Med Surg Acid Base, Fluid, Electrolyte
1 Cup Plain yogurt one cup plain yogurt contains 380g potassium. Therefore, the nurse should recommend this food as containing the most potassium.
A nurse is providing dietary teaching to a client who has heart failure and receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? 1c plain yogurt 1 slice whole grain bread 1/2c chopped celery 1/2c tofu
hyperkalemia
Causes prolonged PR interval and widened QRS complex
slow peripheral pulses
This is an expected finding when the client has low serum phosphorous levels.
0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.
What IV solution to use for hypernatremia
1 large hard boiled egg
Which food has the lowest amount of magnesium? 1c cooked spinach 1 large hard boiled egg 1/2c almonds 1c bran cereal
Cardiac rhythm When using the ABC approach to client care, the nurse should first assess the client's cardiac rhythm because his total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? Deep tendon reflexes Peripheral sensation Bowel sounds Cardiac rhythm
Initiate high-flow oxygen therapy When using the ABC approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5-6 L/min to keep the client's O2 sat above 90%.
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? Provide cardiac monitoring Initiate high-flow oxygen therapy Assist with intubation Administer a rapid-acting diuretic
Hematocrit 34% the nurse should identify that a client who has fluid volume excess can have a hematocrit level that is below the expected range of 37-47% for females or 42-52% for males. Fluid volume excess can cause hemodilution and a decreased HCT level.
A nurse is reviewing the laboratory report of a clinet who has fluid volume excess. Which of the following laboratory values should the nurse expect? Hematocrit 34% Urine specific gravity 1.050 BUN 25 mg/dL Hemoglobin 20 g/dL
serum potassium 3.0 mEq/L this serum potassium level is below the expected reference range of 3.5-5.0. Hypokalemia is a serious complication that can occur when a client who has DKA is receiving insulin to treat the condition. The nurse should report this finding to the provider.
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat DKA. Which of the following findings should the nurse report to the provider? BUN 18 Urine output 30ml/hr Serum potassium 3.0 mEq/L blood glucose 180
0.9 % sodium chloride with 10mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement of offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5-10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1mEq to 10ml of 0.9 sodium chloride
A nurse is admitting a client who takes 40mg lasix daily for HF and has experienced 3days of vomiting. The nurse suspects hypokalemia. Which med should the nurse prepare to administer? Bumetanide 8mg/day 100mL dextrose 10% in water with 10units insulin 0.9% sodium chloride with 10mEq/L potassium chloride at 100 ml/hr sodium polystyrene sulfonate 30g/day
Mental status the greatest risk to this client is injury from a fall due to a decline in the client's mental status. Therefore, assessing the client's mental status is the nurse's priority
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? Skin tugror mental status weight urine output
Hyperactive deep-tendon reflexes hyperactive deep tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? Drowsiness decreased BP hyperactive deep-tendon reflexes increased bowel sounds
Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's LOC will decrease and coma may occur.
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Confusion Peripheral edema Hyperreflexia Facial flushing
Sodium 128 mEq/dL This finding is below the expected reference range and is likely the cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort. (diuretic)
A nurse is assessing a client who is recieving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following values should the nurse report to the provider? Mg 2.0 Sodium 128 Potassium 4.8 Calcium 9.1
PaCO2 the nurse should anticipate that a client who has respiratory alkalosis will have decrased PaCO2 level due to hyperventilation blowing off too much CO2
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His RR is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? PaCO2 PaO2 Bicarbonate Sodium
Serum sodium 138 mEq/L Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 138 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective.
A nurse is evaluating a client who is revieving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? Urine specific gravity 1.035 Serum sodium 138 mEq/L Hct 56% BUN 26 mg/dL
orthostatic hypotension The nurse should plan to monitor the client for orthostatic hypotension, which places him at risk for falls. Ortho hypo is a manifestation of hypokalemia.
A nurse is planning care for a client who has a serum potassium level of 3.0mEq/L. The nurse should plan to monitor the client for which of the following findings? Strong, bounding pulse orthostatic hypotension rapid, deep respirations hyperactive deep tendon reflexes
"I will use the incentive spirometer every hour" Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Therefore, using an incentive spirometer will promote adequate chest expansion.
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates and understanding of the teaching? "I should conserve energy by limiting my physical activity" "I will limit my daily fluid intake to 2-3 glasses" I will wait until my pain is at least a 6 to before using PCA" "I will use the incentive spirometer every hour"
Seizure precautions
When serum calcium levels are low, the nurse should implement ___ ___ due to the client's risk for low excitation threshold as a result of decreased calcium level.