CH 13 (Electrolytes) & CH 14 (Shock) PrepU
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?
"I can use laxatives and enemas but only once a week."
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.
-Compare ABG findings with previous results -Document presenting signs and symptoms -Maintain intake and output records
A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply.
-Phenylephrine -Norepinephrine -Epinephrine -Vasopressin
A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?
158.0 lbs (71.7kg)
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?
Compensatory stage
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?
Confusion and seizures
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to
Encourage the family to touch and talk to the client
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?
Extracellular fluid volume deficit
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?
Hypercalcemia
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?
In the compensation stage, catecholamines are released
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?
Metabolic alkalosis
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory Alkalosis
The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock?
Shallow rapid respirations
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
The client had a liver transplant 2 years ago
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?
Third-spacing
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?
pH 7.48
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?
24
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
5% albumin
The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?
70%
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
Administers oxygen by nasal cannula at 2 liters per minute
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
Aortic insufficiency
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:
Constrict blood vessels in the cardiorespiratory system
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?
Dehydration
The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?
Distributive
The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?
Distributive
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.
Famotidine (Pepcid) Lansoprazole Nizatidine
The nurse is caring for a client who is exhibiting symptoms of tachypnea and circumoral paresthesias. What should be the nurse's first course of action?
Find and correct the cause of tachypnea
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Sodium 134 mEq/L (134 mmol/L) Potassium 3.2 mEq/L (3.2 mmol/L) Chloride 111 mEq/L (111 mmol/L) Magnesium 1.1 mg/dL (0.45 mmol/L) Calcium 8.4 mg/dL (2.1 mmol/L) What fluid and electrolyte imbalance would the nurse relate to the client's findings?
Hypomagnesemia
What is the major clinical use of dobutamine?
Increase cardiac ouput
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increases arterial pH
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
Lungs and kidney
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
Metabolic acidosis
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?
Metabolic acidosis
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?
Progressive
Morphine sulfate has which of the following effects on the body?
Reduces preload
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
Respiratory alkalosis
The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock?
Shallow, rapid respirations
