Adult Health 1 Exam 1

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a. "Breathe in and out quickly." b. "You need to start using the incentive spirometer 2 days after surgery." c. "Before you do the exercise, I'll give you pain medication if you need it." d. "Don't use the incentive spirometer more than 5 times every hour."

"Before you do the exercise, I'll give you pain medication if you need it."

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them." "I'll drink cranberry juice with my breakfast instead of coffee." "I need to check to see whether my cola beverage has potassium in it."

"I will not salt my food; instead I'll use salt substitute."

What kinds of things cause metabolic alkalosis?

over ingestion of antacids prolonged NG suction prolonged vomiting TPN

Relative acidosis

over-elimination (diarrhea)

Actual acid excess

overproduction

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? a. HCO 21 mEq/L b. pH 7.48 c. PaCO 36 d. O saturation 95%

pH 7.48

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The client has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? "Be sure to practice meticulous foot care." "Try to make sure you eat enough protein." "Reduce your activity level to accommodate your limitations." "Consider cutting down on your smoking."

"Be sure to practice meticulous foot care."

Normal bicarb level

22-26

Normal CO2 level

35-45

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. 0.9% NaCl 5% DW 0.45% NS 3% NS

5% DW

Normal pH level

7.35-7.45

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? a. A client has a respiratory rate of 10 breaths per minute b. A client requires permanent ventilation c. A client exhibits symptoms of dyspnea d. A client has respiratory acidosis.

A client requires permanent ventilation

Respiratory acidosis

A drop in blood pH due to hypoventilation (too little breathing) resulting accumulation of Co2. Involves the lungs; low pH, high HCO3

What foods can the nurse recommend for the patient with hyperkalemia? Apples and berries Green, leafy vegetables Milk and yogurt Melons

Apples and berries

What foods can the nurse recommend for the patient with hyperkalemia? a. Apples and berries b. Green, leafy vegetables c. Milk and yogurt d. Melons

Apples and berries

The emergency department (ED) nurse is caring for a client 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? a. PaO2 b. PO2 c. Carbonic acid d. Bicarbonate

Bicarbonate

What things can cause respiratory acidosis?

COPD respiratory depression pulmonary edema (fluid)

Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium

Chloride

Which client would most likely experience neuropathic foot ulcers? Client with Psychosis Client with Hypertension Client with Diabetes Client with Congestive Heart Failure

Client with Diabetes

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. a. Compare ABG findings with previous results b. Maintain intake and output records c. Document presenting signs and symptoms d. Administer IV bicarbonate e. Suction the client's airway.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state? a. Compensated respiratory alkalosis b. Uncompensated respiratory alkalosis c. Compensated metabolic acidosis d. Compensated metabolic alkalosis

Compensated respiratory alkalosis

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Distended neck veins Crackles in the lung fields Shortness of breath Decreased blood pressure Bradycardia

Distended neck veins Crackles in the lung fields Shortness of breath

One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will help to achieve what goal? Distinguish hyponatremia from hypernatremia. Evaluate pituitary gland function, Distinguish reduced renal blood flow from decreased renal function. Provide an effective treatment for hypertension-induced oliguria.

Distinguish reduced renal blood flow from decreased renal function.

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? Generalized Dependent Brassy Pitting

Generalized

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply. Heart failure Pulmonary edema Renal impairment Burns Severe hemorrhage

Heart failure Pulmonary edema Renal impairment

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? Perform mechanical débridement to remove the exudate and prevent further infection. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. Document this finding as an expected phase of graft healing. Inform the primary care provider promptly because the graft may need to be removed.

Inform the primary care provider promptly because the graft may need to be removed.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a. Headache or blurry vision b. Abdominal pain or diarrhea c. Hallucinations or tinnitus d. Light-headedness or paresthesia

Light-headedness or paresthesia

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? a. Kidney and liver b. Heart and lungs c. Lungs and kidney d. Pancreas and stomach

Lungs and kidney

Which of the following is more likely to cause respiratory alkalosis?

Mechanical ventilation

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis

Metabolic acidosis

The client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Respiratory acidosis

Metabolic acidosis

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

Metabolic acidosis

The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? a. Respiratory acidosis with no compensation b. Metabolic alkalosis with compensatory alkalosis c. Metabolic acidosis with no compensation d. Metabolic acidosis with compensatory respiratory alkalosis

Metabolic acidosis with compensatory respiratory alkalosis

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

Metabolic alkalosis

Which oxygen administration device has the advantage of providing a high oxygen concentration? a. Nonrebreathing mask b. Venturi mask c. Catheter d. Face tent

Nonrebreathing mask

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) Hypertension Oliguria Tachycardia Bradycardia Tachypnea

Oliguria Tachycardia Tachypnea

A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily? One beef cube and 8 oz of tomato juice Four beef cubes and 8 oz of tomato juice One beef cube and 16 oz of tomato juice One beef cube and 12 oz of tomato juice

One beef cube and 8 oz of tomato juice

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which terms? Hydrostatic pressure Osmosis and osmolality Diffusion Active transport

Osmosis and osmolality

You are at a carnival when you notice a person on fire. After making sure the scene is safe and the person is no longer on fire, what would be the nurse's immediate, priority concern? Risk of infection Fluid status Respiratory status Nutritional status

Respiratory status

Which condition leads to chronic respiratory acidosis in older adults? a. Decreased renal function b. Erratic meal patterns c. Thoracic skeletal change d. Overuse of sodium bicarbonate

Thoracic skeletal change

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To extinguish flames more quickly To prevent collapse and further injuries To promote blood flow to the brain and vital organs To keep fire and smoke from airway

To keep fire and smoke from airway

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? a. renin-angiotensin-aldosterone system b. bicarbonate-carbonic acid buffer system c. sodium-potassium pump d. ADH-ANP buffer system

bicarbonate-carbonic acid buffer system

1st line of defense

buffer system at cellular level

Metabolic acidosis

decreased pH in blood and body tissues as a result of an upset in metabolism causes hyperventilation (too much breathing); low pH, low HCO3

What does greater concentration of ions mean?

decreased pH levels, more acidity

A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client? bumetanide torsemide hydrochlorothiazide furosemide

hydrochlorothiazide

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: hypernatremia. hypokalemia. hyperkalemia. hypercalcemia.

hyperkalemia.

Early signs of hypervolemia include: a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.

increased breathing effort and weight gain.

What does lower concentration of ions mean?

increased pH levels, alkaline

Signs and Symptoms of Hypovolemia

low bp (hypotension) increased respiration (tachypnea) & heart rate (tachycardia) weak, thirsty prolonged cap refill flattened jugular veins concentrated blood concentrated urine

What are 2 body systems that help regulate pH?

lungs and kidneys

2nd line of defense

lungs buffer system CO2

HCO3 deals with

metabolic

3rd line of defense

renal buffer system (alkaline)

Signs and Symptoms of Hypokalemia

weak pulse orthostatic hypotension decreased bowel sounds muscle cramps

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? vital signs edema intake and output weight

weight

Signs and Symptoms of Hypervolemia

weight gain edema hypertension bounding pulses jugular vein distension tachycardia dyspnea (fluid back up in lungs)

What increases the risk for acid/base imbalance?

-Respiratory issues -Problems of metabolism/nutrition -Medications -Head injuries (TBI) -Kidney problems -Pain -Anxiety

The nurse recognizes what as an early sign of sepsis in a client with a burn injury? Normal body temperature Widened pulse pressure Decreased heart rate Elevated serum glucose

Elevated serum glucose

How can we prevent acid/base imbalances?

-avoid smoking -keep asthma & COPD under control -treat infections before they get bad -healthy diet to prevent GI issues -safety precautions that minimize brain and spinal cord issues

Symptoms of hypovalemia

-elevated heart rate -decreased BP -elevated respiratory rate -decreased urine output -dry mucous membranes -skin turgor -sunken eyes

A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer? 0.45% sodium chloride 0.9% sodium chloride 5% dextrose in water 5% dextrose in normal saline solution

0.45% sodium chloride

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 115 mEq/L 130 mEq/L 145 mEq/L 160 mEq/L

115 mEq/L

The nurse is caring for a client in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) after the procedure. The nurse recognizes that ABGs should be obtained how long after mechanical ventilation is initiated? a. 10 minutes b. 15 minutes c. 20 minutes d. 25 minutes

20 minutes

Normal PaCO2 level

35-45

A client has a burn injury to the following areas: the front and back of each hand and arm as well as the front trunk portion of the body. Using the rule of nines, the nurse estimates that the burned area is what percentage of the person's body? 18 27 9 36

36

The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for? 6 to 12 hours 12 to 24 hours 24 to 36 hours 48 to 72 hours

48-72 hours

In order to have adequate tissue integrity, the following need to be in place. Select all that apply. Adequate perfusion Good nutrition Decreased sensation Lack of external trauma Increased pressure on site

Adequate perfusion Good nutrition Lack of external trauma

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? Restrict fluids and salt for 24 hours. Correct the sodium deficit rapidly with salt. Administer small volumes of a hypertonic solution. Monitor the serum sodium for changes hourly.

Administer small volumes of a hypertonic solution.

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

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 A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine

An elevated hematocrit level Electrolyte imbalance

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? a. Anemic hypoxia b. Histotoxic hypoxia c. Hypoxic hypoxia d. Stagnant hypoxia

Anemic hypoxia

Respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

The nurse is caring for a patient with a diagnosis of hyponatremia. Which nursing intervention is appropriate to include in the plan of care for this patient? Select all that apply. Assessing for symptoms of nausea and malaise Encouraging the intake of low-sodium liquids Monitoring neurologic status Restricting tap water intake Encouraging the use of salt substitute instead of salt

Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Red blood cell crenation Red blood cell hydrolysis Cerebral edema Renal failure

Cerebral edema

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Low heart rate Elevated blood pressure Rapid respiration Subnormal temperature

Elevated blood pressure

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Maintain a low-sodium diet. Encourage the use of over-the-counter calcium supplements. Ensure the client has sufficient potassium intake. Encourage fluid intake.

Ensure the client has sufficient potassium intake.

Hypokalemia can cause which symptom to occur? Excessive thirst Increased release of insulin Production of concentrated urine Decreased sensitivity to digitalis

Excessive thirst

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Opioid overdose

Extreme anxiety

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? Hypokalemia Gastrointestinal hypermotility Respiratory arrest Hemodynamic instability

Hemodynamic instability

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? Hypernatremia Hypomagnesemia Hypophosphatemia Hypercalcemia

Hypercalcemia

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. a. Increased serum HCO3 b. Increased PaCO2 c. Decreased serum HCO3 d. Decreased PaCO2.

Increased PaCO2

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

Intracellular fluid

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? a. Intracellular fluid b. Extracellular fluid c. Interstitial fluid d. Intravascular fluid

Intracellular fluid

The nurse is caring for a client with an arterial blood pH of 7.48 and bicarbonate level of 29 mEq/L (29 mmol/L). Which treatment will the nurse expect to be prescribed for this client? Bronchodilator Potassium supplements Intravenous 0.9% normal saline Oxygen through a rebreather mask

Intravenous 0.9% normal saline

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Irregular heart rate Weight loss of 4 lb Mild confusion Blood pressure 96/53 mm Hg

Irregular heart rate

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Respiratory acidosis

Metabolic acidosis

A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? a. metabolic alkalosis b. metabolic acidosis c. respiratory acidosis d. respiratory alkalosis

Metabolic alkalosis

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs? a. Non-rebreathing mask b. Nasal cannula c. Simple mask d. Partial-rebreathing mask

Nasal cannula

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Strength testing for muscle wasting Skin assessment for edema and turgor

Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema. Administer the ordered furosemide 60 mg po. Monitor intake and output every shift. Administer the ordered potassium 40 mg IV push.

Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift.

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? Suggest a fluid restriction. Encourage oral fluids. Remove the Hemovac. Offer a prescribed antiemetic medication.

Offer a prescribed antiemetic medication.

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low? a. Diarrhea b. Paresthesias c. Increased muscle tone d. Joint pain

Paresthesias

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? Provide oral care every 2-3 hours. Monitor for signs and symptoms of dehydration. Teach the client about increased fluid intake. Assess the client's weight daily for trends.

Provide oral care every 2-3 hours.

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? a. Serum bicarbonate of 28 mEq/L b. PaCO2 less than 35 mm Hg c. Serum bicarbonate of 21 mEq/L d. pH 7.26

Serum bicarbonate of 28 mEq/L

What does the nurse recognize as one of the best indicators of the patient's renal function? Blood urea nitrogen Serum creatinine Specific gravity Urine osmolality

Serum creatinine

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl

Serum sodium level of 124 mEq/L

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis? a. Sodium bicarbonate b. Magnesium sulfate c. Furosemide d. Calcium gluconate

Sodium bicarbonate

The critical care nurse and the other members of the care team are assessing the client to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? a. Stable vital signs and ABGs b. Pulse oximetry above 80% and stable vital signs c. Stable nutritional status and ABGs d. Normal orientation and level of consciousness

Stable vital signs and ABGs

Your client has a wound on their left buttock that has full thickness loss of the epidermis and dermis such that the subcutaneous fat layer is visible in the wound bed. What stage of pressure ulcer would this be? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? Mechanical Surgical Chemical Natural

Surgical

A nurse, who is orienting a newly licensed nurse, is planning care for a nephrology client. The nurse states, "A client with kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability? a. The kidneys regulate and reabsorb carbonic acid to change and maintain pH b. The kidneys buffer acids through electrolyte changes c. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH d. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? a. The lungs are unable to breathe in sufficient oxygen b. The lungs are unable to exchange oxygen and carbon dioxide c. The lungs have ineffective cilia from years of smoking d. The lungs are not able to blow off carbon dioxide.

The lungs are not able to blow off carbon dioxide

You have been asked to change your client's pressure wound and use a wet-to-dry dressing. What is the purpose of this type of dressing? The packed gauze liquefies the slough so it can be cleansed from the wound. The packed gauze works to remove (debride) the dead or injured tissue. The packed gauze is a temporary fix before surgery. The packed gauze is works in wounds that have eschar.

The packed gauze works to remove (debride) the dead or injured tissue.

A client presents to the clinic reporting the inability to grasp objects with her right hand. The client's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary provider may diagnose the woman with what health problem? Upper extremity VTE Raynaud phenomenon Lymphedema Upper extremity arterial occlusive disease

Upper extremity arterial occlusive disease

Which type of ulcer would more likely have drainage? Venous or Arterial ulcers Venous Arterial

Venous

Greater concentration of ions means __ pH levels. Lower concentration of ions means __ pH levels, alkaline.

decreased, increased

Arterial ulcers tend to be symmetrical and form a __ , and venous ulcers tend to be asymmetrical and form a __. shallow wound deep crater

deep crater, shallow wound

What things can cause metabolic acidosis?

diabetic ketoacidosis (DKA) lactic acidosis renal failure aspirin overdose diarrhea chronic diseases

Metabolic alkalosis

elevation of HCO3- usually caused by an excessive loss of metabolic acids. High pH, high HCO3

Pressure ulcers are caused by: Low capillary pressure Increased mobility Extrinsic factors Necrosis

extrinsic factors

Signs and Symptoms of Hypernatremia (NO "FRIED" FOODS)

fever, flushed skin restless, really agitated increased fluid retention edema, extremely confused decreased urine output, dry mouth/skin

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? isotonic fluid no intravenous solution hypertonic solution hypotonic solution

hypertonic solution

Your client has experienced a full thickness burn to 18% of his Total Body Surface area. A full thickness burn can be defined as a burn injury that consists of tissue injury at the depth of: Cellular Epidermis Dermis hypodermis (subcutaneous tissue)

hypodermis (subcutaneous tissue)

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypokalemia hyperkalemia hypocalcemia hypercalcemia

hypokalemia

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the: a. malignancy is causing the electrolyte imbalance. b. client's diet is lacking in calcium-rich food products. c. client may be developing hyperaldosteronism. client has a history of alcohol abuse.

malignancy is causing the electrolyte imbalance.

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis

metabolic alkalosis

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? a. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 b. pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 c. pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d. pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

What things can cause respiratory alkalosis?

pain in some place other than thorax rib cage fracture anxiety/panic attack

A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which electrocardiogram changes will the client display? prolonged T waves elevated ST segment peaked T waves shortened PR interval

peaked T waves

CO2 deals with

respiratory

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

respiratory alkalosis

Signs and Symptoms of Hyponatremia (SALT LOSS)

seizures & stupor abdominal cramping, attitude changes lethargic tendon reflexes, trouble concentrating loss of urine and appetite orthostatic hypotension, overactive bowel sounds shallow respirations spasms of muscles

Which system will compensate someone with a COPD exacerbation?

Renal system (respiratory)

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? a. "I will not salt my food; instead I'll use salt substitute." b. "Bananas have a lot of potassium in them; I'll stop buying them." c. "I'll drink cranberry juice with my breakfast instead of coffee." d. "I need to check to see whether my cola beverage has potassium in it."

"I will not salt my food; instead I'll use salt substitute."

The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? Extravasation of the medication Discomfort to the client Blanching at the site Hypersensitivity reaction to the medication

Extravasation of the medication

The nurse notes that a client has lost 5 lbs. (2.27 kg) of body weight over 5 days. Which additional assessment findings indicate to the nurse that the client is experiencing hypovolemia? Select all that apply. Lung crackles Flat neck veins Bounding pulse Muscle cramps Concentrated urine

Flat neck veins Muscle cramps Concentrated urine

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? Hypercalcemia Hypernatremia Hyperglycemia Hyperkalemia

Hyperkalemia

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? a. Similar causes are present in both conditions b. Hypovolemia contains only low blood volume c. In dehydration, only extracellular is depleted d. Both conditions result in abnormal laboratory studies.

In dehydration, only extracellular is depleted

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Similar causes are present in both conditions. Hypovolemia contains only low blood volume. In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies.

In dehydration, only extracellular is depleted.

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? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis

Metabolic alkalosis

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

Respiratory acidosis

The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 20 mEq/L. The nurse should recognize the likelihood of which acid-base disorder(s)? a. Respiratory acidosis only b. Respiratory acidosis and metabolic alkalosis c. Respiratory alkalosis and metabolic acidosis d. Respiratory acidosis and metabolic acidosis

Respiratory acidosis and metabolic acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Increased PaCO2 d. Metabolic acidosis

Respiratory alkalosis

Which of the following is a factor affecting an increase in urine osmolality? Syndrome of inappropriate antidiuretic hormone release (SIADH) Alkalosis Fluid volume excess Myocardial infarction

Syndrome of inappropriate antidiuretic hormone release (SIADH)

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. Tachypnea Weakness Lethargy Dehydration Hypotension

Tachypnea Weakness Lethargy

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Tetanic contractions Jugular vein distention Weight loss Polyuria

Tetanic contractions

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. a. "Inhale through your nose." b. "Slowly count to 3." c. "Exhale slowly through pursed lips." d. "Slowly count to 7."

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEq/L 130 mEq/L 145 mEq/L 165 mEq/L

165 mEq/L

Normal PaO2 level

80-100

Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 10 mL/hour A patient with a minimal urine output of 30 mL/hour A patient with a minimal urine output of 20 mL/hour

A patient with a minimal urine output of 30 mL/hour

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A patient-controlled analgesia (PCA) system A combination of benzodiazepines and topical anesthetics Oral opioids supplemented by NSAIDs Distraction and relaxation techniques supplemented by NSAIDs

A patient-controlled analgesia (PCA) system

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? Cerebral edema Hypovolemic shock Severe hyperkalemia Tetany

Cerebral edema

A client with emphysema is at a greater risk for developing which acid-base imbalance? a. chronic respiratory acidosis b. metabolic alkalosis c. metabolic acidosis d. respiratory alkalosis

Chronic respiratory acidosis

The nurse is caring for a client who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this client's wound? Hemorrhage Pale-colored wound bed Heavy exudate Deep wound bed

Heavy exudate

A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? a. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance b. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance c. The kidneys react rapidly to compensate for imbalances in the body d. The kidneys regulate the bicarbonate level in the intracellular fluid.

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance

The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? Numbness and tingling in the distal extremities Unequal peripheral pulses between extremities Visible clubbing of the fingers and toes Reddened extremities with muscle atrophy

Unequal peripheral pulses between extremities

57. Which of the following may be the first sign of respiratory acidosis in anesthetized patients? a. Ventricular fibrillation b. Increased pulse c. Mental cloudiness d. Dull headache

Ventricular fibrillation

Oncotic pressure refers to the: number of dissolved particles contained in a unit of fluid. excretion of substances such as glucose through increased urine output. amount of pressure needed to stop the flow of water by osmosis. osmotic pressure exerted by proteins.

osmotic pressure exerted by proteins.

An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? Continue to monitor client with another appointment. Be prepared to administer a lactated Ringer's IV. Be prepared to administer a sodium chloride IV. Consider sodium restriction with discontinuation of salt tablets.

Consider sodium restriction with discontinuation of salt tablets.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Metabolic alkalosis Respiratory acidosis

Extracellular fluid volume deficit

What percentage of potassium excreted daily leaves the body by way of the kidneys? 20 40 60 80

80

What percentage of potassium excreted daily leaves the body by way of the kidneys? a. 20 b. 40 c. 60 d. 80

80%

It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL. 9.8 mg/dL 10.3 mg/dL 11 mg/dL 12 mg/dL

9.8 mg/dL

Normal O2 saturation

95% or above

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? Active transport of hydrogen ions across the capillary walls Pressure of the blood in the renal capillaries Action of the dissolved particles contained in a unit of blood Hydrostatic pressure resulting from the pumping action of the heart

Hydrostatic pressure resulting from the pumping action of the heart

The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? Hypocalcemia Hyponatremia Hyperchloremia Hypophosphatemia

Hyperchloremia

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? Hypernatremia Decreased hematocrit Hyperkalemia Decreased PT (Prothrombin Time)

Hyperkalemia

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance? Hypocalcemia Hyperchloremia Hypermagnesemia Hyponatremia

Hypocalcemia

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client 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? Dehydration Hypokalemia Hypocalcemia Hypomagnesemia

Hypocalcemia

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? a. Hypercalcemia b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory acidosis

Metabolic alkalosis

The nurse is caring for a client with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? Provide a high-calorie, high-protein diet. Apply a clean occlusive dressing once daily and whenever soiled. Irrigate the wound with hydrogen peroxide once daily. Apply an antibiotic ointment on the surrounding skin with each dressing change.

Provide a high-calorie, high-protein diet.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Blood pressure Respirations Temperature Pulse

Pulse

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? a. Blood pressure b. Respirations c. Temperature d. Pulse

Pulse

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

Respiratory alkalosis

Which system will compensate someone with diabetic ketoacidosis?

Respiratory system (metabolic)

Which system will compensate someone with prolonged vomiting?

Respiratory system (metabolic)

Signs and Symptoms of Hyperkalemia (MURDER)

muscle weakness urine production low or absent respiratory failure decreased cardiac contractility early signs of muscle twitching (cramps) rhythm changes

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? a. Metabolic alkalosis b. Hypermagnesemia c. Hypercalcemia d. Hypovolemia

Hypovolemia

Which condition might occur with respiratory acidosis? a. Increased intracranial pressure b. Decreased blood pressure c. Decreased pulse d. Mental alertness

Increased intracranial pressure

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? Increased serum sodium Decreased serum potassium Decreased hemoglobin Increased platelets

Increased serum sodium

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? a. No effect b. Increases arterial pH c. Decreases arterial pH d. Provides long-term pH regulation

Increases arterial pH

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Administering vasopressin as ordered Elevating the head of the client's bed to 90 degrees Restricting sodium intake to 1 gm/day

Restricting fluids to 800 ml/day

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Sodium level of 137 mEq/L Potassium level of 3.8 mEq/L Sodium level of 150 mEq/L Potassium level of 6 mEq/L

Sodium level of 150 mEq/L

Which electrolyte is a major anion in body fluid? a. Chloride b. Potassium c. Sodium d. Calcium

Chloride

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity

Elevated hematocrit level

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence. a. Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing b. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible c. Breathe out through pursed lips while tightening the abdominal muscles d. Press firmly inward and upward on the abdomen while breathing out e. Repeat for 1 minute; follow with a 2-minute rest period.

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by a. muscle weakness b. tremors c. diaphoresis d. constipation.

muscle weakness

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: muscle weakness. tremors. diaphoresis. constipation.

muscle weakness.

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be? a. 7.50 b. 7.45 c. 7.35 d. 7.30

7.50

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? a. Extracellular fluid volume deficit b. Altered blood urea nitrogen (BUN) value c. Metabolic alkalosis d. Respiratory acidosis

Extracellular fluid volume deficit

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? a. The client's calcium will rise dramatically due to pituitary stimulation b. Oxygen will increase the client's intracranial pressure and create confusion c. Oxygen may cause the client to hyperventilate and become acidotic d. Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia