Adult 2 Test #1
A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having? 11 mEq/L 5 mEq/L 2 mEq/L 1 mEq/L
5 mEq/L Explanation: Magnesium excess (>2.7 mEq/L) is associated with the following symptoms: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and cardiac arrest. The respiratory center is depressed when serum magnesium levels exceed 10 mEq/L (5 mmol/L). This is not present in this patient, so the magnesium level is unlikely to be 11 mEq/L. Coma, atrioventricular heart block, and cardiac arrest can occur when the serum magnesium level is greatly elevated and not treated.
A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used? Intravenous furosemide Fluid restriction Oral magnesium oxide Dialysis
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: insert a nasogastric tube (NG) as ordered. administer acetaminophen as ordered. instruct the client to breathe into a paper bag. administer antibiotics as ordered.
A 73-year-old female patient with cirrhosis of the liver is evaluated for clinical manifestations of FVE. Which of the following signs are consistent with that diagnosis? Select all that apply. Crackles Blood pressure of 90/60 Central venous pressure (CVP) reading of 4 mm Hg Hematocrit level of 32% Blood pressure of 140/110 BUN of 8 mg/dL
Crackles Hematocrit level of 32% Blood pressure of 140/110 BUN of 8 mg/dL Explanation: The blood pressure is increased with FVE. Crackles are abnormal lung sounds found in fluid retention. Hematocrit and BUN may be decreased due to plasma dilution.
The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.) Assessing for symptoms of nausea and malaise Encouraging the intake of low-sodium liquids Monitoring neurologic status Restricting tap water intake Encouraging the use of salt substitute instead of salt
Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake Explanation: For patients at risk, the nurse closely laboratory values (i.e., sodium) and be alert for GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping. The nurse must be alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures. Neurologic signs are associated with very low sodium levels that have fallen rapidly because of fluid overloading. For a patient with abnormal losses of sodium who can consume a general diet, the nurse encourages foods and fluids with high sodium content to control hyponatremia. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium. If the primary problem is water retention, it is safer to restrict fluid intake than to administer sodium.
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Debilitating fatigue Bone pain in the back of the ribs Gradual muscle paralysis Severe thrombocytopenia
Bone pain in the back of the ribs Explanation: Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. Crackles on auscultation Cyanosis Hypertension Shoulder pain Dyspnea Tachycardia
Cyanosis Shoulder pain Dyspnea Tachycardia Explanation: Hypotension, along with the other correct choices, is a manifestation of an air embolism. Crackles on auscultation is a major indicator of circulatory system overload.
When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Menstrual history Age and gender Lifestyle assessments, such as exercise routines
Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.
In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply. Heart failure Pulmonary edema Renal impairment Burns Severe hemorrhage
Heart failure Pulmonary edema Renal impairment Explanation: Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) Hypertension Oliguria Tachycardia Bradycardia Tachypnea
Oliguria Tachycardia Tachypnea Explanation: Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria, tachycardia (not bradycardia), and tachypnea.
A client's potassium level is elevated. The nurse is reviewing the ECG tracing. What is the area on the tracing where the nurse would expect to see peaks.
Peaked T segmets Potassium influences cardiac muscle activity. Alterations in potassium levels change myocardial irritability and rhythm. Hyperkalemia is very dangerous; cardiac arrest can occur. Cardiac effects of elevated serum potassium are significant when the level is above 8 mEq/L. Hyperkalemia causes skeletal muscle weakness and even paralysis, related to a depolarization block in t muscle. Therefore, ventricular conduction is slowed. The earliest change that can be seen are peaked, narrow T waves on the ECG.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? CO2 Sodium Chloride Potassium
Potassium Explanation: The nurse should identify potassium: 2.2 mEq/L as critical because a normal potassium level is 3.5 to 5.0 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl) and the chloride level is a bit low (normal is 100 to 110 mEq/L). Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dl) and creatinine (normal is 0.8 to 1.4 mg/dl) are within normal range.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? Potassium: 5.8 mEq/L Sodium: 138 mEq/L Magnesium:2 mEq/L Calcium: 10 mg/dL
Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance? Prolonged PR intervals Prolonged QT intervals Peaked T waves Elevated ST segments
Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium concentration.
What does the nurse recognize as one of the best indicators of the patient's renal function? Blood urea nitrogen Serum creatinine Specific gravity Urine osmolality
Serum creatinine Explanation: Creatinine is the end product of muscle metabolism. It is a better indicator of renal function than BUN because it does not vary with protein intake and metabolic state.
The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. Tachypnea Weakness Lethargy Dehydration Hypotension
Tachypnea Weakness Lethargy Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride concentration is accompanied by a high sodium concentration and fluid retention.
A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe? papilledema stroke seizures hyperglycemia
papilledema Explanation: If respiratory acidosis is severe, intracranial pressure may rise, causing papilledema. Stroke and hyperglycemia are not associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.
Trousseau's sign. Explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.
`A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. b. Increased PaCO2. c. Decreased serum HCO3. d. Decreased PaCO2.
b. Increased PaCO2. Explanation: The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? furosemide hydrochlorothiazide metolazone spironolactone
furosemide Explanation: Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: insert a nasogastric tube (NG) as ordered. administer acetaminophen as ordered. instruct the client to breathe into a paper bag. administer antibiotics as ordered.
instruct the client to breathe into a paper bag. Explanation: A client recovering from an acute asthma attack who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). An NG tube would be indicated for a client with metabolic alkalosis secondary to ingestion of toxic substances; there is no reason to believe that this has occurred. Fever may cause metabolic (not respiratory) alkalosis and would be treated with acetaminophen. A client with sepsis also may have metabolic alkalosis and probably would receive antibiotics; however, this clinical situation doesn't suggest sepsis.
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
pH PaCO2 HCO3 Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.
Which set of arterial blood gas (ABG) results requires further investigation? pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L Explanation: The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3- and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3- 22 to 26 mEq/L.
