Medsurg Exam #2
A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill
D; An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if appropriate) are assessments for circulation distal to the catheter site.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.
D; An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating
A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.
D; Bisphosphonates are used to treat hypercalcemia.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots`
D; Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce.
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch.
D; Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess and respond to this perfusion problem.
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection
D; Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies.
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.
D; Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter.
A nurse assesses a client who is prescribed furosemide for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
D; Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."
A; A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen.
A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography
A; A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation.
A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.
A; 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 caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? SATA a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses
A, B, C, E, F; Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia.
A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18 mmol/L). For which clinical signs and symptoms would the nurse assess? SATA a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau sign f. Flaccid paralysis
A, B, C; Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth.
A nurse is planning interventions that regulate acid-base balance to ensure that the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? SATA a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs f. Changes in GI tract excitability
A, B, D, F; Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs.
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? SATA a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification
A, B, D; The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label.
A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? SATA a. Include a review for the need of the device each day in the client's plan of care. b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.
A, B, D; The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.
A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? SATA a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances
A, B, E, F; Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances.
A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or technicians. What information does the RN consider when delegating components of IV therapy? SATA a. Each state's Nurse Practice Act will regulate who can perform care related to IVs. b. The nurse would check the facility's Policies and Procedures manual. c. The LPN's level of experience primarily guides the decision. d. Technicians cannot participate in any part of caring for IV infusions. e. The RN remains accountable for all aspects of IV care and delegated actions. f. The Infusion Nurses Society has guidelines and standards of IV therapy
A, B, E, F; The state Nurse Practice Act will have the information the RN needs to determine scope of practice, and in some states, LPNs and technicians are able to perform specific aspects of IV therapy. The nurse would also be familiar with facility policies and procedures regarding delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can have their knowledge and skills verified. The nurse remains accountable for all aspects of IV therapy include what has been delegated. The Infusion Nurses Society has published guidelines and standards related to competency for IV therapy.
A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? SATA a. Choose a distal site on the client's nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.
A, B, E; Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client's nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total.
A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? SATA a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.
A, C, D, E, F; Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? SATA a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration
A, C; Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? SATA a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG
A, E, F; Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia.
A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance would the nurse assess? SATA a. Positive Chvostek sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability f. Tetany
A, E; A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and anxiety and irritability.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.
A; Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia.
A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation
A; 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. The nurse responds by performing a thorough cardiovascular assessment.
A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider
A; In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy.
A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the primary health care provider.
A; Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency.
A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? a. "I don't need to manually calculate IV infusion rates with smart pumps." b. "Responding to IV pump alarms is a high priority for client safety." c. "The hospital can preprogram the pumps for high-alert drug limits." d. "These pumps have a system to prevent fluids from free-flowing into the client."
A; The "smarter" the pump is the more programming needs to occur and errors can happen and systems can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.
A; The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes.
While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"
A; The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys
A; This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide.
A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
A; This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client can breathe again normally, so oxygen administration will rapidly increase the PaO2.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? SATA a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics
B, C, D, E, F; Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium.
A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? SATA a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration
B, C, D, F; In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.
A nurse is planning care for a client who is lethargic and confused. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? SATA a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been participating in strenuous activity?" e. "Are you experiencing any shortness of breath?"
B, C, D; This client's symptoms of lethargy and confusion are related to a state of metabolic acidosis. The nurse would ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis. Excessive and strenuous activity can lead to overproduction of hydrogen ions.
A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? SATA a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis—older adult who is following a carbohydrate-free diet c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis—postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux disease
B, C, E; Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, but also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? SATA a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)
B, E; Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.
B; A PICC that is functioning well without inflammation or infection may remain in place for months. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic.
A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line.
B; A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used.
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.
B; All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.
A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman
B; 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 acute respiratory problem rather than a chronic problem, because no renal compensation has occurred. The client who would have these ABG values is the one with the new onset of airway obstruction.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.
B; At the first sign of phlebitis, the catheter will be removed and warm compresses used to relieve pain.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10
B; Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately.
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.
B; Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls.
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.
B; 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.
After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6pm so I won't have to get up at night."
B; One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss.
After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."
B; Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.
A diabetic client becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50, PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance? a. Atelectasis due to respiratory muscle fatigue b. Hyperventilation due to poor oxygenation c. Hypoventilation due to morphine PCA d. Kussmaul respirations due to glucose of 102 mg/ dL (5.7 mmol/ L)
B; The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by low partial pressure of arterial oxygen causing a compensatory mechanism of increased respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would cause respiratory acidosis with a low pH and high PaCO2.
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema
B; 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.
A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L). Which question would the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?
B; The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety.
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek sign
B; The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and Kussmaul respirations.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.
B; This 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.
A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? a. Furosemide 40 mg b. Sodium bicarbonate c. Mechanical ventilation d. Indwelling urinary catheter
B; This client's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client's acid-base balance as the pH is below 7.2 and the bicarbonate level is low.
After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? SATA a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)
C, D; A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.
A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.
C; A client with a critically high serum potassium level and cardiac changes would 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 would be administered with dextrose to prevent hypoglycemia.
A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.
C; A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?
After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."
C; Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis.
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure
C; Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."
C; One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability
A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching? a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device."
C; The nurse would actively engage the client in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing
D; The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment.
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.
D; The most important nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Client's with metabolic alkalosis have muscle weakness and are at risk for falling.
A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."
D; The nurse will ask the AP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry.
A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.
D; To protect the client's skin, the nurse will place a washcloth or the client's gown between the skin and tourniquet.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.
D; Upper extremity swelling could indicate infiltration, and the PICC will need to be removed.
