topics exam 1

symptoms of sinus tachycardia

dizziness, dyspnea, hypotension, angina

Prolonged PR interval & Widened QRS complexes

hypermagnesemia

U waves

hypokalemia

aystole

"flat line"

examples of hypertonic solutions

3% NaCl, D10W

Is a high pCO2 consistent with acidosis or alkalosis?

Acidosis

treatment of ventricular fib.

CPR with defibrillation

treatment of A. Fib.

calcium channel blockers, anticoagulation therapy, conversion Tx, ablation

A patient has recently been diagnosed with hypernatremia. Which of the following is not associated with hypernatremia? A: Hypotension B: Tachycardia C: Pitting edema D: Weight gain

(A) Hypotension would be associated with hyponatremia.

A nurse is caring for an adult that has recently been diagnosed with respiratory alkalosis. Which of the following clinical signs would most likely not be present? A: Anxiety attacks B: Dizziness C: Hyperventilation cyanosis D: Blurred vision

(C) Hyperventilation cyanosis is associated with respiratory acidosis.

A patient has recently been diagnosed with hyponatremia. Which of the following is not associated with hyponatremia? A: Muscle twitching B: Anxiety C: Cyanosis D: Sticky mucous membranes

(D) Stick mucuous membranes are associated with hypernatremia.

examples of hypotonic solutions

0.45% NaCl, 2.5% dextrose in H2O

A patient has a respiratory rate of 20. The nurse calculates this patient's minute ventilation to be: 1. 10 L/min 2. 5 L/min 3. 2 L/min 4. 1 L/min

1. 10 L/min Rationale: The amount of ventilation is generally quantified by how much air the lungs move in one minute, referred to as the minute ventilation. Minute ventilation is the product of respiratory rate and depth, referred to as the tidal volume. Normal resting respiratory rate is about 12 breaths per minute. Normal resting tidal volume is about 500 mL. This yields a normal minute ventilation of 6 L/min: 12 breaths/min x 500mL = 6,000 mL or 6 L. This patient's respiratory rate is 20 breaths per minute. The minute ventilation would be 10 L/min

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? 1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L. 2. A client with renal failure who has a serum magnesium level of 3.0 mEq/L. 3. A client who has experienced a fracture of the femur and has a serum phosphate level of 5.0 mg/dL. 4. A client with dehydration who has a serum sodium level of 128 mEq/L.

1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L. Rationale: Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience low chloride levels, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dL is elevated. Normal serum phosphate level is 2.8 to 4.5 mg/dL. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium level is

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? 1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L. 2. A client with renal failure who has a serum magnesium level of 3.0 mEq/L. 3. A client who has experienced a fracture of the femur and has a serum phosphate level of 5.0 mg/dL. 4. A client with dehydration who has a serum sodium level of 128 mEq/L.

1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L. Rationale: Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience low chloride levels, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dL is elevated. Normal serum phosphate level is 2.8 to 4.5 mg/dL. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium level is 135 to 145 mEq/L.

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? 1. Absent patellar reflex 2. Diarrhea 3. Premature ventricular contractions 4. Increase in blood pressure

1. Absent patellar reflex Rationale: An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension

Which of the following assissment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? 1. Deep tendon reflexes decreasing from +2 to +1 2. Bicarbonate rising from 20 mEq/L to 22 mEq/L 3. Urine pH of less than 6 4. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

1. Deep tendon reflexes decreasing from +2 to +1 Rationale: A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening in diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular spaces.

A patient is admitted to the hospital with a fluid volume excess. Which of the following will the nurse most likely assess for this patient? 1. Depedent edema 2. Heart rate 86 bpm without ectopy 3. Respiratory rate 14 breaths per minute and unlabored 4. Blood pressure - 92/55

1. Dependent edema Rationale: With fluid volume excess, the patient would likely show dependent edema, an increased blood pressure, decreased urine output, shortness of breath, and adventitious sounds. An example of this condition would be a patient with CHF.

The nurse is providing discharge instructions to a patient with hypokalemia. Whcih of the following should the nurse include in these instructions? 1. Eat a balanced diet, including tomato juice and potatoes 2. Take oral Kaexylate as prescribed 3. Limit the intake of spinach and carrots 4. Expect muscle cramps and weakness for at least six weeks

1. Eat a balanced diet, including tomato juice and potatoes Rationale: Discharge teaching of patient/family in regard to hypokalemia includes properly taking potassium supplements such as K-Dur. In addition, increasing potassium rich foods in the diet and recognizing/reporting increased muscle weakness are critical teaching points. Kaexylate enemas are used for hyperkalemia, thus would not be an appropriate measure.

The nurse is caring for a patient with severe vomiting and diarrhea and a NG tube to low wall suction. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances? 1. Hypokalemia 2. Hypophosphatemia 3. Hypercalcemia 4. Hypermagnesemia

1. Hypokalemia Rationale: Diarrhea may increase excretion of potassium to 200 mEq/day. Vomiting/NG tube suction can increase the loss through GI fluids removed. Typical circumstances leading to hypocalcemia include primary hyperparathyroidism, bone malignancy, and drug toxicity. Hypermagnesemia is often associated with renal failure. Hypeophosphatemia is caused by vitamin D deficiency, bowel disorders that lead to malabsorption, excessive use of phosphate-binding antacids, alcoholism, or diabetic ketoacidosis.

The nurse is caring for a patient with pneumonia who has ABG values of: pH 7.20, PaCO2 75, PaO2 44. Which of the following would be a priority for this patient? 1. Placement of the patient in high-Fowler's position 2. Assisting the patient to breathe into a paper bag 3. Preparing to administer Sodium Bicarbonate IV 4. Administration of the prn sedative available

1. Placement of the patient in high-Fowler's position Rationale: The patient is in respiratory acidosis. The main treatment for respiratory acidosis is correction of the underlying disorder that led to its development. for a patient with pneumonia, this would include antibiotic therapy, improving oxygenation, and management of fever. Placing the patient in high-Fowler's position will improve air flow. Breathing into a paper bag and/or giving a sedative are indications for respiratory alkalosis. Sodium bicarbonate administered intravenously is a controversial treatment for metabolic acidosis.

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of 1. acute renal failure 2. malabsorption syndrome 3. nasogastric drainage 4. laxative abuse

1. acute renal failure Rationale: A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndome, nasogastric drainage, and laxative abuse may result in low serum potassium levels because output may be greater than input. Diarrhea results from malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L

The nurse is reviewing a patient's arterial blood gas results. Which of the following values should the nurse study first? 1. pH 2. PaCO2 3. compensation 4. HCO3

1. pH Rationale: The steps to analyze an ABG result are as follows: Step 1: Assess the pH Step 2: Assess the PaCO2 Step 3: Assess the bicarbonate and the base excess Step 4: Evaluate compensation

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse interpret this rhythm? 1.Sinus tachycardia 2.Sinus dysrhythmia 3.Sinus bradycardia 4.Normal sinus rhythm

2) Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? 1. D5.45 NS at 50 ml/hr 2. 0.9 NS at an open rate 3. D5W at 125 ml/hr 4. 0.45 NS at open rate

2. 0.9 NS at an open rate Rationale: A client who recently had surgery is vomiting, becomes dizzy when standing up, has a bp of 55/30 and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? 1. A client with osteoporosis taking vitamin D and calcium supplements. 2. A client who is alcoholic receiving total parenteral nutrition. 3. A client with chronic renal failure awaiting the first dialysis run. 4. A client with hypoparathyroidism secondary to thyroid surgery.

2. A client who is alcoholic receiving total parenteral nutrition. Rationale: Alcoholics and clients receiving TPN are at risk for low phosphorus levels due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose. A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis and a client wiht hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: 1. Sinus tachycardia 2. Atrial fibrillation 3. Ventricular tachycardia 4. Ventricular fibrillation

2. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? 1. Deficient fluid volume related to decreased fluid intake. 2. Excess fluid volume related to increased water retention. 3. Deficient fluid volume related to excessive fluid loss. 4. Risk for injury related to fluid volume loss.

2. Excess fluid volume related to increased water retention. Rationale: The client exhibits signs of excess fluid volume. SIADH is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? 1. Hypernatremia 2. Hypocalcemia 3. Hypokalemia 4. Hyperkalemia

2. Hypocalcemia Rationale: Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dL.

A patient is admitted with the diagnosis of diabetic ketoacidosis. The nurse realizes that this patient's body will attempt to attain acid-base balance by: 1. Decreasing the reabsorption of bicarbonate 2. Increasing the secretion of hydrogen ions 3. Decreasing its respiratory rate 4. Increasing the reabsorption of hydrogen gas

2. Increasing the secretion of hydrogen ions Rationale: The main metabolic acids are lactic acid, pyruvic acid, ketoacids seen in diabetic acidosis, acetoacetic acid, and beta-hydroxybutyric acid. These acids are eliminated by the kidneys or are metabolized by the liver. The capacity for elimination of these metabolic acids is much lower than that of the lungs. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ion and conserve bicarbonate to correct the pH.

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? 1. withhold furosemide (Lasix) 2. Notify the physician 3. Administer the prescribed potassium supplement 4. Instruct the client on foods high in potassium

2. Notify the physician Rationale: The priority intervention for this client would be to notify the physician of the low potassium level. After this, the furosemide may be withheld and a potassium supplement administered as prescribed and may even be increased after talking with the physician. The client may also be instructed on foods high in potassium. These are all appropriate interventions, but not the priority.

A male patient's hematocrit is 56% with serum sodium of 150 mEq/L and potassium of 5.8 mEq/L. Which of the following would be indicated for this patient? 1. Prepare to administer a hypertonic intravenous solution 2. Prepare to administer a hypotonic intravenous solution 3. Implement a fluid and sodium restriction for the patient. 4. Prepare to administer an isotonic intravenous solution.

2. Prepare to administer a hypotonic intraveous solution Rationale: This patient is dehydrated, as evidenced by the elevated hemoglobin and serum sodium and potassium levels. The nurse would prepare to administer a hypotonic solution, which has a lower osmolality to hydrate the patient. A hypertonic solution would exacerbate the dehydration and would not be indicated. An isotonic intravenous solution has the osmolality of blood and would most likely not serve to rehydrate the patient very effectively. This patient is dehydrated, so a sodium and fluid restriction would be detrimental to this patient's care.

A patient is admitted in respiratory acidosis secondary to barbituate overdose. Which of the following will the nurse most likely assess in this patient? 1. Kussmaul's respirations 2. Slow, shallow respirations 3. Increased deep tendon reflexes 4. Seizures

2. Slow, shallow respirations Rationale: Whenever excretion of CO2 via the lungs fails to keep up with the body's CO2 production, such as with drug overdose, respiratory acidosis will occur. Kussmaul respirations (rapid, deep breaths) occur with metabolic acidosis, seizures are associated wtih respiratory alkalosis, and hyperreflexia is a symptom of metabolic alkalosis.

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the implement first? 1. Notify the health-care provider immediately. 2. Tap the cheek about two (2) cm anterior to the ear lobe. 3. Check the serum calcium and magnesium levels. 4. Prepare to administer calcium gluconate IVP.

2. These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the HCP should be notified immediately because hypocalcemia is a medical emergency. - The HCP may need to be notified, but the nurse should perform assessment first. - A positive Chvostek's sign can indicate a low calcium or magnesium level, but serum lab levels may have been drawn hours previously or may not be available. - If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment. TEST-TAKING HINT: Assessment is the first step in the nursing process and is an appropriate option to select if the test taker has difficulty when trying to decide between two options

A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block? 1.Presence of Q waves 2.Tall, peaked T waves 3.Prolonged PR interval 4.Widened QRS complex

3) A prolonged PR interval indicates first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? 1. "The fluid is an adverse reaction ot the chemotherapy." 2. "A decrease in activity has allowed extra fluid to accumulate in the tissues." 3. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." 4. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

3. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." Rationale: Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

An older client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating 1. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." 2. "Most older adults get confused in the hospital." 3. "The sodium level is low, and the confusion will resolve as the levels normalize." 4. The sodium level is high and the behavior is a result of dehydration."

3. "The sodium level is low, and the confusion will resolve as the levels normalize." Rationale: Normal serum sodium is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

the nurse evaluates which of the following clients to have hypermagnesemia? 1. A client who has chronic alcholism and a magnesium level of 1.3 mEq/L. 2. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L. 3. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L. 4. A client who has CHF, takes a diuretic, and has a magnesium level of 2.3 mEq/L.

3. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L. Rationale: A normal serum magnesium level is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has CHF, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within normal range.

The nurse is caring for a patient with metabolic acidosis. The nurse realizes that which of the following laboratory values might be altered for this patient? 1. Prothrombin 2. Creatinine 3. Ammonia 4. Blood-urea-nitrogen

3. Ammonia Rationale: In the face of a high load of metabolic acids, the kidneys also increase their production of the urinary buffer, ammonia. Under normal circumstances, ammonia excretion is about 30 mmol/day, or about 0.5 mmol/kg. this excretion can increase to about 280 mmol/day, but this response takes several days to be completed.

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? 1. Turn down the infusion. 2. Check the latest sodium level 3. Assess for signs of fluid overload 4. Place a call to the physician

3. Assess for signs of fluid overload. Rationale: A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix) and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. 1. Administer an antiemetic prior to giving the digoxin 2. encourage the client ot increase fluid intake 3. call the physician 4. Report the urine output 5. report indications of nausea 6. monitor continuous ECG for peaked T waves and widened QRS

3. Call the physician 4. Report the urine output 5. Report indications of nausea Rationale: Potassium is lost during diuresis wiht a loop diuretic such as furosemide. Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia. Normal serum potassium levels are 3.5 to 5.5 mEq/L.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? 1. Immediately defibrillate 2. Prepare for pacemaker insertion 3. Administer amiodarone (Cordarone) intravenously 4. Administer epinephrine (Adrenaline) intravenously

3. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.

A patient's blood pH is decreasing. The nurse realizes that this patient's hydrogen ion concentration is 1. Decreasing 2. Stabilizing 3. Increasing 4. Being affected by oxygen concentration

3. Increasing Rationale: Blood pH is inversely proportional to hydrogen ion concentration. The hydrogen ion is the smallest ionic particle and it is extremely reactive. The hydrogen ion combines with alkali/bases or other negatively charged ions at low concentrations.

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

3. Metabolic alkalosis Rationale: Clients on gastric suctioning can lose hydrogen ions, (acid) resulting in a metabolic alkalosis.

A registered nurse is delegating nursing tasks for the day. Which of the following tasks may the nurse delegate to a licensed practical nurse? 1. Assess a client for metabolic acidosis 2. Evaluate the blood gases of a client with respiratory alkalosis 3. Obtain glucose level on a client admitted with diabetes mellitus 4. Perform a neurological assessment on a client suspected of having hypocalcemia.

3. Obtain glucose level on a client admitted with diabetes mellitus Rationale: A licensed practical nurse may obtain a finger stick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological ssessment on a client suspected of hypocalcemia.

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention? 1. Administer a sedative 2. Place client in left lateral position 3. Place client in high-Fowler's position 4. Assist the client to breathe into a paper bag.

3. Place the client in a high-Fowler's position. Rationale: The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help th eclient blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? 1. pH of 7.43, PCO2 of 36, HCO3 of 26 2. pH of 7.41, PCO2 of 49, HCO3 of 30 3. pH of 7.33, PCO2 of 35, HCO3 of 17 4. pH of 7.25, PCO2 of 56, HCO3 of 28

3. pH of 7.33, PCO2 of 35, HCO3 of 17 Rationale: A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? 1. pH of 7.43, PCO2 of 36, HCO3 of 26 2. pH of 7.41, PCO2 of 49, HCO3 of 30 3. pH of 7.33, PCO2 of 35, HCO3 of 17 4. pH of 7.25, PCO2 of 56, HCO3 of 28

3. pH of 7.33, PCO2 of 35, HCO3 of 17 Rationale: A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates that serum calcium is low? 1. bone pain 2. depressed deep tendon reflexes 3. positive Chvostek's sign 4. nausea

3. positive Chvostek's sign Rationale: Numbness and tingling around the mouth indicates hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea and depressed deep tendon reflexes are signs of hypercalcemia.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hrs to increase renal ouput and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determine that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

4 Circulatory (fluid) overload is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure also increases. Hematoma is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and decreased level of conciousness. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia.

The nurse is providing discharge instructions to a patient with respiratory alkalosis. Which of the following statements indicates the patient understands the instructions? 1. "I will call my MD the next time I have diarrhea for a few days." 2. "I will not use Mylanta 5-6 times a day like I used to." 3. "I will not take my Lasix without a potassium supplement." 4. "I will take a stress management class or seek counseling."

4. "I will take a stress management class or seek counseling." Rationale: Respiratory alkalosis is characterized by a lower than normal PaCO2 accompanied by an elevated pH. Respiratory rate is a major determinate of the PACO2 level. Excessively fast or deep ventilation "blows off" the carbon dioxide, decreasing the level and increasing the pH causing alkalosis. Psychological conditions such as anxiety and panic or severe pain can also cause overventilation. Patients with psychological hyperventilation syndromes should benefit from reassurance and methods to decrease stress.

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? 1. A client with osteoporosis and a calcium level of 10.6 mg/dL. 2. A client with renal failure and a magnesium level of 2.5 mEq/L. 3. A client with bulimia and a potassium level of 3.6 mEq/L. 4. A client with dehydration and a sodium level of 149 mEq/L.

4. A client with dehydration and a sodium level of 149 mEq/L. Rationale: Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated. Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dL is normal. Normal serum calcium is 9 to 11 mg/dL. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal. Normal serum potassium is 3.5 to 5.5 mEq/L.

A client with chronic renal failure reports a 10 lb weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dL. Which of the following would be the first nursing action? 1. Assess for depressed deep tendon reflexes. 2. Call the physician to report calcium level 3. Place and intravenous catheter in anticipation of administering calcium gluconate 4. Check to see if a serum albumin level is available

4. Check to see if a serum albumin level is available. Rationale: A client with chronic renal failure who reports a 10lb weight loss over 3 months and has had difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing and IV is not a priority action. Depressed reflexes are a sign of hypercalcemia or hypermagnesemia. Normal serum calcium is 9 to 11 mg/dL.

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? 1. Sodium is essential to maintain intracellular fluid water balance 2. Magnesium is essential to the function of muscle, red blood cells, and nervous system. 3. Less calcium is excreted with aging. 4. Chloride is lost in hydrochloride acid.

4. Chloride is lost through hydrochloride acid. Rationale: Chloride is lost through hydrochloride acid. Sodium is essential to maintain extracellular fluid water balance. Phosphate is the major anion in intracellular fluid water balance that is essential in function of muscle, red blood cells, and nervous system. A person tends to excrete more calcium as they age.

The nurse, admitting a patient with diabetes, believes the patient is attempting to correct an acidotic condition. Which of the following did this nurse most likely observe while assessing this patient? 1. Intact extraocular movements 2. Change in level of consciousness 3. Slow methodical respirations 4. Deep, rapid respirations

4. Deep, rapid respirations Rationale: In a state of metabolic acidosis, such as that which exists during diabetic ketoacidosis, the medullary centers will stimulate the lungs to increase the minute ventilation to blow off CO2, even if that level is normal. These rapid, deep respirations, referred to as Kussmaul's respirations, are an attempt to correct the arterial pH by decreasing respiratory acid. This process is referred to as compensation.

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen via nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? 1. Call the physician and report the change in client's condition. 2. Turn the client's O2 up to 4 liters via nasal cannula 3. Encourage the client to sit down and to take deep breaths 4. Encourage the client to rest and to use pursed-lip breathing technique.

4. Encourage the client to rest and to use pursed-lip breathing technique. Rationale: Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

The nurse assesses a client to be experiencing muscle cramps, numbness and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. The nurse reports this assessment as consistent with which of the following? 1. Hypokalemia 2. Hypernatremia 3. Hypermagnesemia 4. Hypocalcemia

4. Hypocalcemia Rationale: Normal serum calcium is 9 to 11 mg/dL. A client who has hypocalcemia would experience muscle cramps, numbess, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypoparathyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? 1. Sodium 2. Phosphorus 3. Calcium 4. Magnesium

4. Magnesium Rationale: Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? 1. Encourage the client to increase fluid intake 2. Administer the dose as ordered 3. Draw a potassium level and administer the dose if the level is low or normal. 4. Notify the physician of the urine output and hold the dose.

4. Notify the physician of the urine output and hold the dose Rationale: Urine output is an indication of renal function. Normal urine output is at least 30 ml/hr. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician's order.

The nurse is caring for a patient in renal failure with a serum potassium level of 7.1 mEq/L. Which of the following should the nurse do first to assist this patient? 1. Have ABGs drawn 2. Assess level of consciousness 3. Measure urine output hourly 4. Obtain electrocardiogram

4. Obtain electrocardiogram Rationale: Obtaining an electrocardiogram is of priority, as serum potassium levels greater than 6.0 mEq/L can be life-threatening due to a decreased ability of the heart to repolarize, as evidenced by tented T-wave, loss of P-wave, and wide, bizarre QRS with a depressed ST segment. Evaluating the level of consciousness would be associated with hyponatremia; measuring urine output hourly would be fruitless for a patient with renal failure, and the ABGs, although likely abnormal, would not serve as a priority intervention.

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? 1. Monitor intake and output 2. encourage the client to increase activity 3. institute deep breathing exercises every hour 4. provide reassurance to the client and administer sedatives

4. Provide reassurance to the client and administer sedative Rationale: A client who is anxious and upset, gets lightheaded, and has tingling in the fingers and the indicated ABGs is in respiratory alkalosis. Administering a sedative will help the client to breathe slowly and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? 1. Monitor intake and output 2. encourage the client to increase activity 3. institute deep breathing exercises every hour 4. provide reassurance to the client and administer sedatives

4. Provide reassurance to the client and administer sedative Rationale: A client who is anxious and upset, gets lightheaded, and has tingling in the fingers and the indicated ABGs is in respiratory alkalosis. Administering a sedative will help the client to breathe slowly and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

The nurse is caring for a patient and has just received the laboratory data report. Which of the following results would cause the most concern to the nurse? 1. Magnesium of 2.0 mg/dL 2. Potassium of 4.0 mEq/L 3. Calcium of 9 mg/dL 4. Sodium of 115 mEq/L

4. Sodium of 115 mEq/L Rationale: Of the four electrolytes presented, the sodium is out of range. Normal values for sodium are 135-145 mEq/L. Normal values for potassium are 3.5 to 5.5 mEq/L Normal values for calcium are 9 to 11 mg/dL Normal values for magnesium are 1.5 to 2.5 mEq/L

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? 1. 50-year-old with pneumonia, diaphoresis, and high fevers 2. 62-year-old with congestive heart failure taking loop diuretics 3. 39-year-old with diarrhea and vomiting 4. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

50-year-old with pneumonia, diaphoresis, and high fevers Rationale: Diaphoresis and high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomitting cause both sodium and water losses. Clients with SIADH have hyponatremia due to increased water reabsorption in the renal tubules.

What is the rate of normal sinus rhythm?

60-100

HCO3 acidosis level

< 22

PaCO2 alkalosis level

< 35

acidosis pH

< 7.35

HCO3 alkalosis level

> 26

PaCO2 acidosis level

> 45

alkalosis pH

> 7.45

Ventricular rate

?

For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

A. Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A.Prolonged bed rest B.Renal insufficiency C.Hyperparathyroidism D.Excessive ingestion of vitamin D

A. Prolonged bed rest

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: A. The skin B. Urinary output C. Wound drainage D.The gastrointestinal trac

A. The skin Rational: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and lungs.

A client who has hypertension asks the nurse why a urine sample is needed. The nurse informs the client it is to check for a. Protein, which may indicate the kidneys are affected b. Illegal drugs, which may have caused the hypertension c. Infection, which may cause the blood pressure to rise d. The appropriate drug level of the antihypertensive medication

A: protein

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A.The client in normal sinus rhythm with a peaked T wave. B.The client diagnosed with atrial fibrillation with a rate of 100. C.The client diagnosed with a myocardial infarction who has occasional PVC. D.The client with a first-degree AV block and a rate of 92.

Answer: 1 1. A client with a peaked wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability. -Fluctuations in rate are expected in clients diagnosed with atrial fibrillation, and a heart rate of 100 is at the edge of a normal rate. -Most people experience an occasional premature ventricular contraction (PVC); this would not warrant the nurse assessing this client first. - A first-degree block is not an immediate problem. TEST-TAKING HINT: The test taker must know the normal data so that the abnormal will be apparent. Normal heart rate is 60-100. The nurse should assess the client who has an abnormal or life-threatening condition.

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume deficit? 1) A client with a colostomy 2) A client with congestive heart failure 3) A client on long term corticosteroid therapy 4) A client receiving frequent wound irrigations

Answer: 1 Rational: A fluid volume deficit occurs when the fluid intakes is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, is at risk for fluid volume excess

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? 1) U waves 2) Absent P waves 3) Elevated T waves 4) Elevated ST segment

Answer: 1 Rational: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noting in a client with atrial fibrillation (A-fib).

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1) The client taking diuretics 2) The client with renal failure 3) The client with and ileostomy 4) The client who requires gastrointestinal suctioning

Answer: 2 Rational: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, congestive heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform? 1. Measure the client's output from the indwelling catheter. 2. Record the client's intake and output on the I & O sheet. 3. Instruct the client on appropriate fluid restrictions. 4. Provide water for a client diagnosed with diabetes insipidus.

Answer: 3 1. An assistant can empty the catheter and measure the amount. 2. The assistant can record intake and output on the I & O sheet. 3. The nurse cannot delegate teaching. 4. The client has a disease, but all the assistant is being asked to do is take water to the client. TEST TAKNING HINT: This is an example of an "except" question. Frequently questions ask which tasks can be assigned to the assistant, but this question asks which action the nurse should implement. If the test taker does not read carefully, it is easy to jump to the first option for actions that the assistant can perform

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? 1. The kidneys produce excess urine and the lungs try to compensate. 2. The respirations increase the amount of carbon dioxide in the bloodstream. 3. The lungs speed up to release carbon dioxide and increase the pH. 4. The shallow and slow respirations will increase the HCO3 in the serum

Answer: 3 1. Kussmaul's respirations are the lung's attempt to maintain the narrow range of pH that is compatible with human life. The respiratory system reacts rapidly to changes in pH. 2. Respiration is the act of moving oxygen and carbon dioxide. Kussmaul's respirations are rapid and deep and allow the client to exhale carbon dioxide. 3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid). 4. HCO3 (sodium bicarbonate) is an alkaline (base) substance that is a metabolic buffer system, not a respiratory system buffer. The excretion and retention of sodium bicarbonate is regulated by the kidneys; therefore, it is a metabolic buffer system. The excretion and retention of carbon dioxide (CO2) are regulated by the lungs and therefore is a respiratory buffer system, TEST-TAKING HINT: Homeostasis is a delicate balance between acids and bases. The test taker can discard option "1" by realizing that production of urine does not affect the respirations.

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A.Weight loss B.Flat neck and hand veins C.An increase in blood pressure D.A decreased central venous pressure (CVP)

Answer: 3 Rational: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid colume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Options 1, 2, and 4 identify signs noted in fluid volume deficit.

A nursing students needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? 1) Obtaining a controlled intravenous (IV) infusion pump 2) Monitoring urine output during administration 3) Preparing the medication for bolus administration 4) Diluting the medication in appropriate amount or normal saline

Answer: 3 Rational: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump or controller. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this types of solution increases intracellular potassium shifting. The IV site is monitored closely because the potassium chloride is irritating to the veins and there is a risk of phlebitis. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr.

A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? 1) Widened T wave 2) Prominent U wave 3) Prolonged QT interval 4) Shortened ST segment

Answer: 3 Rational: The normal serum calcium level is 8.6 - 10.2. A serum calcium level lower than 8.6 indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? 1. Serum calcium. 2. Serum phosphorus. 3. Serum potassium. 4. Serum sodium.

Answer: 3 (potassium) 1. Serum calcium is decreased in conditions such as osteoporosis or post-thyroid surgery, but not in vomiting and diarrhea. 2. Serum phosphorus levels are altered in acute and chronic renal failure or diabetic ketoacidosis, among other conditions, but not with acute fluid losses from the gastrointestinal tract. 3. Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias. 4. The body is not at risk from losing sodium from these sources as it is with potassium. TEST-TAKING HINT: The nurse must recognize basic fluids and electrolytes in the body and the implications of excess or loss. The body holds onto sodium and releases potassium.

A nurse caring for for a client who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1) Lung congestion 2) Decreased hematocrit 3) Increased blood pressure 4) Decreased central venous pressure (CVP)

Answer: 4 Rational: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weigh loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with fluid volume excess

A nurse caring for a group of clients reviews the electrolytes laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is a highest risk for developing a potassium value at this level? 1) The client with colitis 2) The client with Cushing's syndrome 3) The client who has been overusing laxatives 4) The client who has sustained a traumatic burn

Answer: 4 Rational: A serum potassium level higher than 5 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis are at risk for hyperkalemia. the client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

A nurse caring for a client with hypoKalcemia would expect to note which of the following changes on the electrocardiogram? A.Widened T wave B.Prominent U wave C.Prolonged QT interval D.Shortened ST segment

Answer: A Rational: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noting in a client with atrial fibrillation (A-fib).

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A.Twitching B. Negative Trousseau's sign C.Hypoactive bowel sounds D.Hypoactive deep tendon reflexes

Answer: A Rational: The normal serum calcium level is 8.6 - 10.2. A serum calcium level lower than 8.6 indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes and a positive Trouseau's or Chvosteck's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: A. Has renal failure. B. Requires nasogastric suction. C. Has a history of Addison's disease. D. Is taking a potassium-sparing diuretic.

Answer: B Rational: The normal serum potassium level is 3.5 mEq/L to 5 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal section, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A. Urine output. B. Blood pressure. C. Bowel movements. D. ECG for tall, peaked T waves.

C. Bowel movements. Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

A nurse is caring for an adult that has recently been diagnosed with metabolic acidosis. Which of the following clinical signs would most likely not be present? A: Weakness B: Dysrhythmias C: Dry skin D: Malaise

B

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm? a. Sinus tachycardia b. Ventricular fibrillation c. Ventricular tachycardia d. Premature ventricular contractions (PVCs)

B Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options has a recognizable complex that appears on the monitoring screen

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A. D5.45 NS at 50 ml/hr B. 0.9 NS at an open rate C. D5W at 125 ml/hr D. 0.45 NS at open rate

B. 0.9 NS at an open rate A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? A. Sinus tachycardia B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

B. Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

What is the most common ECG abnormality in patients with a pulmonary embolism (PE)? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular ectopy D. Sinus bradycardia E. High grade AV block

B. Sinus tachycardia In most cases, sinus tachycardia is the only abnormality in patients with a PE. You may also find some ECGs that will have non-specific ST-T wave changes. Sinus bradycardia and AV blocks are not common findings that are associated with PE.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? A. Defibrillation B. Synchronized cardioversion C. Automatic external defibrillator (AED) D. Implantable cardioverter-defibrillator (ICD)

B. Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A.Request a physical therapy consult from the physician B.Ensure the client is safe from falls and check the most recent potassium level C.Allow uninterrupted rest periods throughout the day D.Encourage the client to increase intake of dairy products and green leafy vegetables.

B.Ensure the client is safe from falls and check the most recent potassium level Rationale: In the treatment of diabetic ketoacidosis the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

Which part of the blood gas report is used as a guide by clinicians as they consider how much bicarbonate to administer to a patient with a severe metabolic acidosis?

Base excess

How is the anion gap calculated?

By subtracting the sum of the chloride and bicarbonate levels from the sodium level. Reference range is 8 to 16 mEq.

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician

C. Assess for signs of fluid overload A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next

If the pH is high and the bicarbonate is high, what is the diagnosis?

Metabolic alkalosis

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin B. Encourage the client to increase fluid intake C. Call the physician D. Report the urine output E. Report indications of nausea

C. Call the physician D. Report the urine output E. Report indications of nausea Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A.Overhydration. B.Anemia. C.Dehydration. D.Renal failure.

C. Dehydration WHY?

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-Fowler's position D. Assist the client to breathe into a paper bag

C. Place client in high-Fowler's position The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? A.Tap water B.Sterile water C.Sodium chloride D.Distilled wate

C. Sodium chloride

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? A. Unmeasurable rate and rhythm B. Rate 150 beats/min; inverted P wave C. Rate 200 beats/min; P wave not visible D. Rate 125 beats/min; normal QRS complex

C. VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? A. Administer 250 mL of 0.9% saline solution IV by rapid bolus. B. Assess the apical pulse, blood pressure, and bilateral neck vein distention. C. Turn the synchronizer switch to the "off" position and recharge the device. D. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

C. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

A nurse is caring for an adult that has recently been diagnosed with hypokalemia. Which of the following clinical signs would most likely not be present? A: Leg cramps B: Respiratory distress C: Confusion D: Flaccid paralysis

D

A nurse is caring for an adult that has recently been diagnosed with metabolic alkalosis. Which of the following clinical signs would most likely not be present? A: Vomiting B: Diarrhea C: Agitation D: Hyperventilation

D

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A. Bisacodyl (Dulcolax) suppository B. Fiber supplements C. Docusate sodium D. Milk of magnesia

D. Milk of magnesia Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A.Encourage fluids orally. B.Administer 10% saline solution IVPB. C.Administer antidiuretic hormone intranasally. D.Place on seizure precautions.

D.Place on seizure precautions. WHY?

examples of isotonic solutions

D5W, 0.9% NS; NaCl, LR, Ringer's

What are the causes of hypernatremia?

Deficit of water relative to sodium caused by excessive sweating and diabetes mellitus.

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A.Prominent U waves B.Prolonged PR interval C.Depressed ST segment D.Widened QRS complexes

Depressed ST segment Rationale: The normal magnesium level is 6 to mg/dL. A magnesium level of 0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options B and D would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. Test-Taking Strategy: First, you must determine that the client is experiencing hypomagnesemia. Next, identify the electrocardiographic changes that occur in this condition. If you had difficulty with this question, review the normal magnesium level and the electrocardiographic changes that occur in hypomagnesemia and hypermagnesemia.

What must be done before hypokalemia can be corrected?

Hypomagnesemia must be corrected

What are the symptoms of hyponatremia?

Lethargy, headache, personality changes, seizures. Permanent brain damage below 115 mEq/L

9. The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A.Provide passive ROM exercises and encourage fluid intake B.Teach the client to increase intake of whole grains and nuts C.Place a tracheostomy tray at the bedside D.Administer calcium gluconate IM as ordered

Provide passive ROM exercises and encourage fluid intake A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A.Call the physician and report results B.Question the results and redraw the specimen C.Encourage the client to increase the intake of bananas D.Initiate seizure precautions

Question the results and redraw the specimen Rationale: A client who has been healthy up to the present is admitted for cellulitis of the hand. When the serum potassium goes from 4.5 to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of the hemolysis of the specimen. The physician would likely question the results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

If pH is high and pCO2 is low, what is the diagnosis?

Respiratory alkalosis

What are the symptoms of hypernatremia?

Thirst, low grade fever, edema, altered mental status, hypertension, weight gain, coma and seizures.

Ventricular tachycardia

a run of 3 or more PVCs. Ventricular pacing

For which of the following dysrhythmias is defibrillation primarily indicated? a. Ventricular fibrillation b. Third-degree AV block c. Uncontrolled atrial fibrillation d. Ventricular tachycardia with a pulse

a. Ventricular fibrillation Rationale: Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

atrial flutter

atrial tachy-dysrhythmia w/ recurring, regular, saw-tooth-shaped flutter waves. Atrial rate 200-350 BPM. Ventricular rate varies, but often about 150 BPM

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: a. premature ventricular contractions b. ventricular tachycardia c. ventricular fibrillation d. sinus tachycardia

b. ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (greater than 0.14) and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

When a patient has long-term atrial fibrillation, the nurse would expect to include which drug in the plan of care to minimize the greatest risk that is commonly associated with atrial fibrillation? a. Beta blockers b. Digitalis c. Anticoagulants d. Antiarrhythmics

c. Anticoagulants Rationale: c. is correct because it reflects the greatest risk or complication of thrombi or emboli that occurs with long-term atrial fibrillation. Coumadin is often given prophylactically to prevent stroke, clots, or emboli from developing when hospitalizing a patient with long-term atrial fibrillation

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be which rhythm? a. Sinus bradycardia b. Sick sinus syndrome c. Normal sinus rhythm d. First-degree heart block

c. Normal sinus rhythm

Prior to discharge from the Emergency Department, the nurse prints a rhythm strip on a patient and notices that the P wave cannot be detected and the QRS complex is 0.24 seconds. This is a change in the patient's condition. What is the best action for the nurse to take? a. Measure the PR interval. b. Prepare the patient for discharge. c. Notify the physician of this abnormal strip. d. Continue to monitor for abnormalities.

c. Notify the physician of this abnormal strip. Rationale: c. is correct because notifying the physician of the abnormal rhythm would be the most appropriate response. The patient has experienced a rhythm change and requires further treatment. a. is not correct for measuring the PR would not be possible as there is no P wave present. Since the QRS interval and other parameters given are abnormal, discharging the patient would not be appropriate at this point. b. is not correct as discharging the patient is not appropriate or safe practice. d. is not correct because continuing to monitor the patient without any other actions would be inappropriate as the patient has experienced a change in condition.

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? a. Chloride level of 98 mEq/L b. Sodium level of 135 mEq/L c. Potassium level of 6.8 mEq/L d. Magnesium level of 1.6 mEq/L

c. Potassium level of 6.8 mEq/L

A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block? a. Presence of Q waves b. Tall, peaked T waves c. Prolonged PR interval d. Widened QRS complex

c. Prolonged PR interval

treatment of sinus tachycardia

depends on cause and symptoms. Ie meds to Tx fever. Fluids if hypovolemic, vagal maneuvers, beta blockers

treatment of sinus bradycardia

depends on presence of symptoms: atropine or pacemaker. Discontinue meds that cause bradycardia

atrial fibrillation

disorganized atrial activity (3% of people over age 54) atrial rate 350-660 BPM. Irregular vent. rythm

treatment of atrial flutter

calcium channel blockers, cardioversion, antidysrhythmia drugs, ablation Tx

ventricular fibrillation

chaotic rhythm; irregular

symptoms of A. Fib.

clot formation

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? a. Flat neck veins b. Nausea and vomiting c. Hypotension and dizziness d. Clubbed fingertips and headache

d. Hypotension and dizziness

Depressed ST segment& tall T waves

hypomagnesemia

symptoms of ventricular fib.

lethal

Symptoms of ventricular tachycardia

life threatening, decreased cardiac output

What are the symptoms of hyperkalemia?

muscle cramping/weakness, ECG changes, irregular pulse, irritability, abdominal distention and cramping, muscle weakness, paresthesia, diarrhea

QRS duration

normal < 0.12 seconds

PR interval

normal is 0.12-0.2 seconds

symptoms of sinus bradycardia

pale,cool skin; hypotension, weakness, angina, dizziness, confusion, shortness of breath

treatment of aystole

poor prognosis: CPR with ACLS

Which electrolyte should never be given IV push?

potassium

treatment of ventricular tahycardia

pulseless- CPR with defibrillation with pulse- i.d. and treat cause. Beta blockers, alpha blockers, etc

sinus bradycardia

rate <60 BPM

sinus tachycardia

rate > 100 BPM

symptoms of aystole

unresponsive, pulseless, no breathing

symptoms of atrial flutter

usually occurs with CAD, hypertension, mitral valve disorders, PE, lung disease, cardiomyopathy, hyperthyroid, some drugs