Exam 1 Saunder's questions (perioperative, fluid, and electrolytes)

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

Answer: 1 Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

Answer: 1 Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations

Answer: 1 Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Paco2 50 mm Hg (50 mm Hg) 2. pH 7.35, Paco2 40 mm Hg (40 mm Hg) 3. pH 7.50, Paco2 52 mm Hg (52 mm Hg) 4. pH 7.52, Paco2 28 mm Hg (28 mm Hg)

Answer: 1 Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to45 mm Hg). In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

Answer: 1 Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps prevent this complication; however, it is not related to coughing and deep-breathing techniques.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

Answer: 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics containing base products

Answer: 1 Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L)2. Sodium, 145 mEq/L (145 mmol/L)3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) 4. Platelets, 210,000 cells/mm3 (210 × 109/L)

Answer: 1 Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

Answer: 1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

Answer: 1 Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide- based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

Answer: 1 Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6° C (99.6° F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

Answer: 1 Rationale: Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the surgeon. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

Answer: 1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Answer: 1, 2, 4, 5, 6 Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

Answer: 1, 2, 4, 6 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

Answer: 1, 3, 4 Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats per minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants

Answer: 1Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L (145 mmol/L) 2. Potassium level of 3.0 mEq/L (3.0 mmol/L) 3. Magnesium level of 1.8 (0.74 mmol/L) 4. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

Answer: 2 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

Answer: 2 Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse reviews the arterial blood gas results of a client and notes the following:pH7.45,Paco2of30mmHg(30mmHg),andHCO3- of20mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Answer: 2 Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (557 mcmol/L)

Answer: 2 Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL (240 to 501 mcmol/L).

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer: 2 Rationale:Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

Answer: 2, 4 Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

Answer: 3 Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

Answer: 3 Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

Answer: 3 Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

Answer: 3 Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

Answer: 3 Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 498 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

Answer: 3 Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes

Answer: 3, 5 Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus

Answer: 4 Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased Paco2 2. An increased pH and a decreased Paco2 3. A decreased pH and a decreased HCO3- 4. An increased pH and an increased HCO3-

Answer: 4 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- toincrease.Symptomsexperiencedbytheclientwouldincludeadecreasein the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.

Answer: 4 Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a surgeon is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Answer: 4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg(72mmHg), Paco2= 32mmHg(32mmHg), and HCO3-=28mEq/L(28 mmol/L). Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating.

Answer: 4 Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

Answer: 4 Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate ) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

Answer: 4 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

Answer: 4, 5 Rationale: A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.