Nclex/ saunders

A nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bedrest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bedrest Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 8.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bedrest is hypocalcemia.

A nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following? 1. An elevated T4 level 2. An elevated thyroid-stimulating hormone (TSH) level 3. A decreased TSH level 4. A normal T4 level

2. An elevated thyroid-stimulating hormone (TSH) level Rationale: Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. Options 1, 3, and 4 are not diagnostic findings in this condition.

A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client? 1. Calcium chloride 2. Calcium gluconate 3. Calcitonin (Miacalcin) 4. Large doses of vitamin D

3. Calcitonin (Miacalcin) Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

The nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for a potassium deficit?. 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

Correct Answer: 4 The client receiving nasogastric suction Rationale: Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

Postural blood pressure changes Rationale: Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

A nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse tells the client that which food item contains the least amount of calcium? Submit 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter Rationale: Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet

A nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which of the following signs would be an indication of this diagnosis? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Options 1, 2, and 3 identify signs of hypocalcemia.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with a colostomy 3. The client with decreased kidney function 4. The client with congestive heart failure (CHF)

2. The client with a colostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. A nurse assists with performing Allen's test before drawing the blood to determine the adequacy of the: Submit 1. Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Brachial circulation

1. Ulnar circulation

A nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. On the basis of this laboratory value, the nurse takes which action? 1. Documents the value in the client's record 2. Informs the registered nurse of the laboratory value 3. Places the laboratory result form in the client's record 4. Reassures the client that the laboratory result is normal

2. Informs the registered nurse of the laboratory value Rationale: The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is experiencing hypercalcemia, and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, options 1, 3, and 4 are incorrect.

A nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which of the following in the conference? 1. PKU is an autosomal dominant disorder. 2. PKU results in central nervous system (CNS) damage. 3. Some state laws require routine screening of all newborn infants for PKU. 4. Treatment includes dietary restriction of sodium.

2. PKU results in central nervous system (CNS) damage. Rationale: PKU is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake (not sodium). PKU is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood. All 50 states require routine screening of all newborn infants for PKU.

A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn Rationale: A serum potassium level that exceeds 5.1 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is told that the blood gas results indicate a pH of 7.50 and a Pco2 of 32 mm Hg. The nurse determines that these results indicate: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite relationship will be seen between the pH and the Pco2, as is seen in option 4. In an alkalotic condition, the pH is increased. Options 1 and 3 indicate acidosis, and option 2 indicates a metabolic condition.

A client has the following laboratory values: a pH of 7.55, an HCO level of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4. Encourage the client to slow down breathing. Rationale: The client is in respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Option 1 would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Options 2 and 3 are interventions for metabolic acidosis.

A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in the client with this condition? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4. Increased specific gravity of the urine Rationale: Findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. The signs in options 1, 2, and 3 are seen in a client with fluid volume excess.

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration? 1. Mild dehydration 2. Severe dehydration 3. Very mild dehydration 4. Moderate dehydration

4. Moderate dehydration Rationale: Moderate dehydration demonstrates itself with a weight loss in children of 6% to 8% of weight. Mild dehydration would not present with these symptoms. In severe dehydration, additional findings would include lethargy and listlessness. The symptoms listed are all characteristics of moderate dehydration. Very mild dehydration is not a term used to describe dehydration.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at the lowest risk for the development of third-spacing? 1. The client with sepsis 2. The client with cirrhosis 3. The client with renal failure 4. The client with diabetes mellitus

4. The client with diabetes mellitus Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea 2. The client with diabetes insipidus 3. The client with an inadequate daily water intake 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

A nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: 1. The skin 2. Urinary output 3. Wound drainage 4. The gastrointestinal tract

1. The skin Rationale: Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P wave 3. Prominent U wave 4. Narrow, peaked T waves

4. Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; narrow, peaked T waves; and a depressed ST segment.

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe? 1. Respirations that cease for several seconds 2. Respirations that are regular but abnormally slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate

4. Respirations that are abnormally deep, regular, and increased in rate Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which of the following is noted? 1. Temperature of 100.8° F rectally 2. Weight increase of 0.5 kg 3. A decrease in urine output to 0.5 mL/kg/hr 4. Blood pressure (BP) unchanged from baseline

3. A decrease in urine output to 0.5 mL/kg/hr Rationale: The priority assessment is to monitor the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A BP that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.