MEDSURG EXAM 1
The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 115 mEq/L 130 mEq/L 145 mEq/L 160 mEq/L
115 mEq/L Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 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.
A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings? Clammy skin, blood pressure 86/46, headache Confusion, respiratory rate 8 breaths/min, dry skin Blood pressure 188/120, nausea, vomiting Headache, blood pressure 90/54, dry skin
Clammy skin, blood pressure 86/46, headache Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.
A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer? 0.45% sodium chloride 0.9% sodium chloride 5% dextrose in water 5% dextrose in normal saline solution
Correct response: 0.45% sodium chloride Explanation: A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. An isotonic solution (0.9%) is not desirable as a supplement because it provides Na and CL.
Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.
Correct response: increased breathing effort and weight gain. Explanation: 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.
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? Dehydration Hypokalemia Hypocalcemia Hypomagnesemia
Hypocalcemia Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Similar causes are present in both conditions. Hypovolemia contains only low blood volume. In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies.
In dehydration, only extracellular is depleted. Explanation: 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.
What does the nurse recognize as one of the best indicators of the patient's renal function? BUN Serum creatinine Correct response: Serum creatinine
Serum Creatinine Creatinine is the end product of muscle metabolism. It is a better indicator of renal function than BUN because it does not vary with protein intake and metabolic state.
A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? free water loss diuretic use overhydration hyponatremia
free water loss Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.
Which condition might occur with respiratory acidosis? Increased intracranial pressure Decreased blood pressure Decreased pulse Mental alertness
increased intracranial pressure If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.
A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having? 11 mEq/L 5 mEq/L 2 mEq/L 1 mEq/L
Correct response: 5 mEq/L Explanation: Magnesium excess (>2.7 mEq/L) is associated with the following symptoms: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and cardiac arrest. The respiratory center is depressed when serum magnesium levels exceed 10 mEq/L (5 mmol/L). This is not present in this patient, so the magnesium level is unlikely to be 11 mEq/L. Coma, atrioventricular heart block, and cardiac arrest can occur when the serum magnesium level is greatly elevated and not treated.
Hypokalemia can cause which symptom to occur? Excessive thirst Increased release of insulin Production of concentrated urine Decreased sensitivity to digitalis
Correct response: Excessive thirst Explanation: 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.
Which of the following is a function of calcitonin? Select all that apply. Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones Decreases deposition of phosphorous in bones Decreases urinary excretion of phosphate
Correct response: Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW c. 0.45% NS d. 3% NS
Correct response: b. 5% DW Explanation: A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.
An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. An elevated hematocrit level A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine
Correct response: An elevated hematocrit level Electrolyte imbalance Explanation: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
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
Correct response: Light-headedness or paresthesia Explanation: 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? Endocrine system Gastrointestinal system Neurological system Musculoskeletal system
Correct response: Neurological system Explanation: 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.
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema. Administer the ordered furosemide 60 mg po. Monitor intake and output every shift. Administer the ordered potassium 40 mg IV push.
Correct response: Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Explanation: Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output.
The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? Suggest a fluid restriction. Encourage oral fluids. Remove the Hemovac. Offer a prescribed antiemetic medication.
Correct response: Offer a prescribed antiemetic medication. Explanation: When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Correct response: Serum sodium level of 124 mEq/L Explanation: 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.
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 hypercalcemia hypomagnesemia hypermagnesemia
Correct response: hypomagnesemia Explanation: 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.
