PN Test #2

You appropriately elicit a sign of hypocalcemia by: A. Tapping the face about 1 inch from the ear B. Palpating a partially stretched tendon C. Inspecting facial symmetry D. Applying pressure on the radial pulse

A Tapping the face in front of the ear elicits Chvostek sign, which is a sign of hypocalcemia.

The older adult is at greater risk for dehydration than the middle-aged adult is because: (Select all that apply) A. Older adults have a diminished sense of thirst B. Older adults have less muscle mass as years advance C. The older adult's body is almost 80% water D. Compensatory mechanisms work less efficiently E. Older adults have increased surface area and more evaporative losses

A,D The older adult does have a diminished sense of thirst; compensatory mechanisms work less efficiently in older adults and don't quickly correct dehydration.

Which transport mechanism involves cellular energy? A. Diffusion B. Osmosis C. Active transport D. Filtration

C The energy force for active transport is adenosine triphosphate (ATP). Diffusion, osmosis, and filtration are types of passive transport.

A patient with heart failure has lost 4.6 lb. This represents a fluid loss of approximately: A. 1500 mL B. 1 L C. 650 mL D. 2 L

D 2.2 pounds are equivalent to 1 L of fluid; therefore, a loss of 4.6 pounds correlates to more than 2 L of fluid loss.

You are starting an intravenous infusion with D5 1/2NS at 150 mL/h. If the IV tubing delivers 15 drops/mL, you would start the infusion at: A. 37.5 or 38 gtt/min B. 25 gtt/min C. 31 gtt/min D. 21 gtt/min

A 150 mL per hour divided by 60 minutes = 2.5 mL per minute × 15 gtts per mL = 37.5 gtts/min, or 38 gtts/min.

A patient has ingested a large amount of a cathartic containing magnesium. The nurse should observe for which symptom of hypermagnesemia? A. Muscle weakness B. Hyperactive reflexes C. Respirations of 30 breaths/min D. Insomnia, twitching, and tremors

A A patient with excessive magnesium level would have muscle weakness, not hyperactive reflexes.

Your male patient has been ill with pneumonia and was admitted yesterday to start IV antibiotic therapy. He has a history of heart failure and is taking digitalis and furosemide. He has not been eating well the past 3 days because he was feeling so bad. The primary care provider ordered fluids and daily laboratory work yesterday. The patient seems more confused this morning and is very weak. His urine output has fallen. To determine what is causing these symptoms, you would first: A. Check the morning electrolyte levels B. Call his primary care provider C. Check yesterday's laboratory results D. Ask for an order for extra potassium

A Checking the morning electrolyte levels will tell what is out of balance and might be causing his symptoms.

Which organ in the body regulates fluid and electrolyte balance? A. Kidney B. Liver C. Heart D. Adrenal cortex

A Kidneys regulate fluid and electrolyte balance by regulating the volume and composition of extracellular fluid. Liver and heart are not correct options. Adrenal cortex releases aldosterone when the extracellular fluid volume is low or when the sodium concentration is elevated.

The 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? A. Prolonged bed rest B. Adrenal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A The normal serum calcium level is 9 to 10.5. A client with a serum calcium level of 8.0 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 bed rest is hypocalcemia.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse plan to assist in administering to the client? A. Calcitonin B. Calcium chloride C. Calcium gluconate D. Larger doses of vitamin D

A The normal serum calcium level is 9 to 10.5. 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.

What should nurses monitor when a patient is receiving a diuretic regularly? (Select all that apply) A. Skin turgor and integrity B. Daily weight C. Electrolyte status D. Mentation

A,B,C - Skin turgor and integrity should be monitored to ensure that the patient does not become dehydrated from excessive dieresis. - Weight loss will indicate the degree of effectiveness of the diuretic in decreasing the fluid overload. - Electrolyte status must be monitored to catch any electrolyte imbalance caused by the diuretic's effect.

Which of the following are blood cells? (Select all that apply) A. Thrombocytes B. Leukocytes C. Eosinocytes D. Erythrocytes

A,B,D Thrombocytes (platelets), leukocytes (white blood cells), and erythrocytes (red blood cells) are carried in the plasma.

Which patient(s) can be considered at high risk for fluid and electrolyte imbalance? (Select all that apply) A. A 45-year-old woman with thyroid crisis B. A 35-year-old trauma victim on a ventilator C. A 60-year-old woman with temperature of 99.6 F D. A 70-year-old man on anticoagulant therapy E. A 30-year-old woman complaining of persistent diarrhea

A,B,E Thyroid crisis, use of a ventilator, and diarrhea can lead to fluid loss affecting electrolyte balance.

An older adult man is admitted for severe disorientation, confusion, and general weakness. His spouse reports that he is not able to tolerate any food or fluids and has had several episodes of vomiting and diarrhea. Which imbalance is the patient most likely experiencing? (Select all that apply) A. Hypokalemia B. Metabolic acidosis C. Hyponatremia D. Respiratory alkalosis

A,C - Diarrhea and vomiting cause deficits in potassium. - Vomiting may cause a deficit in sodium.

The nurse is caring for a patient with pitting edema to the lower extremities. Which intervention(s) for pitting edema are the nurse likely to include in the nursing care plan of this patient? (Select all that apply) A. Daily weight B. High-calorie diet C. Intake and output record D. Skin care and mouth care E. Edema assessment using an edema scale every shift

A,C,E Measuring the patient's weight daily, monitoring the intake and output, and assessing the edema using the proper scale every shift are methods that will assist the nurse in properly assessing and monitoring any changes in the patient's edema.

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

B A serum potassium level that exceeds 5.0 is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction, 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 health care provider has prescribed an isotonic IV solution administration for a patient. The nursing student correctly identifies which solutions as being isotonic? A. Sterile distilled water, 5% dextrose in water B. 0.9% normal saline, lactated Ringer's solution C. 5% dextrose in 0.45% normal saline, Ringer's solution D. 10% dextrose in water, 5% dextrose in 0.9% normal saline

B An isotonic solution is equal in concentration to that of body fluids. D5W is considered isotonic, but sterile distilled water is hypotonic and is never used as an IV solution. Ringer's solution is isotonic, but D5 in ½ normal saline is a hypertonic solution. 10% dextrose is hypertonic.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? A. Milk B. Butter C. Spinach D. Collard greens

B 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.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? A. The client with cirrhosis B. The client with a ileostomy C. The client with heart failure D. The client with decreased kidney function

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

The new patient on the floor has been diagnosed with gastroenteritis. What would be the most critical level to assess? A. Blood glucose B. Potassium C. Calcium D. Sodium

B Gastroenteritis causes nausea and vomiting as well as diarrhea that depletes potassium in the body.

Which would be the most accurate way to assess for dehydration in an elderly patient? A. Skin turgor B. Urine output C. Respirations D. Thirst levels

B Inadequate urine outflow is an indication that dehydration is occurring. A decrease in weight would be a secondary finding and would occur later.

You respond to a patient complaining of pain, burning, and wetness over the peripheral IV site. On assessment, you find that the IV insertion site is tender and cool to the touch. These are signs and symptoms of: A. Phlebitis B. Infiltration C. Infection D. Venous spasm

B Pain, burning, coolness, and wetness over the IV site are signs of infiltration of IV fluid into the tissue.

Patients who are undergoing diuretic therapy to decrease excess body fluid tend to lose potassium. If too much potassium is lost, the patient will have which electrolyte and acid-base imbalance? A. Hyperkalemia, metabolic acidosis B. Hypokalemia, Metabolic alkalosis C. Hyponatremia, metabolic acidosis D. Hypernatremia, metabolic alkalosis

B Potassium loss causes hypokalemia, which in turn can cause metabolic alkalosis from loss of acid.

The 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. Based on this laboratory value, the nurse should take which action? A. Document the value in the client's record B. Inform the registered nurse of the laboratory value C. Place the laboratory result form in the client's record D. Reassure the client that the laboratory result is normal

B The normal serum calcium level ranges from 9 to 10.5. The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

The nursing caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom? A. Flushing B. Lethargy C. Hyperactivity D. Shallow, slow respirations

B The symptoms of metabolic acidosis include weakness, lethargy, headache, and confusion. If the acidosis is not relieved, these symptoms progress to stupor, unconsciousness, coma, and death.

The patient has been prescribed a non-potassium-sparing diuretic. Which food(s) should the nurse suggest the patient include in his diet? (Select all that apply) A. Eggs B. Bananas C. Tomatoes D. Aged Cheese E. Baked potato with skin

B,C,E Foods high in potassium should be included in the patient's diet if he is taking a diuretic that does not conserve potassium. Bananas, tomatoes, and baked potatoes with the skin are just three foods that are high in potassium.

When a patient receives a hypotonic solution intravenously (IV), what happens to the patient's cells? A. There is a net loss of water across the cell membrane B. There is no change in the cells because there is no fluid shift C. The cells begin to swell as water enters the intracellular compartment D. The cells begin to shrink as water is pulled from the intracellular compartment

C A hypotonic solution has a lower osmotic pressure than that of body fluids. During IV administration with a hypotonic solution, cells will swell as water passes from the less concentrated solution across the cell membrane and into the cell.

A patient who has congestive heart failure has a fluid excess with a weight gain of 1.5 pounds since yesterday and edematous ankles. Which provider's order has the highest priority? A. Maintain accurate intake and output B. Monitor skin for signs of breakdown C. Administer furosemide 20 mg PO once daily D. Obtain daily weight

C Administering the diuretic medication to help remove excess fluid and correct the imbalance has the highest priority, although all of the choices are important to your care of the patient.

An 82-year-old male patient is admitted with vomiting and diarrhea. On assessment, you note that he is apprehensive and his skin is cool, dry, and pale. His pulse is rapid, and his blood pressure is lower than normal. These symptoms are indicative of: A. Fluid overload B. Electrolyte imbalance C. Dehydration D. Intestinal flu

C Apprehension; cool, dry, pale skin; a rapid pulse; and lower blood pressure are indicative of dehydration.

Hyponatremia may be caused by: A. Increased secretion of aldosterone B. Stroke C. Congestive heart failure (CHF) D. Dehydration

C CHF results in excessive water retention without concurrent sodium retention. This results in a hypervolemia combined with hyponatremia. Decreased secretion of aldosterone can result in sodium loss. Stroke does not cause hyponatremia. Dehydration may cause hypernatremia.

In planning care for a patient with congestive heart failure, you choose the problem statement: fluid volume excess due to altered cardiac output. The Problem statement would most likely be supported by which sign or symptom? A. Temperature of 101.5 F B. Hematocrit 35% C. Fine crackles in the lung sounds D. Clear, yellow urine

C Fine crackles in the lungs indicate fluid accumulation and are a sign of fluid overload. This finding is consistent with congestive heart failure (CHF).

The student nurse reviews the records of a patient with pneumonia and finds that the patient has a blood pH of 7.46. The student is correct in determining that this pH is considered: A. Slightly acidic B. Grossly acidic C. Slightly alkaline D. Grossly alkaline

C Normal blood pH is 7.35 to 7.45, so 7.46 would be considered slightly alkaline; 7.36 and lower would be considered acidic.

The nurse is reading the primary health care provider's progress notes in the client's record and se3ds that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? A. The client with a draining wound B. The client with a urinary catheter C. The client with a fast respiratory rate D. The client with a nasogastric tube to low suction

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

Which fluid output measurement is the most concerning for a nurse? A. 720 mL of urine in a 24-hour period B. 600 mL of urine in a 10-hour period C. 100 mL of urine in a 5-hour period D. 60 mL of urine in a 2-hour period

C Urine output should be at least 30 mL/hr.

To understand what type of fluid a patient needs, the LPN/LVN should understand that the term semipermeable membrane indicates that: A. The membrane is only a temporary structure B. Only electrically charged particles may pass through the membrane C. The membrane does not allow for the passage of anything but water D. The membrane allows some particles to pass through and prohibits the passage of others

D A semipermeable membrane allows fluid to move between the interstitial and intracellular compartments and between the interstitial and intravascular compartments by osmosis. Semipermeable membranes are permanent structures. Passage through this type of membrane does not require electrically charged particles. More than just water can pass through semipermeable membranes.

The nurse reviews a client's electrolyte results and notes the potassium level is 5.4 mEq/L. What should the nurse look for on the cardiac monitor as a result of this laboratory value? A. ST elevation B. Peaked P waves C. Prominent U waves D. Narrow, peaked T waves

D A serum potassium level of 5.4 is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

A patient has end-stage chronic obstructive pulmonary disease (COPD). Which acid-base imbalance would be predictable in a patient with COPD? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

D Chronic respiratory acidosis is prevalent among people with COPD. Renal failure may cause metabolic acidosis.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? A. Gurgling respirations B. Increased blood pressure C. Decreased hematocrit D. Increased specific gravity of the urine

D Clients taking diuretics on a long term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration 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. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? A. The client with sepsis B. The client with cirrhosis C. The client with kidney failure D. The client with diabetes mellitus

D Fluid that shifts into the interstitial space 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.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? A. Twitching B. Positive Trousseau's sign C. Hyperactive bowel sounds D. Generalized muscle weakness

D Generalized muscle weakness is seen in client with hypercalcemia. Twitching, positive Trousseau's sign and hyperactive bowel sounds are signs of hypocalcemia.

Which may cause hyperkalemia? A. Blood transfusion B. Diaphoresis C. Diarrhea D. Renal failure

D Hyperkalemia occurs in renal disease.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? A. The client with watery diarrhea B. The client with diabetes insipidus C. The client with an inadequate daily water intake D. The client with the syndrome of inappropriate secretion of antidiuretic hormone

D Hyponatremia is a serum sodium level less than 135. Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? A. Rapid weight loss B. Flat hand and neck veins C. A weak and thread pulse D. An increase in blood pressure

D Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, and elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand bein distention, an altered level of consciousness, and a decreased hematocrit level.

At the beginning of the shift, there is 410 mL of fluid in the IV bag. A piggyback medication containing 150 mL is hung at 12:00 noon to run over 30 minutes. You hang a new bag of 1000 mL at 1:00 PM to run at 125 mL/hr. At the end of shift there is 250 mL left in the bag. The count for the total amount of fluid infused during your shift ending at 7:00 PM is: A. 1260 mL B. 1285 mL C. 1560 mL D. 1310 mL

D Intake is 150 mL from the Piggyback medication, 410 mL from the old IV fluid infusion, and 750 mL infused from the bag hung at 1300. 150 + 410 + 750 = 1310 mL.

One of the best methods to assess whether peripheral edema is increasing or decreasing is to: A. Compare intake with output over several days B. Weigh the patient daily and compare weights C. Use a fingertip to assess for pitting edema of the tissue D. Measure the circumference of the affected extremity in the same location each day

D Measuring the circumference of the extremity in the same location each day will tell whether the edema is increasing or decreasing because the extremity circumference will increase or decrease as edema increases or decreases.

The nurse is assessing a patient who was admitted for dehydration. Which assessment finding is an indication that the dehydration is resolving? A. Loose skin B. Sunken eyes C. 1200 mL urine output D. Moist mucous membranes

D Moist mucous membranes are one sign that the patient's hydration status is resolving.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present? A. Intense thirst B. Slow bounding pulse C. Dry mucous membranes D. Postural blood pressure changes

D Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thread pulse is noted.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? A. The client with Addison's disease B. The client with metabolic acidosis C. The client with intestinal obstruction D. The client receiving nasogastric suction

D Potassium-rich gastrointestinal 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 client has the following laboratory values: a pH of 7.55, HCO3 level of 22, abd a PCO2 of 30. Which action should the nurse plan to take? A. Perform Allen's test B. Prepare the client for dialysis C. Administer insulin as prescribed D. Encourage the client to slow down breathing

D The client is experiencing 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 of slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed.

Which patient is at highest risk for dehydration? A. Infant who has a high fever B. Teenager who has intentionally limited fluid intake to avoid weight gain C. Young patient with diarrhea D. Elderly patient with fever and persistent nausea and vomiting (N&V)

D The elderly person who suffers from nausea, vomiting, or diarrhea is especially prone to dehydration. If the person has fever, this adds to the fluid loss and would place the elderly person at the highest risk of all the possible options.

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a PCO2 of 32. The nurse determines that these results are indicative of which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D The normal pH is 7.35 to 7.45.If a respiratory condition exists, an opposite relationship will be seen between the pH and the PCO2, as is seen in the correct option.

An 82-year-old patient is admitted to the unit with a temperature of 100.2 F, urine specific gravity (SG) of 1.032, and dry tongue. The nurse should recognize which to be the most critical aspect of the plan of care? A. A diuretic B. An antibiotic C. An antipyretic D. IV solution

D The patient is hypovolemic; she requires IV fluid replacement. The slight elevation in temperature may be related to her dehydration. This is further supported by her urine SG of 1.032; normal urine SG is approximately 1.010 to 1.025.

The thirst mechanism is located in the: A. Adrenal gland B. Cerebral cortex C. Pituitary gland D. Hypothalamus

D The thirst mechanism located in the hypothalamus helps control fluid balance in the body. The thirst mechanism is not located in the adrenal gland, cerebral cortex, or pituitary gland.