Wk 12 practice assessment

22. The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted.

19. The client's lab values are sodium 166 mEq/L. potassium 5.0 mEg/L, chloride 115 mEg/L, and bicarbonate 35 mEg/L What condition is this client likely to have, judging by anion gap?

Metabolic acidosis

36. The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 ml/day from urine output. emesis, and Hemovac drainage Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

41. The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern as a result of the high heat and humidity of the day. Although the facility Is offering the residents plenty of fluids for fluid maintenance, what is the nurse most concerned about?

insensible fluid loss

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

pH low, PaCO2 high, HCO30 high

25. The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

🔅An elevated hematocrit level 🔅Electrolyte imbalance

30. A client was admitted to the unit with a diagnosis of hypovolemia. When it is time complete discharge teaching. which of the following will the nurse teach the client and family? Select all that apply

🔅Drink at least eight glasses of fluid each day. 🔅Respond to thirst. 🔅Drink water as an inexpensive way to meet fluid needs

21. The nurse is caring for a cllent prescribed a low-sodium dlet. Which food, Identified as a client favorite, will the nurse discourage?

Ahot dog with catsup

1. Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2 30 mm Hg: and HCO3 21 mEg/L for a client with noted acid-base disturbances. Which acid- base imbalance do both nurses agree is the client's current state?

Compensated respiratory alkalosis

33 The nurse receives report that a clent's pH level is 7.4 Which nursing action would be most appropriate?

Complete a he ad-to-toe assessment.

15. The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?

Decreased abdominal girth

3. Which laboratory result does the nurse identify as a direct resut of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

12. A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

Hypertonic solution

42. Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?

Initiate an IV of albumin,

37. The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see decrease in which fluid location that contains the most body water?

Intracellular fluid

5. The nurse is caring for a dlient with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Kidney and liver

28. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base Imbalance for which the patlent has highest risk?

Level of consciousness

27. The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?

Metabolic alkalosis

16. A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output, fever, a rough tongue and is lethargic. Serum sodium level is above 145 mEg/L Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

39. The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEg/L

10 The nurse is caring for a client diagnosed with chironic obstructive pulmonary disease state. The nurse is most correct to identify which result of the disease process that causes (COPD) and experiencing respiratory acidosis The client asks what is making the acidotic the rise in pH?

The lungs are not able to blow off carbon dioxide.

4. The nurse is caring for a client with severe hypokalemia The physician has ordered V potassium to be administered at10 mEght The clent complains of burning along his vein. What should the nurse do?

Seek a physician's order dilute the infusion.

11. The nurse is caring for a client who has been admitted with a possible clotting disorder. The dient is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

hypocalcemia

40. The patlent is hyperventilating from anxdety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select al that apply.)

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

29. The nurse is correct to state that a client's body needs to have adequate nutrition maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

active transport

13 What is one process by which dissolved chemicals move from one area of the body to arother?

Active transport

7. The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a group of students. Which action by bases keeps the blood pH nearly neutral?

Bases bind with hydrogen.

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

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

17 A nursing instructor is teaching her class about burns The instructor relates the following scenario, A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts What consequences should the nurse expect in this client?

Kidney stones and blood clots

6. The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurologic system

20 The nurse is making a home visit to a child who has a chronic disease: Which finding has the greatest implication for acid-base aspects of this patient's care?

Urine output is very small today.

The nurse is caring for a client with heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

elevated blood pressure

14. Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

hypomagnesemia

31. The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

weight

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

"My blood became too acid because I lost some base in the diarrhea fluid

8. Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.)

"🔅I should take my insulin on time every day." 🔅I have reliable transportation to dialysis sessions." 🔅My aspirin is on a high shelf away from children."

18. The nursing instructor is discussing with the nursing class about fluid and electrolyte balance, What would the Instructor tell the students that the average daily fluid intake for an adult is?

2500 ml.

26. The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-ye ar-old with diarrhea

23. The nurse is caring for a client with frequent dizziness The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

A drop in systolic blood pressure (15 mm Hg) upon rising

9. The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

dark, concentrated urine

24. The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Beverages with alcohol or caffeine:

32. The emergency department (ED) nurse is caring for a cient with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate