Unit 6 Med/Surg (6)
A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor? A. Brudzinski's sign B. Chvostek's sign C. Cullen's sign D. Kernig's sign
B. Chvostek's sign Chvostek's sign is a response of facial twitching when the nurse taps the client's face over the facial nerve. This sign indicates hypocalcemia or hypomagnesemia.
A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions? A. administer potassium gluconate 40 mEq orally B. obtain a 12-lead ECG C. restrict fluid intake D. have the laboratory draw a blood sample for an erythrocyte sedimentation rate
B. obtain a 12-lead ECG The client's potassium level is above the expected reference range. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.
A nurse is collecting data from a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (SELECT ALL THAT APPLY) A. tachycardia B. hypertension C. bounding pulses D. hyperreflexia E. dysrhythmia F. tachypnea
E. dysrhythmia F. tachypnea Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis. Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following findings should the nurse expect? A. hypertension B. purpura C. oliguria D. bradypnea
C. oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.
Which patient is at risk for respiratory acidosis? A. the patient with uncontrolled diabetes mellitus B. the patient with chronic pulmonary disease C. the patient who is very anxious D. the patient who overuses antacids
B. the patient with chronic pulmonary disease
When caring for a patient with fluid excess, which of the following interventions will best help relieve respiratory distress? A. elevate the head of the bed B. encourage the patient to cough and deep breathe C. increase fluids to promote urine output D. perform percussion and postural drainage
A. elevate the head of the bed
A patient gains 2 pounds in 24 hours, weighed on the same scale at 7 a.m. Approximately how much water is represented by the 2 pounds? A. 8 ounces B. 16 ounces C. 24 ounces D. 32 ounces
D. 32 ounces
A nurse is assisting with the delivery of an educational activity for nurses on the unit about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a patient who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to stroke."
A. "Metabolic acidosis can occur due to diabetic ketoacidosis." Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.
Which pH value represents acidosis? A. 7.26 B. 7.35 C. 7.4 D. 7.49
A. 7.26
A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match? A. 0.45% sodium chloride B. Lactated Ringer's C. dextrose 10% in water D. 0.33% sodium chloride
B. Lactated Ringer's Lactated Ringer's solution is administered to the client who has hypovolemic shock because it contains electrolytes and expands plasma volume.
A patient is being placed on a potassium-losing diuretic. Which foods are high in potassium and should be recommended to the patient by the nurse? (SELECT ALL THAT APPLY) A. bread B. potato C. yogurt D. banana E. gelatin
B. potato C. yogurt D. banana
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3- of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances? A. metabolic acidosis B. respiratory alkalosis C. respiratory acidosis D. metabolic alkalosis
C. respiratory acidosis In analyzing blood gases, the nurse should first determine if the result is acidosis (pH less than 7.35) or alkalosis (pH greater than 7.45). A pH of 7.24 is decreased. Therefore, this is acidosis. The next step is to look at the PaCO2 (expected reference range 35 to 45) and the HCO3- (expected reference range 22 to 26). A PaCO2 of 53 is elevated (greater than 45) and the HCO3- of 24 is within the expected reference range. Therefore, if the pH is decreased, the PaCO2 is elevated and the HCO3- is within the expected reference range, the client is experiencing respiratory acidosis.
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take? A. collect a urine specimen for culture and sensitivity B. continue routine care because the results are within the expected reference range C. decrease the IV fluid infusion rate and limit oral fluid intake D. evaluate urine output for amount and urine for specific gravity
D. evaluate urine output for amount and urine for specific gravity These results indicate that the client is hydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.
A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis
A. respiratory acidosis The nurse should expect a client who has an acute respiratory condition - such as pneumonia, pulmonary edema, or respiratory arrest - to have respiratory acidosis. Respiratory acidosis develops when the lungs do not expel carbon dioxide adequately. Decreased ventilation (hypoxemia) causes carbon dioxide retention, resulting in respiratory acidosis.
A nurse is collecting data from a client who has a calcium level of 12 mg/dL. Which of the following manifestations should the nurse expect? A. hypotension B. decreased deep tendon reflexes C. diarrhea D. increased appetite
B. decreased deep tendon reflexes A client who has a calcium level of 12 mg/dL is experiencing hypercalcemia. The nurse should expect to find manifestations including decreased deep tendon reflexes due to the sedative effect on neuromuscular transmission.
A nurse is caring for a client who is postoperative and has an NG tube that has drained 2500 ml in the past 6 hr. The nurse should monitor the client for which of the following electrolyte imbalances? A. elevated sodium level B. decreased potassium level C. elevated magnesium level D. decreased calcium level
B. decreased potassium level Loss of gastric fluid is a common cause of potassium depletion.
A 93-year-old patient with diarrhea and dehydration is admitted to the hospital from a long-term care facility. For which of the following symptoms of dehydration should the nurse expect? A. pale-colored urine, bradycardia B. disorientation, poor skin turgor C. decreased hematocrit, hypothermia D. lung congestion, abdominal discomfort
B. disorientation, poor skin turgor
A nurse is collecting data from a client who has a calcium level of 8 mg/dL. Which of the following manifestations should the nurse expect? A. elevated blood pressure B. tetany C. constipation D. negative Chvostek sign
B. tetant A client who has a calcium level of 8 mg/dL is experiencing hypocalcemia. The nurse should expect to find manifestations including tetany due to the increase in neuromuscular excitability.
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? A. rest in a supine position B. consume a low-protein diet C. breathe in through her nose and out through pursed lips D. limit fluid intake throughout the day
C. breathe in through her nose and out through pursed lips The nurse should reinforce that pursed-lip breathing slows expirations, prevents collapse of alveoli, and helps the client to control the rate and depth of respirations.
A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L. Which of the following medications should the nurse expect to administer? A. lactulose B. triamterene C. sodium polystyrene D. acetylcysteine
C. sodium polystyrene The client's potassium level is above the expected reference range; therefore, the nurse should expect to administer sodium polystytene for the treatment of hyperkalemia.
Which patient is most at risk for fluid excess? A. an infant with pneumonia B. a teen with multiple injuries following an automobile accident C. a middle-aged man who just had surgery D. an older adult patient receiving intravenous therapy
D. an older adult patient receiving intravenous therapy
A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect? A. cool, clammy skin B. hypertension C. increased salivation D. decreased level of consciousness
D. decreased level of consciousness A client who has a sodium level of 155 mEq/L is experiencing hypernatremia. The nurse should expect this client to have a decreased level of consciousness from the dehydration of brain cells.
A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit? A. tenting B. protruding eyeballs C. elevated blood pressure D. dry mucous membranes
D. dry mucous membranes With older adult clients, reliable indicators of dehydration include dry mucous membranes in the nose and mouth, concentrated urine, speech incoherence, and weakness of the extremities.
A patient is being treated for hypokalemia. When evaluating response to potassium replacement therapy, which of the following assessment findings should the nurse observe for? A. improving visual acuity B. worsening constipation C. decreasing serum glucose D. increasing muscle strength
D. increasing muscle strength
A nurse is reviewing the arterial blood gases for a client who has vomited for 24hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24hr? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis
D. metabolic alkalosis Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.
A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse expect? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis
A. respiratory acidosis The nurse should expect a client who has chronic bronchitis, a form of chronic obstructive pulmonary disease, to have respiratory acidosis. An increased respiratory rate and an inability to fully exhale increases retention of carbon dioxide. Carbon dioxide builds up and causes chronic respiratory acidosis.
A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. three tap water enemas B. 0.9% sodium chloride solution IV at 50 ml/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80ml/hr D. antibiotic therapy
A. three tap water enemas Three tap water enemas can result in a decrease in blood sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis
B. respiratory acidosis The nurse should identify the client who has respiratory problems such as obstruction or depression of the respiratory system is at risk for the development of respiratory acidosis. The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that the client is acidotic. The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the results is that the client is in respiratory acidosis.
A nurse is caring for a client whose arterial blood gas results show the following results: pH: 7.2 PaCO2: 50 mm Hg HCO3: 24 mEq/L The nurse should identify the client is experiencing which of the following acid-base conditions? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis
C. respiratory acidosis With uncompensated respiratory acidosis, the client's pH is below 7.35, the PaCO2 is above 45 mm Hg, and the HCO3 is within the expected reference range.
A nurse is caring for a client who has acute kidney injury. The client's ABGs are: pH: 7.26 PaCO2: 30 mm Hg HCO3: 14 mEq/L Which of the following acid imbalances should the nurse identify the client is experiencing? A. metabolic alkalosis B. respiratory alkalosis C. respiratory acidosis D. metabolic acidosis
D. metabolic acidosis Acute renal failure causes metabolic acidosis because clients cannot process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is below 7.35, the PaCO2 is below 35 mm Hg or in the expected reference range, and the HCO3 is below 22 mEq/L.
A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3*C (100.9*F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? A. initiate fluid restrictions to limit intake B. check for peripheral edema C. encourage the client to ambulate to promote oxygenation D. monitor for orthostatic hypotension
D. monitor for orthostatic hypotension Monitor for orthostatic hypotension because they have manifestations of dehydration due to decreased circulatory volume.
A nurse is collecting data from a client who is dehydrated. Which of the following findings should the nurse expect? A. moist skin B. distended neck veins C. increased urinary output D. tachycardia
D. tachycardia Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit.
A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding? A. increased urine specific gravity B. decreased hematocrit C. decreased BUN D. increased urine ketones
A. increased urine specific gravity The client who has an increased urine specific gravity with low urine output is an expected finding of fluid volume deficit.
Which of the following are functions of sodium in the body? (SELECT ALL THAT APPLY) A. maintenance of serum osmolarity B. formation of bones and teeth C. control of bronchodilation D. control of serum glucose E. maintenance of cellular function
A. maintenance of serum osmolarity E. maintenance of cellular function
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (SELECT ALL THAT APPLY) A. decreased skin turgor B. concentrated urine C. bradycardia D. low-grade fever E. tachypnea
A. decreased skin turgor B. concentrated urine D. low-grade fever E. tachypnea
A nurse is collecting data from a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. diabetic ketoacidosis B. heart failure C. Cushing's syndrome D. thyroidectomy
A. diabetic ketoacidosis Hyperkalemia, an increase in blood potassium, is a laboratory finding associated with diabetic ketoacidosis.
A nurse is admitting an older adult client who reports a weight gain of 2.3kg (5 lb) in 48hr. Which of the following manifestations of fluid volume excess should the nurse expect? (SELECT ALL THAT APPLY) A. dyspnea B. edema C. bradycardia D. hypertension E. weakness
A. dyspnea B. edema D. hypertension E. weakness
A patient is being discharged following hospitalization for fluid imbalance. Which instruction by the nurse should take priority? A. "Weigh yourself at the same time three times a week and report changes." B. "Call your doctor immediately if you feel weak or fatigued." C. "Drink eight glasses of water a day." D. "Measure everything you drink, and measure how much you urinate each day."
A. "Weigh yourself at the same time three times a week and report changes."
A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should monitor for which of the following manifestations? A. ECG changes B. constipation C. polyuria D. muscle hypertonicity
A. ECG changes Monitor for ECG changes. Potassium levels can affect the heart and result in arrhythmias.
A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.2 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet? A. bananas B. cabbage C. cheddar cheese D. white rice
A. bananas The client's potassium level is low, most likely due to his diuretic therapy. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have a high potassium content, such as bananas, orange juice, spinach, and fish. The provider might also prescribe potassium supplements in addition to or instead of increasing dietary potassium.
A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia? A. cardiac dysrhymias B. hypoglycemia C. hyperreflexia D. increased appetite
A. cardiac dysrhythmias Low potassium levels affect cardiovascular function, causing ventricular dysrhythmias, ECG changes, and a weak, irregular pulse.
A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia? A. decreased deep-tendon reflexes B. restlessness C. hyperactive bowel sounds D. bounding peripheral pulses
A. decreased deep-tendon reflexes The nurse should expect a client who has hypokalemia to report decreased deep tendon reflexes. Thiazide diuretics cause excessive potassium loss; therefore, it is important for the nurse to monitor for and report findings of hypokalemia.
A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL. Which of the following client findings should the nurse expect? A. muscle tetany B. hypertension C. increased thirst D. diaphoresis
A. muscle tetany This calcium level is below the expected reference range. Therefore, the nurse should check the client for tetany as a finding of hypocalcemia.
A nurse is caring for a client who was in a motor-vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3- 24 mEq/L B. pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3- 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3- 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3- 29 mEq/L
A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3- 24 mEq/L A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis.
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medication has been effective? A. reduction of T wave amplitude B. reduce of P wave duration C. widening of the QRS complex D. restoration of QRS complex amplitude
A. reduction of T wave amplitude The nurse should identify that the polystyrene sulfonate should brine the potassium level back to the expected reference range. Hyperkalemia causes peaked T waves and a widened QRS on ECG, so resolution of the potassium imbalance should restore these ECG changes to baseline.
A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min. Which of the following acid-base imbalances should the nurse expect? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis
A. respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation.
A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? A. flushing B. dyspnea C. bradycardia D. vomiting
B. dyspnea The nurse should monitor the respiratory status of a client who is receiving blood products for reactions to the blood product as well as circulatory overload. Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.
A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect? A. hyporeflexia B. headache C. constipation D. increased appetite
B. headache A client who has a sodium level of 128 mEq/L is experiencing hyponatremia. The nurse should expect this client to have neurologic manifestations such as headache due to swelling of brain cells.
A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? A. cool, clammy skin B. hyperventilation C. increased blood pressure D. bradycardia
B. hyperventilation The nurse should expect to find hyperventilation in a client who is experiencing metabolic acidosis. The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations.
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. hypercalcemia B. hyponatremia C. hyperphosphatemia D. hyperkalemia
B. hyponatremia Monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium.
A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia? A. reports of numbness in the feet B. reports of fatigue C. increased bowel sounds D. positive Trousseau's sign
B. reports of fatigue Fatigue and muscle weakness are manifestations of hypokalemia.
A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L, sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take? A. discontinue the TPN infusion B. request a potassium replacement C. administer glucagon IM D. check the client for a positive Chvostek's sign
B. request a potassium replacement This potassium level is below the expected reference range. Therefore, the nurse should initiate cardiac monitoring and request a potassium replacement.
A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are: pH: 7.6 PaCO2: 40 mm Hg HCO3-: 32 mEq/L Which of the following acid base conditions should the nurse identify the client is experiencing? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalsosis D. respiratory alkalosis
C. metabolic alkalosis The nurse should identify that the client is experiencing metabolic alkalosis. The client's pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEq/L.
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3- 28 mEq/L B. pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3- 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3- 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3- 29 mEq/L
C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3- 18 mEq/L An aspirin toxicity would result in arterial blood gas findings of metabolic acidosis.
A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse? A. switch oxygen to a nonrebreather mask B. increase oxygen to 70% C. place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing D. position the client prone and have the respiratory therapist perform postural drainage
C. place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing Positioning the client to improve gas exchange by deep-breathing, coughing, and removal of secretions may resolve the problem and is an appropriate action by the nurse.
A nurse is collecting data from a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. apply a blood pressure cuff to the client's arm B. place the stethoscope bell over the client's carotid artery C. tap lightly on the client's cheek D. ask the client to lower their chin to their chest
C. tap lightly on the client's cheek Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face.
A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement. Which of the following findings should the nurse identify as effectiveness of the treatment? A. peripheral pulses +1 B. urine specific gravity 1.04 C. urine output 200 ml/4hr D. heart rate 104/min
C. urine output 200ml/4hr This finding indicates a urine output 50ml/hr. The nurse should identify a urine output of at least 30 ml/hr as indicating adequate circulating fluid volume and kidney function.
A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. hyperactive reflexes B. extreme thirst C. weak, irregular pulse D. hyperactive bowel sounds
C. weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.
