Med-Surg Test 1

restrict fluids to 800 mL/24 hours keep partial side rails up notify the doctor prepare to insert a foley catheter

1m 21s An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). What actions should the nurse take?

1. start an IV access site 2. attach the client to a cardiac monitor 3. administer calcium gluconate 4. administer sodium polystyrene sulfonate

1m 25s A client with end-stage chronic renal failure is admitted to the hospital with a serum potassium level of 7 mEq/L. In what order of priority from first to last does the nurse perform the prescriptions? All options must be used. administer calcium gluconate attach the client to a cardiac monitor start an IV access site administer sodium polystyrene sulfonate

right-side lying

A 2-year-old is being treated for pneumonia. After reviewing the respiratory section of the client care flow sheet, the nurse concludes that which position is most beneficial to maximize oxygenation?

PE

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/l). The nurse determines that which of the following is a possible cause for these findings?

BP heart rate respiratory rate skin turgor daily weight

A client is experiencing hypovolemic shock. Which of the following assessments best assists in evaluating the client's fluid status?

change the feeding apparatus every 24 hours slow the administration rate use a diluted formula, gradually increasing the volume and concentration anticipate changing to a lactose-free formula

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do?

hyperventilation muscle discomfort dizziness

A client is taking metformin. To prevent lactic acidosis resulting from use of this drug, the nurse should instruct the client to report which symptoms?

remind the client to drink fluids and rest between active periods

A client questions the nurse about the amount of her postpartum lochia flow. The client is 22 hours postpartum and is saturating a pad after 2 hours. Which of the following should the nurse do first?

weight the client every day provide gum for the client monitor the clients I & O maintain a structured environment

A client with a diagnosis of undifferentiated schizophrenia is admitted to the inpatient unit after developing water intoxication. Which nursing interventions are appropriate?

there is no treatment

A client with chronic renal failure is experiencing metabolic acidosis. The client most likely requires:

multiple myeloma

A client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews his history for conditions that may warrant changes in client preparation. Normally, the client should be mildly hypovolemic (fluid depleted) before excretory urography. Which history finding calls for the client to be well hydrated?

the client has lost 15% of body weight and has prolonged diarrhea

A client with ulcerative colitis is scheduled for a bowel resection. The client is receiving parenteral nutrition prior to surgery. Which of the following is the best explanation for the nurse to give the client about the need for parenteral nutrition?

flushed skin

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg (10.64 kPA); PaCO2, 65 mm Hg (8.64 kPA); HCO3-, 36 mEq/L (29 mmol/l). The nurse should assess the client for:

1. obtain a fingerstick test for blood glucose 2. notify the doctor 3. start an IV infusion with NS solution 4. administer insulin lispro

A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin lispro. The last meal was lunch, 2 hours ago. Place the nursing actions in the order in which the nurse should perform them. All options must be used. notify the doctor obtain a fingerstick start an IV infusion with NS administer insulin lispro

95%

A normal oxygen saturation value for arterial blood is ____.

increased BUN and creatinine levels

A nurse encourages a client to increase fluid intake, based on which laboratory test results?

1. oliguria 2. azotemia 3. acidosis 4. severe hypocalcemia

A nurse is caring for a 4-year-old child who developed acute renal failure after a traumatic injury with hemorrhaging. Place the following events in the order in which they most likely occurred during progression of the severe renal deterioration. All options must be used. azotemia oliguria severe hypocalcemia acidosis

increasing the rate of the IC fluid solution

A nurse is caring for a client whose blood pressure has changed from 136/82 to 120/86. Which is the best nursing intervention?

trousseau's sign cardiac arrhythmias fractures

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which signs and symptoms?

respiratory acidosis from airway obstruction

A nursing student understands that emphysema is directly related to

pedialyte and water

A parent phones the health care provider's office stating that his 13-month-old has had diarrhea for 3 days and he is unsure what fluids to offer. Which suggestions would the nurse provide?

oliguria tachycardia tachypnea

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms assocciated with hypovolemia would cause what clinical manifestations?

11

A patient is admitted with a dx of kidney injury. The patient reports "stomach distress" and describes ingesting several antacid tablets over the past 2 days. BP 110/70, face flushed, and the patient is experiencing generalized weakness. Which is the most likely Mg level associated with the symptoms the patient is having?

2.0

A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted". The nurse observes flat T waves and ST-segment depression on the EKG. Which potassium level does the nurse observe when the lab studies are complete?

calcium

A patient reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau and Chvostek signs. Which decreased lab does the nurse observe?

155 mEq/L

A patient who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue, and a body temperature of 99.3F. The urine specific gravity is 1.020. What is the most likely serum Na value for this patient?

one beef cube and 8 oz of tomato juice

A patient with abnormal Na losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1600 mg of Na daily?

torasemide

A patient with mild FVE is prescribed a diuretic that blocks Na-reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this patient?

275 to 300 mOsm/kg

A patient's serum Na concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

clamp the catheter for 20 minutes

A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next?

1. start an IV infusion 2. start oxygen via nasal cannula 3. administer morphine for the pain 4. draw blood for electrolyte levels and pH balance

A school-age child is admitted to the hospital in vasoocclusive sickle cell crisis. Place the prescriptions in the order of priority (first to last) that the nurse should implement them. All options must be used. start oxygen via nasal cannula draw blood for electrolyte levels and pH balance administer morphine for the pain start an IV infusion

50 6 plasma

About ____% of the ____L of total blood volume is _____.

66 potassium

About _____% of total body fluid is in the intracellular space; the major positively charged ion in intracellular fluid is ____.

gastric output

After having surgery to reduce the invagination of intussusception, an infant has a nasogastric tube in place, is receiving IV fluids, and is allowed nothing by mouth. In addition to body weight, what parameter is most important to use to calculate the amount of IV fluid and electrolyte solution to infuse over the next 24 hours?

8

Cardiac effects of hyperkalemia are usually present when the serum K level reaches ___ mEq/L

CNS depression, overdose, lung issues, narcotics, anesthesia

Causes of respiratory acidosis

nervous, anxious, fear, anxiety, fever, pain

Causes of respiratory alkalosis

the amount of hydrostatic pressure needed to stop the flow of water by osmosis. It is primarily determined by the concentration of solutes.

Define osmotic pressure

1. responsible for monitoring the circulating volume, are small nerve receptors that detect changes in pressure within blood vessels 2. sense changes in sodium concentration

Distinguish between the terms baroreceptors and osmoreceptors

1. measures the kidney's ability to excrete or conserve water 2. urea is an end product of protein metabolism (muscle and dietary) by the liver 3. end product of muscle metabolism, is a better indicator of renal function than BUN

Distinguish between the terms urine specific gravity, BUN, and creatinine

administer a saline bolus as needed

During an initial shift assessment, a nurse finds a diabetic client who is lethargic and who has rapid, deep respirations. Which of the following actions should the nurse take?

only small volumes are needed to elevate the serum Na from dangerously low levels

Explain why the administration of a 3% to 5% NaCl solution requires intense monitoring

by the combined actions of parathyroid hormone and vitamin D

How are calcium levels regulated?

800

In a patient with excess fluid volume, hyponatremia is treated by restricting fluids to how many mL in 24 hours?

dyspnea, cyanosis, a weak pulse, hypotension, unresponsiveness, and pain (chest, shoulders, and low back).

List 4-6 symptoms associated with air embolism, a complication of IV therapy

metastatic calcification of soft tissues, joints, and arteries

Name the primary complication of hyperphosphatemia which occurs when the calcium-magnesium product exceeds 70 mg/dL

loss of HCO3 decreased pH and HCO3 increased CO2 headache, lethargic, nausea increased K

S/S of metabolic acidosis

excessive retention of HCO3 dysrythmias, tetany, weakness, parasthesia, trousseau's sign, and chvostek's sign decreased K

S/S of metabolic alkalosis

rentention of CO2 decreased pH and HCO3 increased CO2 SOB, increased heart rate, restless increased K

S/S of respiratory acidosis

loss of CO2 anxious, decreased K, confusion, hyperventilation, dysrythmias decreased phosphate

S/S of respiratory alkalosis

muscle contraction transmission of the nerve impulses

Sodium establishes the electrochemical state necessary for ____ and the ____.

thirst, ADH, RAAS

Sodium is regulated by ___, ____, and the ____ system.

osmolality affects the movement of water between fluid compartments

Sodium, the most abundant electrolyte in ECF, is primarily responsible for maintaining fluid ______, which _____.

0.45% NS (sodium chloride)

The HCP has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?

1.5

The average daily urinary output in an adult is ___ L.

intravascular interstitial, and transcellular Sodium

The extracellular space is divided into three components____, ____, and _____; the major positively charged ion in extracellular fluid is ____.

treating the underlying health disorder and providing supplementary oxygen

The following blood gas values were obtained on a client in the emergency room: pH < 7.35, PaCO2 > 45 mm Hg, HCO3 24 mEq/L. Based on these values, which of the following nursing interventions is most important?

tetany

The most characteristic manifestations of hypocalcemia and hypomagnesemia is _____.

bicarbonate-carbonic acid buffer system

The most common buffer system in the body is the ____.

continue the child's regular diet

The mother of a child with moderate diarrhea asks how to manage her child's illness. What should the nurse suggest?

PTT 22 seconds Ammonia 96 mg/dL platelets 75,000 cells/mm3

The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process?

maintain IV fluids and vasopressors administer ceftriaxone

The nurse is caring for a client admitted with severe blood pressure 80/40 hypotension and positive blood cultures for Eschirichia coli. Which of the following are the priority interventions for this client?

lung sounds of stridor increased respiratory effort nasal flaring with abdominal retractions ABG-PaCO2 of 48 and PaO2 of 84

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. What will the nurse report?

providing small glasses of fluid offering frequent ice chips encouraging popsicles and gelatin

The nurse is caring for a hospitalized child with a poor appetite. Nursing interventions are focused on increasing the child's fluid intake. Identify the choices that will be successful in meeting the expected outcome.

metabolic acidosis

The nurse is caring for a patient with DMI 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?

assessing for symptoms of nausea and malaise monitoring neurologic status restricting tap water intake

The nurse is caring for a patient with a dx of hyponatremia. What nursing intervention is appropriate to include in the POC for this patient?

cerebral edema

The nurse is caring for a patient with hypernatremia. What complication of hypernatremia should the nurse continuously monitor for?

brush teeth or rinse mouth after vomiting

The nurse is instructing a client's parent on care related to a 200cc emesis from a viral illness. This is the third emesis of the day. Which instruction is stressed first?

serum creatinine

The nurse is reviewing the lab results fora patient suspected of an AKI. What test would be the best indicator of the patient's renal function?

A patient with kidney failure

The nurse is reviewing the lab studies for a group of patients. Which patient is most likely to experience a decrease in serum osmolality?

acidosis

The nurse notes that a patient's urine osmolality is 98. What should the nurse assess as a possible cause of this finding?

call the lab to see how the specimen was obtained

The nurse receives a report of a serum potassium level on an infant of 5.4 mEq/L (5.4 mmol/L). What should the nurse do first?

115 mEq/L

The nurse should assess the patient signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level?

bones soft tissue

The primary concentration of phosphorus (85%) is located in the ____, with about 15% located in the ____.

upper: 7.8 lower: 6.8

The upper and lower blood pH levels that are incompatible with life are ____ and ____.

serum BUN Creatinine levels

To assess the client's renal status, the nurse should monitor which laboratory tests?

D5LR and D5NS give to a hypotonic body

Type of hypertonic fluids

1/2 NS (0.45 NS) give to a hypertonic body

Type of hypotonic fluids

NS, LR, and D5W

Types of isotonic fluids

increase in rate and depth of respirations

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

hyperparathyroidism malignant tumors immobilization because of multiple fractures thiazide diuretics

What are some factors that contribute to hypercalcemia?

tourniquet too tight when collecting sample leukocytosis kidney failure adrenal steroid deficiency

What are some factors that contribute to hyperkalemia?

kidney failure

What are some factors that contribute to hypermagnesmia?

watery diarrhea inability to quench thirst burns over large surface area heat stroke s/p therapeutic abortion diabetes insipidus with water restriction

What are some factors that contribute to hypernatremia?

kidney failure neoplastic disease chemotherapy

What are some factors that contribute to hyperphosphatemia?

massive administration of citrated blood pancreatitis kidney failure aminoglycoside administration

What are some factors that contribute to hypocalcemia?

alkalosis vomiting gastric solution anorexia nervosa hyperaldosteronism furosemide (lasix) administration steroid administration penicillin administration

What are some factors that contribute to hypokalemia?

alcohol abuse diarrhea gentamicin administration untreated ketoacidosis

What are some factors that contribute to hypomagnesemia?

vomiting diarhhea diuretics adrenal insufficiency syndrome of inappropriate ADH excessive parenteral administration of dextrose and water solution

What are some factors that contribute to hyponatremia?

hyperparathyroidism major thermal burns alcohol withdraw

What are some factors that contribute to hypophosphatemia?

tetany

What clinical indication of hypophosphatemia does the nurse assess in a patient?

fruits such as bananas and apricots

What foods can the nurse recommend for the patient with hypokalemia?

Hct level >47% urine specific gravity of 1.027 urine osmolality of >450

What lab findings does the nurse determine are consistent with hypovolemia in a female patient?

urine output 20mL/hr confusion

When assessing a client with heart failure, the nurse should report which findings to the health care provider (HCP)?

they administer iron supplements in combination with fruit juice they brush the child's teeth after administering the iron supplements

Which action indicates that the parents of a 12-month-old with iron-deficiency anemia understand how to administer iron supplements?

drinks 1500 mL/day

Which activity reflects health maintenance for an otherwise healthy older adult?

magnesium sulfate

Which medication does the nurse anticipate administering to antagonize the effects of K on the heart for a patient in severe metabolic acidosis?

i will eat green beans, fish, and white bread for a meal

Which statement indicates that a client with the medical diagnosis of hypoparathyroidism understands diet instructions?

DKA, renal failure, NG, diarrhea, alcohol, starvation, malnutrition

causes of metabolic acidosis

prolonged vomiting, diarrhea, alkaline intake, HCO3 given when in cardiac arrest

causes of metabolic alkalosis

causes: dehydration- fluid loss through N/V/D (water loss in excess of salt loss) or excessive sweating, DKA, fever Tx: replace fluids D5, diuretics (excrete excess volume and excrete) Nsg Considerations: monitor electrolytes, VS, mental status, weight, I&O, sz

causes, treatments, and nursing considerations for hypernatremia

path: most abundant cation in ECF, maintains osmiotic pressure of ECF, regulates renal rentention and excretion of water, responsible for stimulation of neuromuscular reactions and maintains SBP causes: excess Na loss through N/V/D, skin and kidneys, excess diuretic dosage, liver failure, CHF, and increased hypotonic IV fluids Tx: Na containing IV fluids (LR, and NS o.9% or 3% Nsg Considerations: monitor electrolytes, VS, neuro, mental status, headaches, fluids for overload, daily wt, cramps/weakness/tremor

causes, treatments, and nursing considerations for hyponatremia

causes: prolonged immobilization, dehydration, cancer, excess antacid intake tx: eliminate Ca through kidneys through IV fluids, loop diuretics to promote elimination of Ca nsg care: monitor electrolytes, VS, hypertension, monitor GI: N/S, anorexia, dysrhythmias

causes, tx, and nsg care for hypercalcemia

causes: metabolic acidosis, dehydration, excess K intake, K sparing diuretics, tissue damage (burns--> K goes our of the cell), renal failure tx: insulin moves K into the cell, D50 prevents hypoglycemia caused by the infusion of insulin, IV cacium gluconate also given to counteract cardiac effects of K, Sodium bicarbonate-treats the acidosis caused when K moves into the cell and pushes H ions into the serum nsg care: monitor electrolyte, cardiac responses, cramps, weakness, parathesias, peaked T wave/wide QRS, neurological resposes, mental status, headache, irregular heart rate and rhythm for increased ectopy-PVC/Vtach

causes, tx, and nsg care for hyperkalemia

causes: dehydration, severe metabolic acidosis, renal failure, and tissue trauma tx: treat underlying causes, renal patients treat with dialysis, monitor cardiac effects of Mg, icnreased PVCs/Vtach, give calcium gluconate nsg care: monitor electrolytes, VS, bradycardia, hypotension, muscle weakness

causes, tx, and nsg care for hypermagnesemia

causes: ETOH abuse, pancreatitis, chronic renal failure, inadequate intake, decreased vitamin D, lack of weight bearing, loop diuretics, hypomagnesemia tx: oral calcium carbonate/gluconate, calcium chloride, watch for extravasate into subcut tissue nsg care: monitor electrolytes, VS, cardiac output decreased, hypotension, dysrhythmias, monitor neuromuscular responses, sz, tetany, paresthesia, muscle spasms

causes, tx, and nsg care for hypocalcemia

causes: inadequate intake of K, ETOH abuse, CHF/HTN, GI loss from V/D, renal loss, diuretics-loop (lasix and bumex) Tx: oral or parenteral K, diet high in K, balanced electrolyte solutions, pedialyte, sports drinks Nsg care: monitor electrolytes, VS (for decreased BP), cardiac responses, irregular heart rate and rhythm for increased ectopy-PVCs/V-tach

causes, tx, and nsg care for hypokalemia

causes: chronic alcoholism, GI loss via V/Dm impaired absorption, renal disease, and pancreatitis tx: treat underlying causess, GI loss, give Mg replacement nsg care: monitor electrolytes, VS, tachycardia, HTN, tremors, tetany, parasthesias, muscle weakness

causes, tx, and nsg care for hypomagnesemia

poor protein, intake/malnutrition, liver disease, malabsorption syndromes

disease processes that decrease BUN

anemia, CA, fluid retention/overload, hemorrhage

disease processes that decrease HgB

ETOH abuse, anemia, bone marrow depression, viral infections

disease processes that decrease WBC

acute renal failure, CHF, hypovolemia-dehydration, pyelonephritis, hyperalmentation/TPN

disease processes that increase BUN

CHF, dehydration, acute & chronic renal failure, shock

disease processes that increase Creatinine

decreased skeletal muscle inadequate protein intake

disease processes that increase Creatinine

COPD, CHF, dehydration, polycythemia

disease processes that increase Hgb

infection, anemia, inflammatory disorders, steroid use (acute or chronic)

disease processes that increase WBC

pH normal abnormal CO2 & HCO3

fully compensated in ABG

decreased pH (abnormal) elevated CO2 (abnormal) normal HCO3 (normal) step one: acidosis step two: respiratory step three: uncompensated [uncompensated] respiratory acidosis

give result of ABG pH: 7.23 pCO2: 56 HCO3: 24

decreased pH (abnormal) elevated pCO2 (abnormal) normal HCO3 step one: acidosis step two: respiratory step three: uncompensated [uncompensated] respiratory acidosis

give result of ABG pH: 7.28 pCO2: 58 HCO3: 23

normal pH elevated CO2 (abnormal) slightly elevated HCO3 (abnormal) step one: acidosis step two: respiratory step three: fully compensated fully compensated respiratory acidosis

give result of ABG pH: 7.35 pCO2: 50 HCO3: 27

normal pH slightly elevated pCO2 (abnormal) elevated HCO3 (abnormal) step one: alkalosis step two: metabolic step three: fully compensated fully compensated metabolic alkalosis

give result of ABG pH: 7.45 pCO2: 46 HCO3: 32

slightly elevated pH (abnormal) normal pCO2 elevated HCO3 (abnormal) step one: alkalosis step two: metabolic step three: uncompensated [uncompensated] metabolic alkalosis

give result of ABG pH: 7.48 pCO2: 42 HCO3: 30

slightly elevated pH (abnormal) slightly elevated pCO2 (abnormal) elevated HCO3 (abnormal) step one: alkalosis step two: metabolic step three: partial compensation partially compensated metabolic alkalosis

give result of ABG pH: 7.48 pCO2: 46 HCO3: 30

elevated pH (abnormal) decreased pCO2 (abnormal) normal HCO3 step one: alkalosis step two: respiratory step three: uncompensated [uncompensated] respiratory alkalosis

give result of ABG pH: 7.50 pCO2: 30 HCO3: 24

decreased pH (abnormal) normal pCO2 decreased HCO3 (abnormal) step one: acidosis step two: metabolic step three: uncompensated [uncompensated] metabolic acidosis

give result of ABG pH: 7.30 pCO2: 40 HCO3: 19

22-26

normal HCO3 level

35-45

normal pCO2 level

7.35-7.45

normal pH level

> 80%

normal pO2 level

Na: 135-145 K: 3.5-5 Cl: 85-105 CO2: 35-45 BUN: 8-20 Cr: (f) 0.6-1.2 (m) 0.4-1.0 Glucose: 70-110 HCO3: 22-28 Mg: 1.6-2.6 Phosphorus: 2.5-4.5

normal ranges for BMP

WBC: 4.5-10.5 HgB: (f) 13-17 (m) 12-15 Hct: (f) 41-50 (m) 36-44 Plt: 140,000-450,000 RBC: (f) 3.6-5 (m) 4.2-5.4

normal ranges for CBC

abnormal pH, CO2, & HCO3

partial compensation in ABG

most abundant cation in body and necessary for almost all vital processes, half of total body calcium circulates as free ions that participate in coagulation, intracellular regualtion, control of skeletal and cardiac muscle contractility, 98-99% calcium reserves stored in teeth and skeleton

pathophysiology of calcium

2nd most abundant ICF, required for transmission of nerve impulses and muscle relaxation, controls absorption of NA, K, Ca, and Phosphorus. Mg, K, and Ca all go low or high together

pathophysiology of magnesium

most abundant ICF cation and is esstential for transmission of electrical impulses in cardiac and skeletal muscle, helps maintain acid-base balance and has inverse relationship to metabolic pH [decreased in pH of 0.1 (acidosis0 increases K by 0.6, 80-905 K filtered though the kidney

pathophysiology of potassium

most abundant cation in ECF, maintains osmiotic pressure of ECF, regulates renal rentention and excretion of water, responsible for stimulation of neuromuscular reactions and maintains SBP

pathophysiology of sodium

abnormal pH abnormal CO2 OR HCO3 (only one is abnormal, while the other is normal)!

uncompensated ABG