Term 4 Exam 1

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond?

"Diarrhea is expected; that's how your body gets rid of ammonia." The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant.

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first?

"I ran out of money and am cutting my insulin dose in half."

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching?

"I should eat plenty of fresh fruits and vegetables." The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?

"I take sodium bicarbonate after every meal to prevent heartburn." Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

"I will drink apple juice instead of orange juice for breakfast." Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy?

"I will take this medicine immediately before I eat." Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal.

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective?

"My blood became too acid because I lost some base in the diarrhea fluid." Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base.

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? ( Select all that apply. )

-Assess the client's level of consciousness. -Turn the client every two (2) hours. -Maintain intravenous fluids as ordered. -Place the client in the Fowler's position.

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as having the potential of causing complications of this disorder?

-Elevated international normalized ratio (INR) -Elevated serum ammonia -Elevated prothrombin time (PT)

Which findings indicate that a patient may have hypervolemia? (Select all that apply.)

-Increased, bounding pulse -Jugular venous distention -Presence of crackles -Elevated blood pressure -Skin pale and cool to touch

A patient with decompensated cirrhosis is at risk for which complications (Select all that apply.)

-Jaundice - Esophageal varices - Coagulation defects -Spontaneous bacterial peritonitis - Ascites

A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.)

-Moon face -Petechiae -Muscle atrophy

The nurse would identify which body systems as directly involved in the process of normal gas exchange? ( Select all that apply.)

-Neurologic system -Pulmonary system -Cardiovascular system

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? ( Select all that apply.)

-Oxygen saturation level is 98%. -Nail beds are pink with good capillary refill. -There is presence of quiet, effortless breath sounds at lung base bilaterally.

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? ( Select all that apply.)

-Tingling of fingertips -Numbness around mouth -Cramping in feet

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? ( Select all that apply.)

-Tremors -Nervousness -Profuse perspiration

Which signs and symptoms would the nurse expect to assess in a patient with metabolic acidosis? (Select all that apply.)

-kussmaul's respirations -warm flushed skin -Decreased bicarbonate

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

A patient with septicemia who has intercostal and suprasternal retractions This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Administering intravenous fluids through the AV fistula The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?

Assess the client's lung sounds The priority is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?

Consult the provider to test for ketoacidosis. The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath.

The nurse is reviewing the patient's arterial blood gas results. The PaO 2 is 96 mm Hg, pH is 7.20, PaCO 2 is 55 mm Hg, and HCO 3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient?

Disorientation and tremors The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?

Gentamicin (Garamycin) 60 mg IV Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?

Glasgow Coma Scale score is unchanged. A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?

Hemoglobin of 8.5 g/dL The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best?

Hold all medications since both cefazolin and vitamins are dialyzable. Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

A 56-year-old woman is admitted to the ED with a blood pressure of 168/92 and reports of fatigue and muscle weakness. She has bruising on her arms and 2+ swelling in her ankles.Her weight has gone from 150 to 185 lbs over the past 6 months. Assessment reveals that she has truncal obesity and thin extremities. Which diagnosis would the nurse expect?

Hypercortisolism (Cushing's disease)

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?

Institute fall precautions due to potential postural hypotension and weak leg muscles. Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?

Maintaining a balanced intake and output With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

The nurse associates which assessment finding in the diabetic patient with decreasing renal function?

Protein in the urine during a random urinalysis Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

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?

Metabolic alkalosis 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 assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect?

Mid-sternal chest pain Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin.

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?

Milk carton Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets.

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?

Obtain daily weights of the client. Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication.

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?

Oliguric renal disease When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond?

Once you start corticosteroids, you have to be weaned off them. One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone and adrenal production of cortisol. Decreasing hormone therapy slowly ensures self-production of hormone, not hormone effectiveness. Building the clients immune system and rebound inflammation are not concerns related to stopping high-dose corticosteroids.)

The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse's best action?

Positioning the head of the bed flat

The client is being weaned from a ventilator. Arterial blood gases drawn prior to extubation reveal pH is 7.32; PaO2 is 90 mmHg; PaCO2 is 56mmHg; HCO3 is 26 mEq/L? The nurse calls the healthcare provider with these results becasue they indicate that the client is in a state of:

Respiratory acidosis

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?

Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium

A patient recently had abdominal surgery. Which assessment data would support that the patient is experiencing a pulmonary embolus?

Sudden onset of chest pain with dyspnea

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

Teach the client fall prevention measures. 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.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

The patient's PaO2 is 45 mm Hg The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?

The patient's pulse oximetry indicates an O2 saturation of 91%.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?

Urine output via indwelling urinary catheter is 20 mL/hr Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr.

Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing's disease?

Wash hands frequently Cushing's syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland, or the adrenal cortex. Cushing's syndrome can also be caused by taking corticosteroids in the form of medication (such as prednisone) over time - referred to as exogenous Cushing syndrome.

The nurse is teaching a patient about performing PD at home. In order to identify the earliest manifestation of peritonitis, what does the nurse instruct the patient to do?

check the effluent for cloudiness

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis?

chronic lung disease with increased carbon dioxide retention Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

Adrenal gland hypofunction (Addison's disease) occurs due to inadequate secretion of which hormone?

cortisol and aldosterone

The nurse identifies which laboratory value as the usual indication of hepatic encephalopathy?

elevated ammonia level

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see?

pH low, PaCO2 high, HCO3- high Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3.