Exam 2 practice

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?

respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

respiratory alkalosis

A client has a prescription for a sublingual nitroglycerin tablet. Which technique will the nurse teach the client to use?

place the pill under the tongue and let it dissolve

A health care provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication?

administer in the abdomen

the RN teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning?

administering sodium polystyrene sulfonate (Kayexalate)

Which clinical indicators would the nurse expect a client with hyperkalemia to exhibit?

confusion weakness dysrhythmias

To meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take?

initiate an agency incident report

Which finding for a client who has a potassium level of 2.8 mEq/L would be of most concern to the nurse?

irregular heart beat

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply.

leg cramps muscle weakness

A critically ill 5 year old child exhibits Kussmaul respirations. Which would the nurse suspect may be causing an increasing acid-base imbalance?

metabolic acidosis caused by a concentration of cations in body fluids

Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L?

monitor for cardiac dysrhythmias

Which clinical manifestation is indicative of the F&E imbalance associated with a parathyroidectomy?

muscle spasms

A client is receiving furosemide. For which sign of hypokalemia will the nurse monitor the client?

muscle weakness

Based on ECG, a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia?

serum potassium level

Which consideration would the nurse make when preparing to give a preschooler an intramuscular injection in the vastus lateralis site?

the maximum recommended length of the needle insertion at the vastus lateralis site is 1 inch for preschoolers

The nurse places a school aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions?

they keep the child away from uninfected people

Which site would the nurse use to administer vitamin K to a newborn?

vastus lateralis

The client's serum sodium is 123 mEq/L. Which prescription would the nurse question?

Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h

Which clinical manifestations will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L? select all that apply.

muscle weakness irregular heart rhythm hyperactive bowel tones

Which findings are consistent with hypercalcemia after prolonged immobility? select all that apply.

bone pain depressed deep tendon reflexes

Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall?

document the incident in the occurrence report tool

the medication prescribed for an infant is to be given intramuscularly. Which site will the nurse select for administration of the medication?

vastus lateralis

Which information would the registered nurse provide to a student nurse about the important of nursing documentation for risk management? select all that apply.

-"a nurse's documentation is the evidence of care that a client receives." -"the nurse would note assessments and significant changes in the client's health." -"nurses would always document the primary health care providers' responses whenever they are contacted."

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to?

Nosocomial

Which clinical manifestations would the nurse expect to find in a client with hypokalemia? select all that apply.

anorexia leg cramps