Med Surg Chapter 10 prep u
Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 30 mL/hour A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 20 mL/hour A patient with a minimal urine output of 10 mL/hour
A A client with minimal urine output of 30 mL/hour provides the nurse with the information that the patient is maintaining proper fluid balance. Less then 30 mL/hour of urine output indicates dehydration and possible poor kidney function
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Respiratory acidosis Metabolic alkalosis Altered blood urea nitrogen (BUN) value
A Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad A frozen, packaged low-fat dinner with a side salad Tomato juice, low-fat cottage cheese, and three slices of bacon
A Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.
A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects? 114 mEq/L 148 mEq/L 135 mEq/L 130 mEq/L
A Hyponatremia occurs when the serum sodium level dips below 135 mEq/L. When serum sodium levels fall below 115mEq/L, mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, personality changes, convulsions, or coma can occur. A serum sodium level of 148 mEq/L would indicate hypernatremia. Normal serum concentration levels range from 135 to 145 mEq/L.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? In dehydration, only extracellular is depleted. Similar causes are present in both conditions. Hypovolemia contains only low blood volume. Both conditions result in abnormal laboratory studies.
A In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Elevated blood pressure Low heart rate Rapid respiration Subnormal temperature
A Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? metabolic alkalosis metabolic acidosis respiratory acidosis respiratory alkalosis
A Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may create a risk for this condition. Metabolic acidosis refers to decreased plasma pH because of increased organic acids (acids other than carbonic acid) or decreased bicarbonate. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary with expired air.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations
A Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? Provide oral care every 2-3 hours. Monitor for signs and symptoms of dehydration. Assess the client's weight daily for trends. Teach the client about increased fluid intake.
A Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? Increases arterial pH Provides long-term pH regulation No effect Decreases arterial pH
A Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis
A The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
A This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? tingling sensation in the fingers polyuria flank pain hypertension
A Tingling or numbness in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Document presenting signs and symptoms. Compare ABG findings with previous results. Administer IV bicarbonate. Maintain intake and output records. Suction the client's airway.
A B D Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Slurred speech Presence of Trousseau sign Negative Chvostek sign Muscle weakness
B After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? Ingests alcohol occasionally Takes high doses of vitamin D Follows a high-fiber eating plan Works as a customer service representative
B Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive absorption of calcium. Therefore, the nurse would report this finding to the health care provider. The client's symptoms are not associated with occasional alcohol intake, a high-fiber eating plan, or the client's employment status. These findings would not need to be reported.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypocalcemia hypokalemia hyperkalemia hypercalcemia
B Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Give medications that promote fluid retention. Limit sodium and water intake. Assess for dehydration. Teach client behaviors that decrease urination.
B Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? <136 mOsm/kg 275-300 mOsm/kg >408 mOsm/kg 350-544 mOsm/kg
B In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Weight loss Jugular vein distention Tetanic contractions Polyuria
B Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 5% dextrose and normal saline solution Lactated Ringer's solution 10% dextrose in water Half-normal saline solution
B Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
B Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? Hypovolemic shock Cerebral edema Tetany Severe hyperkalemia
B Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.
An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? Be prepared to administer a lactated Ringer's IV. Consider sodium restriction with discontinuation of salt tablets. Continue to monitor client with another appointment. Be prepared to administer a sodium chloride IV.
B The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system
B The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. The renin-angiotensin-aldosterone system regulates blood pressure. The sodium-potassium pump regulate homeostasis. The ADH-ANP buffer system regulates water balance in the body.
Clients diagnosed with hypervolemia should avoid sweet or dry food because it obstructs water elimination. increases the client's desire to consume fluid. can cause dehydration. can lead to weight gain.
B The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.
A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEq/L 165 mEq/L 145 mEq/L 130 mEq/L
B The normal sodium level is 135- 145 mEq/L (135-145 mmol/L). In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.
A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment findings will the nurse expect to assess in the client? Select all that apply. Hyperactive reflexes Abdominal distention Anorexia Muscle weakness Numb fingers
B C D A normal serum potassium level ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clinical signs and symptoms of a low potassium level include anorexia, muscle weakness, and hypoactive reflexes. Hyperactive reflexes are associated with a low calcium or magnesium level. Numb fingers are associated with a low calcium level.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Decreased blood pressure Distended neck veins Crackles in the lung fields Bradycardia Shortness of breath
B C E Clinical manifestations of FVE (hypervolemia) include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
A client admitted with a diagnosis of pancreatitis is found to be malnourished and has begun parenteral nutrition (TPN) as ordered. What lab result will the nurse identify as possibly related to the rate of TPN administration? Select all that apply. Calcium: 9.2 mg/dL Phosphorus: 2.3 mg/dL Sodium: 140 mEq/L Chloride: 99 mEq/L Blood glucose 178 mg/dL
B E The normal adult range for serum phosphorus is 2.5 to 4.5 mg/dL; normal serum calcium is 8.5 to 10.4 mg/dL; normal sodium level is 135 to 145 mEq/L; normal serum chloride level is 96 to 106 mEq/L; normal blood glucose level for someone without diabetes is 70 to 99 mg/dL. The nurse identifies clients who are at risk for hypophosphatemia and monitors them. Because malnourished clients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Both TPN and PPN are high glucose solutions. For example, a 5% solution is administered for PPN, while a 10% solution is administered for TPN at the same rate, owing to the approximate glucose concentration in the two solutions. All the remaining lab results are within normal limits.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? The client sees the health care provider for a check-up yearly. The client has never traveled outside of the country. The client had a liver transplant 2 years ago. The client works in a health insurance office.
C A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.
A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? Potassium Iron Calcium Phosphorus
C Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 52-year-old with diarrhea A 72-year-old with a total knee repair
C Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? PaCO2 less than 35 mm Hg pH 7.26 Serum bicarbonate of 28 mEq/L Serum bicarbonate of 21 mEq/L
C Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Potassium level of 6 mEq/L Potassium level of 3.8 mEq/L Sodium level of 150 mEq/L Sodium level of 137 mEq/L
C Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.
Hypokalemia can cause which symptom to occur? Increased release of insulin Decreased sensitivity to digitalis Excessive thirst Production of concentrated urine
C If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia.
A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? Restrict fluids and salt for 24 hours. Monitor the serum sodium for changes hourly. Administer small volumes of a hypertonic solution. Correct the sodium deficit rapidly with salt.
C In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.
A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of: 250 mOsm/kg. 210 mOsm/kg. 280 mOsm/kg. 230 mOsm/kg.
C Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Low white blood count Abnormal potassium level Elevated hematocrit level Low urine specific gravity
C When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
Which is the preferred route of administration for potassium? Subcutaneous Intramuscular Oral IV (intravenous) push
C When the client cannot ingest sufficient potassium by consuming foods that are high in potassium, administering oral potassium is ideal because oral potassium supplements are absorbed well. Administration by IV is done with extreme caution using an infusion pump, with the patient monitored by continuous ECG. To avoid replacing potassium too quickly, potassium is never administered by IV push or intramuscularly. Potassium is not administered subcutaneously.
A client with emphysema is at a greater risk for developing which acid-base imbalance? metabolic alkalosis metabolic acidosis chronic respiratory acidosis respiratory alkalosis
C Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows:sodium 142 mEq/L (142 mmol/L)potassium 3.0 mEq/L (3.0 mmol/L)chloride 106 mEq/L (106 mmol/L)Magnesium 2.3 mg/dL (0.95 mmol/L)What laboratory value is consistent with the client's symptoms? magnesium 2.3 mg/dL (0.95 mmol/L) sodium 147 mEq/L (147 mmol/L) chloride 112 mEq/L (112 mmol/L) potassium 3.0 mEq/L (3.0 mmol/L)
D Potassium is the major intracellular electrolyte. Hypokalemia (potassium levels lower than 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias. The sodium, chloride, and magnesium levels listed are within normal limits.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? Red blood cell count Sputum culture Total hemoglobin Arterial blood gas (ABG) analysis
D Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
D Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Headache or blurry vision Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
D The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Headache, blurry vision, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Neurological system Gastrointestinal system Musculoskeletal system Endocrine system
A A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Sodium level of 150 mEq/L Potassium level of 3.8 mEq/L Potassium level of 6 mEq/L Sodium level of 137 mEq/L
A Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.
Early signs of hypervolemia include moist breath sounds. increased breathing effort and weight gain. thirst. a decrease in blood pressure.
B Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss? 156.0 lbs (70.8 kg) 157.0 lbs (71.2 kg) 158.0 lbs (71.7 kg) 159.0 lbs (72.1 kg)
C A loss of 0.5 kg, or 1.1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2.2 lbs (1 kg), bringing the client's weight to 158.0 lbs (71.7 kg).
The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? "I need to check to see whether my cola beverage has potassium in it." "I'll drink cranberry juice with my breakfast instead of coffee." "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them."
C The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.35 7.30 7.50 7.45
C The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.
The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? PaO2 PO2 Carbonic acid Bicarbonate
D Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
Which nerve is implicated in the Chvostek's sign? Hypoglossal Spinal accessory Optic Facial
D Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "I can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed."
A The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.
The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be 155 mEq/L (155 mmol/L) 145 mEq/L (145 mmol/L) 135 mEq/L (135 mmol/L) 125 mEq/L (125 mmol/L)
A The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
The calcium concentration in the blood is regulated by which mechanism? Parathyroid hormone (PTH) Thyroid hormone (TH) Adrenal gland Androgens
A The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Interstitial fluid Intracellular fluid Extracellular fluid Intravascular fluid
B About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids.
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO 21 mEq/L pH 7.48 PaCO 36 O saturation 95%
B Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer? Passive osmosis Free flow Passive elimination Active transport
D Active transport is the physiologic pump maintained by the cell membrane that results in the movement of fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate (ATP) for energy. The sodium-potassium pump actively moves sodium against the concentration gradient out of the cell, and fluid follows. Passive osmosis does not require energy for transport. Free flow is the natural transport of water. Passive elimination is a filter process carried out in the kidneys.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Calcium Phosphorus Potassium Magnesium
D Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels Confusion and seizures
D Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia? Hypervolemia Hypermagnesemia Hypercalcemia Hypomagnesemia
D If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl Serum sodium level of 124 mEq/L
D In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
D Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
The nurse is caring for a client with an arterial blood pH of 7.48 and bicarbonate level of 29 mEq/L (29 mmol/L). Which treatment will the nurse expect to be prescribed for this client? Bronchodilator Intravenous 0.9% normal saline Potassium supplements Oxygen through a rebreather mask
Treatment of both acute and chronic metabolic alkalosis is aimed at correcting the underlying acid-base disorder. Because volume depletion is commonly present, treatment includes restoring normal fluid volume by administering normal saline. Bronchodilators are used to treat respiratory acidosis. Potassium supplements would be used to treat metabolic acidosis. Oxygen delivered through a rebreather mask would be used to treat respiratory alkalosis.
