F+E, Acid/base, Burns HURST

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? Select All That Apply 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. PaO2 78 5. SaO2 82

1., &2. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis. 3. Incorrect: Normal HCO3 is 22-26. HCO3 is a base. Initially, the acids bind to the bicarb to reduce the acid levels. Therefore, the HCO3 would be less than 22. So, in DKA, the expected initial finding is a low HCO3?. Keep in mind that with acidosis, as the body compensates later, the kidneys will retain bicarb and you will see the bicarb levels increase. 4. Incorrect: Normal PaO2 is 80-100. An expected finding in DKA will be normal or increased PaO2, not decreased. 5. Incorrect: The client in DKA is kussmauling to blow off the CO2 (acid), so the oxygen saturation of blood will be high if there is no respiratory issue. In this question you are not told that there is a respiratory problem, so you would not expect a low oxygen saturation level. Go to page 17 of your student book if you missed this question.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? Choose One 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

Rationale 4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss. 1. Incorrect: Removing jewelry is important but stop the burning process first. Swelling occurs with burns, so jewlrey must be removed or you will not get it off. This can result in constriction of the extemity. Additionally, metal burns. 2. Incorrect: Wrapping the client in a clean or preferably a sterile blanket will help to hold in body heat. Remember, they have lost skin, the number one way to hold in body heat. 3. Incorrect: Applying a clean, dry cloth to the burn area will help prevent infection, but the priority is to stop the burning process. If you missed this question, go to page 23 of your student book for review.

A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines? Back and arm is burnt

22.5

What sign/symptom would indictate to the nurse that a client has had an inhalation injury? Select All That Apply 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

Rationale 1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing. 4. Incorrect: Blisters found on the oral/pharyngeal mucosa is more likely to indicate a smoke or inhalation injury. If you missed this question, go to page 25 of your student book to review this content.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO324. What action should the nurse initiate? Choose One 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

1. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort. 2. Incorrect: This client has mild respiratory acidosis after surgery. The nurse can fix this by waking the client up and instructing the client to take deep breaths or have the client use incentive spirometry. 3. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis. 4. Incorrect: No more sedation! The client is not breathing enough. This client needs to take deep breaths. Go to page 15 of your student book if you missed this question.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? Choose One 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO Submit

Rationale 3. Correct: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider. 1. Incorrect: You may have picked up on the decreased output and thought that you could increase PO fluid intake to increase output. However, the priority action would be to first stop the potassium infusion until the urinary output is adequate. This is a safety issue. 2. Incorrect: We do not want to administer any more potassium to this client. The urine output is not adequate and the client could be retaining too much potassium. 4. Incorrect: Polystyrene sulfonate (Kayexalate®) is used as a treatment for clients with known hyperkalemia. We are trying to prevent this client from becoming hyperkalemic by stopping the IV potassium infusion as the urine output has decreased.

A client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Causes of respiratory acidosis include any causes of decreased respiratory drive, such as drugs (narcotics) or central nervous system disorders. With a massive cerebral vascular accident (CVA or stroke), the respiratory center in the brain is impaired and affects oxygenation. Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest. 2. Incorrect: Respiratory alkalosis includes hyperventilation and tachypnea which does not describe the characteristics of Cheyne-Stokes respirations. 3. Incorrect: Compensation for metabolic acidosis caused by disorders like DKA includes tachypnea with deep respirations called Kussmaul's respirations. Here, we have a respiratory problem, not a problem that started with a metabolic issue. 4. Incorrect: The most common cause of metabolic alkalosis is vomiting, and this is clearly a respiratory problem, not metabolic. Go to pages 14-15 of your student book if you missed this question.

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: This client has a high fever. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. Here, the ABGs reflect respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: The client is hyperventilating so CO2 (acid) is being blown off. The pH says alkalosis.3. Incorrect: Not a metabolic problem since the HCO?3 is in normal range and remember the pH says alkalosis.4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range. Go to page 16 of your student book if you missed this question.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Choose One 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. 1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. 2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. 4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound. If you missed this question, go to page 24 of your student book for a review.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH 7.35 PaCO2 30 mm Hg Bicarb 19 mEq/liter PaO2 89 mm Hg SaO2 90% Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3., & 7. Correct. These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred. 1. Incorrect. For this problem to indicate respiratory acidosis, the pH would need to be less than 7.35 (or if fully compensated, the pH would be less than 7.40 to be on the acidotic side of normal) and the CO2 would need to be greater than 45. In this problem, we see the CO2 has been blown off to help get rid of the acid. 2. Incorrect. This is not a respiratory problem. The lung chemical, carbon dioxide does not match the acidotic pH. The pH indicates acidosis, not alkalosis. 4. Incorrect. Metabolic alkalosis would have pH greater than 7.45 (or if fully compensated, the pH would be greater than 7.40 to be on the alkalotic side of normal) and a Bicarb level greater than 26. The pH is on the acidosis side of normal, and the bicarb (metabolic chemical) indicates acidosis here. The lungs have compensated by bringing down the CO2 level to decrerase the acidotic state. 5. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. The pH would be abnormal and the PaCO2 would be normal if compensation had not begun. This client has fully compensated. 6. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. With partial compensation, the pH, PaCO2, and bicarb would all be abnormal. This client has fully compensated. If you missed this question, review your notes on page 17 of your student book.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select All That Apply 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

Rationale 1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated. 2. INCORRECT. Albumin, a body protein, is lost through the damaged skin areas and secondary to increased capillary permeability. 5. INCORRECT. Magnesium is a major electrolyte necessary for both muscle and nerve function. Since the body does not produce magnesium naturally, humans need a well-balanced diet which includes a variety of vegetables and seeds. Levels of magnesium are not affected during the initial period after a burn. If you mised this question you need to review FVD on pages 4-5, and burns on pages 26-27.

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? Choose One 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

Rationale 1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites. 2. Incorrect: Since hypertonic solutions, such as albumin, pull fluid from the cell into the vascular space, we would worry about cellular dehydration and shrinkage, not cellular edema. 3. Incorrect: As the fluid is pulled from the cells into the vascular space, you would expect to see an increase in the BP as the volume in the vascular space increases. You know... more volume, more pressure! We would be watching for hypertension, not hypotension. 4. Incorrect: Think about what we said about the BP when considering the CVP. Since the volume in the vascular space increases with hypertonic solutions, you would also expect the CVP to increase as well. We have to watch closely to make sure that we do not start seeing signs that we are overloading the heart when administering hypertonic solutions. So we will watch this client carefully for an increasing CVP.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH: 7.30 PaCo2: 55 Bicarb: 25 Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

., & 5. Correct. Now will a pH of 7.30 make the patient have acidosis or alkalosis? Well it's less than 7.35 so that's a low pH, and you know that a low pH is acidosis. So now we know acidosis, but we still must figure out if it is respiratory or metabolic. Look at the PaCO2, it is 55. That's a lot of CO2, and it's greater than the normal range of 35-45, so the PaCO2 must be acidosis. Now the Bicarb is 25, and a Bicarb of 25 is within the normal range of 22-26. To determine whether this is respiratory or metabolic acidosis, we need to match the pH with either the PaCO2 or the HCO3. The pH that we're trying to match is acidosis, so keep in mind you're trying to match the word acidosis with one of the chemicals. Well look at our problem, the CO2 is also acidosis. So, since these two match and they are both acidosis, we can say this is clearly Respiratory Acidosis because the "respiratory" chemical (CO2) is the one that matches the pH. Now, look at the Bicarb level. The bicarb is normal and doesn't match our pH which is acidosis, so, we can just mark it out. There you have it; this is Respiratory Acidosis. So, is there any compensation going on? No, not yet. The bicarb is still within normal limits. These values indicate uncompensated respiratory acidosis. 2. Incorrect. The pH would need to be above 7.45 and the PaCO2 below 35 for the client to have respiratory alkalosis. 3. Incorrect. The pH would need to be below 7.35 and the Bicarb below 22 for the client to have metabolic acidosis. 4. Incorrect. The pH would need to be above 7.45 and the Bicarb above 26 for the client to have metabolic alkalosis. 6. Incorrect. When partial compensation begins, the bicarb level will be above 26 as it goes UP to put more base in the body. 7. Incorrect. Full compensation will occur when the pH comes back to normal. If you missed this question, go to page 14 of your student book for a review.

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? Choose One 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

2. Correct. These symptoms are indicative of hypokalemia and metabolic alkalosis. What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic. Low potassium levels cause an increase in the reabsorption of bicarb by the kidneys. That is why you sometimes see metabolic alkalosis with Cushing's disease and prolonged steroid use. What electrolyte imbalance do we see with metabolic alkalosis? It's hypokalemia. So, if you have a client who is hypokalemic then they may have muscle weakness, hypotension and life threatening arrhythmias. And we know when the potassium is messed up, we should always think about the heart first. Connect the client to the cardiac monitor. 1. Incorrect. The priority is going to be checking the heart rhythm because a low potassium can cause a life-threatening arrhythmia. 3. Incorrect. The symptoms are most likely due to low potassium levels. This could lead to life-threatening arrhythmias. How would you fix this problem? Yes, give potassium, not oxygen. 4. Incorrect. You can do this after you check the heart rhythm. The priority is going to be checking the heart rhythm because a low potassium can cause a life-threatening arrhythmia. If you missed this question, review your notes on page 18 of your student book.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 ml Rationale The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 337.5 mL per hour, rounds up to 338 mL/hr. If you missed this question go to page 22 and 26 of your student book for review.

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis. 1. Incorrect: Respiratory Acidosis signs and symptoms include decreased respiratory rate, hyportension and a decrease in level of consciousness. Remember, if it's respiratory acidosis, it traces back to the lungs. This problem describes a metabolic issue. 2. Incorrect: Repiratory Alkalosis signs and symptoms include an inability to concentrate, light-headedness, numbness and tingling, tinnitus and loss of consciousness. The loss of CO2 from the lungs would be the problem with respiratory alkalosis, but the problem described in the question is metabolic. 3. Incorrect: Metabolic Acidosis signs and symptoms include headache, confusion, increased respiratory rate and depth, drowsiness, and nausea and vomiting. This can occur in cases of diarrhea, when more bicarb is lost through the lower GI tract. Go to page 18 of your student book if you missed this question.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? Choose One 1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

4. Correct: This ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO?2 and normal HCO?3. 1. Incorrect: This ABG result indicates metabolic alkalosis. The pH is high, PaCO?2 is normal and HCO?3 is high. Normal pH is 7.35-7.45, normal PaCO?2 is 35-45, normal HCO?3 is 22-26. 2. Incorrect: The client with an initial aspirin overdose will have a respiratory alkalosis. This ABG result indicates metabolic acidosis. The pH is less than 7.35 (acidotic); the PaCO2 is within normal limits, and the bicarb is low (less than 22), which creates acidosis. 3. Incorrect: This ABG indicates partially compensated metabolic acidosis. The problem in the stem would initially result in a respiratory problem. The pH is low (acidosis). The PaCO2 is low (alkalosis) as the body tries to compensate by decreasing the acid in the body. The metabolic chemical, bicarb, is low (acidosis) which matches the acidotic pH. Since the pH, PaCO2, and bicarb are all abnormal, we know that partial compensation has occurred. Go to page 16 of your student book if you did not get this question correct.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH 7.44 PaCO2 51 mm Hg Bicarb 31 mEq/liter PaO2 91 mm Hg SaO2 91% Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 7. Correct. The pH is on the alkalosis side of normal (7.35-7.45). Anything above 7.0 is on the alkalotic side of normal. Look at the CO2. The CO2 is high, which indicates acidosis, so this does not match the alkalotic pH, does it? No. Look at the Bicarb. The bicarb is high, indicating alkalosis, so there is your match. The bicarb is higher than 26, so there is a lot of base in the body. So, this is metabolic alkalosis. Has compensation begun? Yes. The PaCO2 is high. The lungs are attempting to compensate by holding on to carbon dioxide, an acid, to make the pH normal. Since the pH is normal, full compensation has occurred. 1. Incorrect. For this problem to indicate respiratory acidosis, the pH would need to be less than 7.35 (or less than 7.40 if fully compensated to be on the acidotic side of normal) and the CO2 would need to be greater than 45. This pH does not indicate acidosis, so the lungs are not the problem. The lungs are compensating for a metabolic problem. 2. Incorrect. This is not a respiratory problem. The lung chemical, carbon dioxide is high, which would cause acidosis. However, this does not match the alkalotic pH. The pH indicates alkalosis, not acidosis. 3. Incorrect. The pH would need to be below 7.35 (or if fully compensated, the ph would be less than 4.0 to be on the acidotic side of normal) and the Bicarb below 22 for the clint to have metabolic acidosis. 5. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal, so compensation has occurred. The pH would be abnormal and the PaCO2 would be normal if compensation had not begun. This client has fully compensated. 6. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. With partial compensation, the pH, PaCO2, and bicarb would all be abnormal. This client has fully compensated. If you missed this question, review your notes on page 18 of your student book.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? Choose One 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

Rationale 1. Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained. 2. Incorrect: Furosemide is a potassium depleting diuretic which would further deplete the potassium level. 3. Incorrect: Bumetanide is a potassium depleting diuretic which would further deplete the potassium level. 4. Incorrect: Hydrochlorothiazide also leads to potassium loss, which would further deplete the potassium level. Go to page 3 of your student book if you missed this question.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Select All That Apply 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

Rationale 1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully. 5. Incorrect: This statement is false. The rule of nines is not used for electrical burns, but for thermal burns. Most of the damage from electrical burns is internal and cannot be determined by using the rule of nines. If you did not get this question correct, go to page 34 of your student book to review this content.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select All That Apply 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

Rationale 1., 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up! 2. Incorrect: IV Calcium should be administered slowly or by slow infusion and the client should always be on a heart monitor. If you give calcium too rapidly by IV, the client may have vasodilation, hypotension bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. Don't forget to be watching for the widening of the QRS complex when administering IV calcium! 5. Incorrect: Phosphate supplements would cause the calcium to be even lower in this client. Remember, phosphorus and calcium have an inverse relationship. We would give phosphate binders, not supplements.

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? Choose One 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

Rationale 2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water. 1. Incorrect: Cushing's is a problem associated with an increased production of aldosterone, not ADH. The client will be retaining both sodium and water. 3. Incorrect: The client would not be losing excess fluid as is seen in clients with Diabetes Insipidus (DI), an ADH problem. The client will be retaining both sodium and water due to the increased aldosterone and would be at risk for fluid volume excess. 4. Incorrect: Increased thyroxine levels is related to hyperthyroidism, not Cushing's disease. This client has a problem with too much aldosterone and a resulting FVE.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? Choose One 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

Rationale 2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important. 1. Incorrect: What type of fluid is 3% NS? It's a hypertonic solution that contains a lot of sodium! That would be a killer answer here because this client's sodium level is already too high! 3. Incorrect: The sodium level is too high. The nurse would have the client to decrease, not increase, the oral intake of sodium. 4. Incorrect. With hypernatremia, there is too much sodium and not enough fluid. Therefore, you would want this client to increase, not decrease, the fluid intake to dilute the sodium level in the blood. Go to page 10 of your student book if you missed this question.

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select All That Apply 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

Rationale 2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated. 1. Incorrect: The client with a severe burn will lose fluids from the burn area and will also third space fluid to a place that does them no good. Therefore, they will go into a fluid volume deficit, not a fluid volume excess. 4. Incorrect: When the fluid volume becomes depleted, such as what occurs with burns, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. Go to pages 4-5 of your student book if you missed this question.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select All That Apply 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

Rationale 2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained. 1. Incorrect: Magnesium administration does not impair liver function, so although the alcoholic client may have altered liver function, this is not an assessment that the nurse would be most concerned about related to magnesium administration. In fact, hypomagnesemia is a common problem in alcoholics which may require increasing foods high in magnesium or magnesium supplementation by PO or IV routes. 3. Incorrect: Magnesium levels are not influenced by calcium levels, so this is not an assessment that would be a priority for the nurse at this time.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select All That Apply 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

Rationale 2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home. 1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. 3. Incorrect: Space heaters need space at least three feet (0.91 meters) away from anything that can burn. If you missed this question, review your notes on page 20 of your student book.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select All That Apply 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

Rationale 2., 4., & 5. Correct: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided. 1. Incorrect: Fresh fish is a good, healthy selection that is low in sodium, which is what this client needs. Make sure to avoid smoked or cured fish/meats because these would have a higher sodium content. 3. Incorrect: Salt, as a seasoning, should be avoided because this would increase the fluid retention problem. However, a good alternative to salt for seasoning foods is to use lemon, lemon juice, and pepper. These are lower in sodium than salt.

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? vitals are normal Choose One 1. The cardiovascular system is becoming seriously overloaded 2. The speed of the IV should be reduced since CVP is now normal 3. The changes in vital signs indicate an expected response to fluids 4. The client is deteriorating because of age and extent of the burns

Rationale 3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time. 1. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits. 2. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve. 4. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns. If you missed this question you need to review fluid volume deficit, pages 4-5, and pages 25-26 of your student book.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Choose One 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

Rationale 4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die. 1. INCORRECT. Guillian-Barre is a muscle disorder occurring when the immune system attacks peripheral nerves, destroying the surrounding myelin sheath. The damage can develop over hours or days, but will take months to resolve. The client experiences severe weakness, drooping of the eye muscles and pain or tingling in hands and feet. The client also develops paresthesia and paralysis, which was not reported as symptoms in the scenario. Of major concern would be paralysis of the respiratory muscles. 2. INCORRECT. Although the client reported nausea and vomiting, there are no assessment findings in the scenario to corroborate severe dehydration. 3. INCORRECT. The client has reported flu-like symptoms, such as dizziness, nausea and vomiting along with headache. However, additional reported symptoms like blurred vision suggest a different problem. If you missed this question, go to page 24 of your student book for a review.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? Choose One 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

Rationale 4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low. 1. Incorrect: As the client loses volume through the kidneys, the blood (serum) will become very concentrated. Therefore, you would expect the hematocrit to be high, not low. 2. Incorrect: Don't let the name diabetes insipidus trick you into thinking it affects the glucose level. It is an ADH problem, not a glucose problem. We are worried about fluid volume deficit here. 3. Incorrect: You do not expect to see protein in the urine in DI. In fact, protein is not seen in the urine unless there is a kidney problem. This is an ADH problem, not a kidney problem. You are worried about a large amount of water loss with this client. If you missed this question, review the content again on page 2 of your student book.