Module 1: Complex Health Disturbances Related to Fluid & Electrolytes, Acid/Base Balance, and Shock

The nurse notes that a pt who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a) Give the prescribed PRN lorazepam (Ativan). b) Start the prescribed PRN oxygen at 2 to 4 L/min. c) Administer the prescribed normal saline bolus and insulin. d) Encourage the patient to take deep, slow breaths with guided imagery.

c) Administer the prescribed normal saline bolus and insulin. The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the pt will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

A 19-year-old pt with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a) Inspiratory crackles. b) Cool, clammy extremities. c) Apical heart rate 45 beats/min. d) Temperature 101.2 F (38.4 C).

c) Apical heart rate 45 beats/min. Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Which action should the nurse take first when a pt complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a) Notify the health care provider. b) Offer reassurance to the patient. c) Auscultate the patients breath sounds. d) Give the prescribed PRN morphine sulfate IV.

c) Auscultate the patients breath sounds. The initial action should be to assess the pt further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the pt is needed before notifying the health care provider, offering reassurance, or administration of morphine.

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the pts condition has improved? a) Hematocrit 28% b) Absence of skin tenting c) Decreased peripheral edema d) Blood pressure 110/72 mm Hg

c) Decreased peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the pts protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

The nurse assesses a pt who has been hospitalized for 2 days. The pt has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a) Oral temperature of 100.1 F b) Serum sodium level of 138 mEq/L (138 mmol/L) c) Gradually decreasing level of consciousness (LOC) d) Weight gain of 2 pounds (1 kg) above the admission weight

c) Gradually decreasing level of consciousness (LOC) The pts history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?

27 In order to administer the dobutamine at the prescribed rate of 5 mcg/kg/minute from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hour.

A newly admitted pt is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a) Assign the pt to a room near the nurses station. b) Place the pt in a room nearest to the water fountain. c) Place the pt on telemetry to monitor for peaked T waves. d) Assign the pt to a semi-private room and place an order for a low-salt diet.

a) Assign the pt to a room near the nurses station. The pt should be placed near the nurses station if confused in order for the staff to closely monitor the pt. To help improve serum sodium levels, water intake is restricted. Therefore a confused pt should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused pt could be distracting and disruptive for another pt in a semiprivate room. This pt needs sodium replacement, not restriction.

The nurse is caring for a pt with a massive burn injury & possible hypovolemia. Which assessment data will be of most concern to the nurse? a) Blood pressure is 90/40. b) Urine output is 30mL over the last hour. c) Oral fluid intake is 100mL for the last 8hrs. d) There is prolonged skin tenting over the sternum.

a) Blood pressure is 90/40. Blood pressure indicates the pt may be developing hypovolemic shock as result of intravascular fluid loss due to burn injury. This finding will require immediate intervention to prevent complications associated with systemic hypoperfusion. Poor oral intake, decreased urine output, and skin tenting all indicate need for increasing pts fluid intake but not as urgently as hypotension.

A nurse in the outpatient clinic is caring for a pt who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a) Daily alcohol intake b) Intake of dietary protein c) Multivitamin/mineral use d) Use of over-the-counter (OTC) laxatives

a) Daily alcohol intake Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

A 78-kg pt with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a) Give PRN furosemide (Lasix) 40 mg IV. b) Increase normal saline infusion to 250 mL/hr. c) Administer hydrocortisone (Solu-Cortef) 100 mg IV. d) Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

a) Give PRN furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further for the pt with septic shock. The other orders are appropriate.

A pt with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a) Give normal saline IV at 500 mL/hr. b) Give acetaminophen (Tylenol) 650 mg rectally. c) Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d) Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

a) Give normal saline IV at 500 mL/hr. Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

The home health nurse cares for an alert and oriented older adult pt with a hx of dehydration. Which instructions should the nurse give to this pt related to fluid intake? a) Increase fluids if your mouth feels dry. b) More fluids are needed if you feel thirsty. c) Drink more fluids in the late evening hours. d) If you feel lethargic or confused, you need more to drink.

a) Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older pts prefer to restrict fluids slightly in the evening to improve sleep quality. The pt will not be likely to notice and act appropriately when changes in LOC occur.

A postop pt who had surgery for a perforated gastric ulcer has been receiving NG suction for 3 days. The pt now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a) Infuse 5% dextrose in water at 125 mL/hr. b) Administer IV morphine sulfate 4 mg every 2 hours PRN. c) Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d) Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

a) Infuse 5% dextrose in water at 125 mL/hr. Because the pts gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringers solution would usually be ordered for this pt. The other orders are appropriate for a postop pt with gastric suction.

A nurse is caring for a pt with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a) Infuse normal saline at 250 mL/hr. b) Keep head of bed elevated to 30 degrees. c) Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d) Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm.

a) Infuse normal saline at 250 mL/hr. The pts elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the pt.

A pt receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a) Lung sounds b) Urinary output c) Peripheral pulses d) Peripheral edema

a) Lung sounds Hypertonic solutions cause water retention, so the pt should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A pt who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

a) Metabolic acidosis The pH and HCO3 indicate that the pt has a metabolic acidosis. The ABGs are inconsistent with the other responses.

The nurse notes a serum calcium level of 7.9 mg/dL for a pt who has chronic malnutrition. Which action should the nurse take next? a) Monitor ionized calcium level. b) Give oral calcium citrate tablets. c) Check parathyroid hormone level. d) Administer vitamin D supplements.

a) Monitor ionized calcium level. This pt with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

During change-of-shift report, the nurse is told that a pt has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a) New onset of confusion b) Heart rate 112 beats/minute c) Decreased bowel sounds d) Pale, cool, and dry extremities

a) New onset of confusion The changes in mental status are indicative that the pt is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

A pt is admitted to the emergency department (ED) for shock of unknown etiology. Thefirst action by the nurse should be to a) administer oxygen. b) obtain a 12-lead electrocardiogram (ECG). c) obtain the blood pressure. d) check the level of consciousness.

a) administer oxygen. The initial actions of the nurse are focused on the ABCs airway, breathing, and circulation and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

A pt with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The pt arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a) Notify the pts health care provider. b) Obtain an order to draw a potassium level. c) Review the magnesium level on the patients chart. d) Teach the pt about the risk of magnesium-containing antacids

a) Notify the pts health care provider. The health care provider should be notified immediately. The pt has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The pt needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for pts with renal failure, but the pts current symptoms are not consistent with hyperkalemia

A pt who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a) Oral digoxin (Lanoxin) 0.25 mg daily b) Ibuprofen (Motrin) 400 mg every 6 hours c) Metoprolol (Lopressor) 12.5 mg orally daily d) Lantus insulin 24 U subcutaneously every evening

a) Oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

A pt with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a) Prepare to administer atropine IV. b) Obtain baseline body temperature. c) Infuse large volumes of lactated Ringers solution. d) Provide high-flow oxygen (100%) by non-rebreather mask. e) Prepare for emergent intubation and mechanical ventilation.

a) Prepare to administer atropine IV. b) Obtain baseline body temperature. d) Provide high-flow oxygen (100%) by non-rebreather mask. e) Prepare for emergent intubation and mechanical ventilation. All of the actions are appropriate except to give large volumes of lactated Ringers solution. The pt with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the pt. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.

Following a thyroidectomy, a pt complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately? a) Presence of the Chvosteks sign b) Abnormal serum potassium level c) Decreased thyroid hormone level d) Bleeding on the patients dressing

a) Presence of the Chvosteks sign The pts symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

A pt has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a) The patient is experiencing laryngeal stridor. b) The patient complains of generalized fatigue. c) The patients bowels have not moved for 4 days. d) The patient has numbness and tingling of the lips.

a) The patient is experiencing laryngeal stridor. Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the pts calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

Which data collected by the nurse caring for a pt who has cardiogenic shock indicate that the pt may be developing multiple organ dysfunction syndrome (MODS)? a) The patients serum creatinine level is elevated. b) The patient complains of intermittent chest pressure. c) The patients extremities are cool and pulses are weak. d) The patient has bilateral crackles throughout lung fields.

a) The patients serum creatinine level is elevated. The elevated serum creatinine level indicates that the pt has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the pts diagnosis of cardiogenic shock.

Norepinephrine (Levophed) has been prescribed for a pt who was admitted with dehydration and hypotension. Which pt data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a) The pts central venous pressure is 3 mm Hg. b) The pt is in sinus tachycardia at 120 beats/min. c) The pt is receiving low dose dopamine (Intropin). d) The pt has had no urine output since being admitted

a) The pts central venous pressure is 3 mm Hg. Adequate fluid administration is essential before administration of vasopressors to pts with hypovolemic shock. The pts low central venous pressure indicates a need for more volume replacement. The other pt data are not contraindications to norepinephrine administration.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in pts admitted to the hospital (select all that apply)? a) Use aseptic technique when caring for invasive lines or devices. b) Ambulate postoperative patients as soon as possible after surgery. c) Remove indwelling urinary catheters as soon as possible after surgery. d) Advocate for parenteral nutrition for patients who cannot take oral feedings. e) Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

a) Use aseptic technique when caring for invasive lines or devices. b) Ambulate postoperative patients as soon as possible after surgery. c) Remove indwelling urinary catheters as soon as possible after surgery. e) Administer prescribed antibiotics within 1 hour for patients with possible sepsis. Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

A pt comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a) Obtain the baseline weight. b) Check the patients blood pressure. c) Draw blood for serum electrolyte levels. d) Ask about any extremity numbness or tingling.

b) Check the patients blood pressure. Because the pts history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the pts perfusion status.

A pt is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a) Skin turgor. b) Daily weight. c) Presence of edema. d) Hourly urine output.

b) Daily weight. Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or fluid loss through insensible loss, sweating, or loss from GI tract or wounds.

An older adult pt who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a) Pallor b) Edema c) Confusion d) Restlessness

b) Edema The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

A pt with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a) 5% human albumin b) Furosemide (Lasix) IV c) Epinephrine (Adrenalin) drip d) Hydrocortisone (Solu-Cortef)

b) Furosemide (Lasix) IV The PAWP indicates that the pts preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a) Start a normal saline infusion. b) Give epinephrine (Adrenalin). c) Start continuous ECG monitoring. d) Give diphenhydramine (Benadryl).

b) Give epinephrine (Adrenalin). Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

A pt who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The pts respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a) Discontinue the nasogastric suction. b) Give the patient the PRN IV morphine sulfate 4 mg. c) Notify the health care provider about the ABG results. d) Teach the patient how to take slow, deep breaths when anxious.

b) Give the patient the PRN IV morphine sulfate 4 mg. The pts respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurses first action should be to medicate the pt for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the pt needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The pt will not be able to take slow, deep breaths when experiencing pain.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a) Administer the KCl as a rapid IV bolus. b) Infuse the KCl at a rate of 10 mEq/hour. c) Only give the KCl through a central venous line. d) Discontinue cardiac monitoring during the infusion

b) Infuse the KCl at a rate of 10 mEq/hour. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some pts. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while pt is receiving potassium because of the risk for dysrhythmias.

When caring for a pt with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the pts food tray? a) Grape juice b) Milk carton c) Mixed green salad d) Fried chicken breast

b) Milk carton Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

Which intervention will the nurse include in the plan of care for a pt who has cardiogenic shock? a) Check temperature every 2 hours. b) Monitor breath sounds frequently. c) Maintain patient in supine position. d) Assess skin for flushing and itching.

b) Monitor breath sounds frequently. Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a) Administer IV antibiotics through the implantable port. b) Monitor the IV sites for redness, swelling, or tenderness. c) Remove the patients nontunneled subclavian central venous catheter. d) Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

b) Monitor the IV sites for redness, swelling, or tenderness. An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

After change-of-shift report in the progressive care unit, who should the nurse care for first? a) Pt who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b) Pt with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c) Pt who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d) Pt admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

b) Pt with suspected urosepsis who has new orders for urine and blood cultures and antibiotics Antibiotics should be administered within the first hour for pts who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other pts indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a pt who has had a myocardial infarction. Mild bradycardia does not usually require atropine in pts who have a spinal cord injury. The findings for the pt admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

A pt is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a) Arterial blood pH is 7.32. b) Serum calcium is 18 mg/dL. c) Serum potassium is 5.1 mEq/L. d) Arterial oxygen saturation is 91%.

b) Serum calcium is 18 mg/dL. The serum calcium is well above the normal level and puts the pt at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

The nurse is caring for a pt who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a) Blood pressure (BP) 92/56 mm Hg b) Skin cool and clammy c) Oxygen saturation 92% d) Heart rate 118 beats/minute

b) Skin cool and clammy Because pts in the early stage of septic shock have warm and dry skin, the pts cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patients status.

When assessing a pregnant pt with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a) The bibasilar breath sounds are decreased. b) The patellar and triceps reflexes are absent. c) The pt has been sleeping most of the day. d) The pt reports feeling sick to my stomach.

b) The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the pts magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the pt needs to cough and deep breathe to prevent atelectasis.

Which finding is the best indicator that the fluid resuscitation for a pt with hypovolemic shock has been effective? a) Hemoglobin is within normal limits. b) Urine output is 60 mL over the last hour. c) Central venous pressure (CVP) is normal. d) Mean arterial pressure (MAP) is 72 mm Hg.

b) Urine output is 60 mL over the last hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

The nurse is caring for a pt who has a central venous access device (CVAD). Which action by the nurse is appropriate? a) Avoid using friction when cleaning around the CVAD insertion site. b) Use the push-pause method to flush the CVAD after giving medications. c) Obtain an order from the health care provider to change CVAD dressing. d) Position the patients face toward the CVAD during injection cap changes.

b) Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes

After receiving 2 L of normal saline, the central venous pressure for a pt who has septic shock is 10 mmHg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a) nitroglycerine (Tridil). b) norepinephrine (Levophed). c) sodium nitroprusside (Nipride). d) methylprednisolone (Solu-Medrol).

b) norepinephrine (Levophed). When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR.

An older pt with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a) Increase the rate for the dopamine (Intropin) infusion. b) Decrease the rate for the nitroglycerin (Tridil) infusion. c) Increase the rate for the sodium nitroprusside (Nipride) infusion. d)Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

c) Increase the rate for the sodium nitroprusside (Nipride) infusion. Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

A nurse is assessing a newly admitted pt with chronic heart failure who forgot to take prescribed medications and seems confused. The pt complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a) Skin turgor b) Heart sounds c) Mental status d) Capillary refill

c) Mental status Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on pt outcomes as cerebral edema.

An older pt receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a) K+ 3.4 mEq/L (3.4 mmol/L) b) Ca+2 7.8 mg/dL (1.95 mmol/L) c) Na+ 154 mEq/L (154 mmol/L) d) PO4-3 4.8 mg/dL (1.55 mmol/L)

c) Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the pts neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.

After reviewing the information shown in the accompanying figure for a pt with pneumonia and sepsis, which information is most important to report to the health care provider? a) Temperature and IV site appearance b) Oxygen saturation and breath sounds c) Platelet count and presence of petechiae d) Blood pressure, pulse rate, respiratory rate.

c) Platelet count and presence of petechiae The low platelet count and presence of petechiae suggest that the pt may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patients condition is deteriorating or that a change in therapy is needed immediately.

A pat who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a) Insert two large-bore IV catheters. b) Initiate continuous electrocardiogram (ECG) monitoring. c) Provide oxygen at 100% per non-rebreather mask. d) Draw blood to type and crossmatch for transfusions

c) Provide oxygen at 100% per non-rebreather mask. The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.

After receiving change-of-shift report, which pt should the nurse assess first? a) Pt with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping. b) Pt with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water. c) Pt with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. d) Pt with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates.

c) Pt with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the pt may be at risk for seizures. The other pts have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications.

During the admission process, the nurse obtains information about a pt through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a) Deficient fluid volume b) Impaired gas exchange c) Risk for injury: Seizures d) Risk for impaired skin integrity

c) Risk for injury: Seizures The pts muscle cramps and low serum calcium level indicate that the pt is at risk for seizures and/or tetany. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.

A pt who has a small cell carcinoma of lung develops syndrome of inappropriate antidiuretic hormone (SIADH). Nurse should notify health care provider about which assessment finding? a) Reported weight gain. b) Serum hematocrit of 42%. c) Serium sodium level of 120mg/dL. d) Total urinary output of 280mL during past 8hrs.

c) Serium sodium level of 120mg/dL. Hyponatremia is the most important finding to report. SIADH causes water rentention and decrease in serum sodium level. Hyponatremia can cause confusion and other CNS effects. A critically low value likely needs to be treated. At least 30mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.

A pt has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a) There is a decreased risk for infection when 25% dextrose is infused through a central line. b) The prescribed infusion can be given much more rapidly when the patient has a central line. c) The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d) The required blood glucose monitoring is more accurate when samples are obtained from a central line.

c) The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

The pt with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a) The patients heart rate is 58 beats/minute. b) The patients extremities are warm and dry. c) The patients IV infusion site is cool and pale. d) The patients urine output is 28 mL over the last hour.

c) The patients IV infusion site is cool and pale. The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

Which finding about a pt who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a) The pts urine output is 18 mL/hr. b) The pts heart rate is 110 beats/minute. c) The pt is complaining of chest pain. d) The pts peripheral pulses are weak.

c) The pt is complaining of chest pain. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the pts diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.

A nurse is assessing a pt who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a) No new heart murmurs b) Decreased troponin level c) Warm, pink, and dry skin d) Blood pressure 92/40 mm

c) Warm, pink, and dry skin Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock

The emergency department (ED) nurse receives report that a pt involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the pts arrival, the nurse will obtain a) hypothermia blanket. b) lactated Ringers solution. c) two 14-gauge IV catheters. d) dopamine (Intropin) infusion.

c) two 14-gauge IV catheters. A pt with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

A pt who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a) Assess for facial muscle spasms. b) Ask the pt about loose stools. c) Suggest that the pt avoid OJ with meals. d) Ask the health care provider to order a basic metabolic panel.

d) Ask the health care provider to order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. OJ is high in potassium and would be advisable to drink if the pt was hypokalemic. Loose stools are assoicated with hyperkalemia.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a pt with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a) Auscultate bowel sounds. b) Palpate for abdominal pain. c) Ask the patient about nausea. d) Check stools for occult blood.

d) Check stools for occult blood. Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

The nurse is caring for a pt who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a) Maintain the patient on bed rest. b) Auscultate lung sounds every 4 hours. c) Monitor for Trousseaus and Chvosteks signs. d) Encourage fluid intake up to 4000 mL every day.

d) Encourage fluid intake up to 4000 mL every day. To decrease the risk for renal calculi, the pt should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in pts with hypercalcemia. Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia. There is no indication that the pt needs frequent assessment of lung sounds, although these would be assessed every shift.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a pt. Which statement by the pt indicates that the teaching about this med has been effective? a) I will try to drink at least 8 glasses of water every day. b) I will use a salt substitute to decrease my sodium intake. c) I will increase my intake of potassium-containing foods. d) I will drink apple juice instead of orange juice for breakfast.

d) I will drink apple juice instead of orange juice for breakfast. Because spironolactone is a potassium-sparing diuretic, pts should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the pt is using spironolactone as a diuretic, the nurse would not encourage the pt to increase fluid intake. Teach pts to avoid salt substitutes, which are high in potassium.

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for pts experiencing shock, which action by the new RN indicates a need for more education? a) Placing the pulse oximeter on the ear for a patient with septic shock b) Keeping the head of the bed flat for a patient with hypovolemic shock c) Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d) Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock

d) Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock Pts with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a pt with anaphylactic shock has been effective? a) Heart rate b) Orientation c) Blood pressure d) Oxygen saturation

d) Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

A pt who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

d) Respiratory alkalosis The pH indicates that the pt has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

A pt is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a) The pts radial pulse is 105 beats/minute. b) There is sediment and blood in the patients urine. c) The blood pressure increases from 120/80 to 142/94. d) There are crackles audible throughout both lung fields.

d) There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the pt may be experiencing pulmonary edema, a life threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions? a) Obtain blood and urine cultures. b) Give vancomycin (Vancocin) 1 g IV. c) Start norepinephrine (Levophed) 0.5 mcg/min. d) Infuse normal saline 2000 mL over 30 minutes. e) Titrate oxygen administration to keep O2 saturation >95%.

e) Titrate oxygen administration to keep O2 saturation >95%. d) Infuse normal saline 2000 mL over 30 minutes. c) Start norepinephrine (Levophed) 0.5 mcg/min. a) Obtain blood and urine cultures. b) Give vancomycin (Vancocin) 1 g IV. The initial action for this hypotensive and hypoxemic pt should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.