FlexiQuiz 11 2of2

american cheese canned tuna fish

A 2-g sodium diet is ordered for a patient with hypertension. Which foods should the nurse teach the patient to avoid? Select all that apply. A. American cheese B. Potatoes C. Canned tuna fish D. Cashews E. Shredded wheat

No, sodium intake should be restricted.

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

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

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. A. Drink water as an inexpensive way to meet fluid needs. B. Drink at least eight glasses of fluid each day. C. Drink caffeinated beverages to retain fluid. D. Drink carbonated beverages to help balance fluid volume. E. Respond to thirst.

Intake should be slightly more than the output

A nurse evaluates a patient's fl uid balance by monitoring the patient's intake and output. Which must the nurse understand about the ratio of the patient's fluid intake to output?

tgaut and shiny

A nurse identifi es that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion?

Muscle weakness Mental confusion

A nurse is assessing several patients for fl uid and electrolyte imbalances. Which responses are common to both excess fl uid volume and defi cient fluid volume?Select all that apply. A. Muscle weakness B. Mental confusion C. Increased pulse amplitude D. Difficulty breathing E. Decrease blood pressure

30mL

A nurse is caring for a critically ill patient with a urinary retention catheter. Which hourly urine output should fi rst alert the nurse that the primary health-care provider should be notified?

increased bowel sounds bradycardia flaccid paralysis

A nurse is caring for a patient in the emergency department. The patient's ECG tracing is indicated below. For which additional responses should the nurse assess the patient that can be clustered with the results of this ECG tracing? Select all that apply. A. Decreased deep tendon reflexes B. Increased bowel sounds C. Bradycardia D. Flaccid paralysis E. Ventricular dysrhythmias

decreased urine output

A nurse is caring for a patient who has a reduced fluid intake. The nurse assesses the patient for which response to this reduced fluid intake?

hydrostatic pressure

A nurse is caring for a patient who has dependent edema. Which pressure has caused the excess fl uid in the interstitial compartment?

1,220 mL

A nurse is caring for a postoperative patient over an 8-hour period. The patient vomits 300 mL of greenish-yellow fluid. The patient's intravenous fluids are infusing at 125 mL per hour. The patient received 2 intermittent infusions of antibiotics each in 50 mL of solution and they were infused at a different site than the IV fluid infusion. The patient was given 8 ounces of ice chips which were retained. The patient urinated twice—250 mL and 400 mL. Which is the patient's total fluid intake at the end of the 8-hour period?

Dyspnea, headache, and increased blood pressure

A nurse is monitoring a patient who is receiving intravenous fluid. Which clinical fi ndings indicate that the patient has a fluid overload?

1,4,2,5,3

A nurse must discontinue a patient's intravenous infusion. The nurse shuts off the infusion, washes the hands, and dons clean gloves. Place the following steps in the order in which they should be performed. 1. Apply counter-traction to the skin while loosening the tape at the venipuncture site. 2. Apply fi rm pressure to the site with sterile gauze for two to three minutes. 3. Apply a sterile dressing with tape over the venipuncture site. 4. Withdraw the needle/catheter along the line of insertion. 5. Examine the end of the needle/catheter.

Serum laboratory values

A nurse suspects that an older adult may have a fl uid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult?

Increase in pulse volume

A patient exhibits an increasing blood pressure and 2-lb weight gain over 2 days. Which additional clinical manifestation can be clustered with these data?

Deduct it from the total urine output.

A patient has continuous bladder irrigation. Which should the nurse do with the irrigant on the I&O sheet when calculating the fl uid balance for this patient?

Metabolic acidosis

A patient in the hospital emergency department tells the nurse, "I feel lousy and I've had diarrhea for several days. I have nausea and I don't feel like eating or drinking." The nurse obtains the patient's vital signs, performs a focused physical assessment, and reviews the results of laboratory studies. Which should the nurse conclude is the patient's human response based on this information? PATIENT'S CLINICAL RECORD: VITAL SIGNS: Temperature: 101.2°F, oral Pulse: 92 beats per minute, regular, thready Respirations: 26 breaths per minute, deep Blood pressure: 100/60 mm Hg FOCUSED PHYSICAL ASSESSMENT: Weight loss of 4 pounds in 3 days Tenting of the skin LABORATORY VALUES: Urine specific gravity: 1.036 Serum potassium: 5.3 mEq/L Arterial blood gases: pH: 7.30 Pa CO 2 : 24 mEq/L HCO 3 : 18 mEq/L

hypernatremia

A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. Which electrolyte imbalance does this data support?

14 drops/min

A patient is to receive 250 mL of 0.9% sodium chloride over 30 minutes. The nurse obtains an electronic infusion devise. At which hourly rate should the nurse set the infusion device? Record your answer using a whole number.

hypertonic

A patient receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea?

Cream of wheat Milk Vanilla ice cream

A patient's diet is progressed from clear liquid to full liquid. Which can the nurse include on the full-liquid diet that is not included on the clear-liquid diet? Select all that apply. A. cream of wheat B. Milk C. Gelatin D. Vanilla cream E. Cranberry juice F. Ginger ale

Determine the presence of urinary output

A primary health-care provider orders an intravenous infusion containing potassium for a patient. Which is the most important nursing intervention before administering this solution to the patient?

Electrolyte values

An assessment of which of the following is most important when a nurse is caring for an adult patient experiencing vomiting?

Formation of kidney stones

Several patients are taking supplemental calcium daily. The nurse teaches them to maintain their fl uid intake at a minimum of 2,500 mL. The nurse explains that this intervention is designed to prevent which complication?

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?

Bicarbonate

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 themost important indications of an acid-base imbalance that is shown in an ABG?

Tap over the patient's facial nerve.

The illustration refl ects a patient's upper extremity while the nurse is obtaining the patient's blood pressure. Which should the nurse do next after releasing the pressure in the sphygmomanometer cuff?

Offer a prescribed antiemetic medication.

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?

Neurologic system

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

The lungs are not able to blow off carbon dioxide.

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 rise in pH?

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?

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

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

dark, concentrated urine

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

??

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?

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 that contains the most body water?

A 52-year-old with diarrhea

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

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?

Decreased abdominal girth

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

Bases bind with hydrogen.

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

weight

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

Potassium: 5.8 mEq/L

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

An elevated hematocrit level Electrolyte imbalance

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. A. An elevated hematocrit level B. Absence of ketones in urine C. A low urine specific gravity D. Electrolyte imbalance E. Low protein level in the urine

Metabolic alkalosis

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?

Complete a head-to-toe assessment.

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

2500 mL

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

Compensated respiratory alkalosis

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; 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?

Active transport

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

Spinach Yogurt

When a nurse evaluates the effectiveness of patient teaching, which food selections by a patient indicate understanding regarding an abundant source of calcium? Select all that apply. A. Peanut butter B. Spinach C. Green beans D. Yogurt E. Bread

urinary output

When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse plans to monitor the patient routinely because an increase in these hormones will cause a decrease in which of the following?

Initiate an IV of albumin.

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

hypomagnesemia

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

Offer the patient something to drink every hour.

Which should a nurse do to encourage a confused patient to drink more fluid?

fluid overload

With which complication of the administration of intravenous fluids should the nurse slow the rate of flow of the infusion rather than stop the infusion and remove the catheter?