and slowing the heart rate D. Restoring fluid balance by controlling causes of dehydration

D

After reviewing the health records of four assigned patients, which patient would the nurse determine has a risk for fluid overload? A. 40-year-old woman with Crohn disease B. 50-year-old man with second-degree burns C. 60-year-old woman with nausea and vomiting D. 70-year-old man with chronic kidney disease

D

After successful resuscitation of cardiopulmonary arrest, the patient has the following arterial blood gas reading: pH 7.28; partial pressure of arterial carbon dioxide (PaCO 2) 52; and bicarbonate (HCO 3 -) 16. Which interpretation of these values is accurate? A. Fully compensated respiratory acidosis B. Partially compensated metabolic acidosis C. Partially compensated respiratory acidosis D. Combined respiratory and metabolic acidosis

D

An older adult is brought into the emergency department with persistent vomiting and diarrhea. The caregiver states that the patient has lost 4 lb since the symptoms began. Approximately how much fluid has the patient lost? A. 500 mL B. 1L C. 1.5 L D. 2L

D

Laboratory results for a patient show the following: pH 7.48; bicarbonate 26; partial pressure of arterial oxygen (PaO 2) 90; and partial pressure of arterial carbon dioxide (PaCO 2) 32. These findings are consistent with which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D

The nurse expects that which laboratory count will be increased in a patient who is experiencing recurrent episodes of allergic manifestations? A. Platelet count B. Basophil count C. Neutrophil count D. Eosinophil count

D

Which assessment finding is consistent with fluid overload? A. Heart murmur B. Decreased pulse rate C. Decreased respiratory rate D. Moist crackles in the lungs

D

Which route of fluid loss is unmeasurable? A. Urine B. Feces C. Emesis D. Perspiration

D

Which assessment finding would lead the nurse to revise the plan of care initiated 2 days ago to restore fluid and electrolyte balances for a patient with hypernatremia secondary to dehydration? A. Serum sodium level 128 mEq/L B. Oriented to person, place, and time C. Achilles and patellar reflexes present D. Blood pressures average 110/70 mm Hg

A

Which diuretic is preferred for patients with hypokalemia? A. Amiloride B. Furosemide C. Bumetanide D. Chlorothiazide

A

Which factor is associated with a cause of respiratory alkalosis? A. Anxiety B. Antacid use C. Kidney failure D. Diuretic therapy

A

Which arterial blood gas result would be expected in a patient diagnosed with acute kidney failure? A. pH 7.33, PaO 2 82 mm Hg, PaCO 2 35 mm Hg, HCO 3 - 19 mEq/L pH B. 7.37, PaO 2 93 mm Hg, PaCO 2 52 mm Hg, HCO 3 - 32 mEq/L C. pH 7.48, PaO 2 82 mm Hg, PaCO 2 32 mm Hg, HCO 3 - 25 mEq/L pH D. 7.49, PaO 2 72 mm Hg, PaCO 2 52 mm Hg, HCO 3 - 30 mEq/L

A

The nurse is teaching a patient with congestive heart failure about monitoring fluid volume at home. Which patient action would provide the best indicator of fluid losses or gains? A. Monitoring daily weights B. Observing ankles for swelling C. Monitoring daily intake and output D. Observing for pulse elevations with activity

A

The nurse obtains laboratory results for a patient that show the following: pH 7.24; bicarbonate 20; partial pressure of arterial oxygen (PaO 2) 82; and partial pressure of arterial carbon dioxide (PaCO 2) 35. These findings are consistent with which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A

The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction? A. "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." B. "The hypothalamus contains osmoreceptors sensitive to changes in blood osmolarity." C. "Antidiuretic hormone (ADH) is released from the posterior pituitary gland in response to changes in blood osmolarity." D. "Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low."

A

Which acid-base imbalance would be expected in a patient who has been having acute diarrhea for more than 24 hours? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A

Which hormone regulates sodium balance? Select all that apply. One, some, or all responses may be correct. A. Cortisol B. Aldosterone C. Angiotensin D. Natriuretic peptide (NP) E. Antidiuretic hormone (ADH)

B D E

For a patient who presents with hypokalemia secondary to loop diuretic use, which food would the nurse teach the patient to eat? Select all that apply. One, some, or all responses may be correct. A. Pasta B. Apples C. Bananas D. Cauliflower E. Blackberries

C

For which purpose would a patient with edema receive a hyper osmotic IV solution? A. Improve diffusion of electrolytes within cells. B. Reduce diffusion of potassium into the extracellular space. C. Pull excessive fluid from the interstitial space. D. Reduce filtration of body fluids.

C

In the presence of significant infection in the body, which type of circulating neutrophils does the nurse expect to be most abundant in the patient's white blood cell count (WBC) differential? A. 1 B. 2 C. 3 D. 4

C

The nurse is assessing the leg of a patient who sustained a cut while hiking. Which chemical is released that facilitates arterial dilation and small vein constriction after this injury? A. Kinins B. Heparin C. Histamine D. Leukotrienes

C

The nurse would anticipate which laboratory finding when caring for a patient who has taken a large quantity of a loop diuretic to promote weight loss? A. pH of 7.31 B. Partial pressure of arterial oxygen (PaO 2) of 78 mm Hg C. Bicarbonate (HCO 3 -) of 34 mEq/L D. Partial pressure of arterial carbon dioxide (PaCO 2) of 56 mm Hg

C

When analysis of a patient's telemetry strip reveals a widened QRS complex with peaked T waves, which laboratory value would the nurse review before notifying the health care provider? A. Sodium B. Calcium C. Potassium D. Magnesium

C

When caring for a patient with a pulse oximetry level of 90%, which action would the nurse take first? A. Get the patient out of bed. B. Auscultate breath sounds. C. Apply oxygen as prescribed. D. Notify the patient's health care provider.

C

When evaluating the laboratory results of a patient with diabetic ketoacidosis, which laboratory value indicates the body has fully compensated from this acid-base imbalance? A. Normal serum glucose B. Normal serum potassium C. Normal pH on arterial blood gases D. Normal bicarbonate on arterial blood gases

C

When providing care for an older female patient with diarrhea, which intervention would the nurse implement first, after reviewing the laboratory results? A. Administer potassium. B. Limit dietary salt intake. C. Encourage oral fluid intake. D. Transfuse 1 unit packed RBCs.

C

Which acid-base imbalance would the nurse anticipate that a patient with morbid obesity may develop? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C

Which body system would the nurse reassess if a patient's laboratory result indicates a serum potassium level of 5.9 mEq/L? A. Respiratory B. Genitourinary C. Cardiovascular D. Integumentary

C

Which cardiovascular change would the nurse expect to find in a patient with fluid overload? A. Flat jugular veins B. Increased heart rate C. Widened pulse pressure D. Decreased blood pressure

C

Which condition commonly occurs in patients who are on long-term furosemide therapy? A. Hypocalcemia B. Hypercalcemia C. Hyponatremia D. Hypernatremia

C

Which condition does the nurse suspect in a patient with a white blood cell differential count that indicates bandemia? A. Lupus B. Bone marrow disorders C. Sepsis D. Ongoing radiation therapy

C

Which fluid is critical to prevent death? A. Urine B. Perspiration C. Blood volume D. Interstitial fluid

C

Which hormone is secreted in response to an elevated blood pressure? A. Insulin B. Aldosterone C. Natriuretic peptides (NPs) D. Antidiuretic hormone (ADH)

C

Which nursing action is the greatest priority in the plan of care for a patient recovering from an acute episode of chronic obstructive pulmonary disease (COPD)? A. Assess nail beds every 2 hours for cyanosis. B. Assess orientation status every 4 hours. C. Monitor the respiratory rate and effort hourly. D. Monitor arterial blood gas (ABG) results as ordered.

C

Which change would indicate that a patient with impaired kidney function is in metabolic acidosis? A. Increase in arterial blood pH B. Increase in partial pressure of arterial oxygen C. Decrease in partial pressure of carbon dioxide D. Decrease in serum bicarbonate level

D

Which concept is accurate regarding acid-base chemistry in acidosis? A. Acids bind free hydrogen ions in solution. B. Acetic acid (CH 3COOH) is a strong acid. C. Normally, blood is slightly acidic in nature. D. Fluids with lower pH have higher acidity.

D

Which goal must the patient with diabetes mellitus strive for to decrease the risk for acid-base imbalance? A. Drinking 3 L of fluid per day B. Eating regularly, every 4 to 8 hours C. Checking blood glucose levels once daily D. Maintaining blood glucose level within normal limits

D

Which patient would exhibit the following arterial blood gas (ABG) results: pH 7.30; partial pressure of arterial carbon dioxide (PaCO 2) 49; bicarbonate (HCO 3 -) 26; and partial pressure of arterial oxygen (PaO 2) 76? A. Patient with kidney failure B. Patient with hyperkalemia C. Patient with anxiety disorder D. Patient taking opioids

D

Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? A. 32-year-old man consuming alcoholic beverages B. 28-year-old woman with type 1 diabetes mellitus C. 68-year-old man frequently wiping sweat from his forehead D. 72-year-old woman who is 20 lb overweight

D

Which prescribed treatment would the nurse administer to a patient admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) whose laboratory values reveal a pH of 7.29 with a decreased partial pressure of arterial oxygen (PaO 2) and an elevated partial pressure of arterial carbon dioxide (PaCO 2)? A. IV fluids B. Antiemetics C. Sodium bicarbonate D. Bronchodilator therapy

D

Which type of medication may affect the assessment of a patient's fluid balance? A. Anticoagulant once daily B. Cardiac glycoside once daily C. Antibiotic every 6 hours D. Angiotensin-converting enzyme (ACE) inhibitor twice daily

D

Which value falls within the range for the minimal amount of urine that needs to be produced in 24 hours? A. 150 mL/day B. 250 mL/day C. 350 mL/day D. 450 mL/day

D