EXAM 4 Practice Questions

With which member of the interprofessional team will the nurse collaborate when providing instructions for a client who has anemia cause by vitamin B12 acid deficiency? A. Registered dietitian nutritionist B. Mental health professional C. Physical therapist D. Wound care specialty nurse

A. Registered dietitian nutritionist

What might happen to the blood potassium levels in the acidotic state? A. Potassium in the blood would rise B. Potassium in the blood would fall

A. Potassium in the blood would rise acidosis causes serum potassium to go UP

The nurse is teaching a client with peripheral arterial disease. What teaching will the nurse include? A. "Walking to the point of leg pain, then rest, resume when pain stops." B. "Inspect legs daily for brownish discoloration around the ankles" C. "Apply a heating pad to the legs if they feel cold." D. "Elevate your legs above heart level to prevent swelling"

A. "walk to the point of pain, rest, resume." Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.

Which client arterial blood pH value will the nurse interpret as normal? A. 7.37 B. 7.27 C. 7.47 D. 7.5

A. 7.37 Normal is 7.35-7.45

The nurse is admitting a client with an ulcer on the right foot. Which statement made by the client indicates venous insufficiency? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

A. Ankles swell D. Veins stick out E. Discolored ankles Symptoms of venous insufficiency include ankle and leg swelling, ankle discoloration, and full veins with dependent positioning of the legs.

What are key hormones that regulate fluid balance? A. Antidiuretic hormone (ADH), Aldosterone B. Parathyroid hormone, Calcitonin C. Thyroxine, Thyroid Stimulating Hormone D. Insulin, glucagon E. Adrenaline, Noradrenaline

A. Antidiuretic hormone (ADH), Aldosterone

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply. A. Assess daily weights. B. Encourage consumption of citrus fruits. C. Weigh the client weekly. D. Monitor serum potassium. E. Discourage intake of spinach. F. Monitor for bradycardia.

A. Assess daily weights. B. Encourage consumption of citrus fruits. D. Monitor serum potassium. Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs.

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

A. BP D. Pulse rate/quality F. Urine output

Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm/Hg

A. Bruit A bruit is considered an abnormal finding that is associated with atherosclerotic disease. A bruit is a turbulent, swishing sound that occurs when blood is passing through a narrowed artery.

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

A. Calcium D. Potassium Within cells and the blood, magnesium levels are related to the levels of potassium and calcium and help maintain proper balance of these electrolytes

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A. Calcium level of 9.5 mg/dL (2.4 mmol/L) B. Magnesium level of 4.1 mEq/L (2.1 mmol/L) C. Potassium level of 6.0 mEq/L (6.0 mmol/L) D. Sodium level of 120 mEq/L (120 mmol/L)

A. Calcium level of 9.5 mg/dL (2.4 mmol/L)

A client has just returned from coronary artery bypass graft surgery. Which assessment data requires immediate nursing action? A. Chest tube drainage 175 mL last hour B. Temperature 98.2° F (36.8° C) C. Incisional pain 6 on a scale of 0-10 D. Serum potassium 3.9 mEq/L (3.9 mmol/L)

A. Chest tube drainage 175 mL last hour

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious to lethargic B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours

A. Client behavior that changes from anxious to lethargic Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.

The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client will the nurse see first? A. Client with third-degree heart block on the monitor B. Client with dyspnea on exertion when ambulating to the bathroom C. Client who refuses to take heparin or nitroglycerin D. Client with normal sinus rhythm and PR interval of 0.28 second

A. Client with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion.

Which assessment data cause the nurse to suspect that a client who had a myocardial infarction (MI) is developing cardiogenic shock? (Select all that apply.) A. Cool, diaphoretic skin B. Crackles in the lung fields C. Anxiety and restlessness D. Respiratory rate of 12 breaths/min E. Temperature of 100.4° F (38.0° C) F. Bradycardia

A. Cool, diaphoretic skin B. Crackles in lung fields C. Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which teaching will the nurse include? A. Cover the infected area with a clean, dry bandage. B. Take daily tub baths using a mild soap. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

A. Cover the infected area with a clean, dry bandage.

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? A. Do not smoke or chew tobacco. B. Avoid alcoholic beverages. C. Reduce abdominal fat. D. Implement stress-reduction techniques.

A. Do not smoke or chew tobacco Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.

The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis? A. Ensure adequate oxygenation B. Restrict carbohydrates C. Supplement potassium D. Monitor hemoglobin

A. Ensure adequate oxygenation When caring for a client with sepsis and impending shock the nurse will ensure adequate oxygenation to help prevent lactic acidosis. Cellular metabolism under anaerobic (no oxygen) conditions forms lactic acid. Shock states are due to a lack of cellular perfusion and delivery of oxygen to the tissues. Providing adequate oxygenation and perfusion will help to reverse the need for the body to make ATP without oxygen which causes lactic acid to accumulate.

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? Select all that apply. A. Ensuring that the concentration is no greater than 1 mEq/10 mL of solution B. Use a vein in the hand for better flow C. Use an IV pump to deliver the medication D. Check IV access for blood return after the infusion E. Push the medication over 5 minutes

A. Ensuring that the concentration is no greater than 1 mEq/10 mL of solution C. Use an IV pump to deliver the medication

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) Select all that apply. A. Red meat B. Cereal C. Citrus fruit D. Salt substitutes E. Eggs F. Bread

A. Red meat C. citrus fruit D. Salt substitutes

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? A. Every 2 hours, reposition a client who has had a stroke and is incontinent. B. Use the Braden Scale to determine pressure injury risk for a newly admitted client. C. Complete daily sterile dressing changes for a client with a venous leg ulcer. D. Admit a newly transferred client who had pedicle flap surgery 1 week ago.

A. Every 2 hours, reposition a client who has had a stroke and is incontinent.

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment data indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 ml of bloody drainage in chest tube over 4 hours

A. HR of 50bpm

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure (BP) C. Increases in edema D. Sodium level

A. Heart rate The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range.

Take action if I am too low I can make your client's muscles weak and slow U waves seen Seen on telemetry I mean Need to infuse KCl don't do it quick 10 mEq/hr that is the trick Don't give KCl subcut, IM, or push it fast Your client's heart or skin will never last I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

A. Hypokalemia

Which of these findings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation? A. Increasing somnolence B. Pallor C. Deep respirations D. Bounding pulse

A. Increasing somnolence The critical nurse notifies the primary health care provider for somnolence consistent with worsening respiratory acidosis. Other client findings related to worsening respiratory acidosis caused by CO2 retention include: headache

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? A. Insulin B. atropine C. Sodium polystyrene sulfonate (Kayexalate) D. potassium phosphate

A. Insulin The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water. This may be prescribed to promote movement of potassium from the blood into the intracellular fluid.

Potassium level comes up to only 3.4 meq/L on repeat lab draw. The nurse knows that typically for every 10meq of potassium given the serum potassium level will raise by 0.1 meq/L. The nurse suspects something is off. What is likely the issue? A. Low Magnesium B. High Calcium C. Low bicarbonate D. High chloride

A. Low Magnesium

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. assess for orthostatic hypotension. E. initiate cardiac monitoring

A. Place the client on bed rest. B. Evaluate the electrolyte levels. D. assess for orthostatic hypotension. E. initiate cardiac monitoring

What mechanism is occuring with this patient in order to compensate for the metabolic acidosis (pH: 7.28, PaO2: 80, PaCO2: 30 , and HCO3: 16) A. Respiratory Alkalosis B. Repiratory Acidosis C. Metabolic Alkalosis D. Positive intentions!

A. Respiratory Alkalosis The patient is attempting to compensate with Respiratory Alkalosis. Patient is attempting to breath faster or more rapidly to get out more CO2 and raise the PH towards normal. From the looks of it, it is not working well.

When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis The nurse plans to observe the client with a burn injury and eschar banding the chest for respiratory acidosis related to decreased chest excursion. Circumferential eschar will result in hypoventilation, accumulation of carbon dioxide and resulting respiratory acidosis.

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased

A. ST changes C. Pain lasts 15-25 min D. Increased number of angina attacks E. Increased chest pain intensity

Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? A. Serum calcium B. Serum magnesium C. Serum glucose level D. Serum sodium

A. Serum calcium A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider so actions can be taken to prevent harm.

With which types of anemia does the nurse ask the client about the presence of the disorder in other family members? Select all that apply. A. Sickle cell anemia B. Folic acid deficiency anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia D. Iron deficiency anemia E. Pernicous anemia F. Vitamin B12 deficiency anemia

A. Sickle cell C. Glucose-6-phosphate dehydrogenase deficiency anemia E. Pernicious

The nurse is assigned to all of these clients. Which client would the nurse assess first? A. The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. B. The client admitted with hypertensive crisis who has a nitroprusside drip and blood pressure of 149/80 mm Hg. C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid. D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot.

A. The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.

The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia? A. The client who has metabolic acidosis B. The client receiving total parenteral nutrition C. The client who has profuse vomiting D. The client taking a thiazide diuretic

A. The client who has metabolic acidosis The nurse would carefully observe for signs of metabolic acidosis in a client with hyperkalemia. Hyperkalemia occurs as the body attempts to buffer the acidosis by moving hydrogen ions into the cells. An equal number of potassium ions move from the cells into the blood to maintain intracellular electroneutrality, resulting in hyperkalemia.

Which one of the following patients on your unit should be observed closely for indications of excessive loss of potassium?The patient who has: A. the flu with frequent, large amounts of emesis and diarrhea B. renal failure C. excessive intake of bananas D. intravenous potassium

A. The flu- emesis and diarrhea

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? A. Topical mupirocin B. IV vancomycin C. Oral amoxicillin D. Oral linezolid

A. Topical mupirocin

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply. A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.

A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour.

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A. carbon dioxide loss through exhalation can rise arterial pH levels Whenever the CO2 level changes, the pH changes to the same degree, in the opposite direction.

Upon assessment, where will you see the primary effects of magnesium deficit? A. cardiac dysrhythmias and tetany of muscles B. hypoactive reflexes C. hypertension D. depression

A. cardiac dysrhythmias and tetany of muscles

You are caring for a client who has had a sub-total thyroidectomy. What assessment would you make to determine if there has been any trauma to the parathyroid gland? A. Check Chvostek's sign. B. Check capillary refill. C. Monitor urine output. D. Check for edema in the legs.

A. check Chvostek's sign. low calcium = positive sign

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? A. Checking pulse oximetry B. Measuring blood pressure C. Listening to bowel sounds in all four quadrants D. Observing the ECG for flat T-waves

A. checking pulse ox Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death.

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? A. Deflating the blood pressure cuff and giving the client oxygen B. Documenting the finding as the only action C. Initiating the Rapid Response Team D. Placing the client in the high-Fowler position and increasing the IV flow rate

A. deflate BP cuff and give O2 Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau sign.

Your patient has been on a mechanical ventilator for some time. A nursing action would be to observe them for: A. hypernatremia due to water loss, without sodium loss B. hyperglycemia C. hypertension D. polyuria

A. hypernatremia - water loss without sodium loss

Your patient has hyponatremia with dehydration. What would you expect to find on assessment? A. Hypotension, dry mucous membranes, tachycardia B. Hypertension, edema, weight gain C. Hypotension, bradycardia, decreased skin turgor D. Tachycardia, hypertension, edema

A. hypotension, dry mucous membranes, tachycardia

Hypokalemia can be treated with oral or intravenous potassium, but what high potassium foods could you suggest to the patient taking diuretics? A. fruit juices, tea, cola beverages B. bread, pasta, rice C. beer, wine D. pizza, sausage

A. juice, tea, cola

What nursing action is appropriate with a patient who has had potassium chloride added to the intravenous infusion for several days? A. ask for lab work; observe for brachycardia B. restrict oral fluid intake C. check the hemoglobin D. check Trousseau's sign

A. lab work and observe for bradycardia

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) Select all that apply. A. Management of hypertension with an angiotensin converting enzyme inhibitor B. Presence of chronic kidney disease C. Vegan diet D. Excessive use of salt substitute E. Daily therapy with a potassium-sparing diuretics F. Past history of hepatitis A

A. management of hypertension with ACE inhibitor B. Presence of chronic kidney disease D. excess salt substitute E. Daily potassium-sparing diuretic use

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? A. Reports having a bowel movement daily. B. ECG shows an inverted T wave. C. Fasting blood glucose level is 106 mg/dL. D. Two lb weight gain during the past week.

A. reports having bowel movement daily Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? A. Shortened QT-interval B. Absent P wave C. Prominent U wave D. Inverted T waves

A. shortened QT interval Common ECG changes include wide T-waves and shortened QT-intervals.

To assess if a client has had a myocardial infarction (MI), which lab value will the nurse assess? A. Troponin B. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol C. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase D. Homocysteine and C-reactive protein

A. troponin Positive findings for troponin are the most specific cardiac marker used to determine whether an MI has occurred.

Which conditions could cause a client to develop acidosis? (Select all that apply.) Select all that apply. A. Ventilator at too low a tidal volume B. Sepsis C. Severe diarrhea D. Hypovolemic shock E. Prolonged nasogastric suctioning F. Hyperventilation

A. ventilator at too low tidal volume B. Sepsis C. Severe diarrhea D. Hypovolemic shock Sepsis and hypovolemic shock = anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. ventilator too low of a tidal volume for the client's size--> hypoventilation occurs--> retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis.

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? A. "Be careful not to overload them with too many oral fluids." B. "Offer fluids that they prefer frequently and on a regular schedule." C. "Restrict their fluids if they are incontinent." D. "Wake them every 2 hours during the night with a drink."

B. "Offer fluids that they prefer frequently and on a regular schedule."

The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners? A. "The client is acting out and we should pay him no mind" B. "Rapid breathing is a way to compensate for acidosis caused by his condition" C. "Normally a client with this disorder will breathe slowly, I will go assess him" D. "Deep breathing is a symptom of diabetes, I will check his blood glucose"

B. "Rapid breathing is a way to compensate for acidosis caused by his condition" The nurse explains that kussmaul or rapid and deep breathing helps the body compensate for metabolic acidosis by blowing off the CO2 or respiratory acid through the lungs. This will also increase the body's pH level.

The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance? A. "The excess glucose in the blood causes the client to hypoventilate and retain carbon dioxide resulting in respiratory acidosis" B. "The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats" C. "The client has a hyperosmolar condition causing polyuria and polyphagia, but the acid base balance is normal" D. "The client is retaining carbon dioxide which led to respiratory acidosis and somnolence"

B. "The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats" The nursing student understands the relationship between blood glucose and acid base balance when the student states that hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats. Glucose cannot enter the cell to provide energy without the presence of insulin. The body begins to break down fat for energy which produces ketones and causes ketoacidosis.The client with ketoacidosis will hyperventilate, breathing more rapidly and deeply to rid the body of respiratory acids such as CO2. This process buffers the acidosis.

A 45 year old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? (Select all that apply.) A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

B. Tobacco use D. Diet F. Weight

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." Which nursing response is appropriate? A. "You must find someplace to walk." B. "Where might you be able to walk?" C. "You are right. Focus more on your diet." D. "Walk around the edge of your apartment complex."

B. "Where might you be able to walk?"

Your patient has hypernatremia. Which of the following orders would you question? A. Limit fluid intake to 1000 ml/24 hours B. 1000 ml sodium chloride IV to infuse at 125 ml/hr C. Restrict salt intake D. Monitor urine output hourly

B. 1000 ml sodium chloride IV at 125 ml/hr Should be 5% Dextrose in water until sodium is normal

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A. A 26 year old with hyperparathyroidism B. A 70 year old who has alcoholism and malnutrition C. A 40 year old taking tetracycline for an infection D. A 35 year old athlete taking NSAIDs for joint pain

B. 70 year old with alcoholism and malnutrition Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient.

An LPN/LVN is scheduled to work on the stepdown cardiac unit. Which client will the charge nurse assign to the LPN/LVN? A. A 69 year old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia. B. A 66 year old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a long-term care later today. C. A 60 year old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. D. A 62 year old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8° F (38.2° C).

B. A 66 year old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a long-term care later today.

Who might be a patient that has this type of compensated presentation (respiratory acidosis with compensated metabolic alkalosis). pH: 7.38 PaCO2: 72 HCO3: 42? A. A patient with terrible diarrhea B. A patient with chronic severe COPD C. A patient with intractable vomiting D. A patient with acute asthma exacerbation

B. A patient with chronic severe COPD A patient with severe COPD may retain CO2 and given a long enough time (typically 24-48hrs) the kidneys will buffer the long standing CO2 by creating and reabsorbing bicarbonate hence we have a picture of compensated respiratory acidosis from metabolic alkalosis

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. A. Breast cancer B. Abdominal obesity C. Family history D. Increasing age E. Premenopausal

B. Abdominal obesity C. Family history D. Increasing age

For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.) Select all that apply. A. Hyperactive deep tendon reflexes B. Acute confusion C. Lethargy D. Hypotension E. pH 7.49 F. Tall T-waves

B. Acute confusion C. Lethargy D. Hypotension F. Tall T waves When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes).

The nurse is assessing a 54-year-old male client for risk of atherosclerosis. What assessment data is associated with an increase in risk? (Select all that apply.) A. Takes acetylsalicylic acid daily. B. BMI is 32 C. History of type 2 diabetes mellitus. D. LDL of 160 mg/dL. E. The client's father has lung cancer. F. Current smoking history.

B. BMI C. Hx DM D. LDL 160 F. Current smoker Risk factors that contribute to atherosclerosis include: an increase in LDL (160 mg/dL is high), obesity (as indicated by a BMI is 32), smoking, and type 2 diabetes.

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? Select all that apply. A. Apples B. Bananas C. ACE inhibitors D. Grapes E. Salt substitute

B. Bananas C. ACE inhibitors E. Salt substitute

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment one hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

C. Assess client's O2 sat Progressive skeletal muscle weakness is associated with increasing severity of the acidosis. Muscle weakness can lead to severe respiratory insufficiency.

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply. A. Blood serum glucose B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity

B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.

Which assessment by a new nurse requires the charge nurse to intervene? A. Assessing pedal pulses by Doppler B. Simultaneously palpating bilateral carotids C. Measuring blood pressure in both arms D. Measuring capillary refill in the fingertips

B. Carotid pulses simultaneously Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.

A client has an odorous, purulent wound, and reports feeling embarrassed. Which nursing intervention is appropriate? A. Place room deodorizers in the room. B. Change the dressing frequently. C. Suggest whirlpool therapy. D. Encourage a diet high in protein.

B. Change the dressing frequently.

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A. Assesses for dry oral mucous membranes B. Checks for orthostatic blood pressure changes C. Notes pulse rate is 72 beats/min and bounding D. Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

B. Checks for orthostatic blood pressure changes

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? A. Apply a barrier cream to the area. B. Clean and dry the client's skin. C. Assess the area for skin breakdown. D. Place the client in a side-lying position.

B. Clean and dry the client's skin

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.

B. Client states that she is able to sleep on one pillow.

A new nurse is caring for four clients. Which client is at risk for secondary hypertension? A. The client who is physically inactive. B. The client with kidney disease C. The client with depression. D. The client who eats a high-sodium diet.

B. Client with kidney disease The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B. Crackles C. Tachycardia E. Tachypnea F. S3 gallop For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop. Peripheral edema and ascites are associated with right sided heart failure.

The client in the cardiac care unit has had a large myocardial infarction. What assessment data indicates to the nurse the onset of left ventricular failure? A. Expectoration of yellow sputum B. Crackles in the lung fields C. Pedal edema D. Urine output of 1500 mL on the preceding day

B. Crackles in the lung fields Signs and symptoms of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.

A client with obesity requires frequent dressing changes for an infection on the foot. Which nursing assessment is the priority? A. Provide the necessary dressing materials. B. Determine whether the client can reach the affected area. C. Demonstrate how to change the dressing. D. Ask the client if he or she is squeamish.

B. Determine whether the client can reach the affected area.

The nurse is very concerned with the EKG changes (indiscernible P waves, and spiked T waves). The nurse realizes something has to be given immediately to decrease potassium levels. Bert is also having nausea, vomiting, and diarrhea. The nurse decides the best option for reducing potassium in an emergency is? A. Kayexalate B. Dextrose and insulin infusion C. Diuretic D. 1 L Normal Saline with 20 meq of potassium chloride

B. Dextrose and insulin infusion

The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change? A. Apply a mask. B. Don disposable gloves. C. Place soiled dressings directly in the trash. D. Use sterile technique.

B. Don disposable gloves.

The nurse is caring for a client who is being treated for hypertensive crisis. Which prescribed medication would the nurse question? A. Enalapril B. Dopamine C. Labetalol D. Sodium nitroprusside

B. Dopamine Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive crisis.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) A. Sharp, inspiratory chest pain B. Dyspnea C. Extreme fatigue D. Dizziness E. Anorexia

B. Dyspnea C. Extreme fatigue D. Dizziness

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position

B. Elevates the head of the bed

A client with a foot ulcer says, "I feel helpless." What is the appropriate nursing response? (Select all that apply.) A. State,"I know how you feel." B. Encourage participation in care of the wound. C. Assure that everything will be OK. D. Suggests inviting visitors to come. E. Ask what coping strategies have worked in the past.

B. Encourage participation in care of the wound. E. Ask what coping strategies have worked in the past.

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem? A. Medicate for pain. B. Encourage use of incentive spirometer. C. Perform fingerstick blood glucose. D. Encourage protein intake.

B. Encourage use of incentive spirometer. The intervention that will best help the client with postoperative respiratory acidosis is to encourage the client to use the incentive spirometer. Respiratory acidosis is caused by hypoventilation. Improving ventilation through lung expansion, suctioning, or upright positioning will help to resolve this.While pain medication may make use of the incentive spirometer easier, narcotic analgesics may suppress respirations and worsen acidosis.

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? Select all that apply. A. Hyperactivity B. Headache C. Shallow breathing D. pH 7.49 E. Fatigue

B. Headache C. Shallow breathing E. Fatigue When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, flushing, headache, shallow breathing, and fatigue. Clients experiencing acidosis have problems associated with the decreased function of excitable membranes.Generally, the client with respiratory acidosis will be lethargic rather than hyperactive and have a pH <7.35, which is a characteristic of acidosis.

You have a patient in metabolic acidosis (high serum hydrogen and low pH). What would you expect to find in lab test results which indicate the body is trying to compensate for this problem? A. high serum sodium and low serum hydrogen H+ B. high serum potassium; increased urinary H+ C. low serum potassium and low serum H+ D. increased urinary potassium and decreased urinary H+

B. High potassium, increased urine pH

Check if your client is on an ACE, ARB, or spironolactone medication Cardiovascular changes from me could send your client on a permanent vacation Kidney function that is poor or a client who doesn't make pee Your emergency option is dextrose and insulin to lower me Tall peaked T waves are bad and could signal I am here Sometimes sodium polystyrene sulfonate for me will make a mess out the rear I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

B. Hyperkalemia

Your patient's blood volume is low due to hemorrhage. What finding would you expect to see? A. increased blood pressure B. increased heart rate C. dry, hot skin D. increased urine output

B. Increased HR

The nurse is teaching the client dietary methods to reduce LDL levels. What teaching will the nurse include? (Select all that apply.) A. Aim for 10% of calories from sat fat B. Limit trans fat intake C. Emphasize the intake of whole grains D. Avoid cooking with all oil E. Nuts are a good snack food F. Try to purchase skinless chicken to cook with

B. Limit trans fat intake C. Emphasize whole grains E. Nuts are good F. Skinless chicken

pH: 7.28, PaO2: 80, PaCO2: 30 , and HCO3: 16. Are we...? A. Fully compensated B. Partially Compensated

B. Partially Compensated The CO2 is lower then normal at 30 which means the body is trying to breathe off CO2 in order to decrease acid. However, the pH is still acidic at 7.28

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? A. Planning and participating in a walking program B. Placing a chair in the shower for independent hygiene C. Consultation with social worker for disability planning D. The need to increase activities slowly at home

B. Placing a chair in the shower for independent hygiene Placing a chair in the shower is an activity performed in phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.

what would happen to blood potassium levels in an Alkalotic state? Let us say pH: 7.55 A. Potassium level in the blood would rise B. Potassium level in the blood would fall

B. Potassium level in the blood would fall

The nurse is evaluating the effectiveness of interventions for pressure injury management. Which laboratory will the nurse monitor? A. Calcium B. Serum albumin C. Numbers of immature white blood cells (WBCs) D. Hematocrit

B. Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.

What clinical situation from this blood gas pH: 7.50; PaCO2: 44; HCO3: 30; might be occurring? A. The patient is breathing rapidly due to a panic attack B. The patient's Nasogastric canister has been continuously filling up with significant quantities of gastric secretions C. The patient has been abusing laxatives and reports frequent diarrhea D. The patient is in diabetic ketoacidosis

B. The patient's Nasogastric canister has been continuously filling up with significant quantities of gastric secretions Significant decrease in acids and liquids from the stomach can shift the balance to metabolic alkalosis. The suctioning needs to stop and likely electrolytes will need to be corrected.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests

B. The risk for hypotension

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? Select all that apply. A. History of liver disease B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics E. Prescription for insulin

B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.

For what other manifestation of hypocalcemia would you want to observe in the patient who is post-op thyroidectomy? A. Dry, rough skin. B. Bradycardia, dysrhythmias. C. Decreased urine output. D. Diarrhea.

B. bradycardia, dysrhythmias

What would you find on assessment of the person who has hyperkalemia? A. polyuria B. hyperreflexia, muscle weakness C. hypertension D. tachycardia

B. hyperreflexia, muscle weakness. potassium= neuromuscular irritability

The nurse is assessing a client with arterial insufficiency. What assessment data would cause the nurse to suspect an acute arterial occlusion of the right lower extremity? (Select all that apply.) A. Tachycardia B. Mottling of right foot and lower leg C. Bounding right pedal pulses D. Numbness and tingling of right foo E. Hypertension F. Cold right foot

B. mottling D. Numbness/tingling F. Cold right foot Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.

You have the flu with repeated episodes of vomiting and diarrhea. What symptoms would indicate low serum potassium? A. hyperreflexia B. muscle fatigue, weakness C. increased blood pressure D. oliguria

B. muscle fatigue, weakness. potassium has a primary effect on muscle cells and the ability of the cells to fire.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? A. Nose and ears have a slightly yellow-tinged appearance. B. Neck veins are now distended in the sitting position. C. Breath sounds can be heard in the right lower lung lobe. D. Weight is unchanged from that obtained yesterday.

B. neck veins distended when sitting

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. potassium supplements with spironolactone Spironolactone is a potassium sparing diuretic. This drug can cause hyperkalemia and as such the client would not take potassium supplements with this drug

Which one of these patients is at risk for fluid volume excess? One who has: A. chronic diarrhea B. renal failure C. decrease aldosterone production D. restricted salt intake

B. renal failure (increased risk FLE)

A patient has been receiving 20mEq potassium chloride in IVs of D5/.45 Na. Cl at 125 ml/hour for several days. Vital signs have been normal until now when you found him to have a slow, irregular pulse. The first thing you would do is: A. call the physician B. slow the IV flow rate C. change the IV fluid to D5W D. obtain an order for serum electrolytes

B. slow the rate of infusion slow IV rate, then call doctor.

Which one of these cardiac monitor findings would you report as indicative of hyperkalemia? A. elevated, prolonged P wave B. tall, peaked, tented T wave C. narrow QRS D. short P-R interval

B. tall, peaked, tented T waves

Priority Nursing Care Percutaneous Vascular Intervention...

Before: Dye allergy After: Bleeding at arterial puncture site Monitoring distal pulses to ensure adequate perfusion.

The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? A. "The client's PT and INR may be prolonged while taking this medication." B. "The client may develop hypoglycemia during treatment." C. "Inverted T waves and a U wave may appear on the ECG." "D. I need to tell the client to avoid salt substitutes."

C. "Inverted T waves and a U wave may appear on the ECG." The nursing student understands the side effects of Bumex when commenting that inverted T waves and a U wave may appear on the EKG. Hypokalemia may cause depressed ST segments, flat or inverted T waves or the presence of a U wave on the ECG as well as dysrhythmias. High-ceiling (loop) diuretics, such as furosemide (Lasix, furosemide), promote loss of water, sodium, and potassium.

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A. A client admitted with dehydration who has a heart rate of 126 beats/min B. A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home C. A client admitted yesterday with heart failure with dependent pedal edema D. A client who has just been admitted with severe nausea, vomiting, and diarrhea

C. A client admitted yesterday with heart failure with dependent pedal edema

After receiving change-of-shift report, which client does the RN assess first? A. A client with nausea and vomiting who complains of abdominal cramps B. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg D. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg A. Endotracheal suctioning B. Applying oxygen C. Administering an antiemetic D. Administering sodium bicarbonate

C. Administering an antiemetic This blood gas demonstrates metabolic alkalosis typically caused by vomiting or NG suction. The client loses potassium and retains bicarbonate; an antiemetic will reduce vomiting and correct the imbalance.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion

C. Asses response to Chvostek's test Severe diarrhea can cause excessive calcium loss and result in hypocalcemia. Symptoms of hypocalcemia include tingling of the lips and mouth, muscle cramps (especially in the presence of hypoxia), positive responses to the Trousseaus' and Chvostek's test, and seizures

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A. Monitoring 24-hour urine output B. Asking the client about feeling depressed C. Assessing the blood pressure hourly D. Monitoring the serum calcium levels

C. Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom of hypermagnesemia during magnesium infusion

Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis? A. Gastrointestinal system B. Respiratory system C. Cardiovascular system D. Autonomic nervous system

C. Cardiovascular system acidosis --> hyperkalemia--> alters all excitable membranes --> cause severe bradycardia and even cardiac arrest.

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

C. Chronic ingestion of bicarb D. Continuous gastric suction for 48 hours Metabolic alkalosis is caused by a loss of hydrogen ions and/or excessive bicarbonate ions. With continuous gastric suction, hydrochloric acid is removed, and the concentration of free hydrogen ions can get too low. Clients who ingest sodium bicarbonate daily are at risk for having metabolic alkalosis from excess bicarbonate

After exercising all day in the hot sun and taking his diuretic Bert's sodium comes in at 118 meq/L. What finding is most concerning? A. Nausea and abdominal cramping B. Arm and leg cramping C. Confused to person, place, and time D. Headache

C. Confused to person, place, and time

The nurse is teaching a client the precautions to take while on warfarin therapy. Which client statement demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "When taking warfarin, I may notice some blood in my urine." C. "Eating foods like green beans won't interfere with my warfarin therapy." D. "If I notice I am bleeding a lot, I should stop taking warfarin right away."

C. Eating foods like green beans wont interfere with warfarin. Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.

The day shift nurse reviews his morning CMP and it shows sodium of 152 meq/L. The nurse notices 3% hypertonic saline solution was hanging and running all night on this patient (:0). The nurse immediately stops the 3% saline solution. What two interventions take priority? A. Ambulate every four hours and encourage leg exercises while lying in bed B. Monitor muscles for twitching and deep tendon reflexes C. Frequent neurological assessments and close monitor of blood pressure and pulse rate D. Use of incentive spirometer and flutter valve E. Encourage salty foods and addition of salt tabs

C. Frequent neurological assessments and close monitor of blood pressure and pulse rate

I could cause your client's face to twitch when you tap it You should know this and Trousseau's for your wit when you split Tingling in the face, muscle cramps, and spasms can all take a turn Thyroid surgery or post menopause could cause me to become a concern Avoid falls with brittle bones, and decrease environmental stimulation as needed Laryngospasm is rare but can occur because I am depleted I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

C. Hypocalcemia

The nurse is teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury. Which daily prevention strategy to protect skin integrity does the nurse include in the teaching plan? A. Eat a low-fat, low-protein diet. B. Massage reddened areas several times daily. C. Lift hips off the chair at least every hour. D. Complete a pressure map to identify areas of concern.

C. Lift hips off the chair at least every hour.

Which assessment finding would you report as indicative of fluid volume excess? A. flat neck veins B. weak pulse C. moist rales D. low central venous pressure(CVP)

C. Moist rales indicates pulmonary edema d/t fluid overload

Your patient has heart failure and takes Lasix (a diuretic) and Digoxin (slows and strengthens heart contraction). The lab work comes back and reveals the serum potassium level to be 3.0 mEq/L. Which action would be appropriate? A. Restrict the potassium intake. B. Give insulin and glucose. C. Observe for symptoms of digitalis toxicity. D. Give calcium gluconate intravenously.

C. Observe for symptoms of digitalis toxicity. loss of potassium in urine due to diuretic use makes heart more sensitive to the action of digoxin

A client with peripheral arterial disease (PAD) has a percutaneous vascular intervention. What is the priority nursing assessment? A. Dye Allergy B. Gag reflex C. Pedal Pulses D. Ankle-brachial index

C. Pedal pulses Essential to assess pedal pulses after percutaneous vascular intervention.

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? A. Administer sodium polystyrene sulfonate (Kayexalate) orally. B. Ensure that a potassium-restricted diet is ordered. C. Place the client on a cardiac monitor. D. Teach the client about foods that are high in potassium.

C. Place the client on a cardiac monitor. The nurse must first place this client on a monitor. Because hyperkalemia can lead to life-threatening bradycardia, placing the client on a cardiac monitor permits early intervention in the event of dysrhythmias.

An older adult client who is bedridden has a documented history of protein deficiency. For which condition will the nurse monitor and attempt to prevent? A. Decreased wound healing B. Melanoma C. Pressure injury development D. Bed bugs

C. Pressure injury development This client is at risk for developing pressure injuries related to protein deficiency if he or she remains bedridden.

Which foods will the nurse help the client with vitamin B12 deficiency to increase in the diet? A. Grains B. Unsaturated fats C. Red meat D. Starchy vegetables

C. Red meat The nurse encourages the client to increase foods such as animal proteins, fish, eggs, nuts, dairy products, dried beans, citrus fruit, and leafy green vegetables, as sources of vitamin B12.

The nurse is caring for a client 36 hours after coronary artery bypass grafting. Which assessment causes the nurse to terminate an activity and return the client to bed? A. Incisional discomfort B. HR 72 beats/min and regular C. Respiratory rate 28 breaths/min D. Urinary frequency

C. Respiratory rate 28 breaths/min The activity should be terminated when the nurse assesses the client's respiration rate of 28 breaths/min. This indicates activity intolerance.

The nurse is assessing a client with chest pain to evaluate whether the client is experiencing angina or myocardial infarction (MI). Which assessment is indicative of an MI? A. Chest pain brought on by exertion or stress. B. Substernal chest discomfort relieved by nitroglycerin or rest C. Substernal chest pressure relieved only by opioids D. Substernal chest discomfort occurring at rest.

C. Substernal chest pressure relieved only by opioids

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L). B. The client's heart rate is 101 beats per minute. C. The client is free from adventitious breath sounds. D. The client has experienced a weight gain of 1 pound (0.5 kg).

C. The client is free from adventitious breath sounds

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? A. The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) B. The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) D. The client with a sodium level of 143 mEq/L (143 mmol/L)

C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) The first client the nurse sees with electrolyte and blood chemistry abnormalities is the client whose potassium is 6.2 mEq/L (6.2 mmol/L). A potassium value of 6.2 mEq/L (6.2 mmol/L) is elevated and the client has potential for cardiac dysrhythmias

A client shows the nurse two pictures of the same lesion, taken one month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

C. The lesion borders have expanded and are shaped differently in the second picture.

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) Select all that apply. A. Keeping the client NPO during drug treatment B. Pushing the drug as a bolus slowly over 5 minutes C. Using an IV controller to deliver the drug D. Checking IV access for blood return after the infusion E. Initiating the IV in a hand vein for rapid access F. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

C. Using IV controlled to deliver the drug F. Ensuring concentration is no greater than 1mEq/10mL

The nurse in the cardiology clinic is reviewing teaching provided at the client's last appointment regarding hypertension management. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Reports walking the neighborhood once weekly. B. Reports eating fast food frequently to cut down on food costs. C. Weight loss of 3 lb (1.4 kg) D. Reports eating a low-sodium diet. E. Reports drinking one less cup of coffee daily.

C. Weight loss D. low sodium diet E. Less coffee

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? A. Monitoring 24-hour urine output B. Monitoring the serum calcium levels C. Assessing the blood pressure hourly D. Asking the client whether a headache is present

C. assessing BP hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) Select all that apply. A. Testing skin turgor B. Asking about any abdominal pain C. Assessing cognition D. Checking deep tendon reflexes E. Monitoring urine output F. Checking for the presence of fever

C. assessing cognition E. monitoring urine output

The treatment of hypermagnesemia would be: A. reduce fluid intake B. give Mg++ containing antacids C. calcium gluconate

C. calcium gluconate

Which one of the following in the history, physical, and review of data would lead to a diagnosis of hypomagnesemia? A. increased serum calcium B. excess intake of Mg++ containing antacids C. excessive diarrhea and vomiting D. hypoaldosteronism

C. excessive diarrhea and vomiting

The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.

C. increase potassium D. Affects glucose control E. Increased urination expected

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? A. Monitoring urine output B. encouraging sodium rich fluids and foods throughout the day C. instructing the client not to ambulate without assistance D. assessing deep tendon reflexes

C. instructing the client not to ambulate without assistance Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.

Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? A. Water retention B. Partial airway obstruction C. Nasogastric suction D. Diabetic ketoacidosis

C. nasogastric suctioning Nasogastric suction results in alkalosis from over elimination of hydrogen ions when stomach hydrochloric acid removed by the continuous suction.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? A. Chvostek sign is negative. B. Respiratory rate is 22 breaths/min. C. Pulse rate is 76 beats/min and regular. D. Hematocrit is 42%.

C. pulse rate 76 bpm Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia.

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

C. pulse rate and rhythm Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias.

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? A. Sodium 132 mEq/L (mmol/L) B. Potassium 3.5 mEq/L (mmol/L) C. Sodium 148 mEq/L (mmol/L) D. Potassium 5.3 mEq/L (mmol/L)

C. sodium 148 mEq/L

A patient has been admitted with hyperkalemia (excess serum potassium). Which information obtained in the patient's history tells you the probable cause of the hyperkalemia? A. episode of diarrhea B. heart failure C. using salt substitutes D. uses laxative regularly

C. using salt substitues

What changes should you assess for to determine whether the patient is becoming hyperkalemic?

Cardiac changes are often the first indications of higher than normal potassium levels. These include bradycardia, hypotension, and ECG changes of tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes (and possible ectopic beats).

A client with hypertension is started on verapamil. What teaching will the nurse provide for this client? A. "consume foods high in potassium" B. "Monitor for muscle cramping" C. "Monitor for irregular pulse" D. "Avoid grapefruit juice"

D. "Avoid grapefruit juice" Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? A. "I can gain 2 pounds (1 kg) of water a day without risk." "B. I should call my provider if I gain more than 1 pound (0.5 kg) a week." C. "Weighing myself daily can determine if my caloric intake is adequate." D. "Weighing myself daily can reveal increased fluid retention."

D. "Weighing myself daily can reveal increased fluid retention."

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

D. 22 year old IV insulin, ketoacidosis.

Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation? A. A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). B. A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness. C. A 69 year old with a 40-pack-year cigarette history who is reporting foot numbness. D. A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic.

D. A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.

For which client does the nurse remain alert for the possibility of respiratory acidosis? A. Client with increased urinary output B. Client who is anxious and breathing rapidly C. Client receiving IV normal saline bolus D. Client with multiple rib fractures

D. Client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess? A. Decreased rate of breathing B. Increased loss of bicarbonate through the kidney C. Decreased depth of breathing D. Decreased loss of bicarbonate through the kidney

D. Decreased loss of bicarbonate through the kidney The compensatory mechanism the nurse anticipates is present in the client with long standing emphysema and respiratory acidosis is conservation of bicarbonate. A partially compensated respiratory acidosis will typically result.Increased loss of bicarbonate through the kidney, decreased rate, and depth of breathing will promote acidosis.

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A. Restrict the client's intake of sodium B. Administer a diuretic C. Monitor the serum osmolarity D. Encourage fluid intake

D. Encourage fluid intake When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.Hypernatremia and fluid loss typically occur in tandem in the older adult.

Which statement is correct about how the kidneys operate for fluid-electrolyte balance? A. Reduced renal blood flow will result in the kidney eliminating more water. B. Prostaglandin action permits water reabsorption by the tubules. C. It is where ADH acts. D. The glomerular filtration rate (GFR) changes in response to increased or decreased blood volume.

D. GFR changes with increased and decreased blood volume

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? A. Serum chloride level is 100 mEq/L (mmol/L) B. Blood urea nitrogen (BUN) is elevated C. Arterial blood pH is 7.37 D. Hematocrit is 29% (0.29 volume fraction)

D. Hematocrit 29% When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia.

Sometimes I am found because of your client's cancer Overactive parathyroid glands or taking too much calcium and vitamin D could also be the answer Risk for arrhythmias like bradycardia could cause a real big issue Watch for clots due to slow blood flow through tissue I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

D. Hypercalcemia

The nurse observes an assistive personnel (AP) interacting with a client with a pressure injury. Which AP action requires intervention by the nurse? A. Repositions the client every 1 to 2 hours. B. Uses a moisturizing lotion on skin without pressure injuries. C. Avoids touching reddened areas. D. Massages bony prominences.

D. Massages bony prominences. Massaging bony prominences should be avoided in clients with pressure injuries because they are at high risk for skin tears.Reddened areas should not be touched because this can damage capillary beds and increase tissue necrosis. T

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's weight

D. Measurement of the client's weight

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A. Administers oxygen therapy. B. Provides pain relief medication. C. Remains calm and stays with the client. D. Obtains the client's description of the chest discomfort.

D. Obtains the client's description of the chest discomfort.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Assessing oral mucosa for dryness B. Choosing appropriate oral fluids C. Monitoring skin turgor for tenting D. Offering fluids to drink every hour

D. Offering fluids to drink every hour

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) B. Oral calcium supplements to a client with severe osteoporosis C. Oral phosphorus supplements to a client with acute hypophosphatemia D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)

D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum potassium levels can cause life-threatening dysrhythmias

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor

D. Place the client on a cardiac monitor Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate

When considering administering IV potassium what is important for the nurse to consider? A. Potassium can only be infused through a central line B. Potassium should be infused at 30 meq/hr through a central venous line C. Oral replacement of potassium can only be given by nasogastric tube D. Potassium should be infused between 5-10 meq/hr in a peripheral venous line

D. Potassium should be infused between 5-10 meq/hr in a peripheral venous line

The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? A. Decreased pain when legs elevated B. Unilateral swelling of affected leg C. Pulse ox 90% D. Reproducible leg pain with exercise

D. Reproducible leg pain with exercise The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.

After receiving change-of-shift report in the coronary care unit, which client will the nurse assess first? A. The client who had a percutaneous coronary angioplasty who has a dose of heparin scheduled. B. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction. C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min. D. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.

D. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

D. The hematocrit is 52%. The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium, or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration.

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? A. Ask the client how much fluid was consumed yesterday. B. Place an indwelling catheter to measure urine output. C. Auscultate the lungs for adventitious sounds. D. Weigh the client daily, at the same time.

D. Weigh the client daily, at the same time.

Which action does the nurse expect is most likely to help restore acid-base balance in a client whose arterial blood pH is 7.17 immediately after a grand mal seizure? A. Administering bicarbonate orally or intravenously B. Providing hydration with IV normal saline C. Administering insulin D. Applying oxygen

D. applying O2 The severe acidosis seen immediately following a grand mal seizure is both respiratory and metabolic in origin (a combined acidosis). The client does not breathe during the actual seizure, which causes a huge retention of carbon dioxide (respiratory acidosis). The carbon dioxide level is very high because the seizing muscles are working hard under anaerobic conditions creating lots of lactic acid and hydrogen ions (metabolic acidosis), which are then converted to carbon dioxide through the carbonic anhydrase reaction. If the client stops having seizure activity, he or she will return to acid-base balance without intervention. This return occurs earlier when oxygen is applied.

What drug will you want to be sure is available on the nursing unit for your post-op patient who has had a thyroidectomy? A. Benadryl B. Epinephrine C. sodium bicarbonate D. calcium gluconate

D. calcium gluconate

Which of the following assessment findings would you expect to see in hypermagnesemia? A. hyperreflexia B. spastic muscles C. hyperactivity D. decreased pulse and blood pressure

D. decreased pulse and BP

Your friend played tennis a long time in 100 degree weather. He was careful to drink plenty of water during the match. Later he became ill and went to the hospital where he was admitted in a hypoosmolar state. Your assessment is likely to reveal: A. extreme thirst B. serum sodium 180 mEq/L C. hyporeflexia D. disorientation

D. disorientation Sodium diluted and water moved into the cells. Possible cerebral edema.

What cardiac changes might be seen in hypokalemia? A. bounding pulse B. narrow QRS complex C. irregular pulse D. flat or inverted T waves

D. flattened or inverted T waves

1. The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day. B. "I will restrict my intake of daily dietary lean protein. C. "I am only going to drink one cup of coffee to start my day.". D. "I will drink a glass of low fat milk with my breakfast."

D. glass of low fat milk

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? A. Teaching the client which foods to avoid B. Administering sodium polystyrene sulfonate orally C. Collaborating with the registered dietitian nutritionist to provide a potassium-restricted diet D. Initiating continuous cardiac monitoring

D. initiating continuous cardiac monitoring

Why does hyperkalemia occur in the patient in metabolic acidosis (excess H+, low pH)? A. The lungs are retaining CO2 . B. The kidneys are retaining Na+ and secreting K+. C. The kidneys are excreting bicarbonate. D. The kidneys are secreting excess H+ and retaining K+.

D. kidneys excrete excess H+ and retaining K+

Which of the following is a factor which influences serum calcium levels? A. vitamin K B. sodium C. potassium D. parathyroid hormone

D. parathyroid hormone regulates calcium and phosphorous

How does aldosterone contribute to fluid and electrolyte balance? A. stimulates prostaglandins B. stimulates the adrenal gland to release cortisol C. promotes increased colloid osmotic pressure D. promotes sodium retention and potassium loss

D. promotes sodium retention/potassium loss

The treatment for a hyperosmolar imbalance (hyponatremia) would include: A. increase water intake B. low sodium diet C. intravenous fluids of 5% dextrose in water D. treat the cause

D. treat the cause

Malnutrition and alcoholism may cause me to stand out Use of thiazide and loop diuretics could also be what I am all about With me it's hard to keep potassium at a good state Watch for arrhythmias and tetany before it's too late I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

E. Hypomagnesemia

Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia? A. Underelimination of bicarbonate ions B. Underproduction of hydrogen ions C. Overelimination of bicarbonate ions D. Overelimination of hydrogen ions E. Overproduction of hydrogen ions F. Underelimination of hydrogen ions G. Underproduction of bicarbonate ions H. Overproduction of bicarbonate ions

E. overproduction of hydrogen ions Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions.

With me it's all about relaxing and getting everything to just go slowww IF your client's breathing is shallow and their heart is decreased you should know Stop the magnesium if it is going and call for support A weak, lethargic client will have very little to report I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

F. Hypermagnesemia

If your client is at risk for me than daily weights gives great info Before breakfast, same time, same style, wait... more than 2 lbs in 24hr to the doctor you GO Monitor heart and lungs because I can surely overwhelm them and that is just not fair With edema I can make the skin breakdown and tear. I am... A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

G. Fluid Volume Excess

Increased hematocrit, BUN, and urine specific gravity may signal me Weak pulses, agitation, and thirst is what you may see Tented skin, tachycardia, dry mouth, and fast breathing rate Fall safety is of utter importance so your client and the floor don't meet for a date A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia E. Hypomagnesemia F. Hypermagnesemia G. Fluid Volume Excess H. Fluid Volume Deficit

H. Fluid Volume Deficit

I am reviewing notes and I read that the patient has fully compensated respiratory acidosis. I would expect to see the pH in the normal range. True False

True Fully compensated means that a mechanism has occurred to correct the pH to a normal range (7.35-7.45). Example Respiratory Acidosis in the patient becomes compensated with Metabolic Alkalosis. That may look like this. pH: 7.38 PaCO2: 72 HCO3: 42

AHA recommendations to decrease LDL levels...

Whole grains, vegetables, and fruits Skinless chicken low-fat dairy products Nuts cooking with nontropical oils (e.g. Canola) limit trans-fat intake 5-6% of calories from saturated fat.

A client diagnosed with atherosclerosis and hypertension has been newly prescribed a combination drug of amlodipine and atorvastatin (Caduet). Which statement by the client indicates a need for further teaching? a. "I will continue to take my amlodipine with the new medication." b. "I'll follow up with my nurse practitioner on a regular basis." c. "I need to quit smoking as soon as I possibly can." d. "I shouldn't drink grapefruit juice while on this drug."

a. "I will continue to take my amlodipine with the new medication."

A client is prescribed lisinopril (Zestril) for control of hypertension. What health teaching will the nurse provide to this patient? (Select all that apply.) a. "This medication can cause increased potassium levels." b. "It is important to change positions slowly when you start this medication." c. "This medication may cause you to develop a persistent, non-productive cough." d. "To achieve maximum benefit of Zestril, your diet should include foods high in sodium." e. "Be sure to monitor your BP regularly while taking this medication."

a. "This medication can cause increased potassium levels." b. "It is important to change positions slowly when you start this medication." c. "This medication may cause you to develop a persistent, non-productive cough." e. "Be sure to monitor your BP regularly while taking this medication." Lisinopril (Zestril) is an ACE inhibitor which is known to cause orthostatic hypotension associated with vasodilation; thus changing positions slowly is important. Persistent, nagging cough is also common in this drug category. Because this medication is being used to modify BP, regular monitoring is important to assess effectiveness. Hyperkalemia is also associated with ACE Inhibitors especially for clients with diabetes mellitus and renal dysfunction.

An 84-year-old client with heart failure presents to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning to the nurse? a. Digoxin (Lanoxin) therapy daily. b. Daily metoprolol (Lopressor). c. Furosemide (Lasix) twice daily. d. Currently taking an antacid for upset stomach.

a. Digoxin (Lanoxin) therapy daily. Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment

Which signs and symptoms does the nurse expect to find in clients with any type of anemia? (Select all that apply.) a. Exercise intolerance b. Fatigue c. Glossitis d. Jaundice e. Leukopenia f. Microcytic red blood cells g. Paresthesias of the hands and feet h. Tachycardia

a. Exercise intolerance b. Fatigue h. Tachycardia With any type of anemia, the number or quality of red blood cells is low, thus reducing oxygen perfusion to all tissues. This results in fatigue with exercise intolerance. Tachycardia is a compensatory mechanism to help maintain oxygen perfusion. Jaundice is present only when anemia is caused by red blood cell damage/destruction with release of hemoglobin and not by anemia caused by blood loss or deficiencies of iron or B12. Glossitis is associated only with deficiencies of folic acid and B12. Iron deficiency anemia results in microcytic red blood cells, whereas B12 deficiency causes macrocytic red blood cells. Red blood cell size is not affected by most other types of anemia. Paresthesia of the hands and feet are associated with B12 deficiencies severe enough to alter nerve function.

A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? (Select all that apply.) a. Peripheral edema b. Crackles in both lungs c. Increased abdominal girth d. Ascites e. Tachypnea

a. Peripheral edema c. Increased abdominal girth d. Ascites e. Tachypnea Peripheral edema, increased abdominal girth, ascites, and tachypnea are all symptoms associated with right-sided heart failure due to the back up into the peripheral system. Crackles in the lungs are associated with left-sided heart failure.

A client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him to hyperventilate. What is the nurse's best response? a. "Even your exhaled breath still has some oxygen in it and rebreathing this air ensures that you won't pass out from lack of oxygen." b. "When you breathe fast you can lose too much carbon dioxide and rebreathing this air keeps you from becoming dizzy and falling." c. "Rapid breathing can lead to dehydration from excessive fluid loss and rebreathing this air helps you retain fluid in the form of vapor moisture." d. "Breathing into the bag for several minutes helps you become distracted from whatever is making you anxious and allows you to calm down."

b. "When you breathe fast you can lose too much carbon dioxide and rebreathing this air keeps you from becoming dizzy and falling."

Which food items selected by a client who must restrict potassium because of a continuing risk for hyperkalemia indicates to the nurse that more teaching is needed? a. Strawberries, Cheerios, eggs b. Cantaloupe, broccoli, sweet potatoes c. Apple pie, black coffee with sugar, carrot sticks d. Whole wheat toast with butter, canned pineapple chunks

b. Cantaloupe, broccoli, sweet potatoes

Which blood laboratory values does the nurse need to evaluate to determine whether the client's acidosis has a respiratory origin or a metabolic origin? (Select all that apply.) a. Calcium b. HCO3− c. Lactic acid (lactate) d. PaCO2 e. PaO2 f. pH g. Potassium

b. HCO3− d. PaCO2 e. PaO2 In acidosis, the pH is low, and the potassium and lactic acid levels are elevated regardless of the origin or cause of the acidosis, making C, F, and G incorrect. The calcium level is not affected by acidosis, making response A incorrect. In metabolic acidosis, the PaO2 and the PaCO2 remain normal (or the PaCO2 slightly low) and the HCO3− is usually low as a cause of metabolic acidosis. In respiratory acidosis the PaO2 is low and the PaCO2 is high because the problem causing the acidosis is poor gas exchange with carbon dioxide retention. The HCO3− level is normal in acute respiratory acidosis and high in chronic respiratory acidosis.

How are blood hydrogen ion levels and blood carbon dioxide levels related? a. These two blood values are negatively related to the extent that as carbon dioxide levels rise, the concentration of hydrogen ions decreases. b. Carbon dioxide is attached to and becomes part of hydrogen ions in the blood so that the loss of one always leads to the loss of the other. c. There is no relationship between blood hydrogen ion level and carbon dioxide making the concentration of each substance independent of the other. d. Blood hydrogen ion levels and blood carbon dioxide levels are directly related so that when the level of one increases the level of the other increases to the same degree.

d. Blood hydrogen ion levels and blood carbon dioxide levels are directly related so that when the level of one increases the level of the other increases to the same degree.

A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs and symptoms indicate to the nurse that this therapy is effective? a. The client reports hand swelling. b. Bowel sounds are present in all four abdominal quadrants. c. Serum potassium level has decreased from 4.4 mEq/L (mmol/L) to 4.2 mEq/L (mmol/L). d. Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg.

d. Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg. Where sodium goes, water follows. Clients with severe hyponatremia are most often hypovolemic and hypotensive because fluid does not stay in the plasma volume when sodium levels are low. The plasma volume leaks into the interstitial space, which leads to edema formation. Having the blood pressure increase is the best nonlaboratory indicator that the treatment is effective.