Med Surg I Exam 1

The nurse provides dietary instructions for the client receiving spironolactone. Which foods should the nurse instruct the client to avoid while taking this medication? Select all that apply. 1. Rice 2. Pasta 3. Raisins 4. White bread 5. Whole-grain cereal

3 & 5 Rationale: Spironolactone is a potassium-retaining diuretic, and the client needs to avoid foods high in potassium, such as whole-grain cereals, legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Some foods that are low in potassium include rice, pasta, and bread (not whole-grain).

A nurse is assessing clients on a med-surg unit. Which client is at risk for hypokalemia? 1. Client with pancreatitis who has continuous nasogastric suctioning 2. Client who is prescribed an ACE inhibitor 3. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells 4. Client with uncontrolled diabetes and a serum pH level of 7.33

1 Rationale: A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? 1. Depth of respirations 2. Bowel sounds 3. Grip strength 4. Electrocardiography

1 Rationale: A client with low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the clients respiratory status.

A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, Pao2 86 mmHg, PaCO2 55 mmHg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? 1. Assess the airway 2. Administer prescribed bronchodilators 3. Provide oxygen 4. Administer prescribed mucolytics

1 Rationale: All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? 1. A 34-year-old on NPO status who is receiving intravenous D5W 2. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic 3. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) 4. A 73-year-old with tachycardia who is receiving digoxin (Lasix)

1 Rationale: Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal saline excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put the client at risk for hyponatremia.

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mmHg, PaCO2 38 mmHg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? 1. Cardiac rate and rhythm 2. Skin and mucous membranes 3. Musculoskeletal strength 4. Level of orientation

1 Rationale: Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

A nurse is assessing a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mmHg, PaCO2 34 mmHg, and HCO3 16 mEq/L. What action should the nurse take next? 1. Assess the clients rate, rhythm, and depth of respiration 2. Measure the clients pulse and blood pressure 3. Document the findings and continue to monitor 4. Notify the physician as soon as possible

1 Rationale: Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to sever respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would be best to assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

The nurse is assigned to care of four clients. Which diagnosis most likely puts the client at risk for deficient fluid volume? 1. Heart failure 2. A draining fistula 3. Pulmonary edema 4. Chronic kidney disease

2 Rationale: The client with a draining fistula is at risk for deficient fluid volume as a result of fluid loss through the fistula. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient intravenous (IV) fluid replacement, fever and diaphoresis, and the presence of an ileostomy or colostomy. Clients who have heart failure, pulmonary edema, or chronic kidney injury are at risk for excess fluid volume.

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mmHg, PaCO2 33 mmHg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? 1. Increased rate and depth of respirations 2. Increased urinary output 3. Increased thirst and hunger 4. Increased release of acids from the kidneys

1 Rationale: The client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.

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

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

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mmHg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all the apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

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

A nurse is assessing a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (select all that apply). 1. Increased pulse rate 2. Distended neck veins 3. Decreased blood pressure 4. Warm and pink skin 5. Skeletal muscle weakness

1, 2, 5 Rationale: Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

A nurse is caring for clients with electrolyte imbalances on a merd-surg unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (select all the apply) 1. Hypokalemia Flaccid paralysis with respiratory depression 2. Hyperphosphatemia Paresthesia with sensations of tingling and numbness 3. Hyponatremia decreased level of consciousness 4. Hypercalcemia positive trousseaus and Chvostek's signs 5. Hypomagnesemia bradycardia, peripheral vasodilation, and hypotension

1, 3 Rationale: Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Positive trousseaus and Chvostek's signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.

The nurse plans care for a client with dehydration requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply. 1. Hypernatremia 2. Bounding pulse rate 3. Chronic kidney disease 4. Isolated syncope episodes 5. Rapid, weak, and thready pulse 6. Abnormal serum and urine osmolality levels

1, 5, 6 Rationale: Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormalities found with fluid and electrolyte imbalances, such as hypernatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.

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

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

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? 1. pH 7.25, PaCO2 50 mmHg 2. pH 7.35, PaCO2 40 mmHg 3. pH 7.50, PaCO2 52 mmHg 4. pH 7.52, PaCO2 28 mmHg

1. pH 7.25, PaCO2 50 mmHg Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 35 to 45. In respiratory acidosis, the pH is decreased and the PaCO2 is elevated. Option 2 identifies normal values. Option 3 identifies normal values, and option 4 identifies respiratory alkalosis.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mmHg, PaCo2 65 mmHg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? 1. Diabetic ketoacidosis in a person with emphysema 2. Bronchial obstruction related to aspiration of a hot dog 3. Anxiety-induced hyperventilation in an adolescent 4. Diarrhea for 36 hours in an older, frail woman

2 Rationale: Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an accurate respiratory problem rather than a chronic problem, because no real compensation has occurred.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? 1. Measure intake and output every 4 hours 2. Apply oxygen by mask or nasal cannula 3. Increase the IV flow rate to 250 mL/hr 4. Place the client in a high-fowlers position

2 Rationale: Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.

The nurse is reviewing the client's arterial blood gas results. Which finding would indicate the the client is experiencing respiratory acidosis? 1. pH 7.5, Pco2 of 30 2. pH7.3, Pco2 of 50 3. pH 7.3, HCO3 of 19 4. pH 7.5, HCO3 of 30

2 Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the Pco2 (pH decreased, Pco2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.

A nurse is assessing clients on a med-surg unit. Which adult should the nurse identify as being at greatest risk for insensible water loss? 1. Client taking furosemide (Lasix) 2. Anxious client who has tachypnea 3. Client who is on fluid restrictions 4. Client who is constipated with abdominal pain

2 Rationale: Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? 1. Encourage oral fluid intake 2. Connect the client to a cardiac monitor 3. Assess urinary output 4. Administer oral calcium (Calcimar)

2 Rationale: The client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mmHg, PaCO2 28 mmHg, and HCO3 22 mEq/L, Which client condition should the nurse correlate with these results? 1. Diarrhea and vomiting for 36 hours 2. Anxiety-induced hyperventilation 3. Chronic obstructive pulmonary disease (COPD) 4. Diabetic ketoacidosis and emphysema

2 Rationale: The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, CPOD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of mild, chronic respiratory acidosis.

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

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

The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender upon palpation and a red streak has formed. Which intervention should the nurse implement first? 1. Start a new IV line in the right hand 2. Discontinue the intravenous line 3. Complete an incident report 4. Place a warm washcloth over the site

2. Discontinue the intravenous line Rationale: The client has signs of phlebitis and the IV must be removed to prevent further complications.

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

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

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mmHg, and HCO3- of 20 mEq/L. The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO2. In this situation, the pH is at the high end of the normal value and PaCO2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? 1. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15g by mouth 2. Provide a heart healthy, low potassium diet 3. Prepare to administer dextrose 20% and 10 units of regular insulin IV push 4. Prepare the client for hemodialysis treatment

3 Rationale: A client with a high potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client current potassium level.

A nurse teaches clients at the community center about risks for dehydration. Which client is at greatest risk for dehydration? 1. A 36-year-old who is prescribed long-term steroid therapy 2. A 55-year-old receiving hypertonic intravenous fluids 3. A 76-year-old who is cognitively impaired 4. An 83-year-old with congestive heart failure

3 Rationale: Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

The nurse is assessing the fluid balance of an unconscious client. Which observation by the nurse most indicates deficient fluid volume? 1. Unchanged weight 2. Moist mucous membranes 3. Presence of tongue furrows 4. Intake approximately equaling output

3 Rationale: Signs of fluid balance include equal intake and output for 24, 48, and 72 hours; stable body weight; moist mucous membranes; absence of tongue furrows; good skin turgor; and blood urea nitrogen and electrolytes within normal limits.

A primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client diagnosed with a cardiac dysrhythmia. When administering the IV potassium chloride, which action would the nurse take? 1. Inject it as a bolus 2. Use the filter in the IV line 3. Dilute it per medication instructions 4. Apply cool compress to the IV site

3. Dilute it per medication instructions Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compress would constrict the blood vessel, which could possibly be more irritating to the vein.

The nurse evaluates the arterial blood gas (ABG) results of a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate? 1. 45 mmHg 2. 50 mmHg 3. 60 mmHg 4. 80 mmHg

4

A nurse is caring for an older client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? 1. Ask family members to speak quietly to keep the client calm 2. Assess urine color, amount, and specific gravity each day 3. Encourage the client to drink at least 1 liter of fluids each shift 4. Dangle the client on the bedside before ambulating

4 Rationale: An older adult with moderate dehydration mat experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an old adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

The school nurse teaches an athletic coach how to prevent dehydration among athletes practicing in the hot weather. What is the best advice for the nurse to give to the coach? 1. Drink plenty of fluids before and after practice 2. Have the athletes take a salt tablet before practice 3. Reschedule practice for before school and after sunset 4. Provide a fluid break every 30 minutes during practice

4 Rationale: Hot weather accelerates the body's loss of fluid and electrolytes during strenuous physical activity, so the nurse encourages the coach to schedule fluid breaks at 30-minute intervals so that the athletes can periodically rest and restore body fluids. Drinking fluid before and after practice is a reasonable suggestion; however, because the hot weather accelerates fluid and electrolyte losses, body fluids must be periodically replenished to maintain the fluid and electrolyte balance. Although a sodium load increases fluid retention, the nurse avoids suggesting salt tablets for the athletes because the nurse needs approval from each athlete's primary health care provider before recommending the salt. Rescheduling practice times is unrealistic.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4 Rationale: Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? 1. Increased respiratory rate from 12 breaths/min to 22 breaths/min 2. Decreased skin turgor on the clients posterior hand and forehand 3. Increased urine specific gravity from 1.012 to 1.030 g/mL 4. Decreased orthostatic light-headedness and dizziness

4 Rationale: The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? 1. Monitor daily hemoglobin and hematocrit values 2. Administer furosemide (Lasix) intravenously 3. Encourage the client to take deep breaths 4. Teach the client fall prevention measures

4 Rationale: The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) 1. Respiratory rate of 8 breaths/min 2. Absent deep tendon reflexes 3. Strong productive cough 4. Active bowel sounds 5. U waves present on the electrocardiogram (ECG)

4, 5 Rationale: A strong productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present of the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PaCO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3- 4. An increased pH and an increased HCO3-

4. An increased pH and an increased HCO3- Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90 mmHg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mmHg. In respiratory acidosis the pH is decreased and the PCO2 is elevated. The normal bicarbonate level is 21 to 28 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH=7.53, PaO2=72 mmHg, PaCO2=32 mmHg, and HCO3-=28 mEq/L. Which conclusion about the client should the nurse make? 1. The client has acidotic blood 2. The client is probably overreacting 3. The client is fluid volume overload 4. The is probably hyperventilating

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

A client has a serum Na level of 128 mEq/L and plasma osmolarity of 267. What are some potential causes of the client's altered lab findings? Select all that apply. a. Dehydration b. Hemorrhage c. SIADH (syndrome if inappropriate antidiuretic hormone secretion) d. Hypervolemia

C & D

A client with type 1 diabetes mellitus presents to the ER with a blood glucose of 525 mg/dL, thirst, BP 84/50 and HR of 120 bpm. Which type of fluid imbalance is this client likely experiencing? a. Isotonic dehydration b. Hypervolemia c. Third spacing d. Cellular dehydration

Cellular dehydration

Isotonic fluids cause shifting of fluid from extracellular space to the intracellular space. True or False

False

A client had a serum Na level of 128 mEq/L and a plasma osmolarity of 267. This client's plasma is: a. Isotonic b. Hypotonic c. Hypertonic

Hypotonic

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply) A. "The temperature around the IV site is cooler." B. "The rate of the infusion increases." C. "The skin at the IV site is red." D. "The IV dressing is damp." E. "The tissue around the venipuncture site is swollen."

a, d, e Rationale: A decrease in skin temperature around the site and a damp IV dressing is a common finding with infiltration due to the IV solution entering the subcutaneous tissue and leaking out through the venipuncture site. Swollen tissue around the venipuncture site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein.

Which of the following IV fluids is considered both isotonic and hypotonic? a. 0.9% sodium chloride b. lactated ringers c. 5% dextrose lactated ringers d. 5% dextrose in water

d

A client with type 1 diabetes and a blood glucose of 525 mg/dL will have plasma that is: a. Isotonic b. Hypertonic c. Hypotonic

b

A client with type 1 diabetes and a blood glucose of 525 mg/dL will need what type of IV fluid? a. 5% dextrose 0.9% sodium chloride (D5NS) b. 0.45% sodium chloride (1/2NS) c. 3% sodium chloride d. 5% dextrose lactated ringers (D5LR)

b

A client's serum Na level is 128 mEq/L and plasma osmolarity is 367. Which of the following IV fluids could potentially be ordered for this client? Select all that apply. a. 5% dextrose in water (D5W) b. 5% dextrose 0.9% sodium chloride (D5NS) c. 3% sodium chloride d. 0.45% sodium chloride (1/2NS)

b & c

A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) a. "I feel lightheaded." b. "I feel as though my heart is racing." c. "I feel a little short of breath." d. "The nurse technician told me that my blood pressure was 150 over 90." e. "I think my ankles are less swollen."

b, c, d Rationale: A manifestation of fluid overload is tachycardia due to the increased blood volume, which causes the heart rate to increase, and shortness of breath or dyspnea due to the increased amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen. Another manifestation of fluid overload is hypertension due to the increased blood volume, which causes the blood pressure to increase.

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." c. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

b. "I will insert the needle into the clients' skin at an angle of 10 to 30 degrees with the bevel up." Rationale: Use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein.

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hr has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? a. Notify the health care provider b. Place the client on oxygen c. Sit the client upright in bed d. Assess the client's lung sounds

b. Place the client on oxygen

The physician orders an isotonic IV fluid for a patient. Which fluid is NOT an isotonic fluid? a. 0.9% sodium chloride b. Lactated ringers c. 0.45% sodium chloride d. 5% dextrose 0.225% sodium chloride

c

Which condition below could lead to cell lysis if not properly monitored? a. Isotonicity b. Hypertonicity c. Hypotonicity

c

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? a. contact the primary health care provider b. document findings in the electronic health record c. change the IV site to a new location d. stop infusion of the drug

c. change the IV site to a new location

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? a. "I will leave the IV catheter in place after the client completes the course of IV antibiotics." b. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." c. "If my client needs to use the restroom, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." d. "I will replace any IV catheter when I suspect contamination during insertion."

d. "I will replace any IV catheter when I suspect contamination during insertion." Rationale: Replace IV catheters when suspecting any break in surgical aseptic technique (in emergency situations).

A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? a. Obtain a specimen for culture b. Apply a warm compress c. Administer analgesics d. Discontinue the infusion

d. Discontinue the infusion Rationale: The greatest risk to the client is further injury to the irritated vein. The first action is to stop the infusion and remove the catheter to prevent further harm.