nursing exam 5

Which question about fluid balance would be appropriate when conducting a health history for a client?

"Describe your usual urination habits."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

"I can assist you to the bathroom and back to bed."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

normal ranges for urine specific gravity test:

1.002 and 1.030

magnesium ranges:

1.5-2.5 mEq/L

sodium range value:

135 - 145 mEq/L

phosphate range:

2.5-4.5 mg/dL

bicarbonate range:

22-26 mEq/L

potassium range value:

3.5 - 5 mEq/L

pH balance:

7.35 - 7.45

calcium range:

8.6 - 10.2 mg/dL

chloride range:

97 - 107 mEq/L

hypertonic solution:

A solution in which the concentration of solutes is greater than that of the cell that resides in the solution

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 20 bpm

What food would the nurse provide for a client who has hypokalemia?

Bananas

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client?

Fowler's position

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst.

The nurse should assess for respiratory depression before and after the administration of which drugs?

Opioid analgesics

what are the types of CVADs?

PICCs, nontunneled percutaneous central venous catheters, tunneled venous catheters, and implanted ports

A client 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of the thorax. Based on age and the injury, the client is at risk for what complication?

Pneumonia

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which nursing intervention is appropriate to include in the client's care plan?

Provide six small meals daily.

The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication?

Regulate flow to allow 25 gtts every 15 seconds

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume

what would hypertonic solutions be used to treat?

SIADH fluid volume excess

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

The client donates his or her own blood.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted?

The graduate nurse auscultates breath sounds as the client breathes through the nose.

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?

The nurse recognizes these symptoms of hypokalemia.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition?

Wheezes

hyperphosphatemia:

above normal serum concentration of inorganic phosphorus

phosphate purpose:

acid/base balance as H+ buffer promotes energy storage carb, protein, and fat metabolism bone, teeth, muscle, RBC function

a body with diarrhea is acidotic or alkadotic?

acidotic

when sleeping, is body acidotic or alkadotic?

acidotic

a body vomiting is acidotic or alkadotic?

alkadotic

when hyperventilating, is body acidotic or alkadotic?

alkadotic

special considerations when caring for clients with CVADs:

be aware how long the catheter will remain in patient, what veins are most safely accessible for location, what med is being given with catheter

hypophosphatemia:

below normal serum concentration of inorganic phosphorus:

calcium function:

blood coagulation and transmission of nerve impulses regulates muscle contraction and relaxation bones/teeth strength

what would a nurse have at the bedside of the client with a chest tube?

bottle of sterile saline or water for submerging the end in to recreate seal in event of disconnection

what is diaphragmatic breathing?

breathing using the abdomen muscles instead of the chest muscles to breath

issues when using hypotonic solution:

can cause cell bursting

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?

cheese

CPR list in order per the text book:

chest compressions, airway clearing, breathing, defibrillation

how would you choose a supplemental oxygenation method for a patient?

chosen based on how the patient is accepting the O2; how many liters per minute (LPM) they need.

A client's PaCO2 is abnormal on an ABG report. What is the most likely medical diagnosis?

chronic obstructive pulmonary disease (COPD)

urine specific gravity test:

compares density of urine with density of water. allows doctors to see concentrations of all particles that are present in urine

CBC:

complete blood count test; used to evaluate overall health and detect disorders like anemia, infection/leukemia

signs of hyponatremia

confusion, hypotension, edema, muscle cramps, weakness, dry skin

what are abnormal breath sounds?

crackles -- soft high pitched sounds Wheezes -- musical sounds , produced by constricted airways

A client has been admitted with fluid volume excess related to left-sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? Select all that apply.

crackles in the lungs distended neck veins

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup

what is the difference between cuffed and uncuffed trach tubes?

cuffed tubes prevent air leakage and bronchial aspiration of foreign material while allowing more precise control of O2 and mechanical ventilation

what are signs of poor perfusion in a client?

decreased BP, diminished peripheral pulse, slow cap refill

dehydration:

decreased water volume in body tissue

how is the location of the chest tube decided?

determined by fluid (lower) or air (higher) (ocean air is above ocean)

peak flow meter:

devise that measures the amount of exhalation

signs of FVE:

edema in feet, ankles, wrists, and face discomfort in body, causing cramping, headaches and stomach bloating high BP via excess fluid in blood stream

insensible fluid loss:

evaporation through skin, cellular metabolism, respiration

hypercalcemia:

excess amount of calcium in extracellular fluid

hypermagnesemia:

excess amount of magnesium in ECF

Hyperkalemia:

excess amount of potassium in extracellular fluid

hypernatremia

excess of sodium in extracellular fluid

chest tube:

flexible plastic tube inserted through chest wall into pleural space or mediastinum

when is parenteral nutrition used:

for patients who are NPO and cannot absorb from tube feeding for GI issues or formula issues

hypotonic solutions:

having a lesser concentration than the solution with which it is being compared; replaces ICF

Isotonic solution:

having about the same concentration as solution with which it is being compared

extracellular dehydration examples:

hemorrhage, sodium depletion, vomiting, diarrhea

hyperchloremia:

high levels of chloride in body

risk factors associated with FVE:

high sodium intake, IV/blood transfusions, medications or diagnostic contrast dyes

signs of hypochloremia:

hyper excitability of muscles, tetany, hyperactive DTRs, weakness, muscle cramps

what would hypotonic solutions be used for?

hypernatremia, intracellular dehydration

5% dextrose in water (D5W), 0.9% saline (NS), 5% dextrose in 0.225%, saline (5% D/¼ NS) are examples of:

hypertonic solutions

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia.

what would isotonic solutions be used for?

hypovolemia, dehydration, blood transfusions

Fluid Volume Excess (FVE):

increase in isotonic fluid retention; refers to isotonic expansion of ECF due to increase in total body sodium content and increase in total body water

signs/symptoms of dehydration:

increased thirst, dry mouth, tired, decreased urine dark urine color, headache, dry skin (poor skin turgor), dizziness

what is the role of the respiratory system in acid/base balance?

increases pH by removing CO2 (an acid) during exhalation

List age related physiological changes that impact oxygenation/perfusion in infants?

infants: chest size, shorter airway, more rapid respiratory rate, smaller respiratory system organs, abdominal breathing, thin chest wall, louder breath sounds, round thorax

hypocalcemia:

insufficient amount of calcium in ECF

Hypomagnesemia:

insufficient amount of magnesium in ECF

hypokalemia:

insufficient amount of potassium in ECF

hyponatremia:

insufficient amount of sodium in the extracellular fluid

intracellular dehydration examples:

insufficient fluid intake; stimulates thirst control center

chloride function in body:

interstitial and lymph fluids gastric/pancreatic juices sweat, bile, saliva osmotic pressure HCl (stomach acid)

where is the largest volume of fluid contained in the adult?

intracellular (ICF) holds 70% of body's water and makes up 40% of weight

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

what are the fluid compartments in the body?

intracellular fluid (ICF) and extracellular fluid (ECF)

Potassium function in body:

intracellular osmolality enzyme regulator electrical impulses in nerves, heart, skeletal, intestinal and lung tissue exchange H+ for pH balance

signs of hypophosphatemia:

irritability, fatigue, weakness, paresthesias, confusion, seizures, coma

what is a CVAD (central venous access device)?

it is a venous catheter that is designed to deliver medication and fluids directly into the SVC, IVC, and RA

what can the nurse do to prevent atelectasis?

keep airway clear of foreign bodies, mucus, and monitor for tumors or enlarged blood vessels. keep patients mobilized

symptoms of hypernatremia:

lethargy, muscle twitching, focal weakness, hemiparesis, seizures, death

hypochloremia:

low levels of chloride in body

what can impact respiration?

medications, heart, lung, breathing conditions, changes in environment, smoking, obstructions, pain, dyspnea, fever, fluids in lungs

what are diuretics:

meds or substances designed to increase amount of water and salt expelled from body in urine

magnesium function in body:

metabolism of carbs/proteins role in neuromuscular function cardiovascular system produces vasodilation

capnography:

method to monitor ventilation and blood flow through lungs. exhaled air passes through sensor that measures amount of CO2 in each breath

active transport:

moment of ions or molecules across cell membranes, usually against a pressure gradient and with the expenditure of metabolic energy

signs of hypokalemia:

muscle weakness and leg cramps, fatigue, parenthesis, dysrhythmias

signs of hyperkalemia:

muscle weakness, paralysis, cardiac arrest

signs of hypomagnesemia:

muscle weakness, tremors, tetany, seizures, heart block, mental changes, hyperactivity, deep tendon reflexes, respiratory paralysis

what are the different ways to apply supplemental oxygen?

nasal cannula (high/low flow) simple mask (low flow) partial rebreather mask (low flow) nonrebreather mask (low flow) venturi mask (high flow)

signs of hypercalcemia:

nausea, vomiting, constipation, one pain, excessive urination, thirst, confusion, lethargy, slurred speech, cardiac arrest

signs of hypermagnesemia:

nausea, vomiting, weakness, flushing, lethargy, DTR loss, respiratory depression, coma, cardiac arrest

what are signs of good perfusion in a client?

normal BP, good peripheral pulse, fast cap refill

examples of isotonic solution:

normal saline (0.9% NaCl), lactated ringers

what are the components of the upper airway system?

nose, pharynx, larynx, epiglottis

parenteral nutrition:

nutrition given via IV; used for proteins, carbs, fats, minerals, and electrolytes

what can impact ventilation:

obstruction, damage to organs, illness

why would provider order thoracentesis?

obtain specimen for diagnostic purposes or to removed fluid that accumulated in pleural cavity and causes respiratory issues

what is third spacing?

occurs when fluid moves from intravascular compartment into body compartment where it cannot contribute to cardiac output

differences in fluid distribution and age:

older adults have decreased fluid due to increased fat cells and lost muscle mass after age 60, body water is 45% of persons weight, leading to risks of fluid imbalance

peripheral venous catheter:

over the needle catheter used for time periods of less than one week

osmosis:

passage of a solvent through a semipermeable membrane from an area of lesser concentration to higher concentration

capillary filtration:

passage of fluid across the wall of a capillary; results from force of blood pushing against walls of capillaries

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

The nursing instructor is teaching a nursing student about IV solutions. Which action by the nursing student requires the nursing instructor's intervention?

planning to use the solution one month after the expiration date

thoracentesis:

procedure of puncturing the chest wall and aspirating pleural fluid

perfusion:

process by which oxygenated blood passes through body tissues

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

prolongs expiration to reduce airway resistance

A client is having difficulty breathing; list in priority the interventions the nurse could do, and do you need a provider's order to implement?

promote coughing, suction airway, medicate, provide O2, manage chest tubes, use artificial airways, clear obstructions, CPR

what can nurses do to clear a congested airway?

promote coughing, suction, push fluids

sodium function in body:

regulates ECF osmolality regulates pH muscle contraction and transmission of nerve impulses

bicarbonate purpose:

regulates acid/base balance

what system can act first to assist our body to compensate our needs in acid/base imbalances and why?

respiration acts faster, as it is always excreting CO2

what is important to understand before giving patient potassium supplementation?

risk possibilities of dehydration, confusion, anxiety, uneven heartbeat, thirst/urination, leg discomfort, numbness in hands, feet, and mouth, stomach pain, diarrhea, and vomiting

peripheral venous catheter site assessment and location:

site is assess every 4 hours and will go in peripheral vein, usually on arm away from joint

list age related physiological changes that impact oxygenation/perfusion in older adults?

slower respirations, thoracic pattern, clear breathing, barrel shaped thorax

aveoli:

small air sacs at the end of the terminal bronchioles that are the site of gas exchange

what are some environmental factors that impact oxygenation and perfusion?

smoke, smog/pollution, dust, humidity, temp, altitude

what are some lifestyle factors that impact oxygenation and perfusion?

smoking, diet, exercise, occupation, sex life, happiness level

what do we teach clients who are going home on oxygen, using liquid tanks or concentrators?

stay way from fire how to operate equipment

if unit became unattached from underwater sealed device, what action would be taken?

sterile fluid be instilled into water seal and suction chambers, has positive/negative pressure release valves, intermittent bubbling indications system is functioning properly, adding more suction

buffer:

substance that prevents body fluid from becoming acid or alkaline (base)

Which nursing skill requires the nurse to use sterile technique?

suctioning a tracheostomy

signs of hyperchloremia:

tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, coma

diffusion:

tendency of solutes to move freely throughout a solvent from an area of higher concentration to an area of lower concentration until equilibrium is established

renal function test:

test conducted to identify problems with kidneys, recommended if patient has diabetes or high BP

pulmonary function test:

tests that are used to assess respiratory function to assist in evaluating respiratory disorders. provide eval of lung dysfunction, diagnose, assess and assist in management of disease.

signs of hyperphosphatemia:

tetany, anorexia, nausea, muscle weakness, tachycardia

what causes abnormal breath sounds?

they occur as a result of alterations in respiratory and cardio systems that lead to impaired oxygenation

signs of hypocalcemia:

tingling in fingers/mouth/feet, tetany, muscle cramps, seizures

why would a client need a tracheostomy?

to replace endotracheal tube, provide method for mechanical ventilation, to bypass upper airway obstruction, or to remove tracheobronchial secretions

what function does water serve in blood?

transport nutrients, hormones, enzymes, platelets, RBCs, and WBCs transport waste away from cells metabolism and proper chemical function of cells solvent for electrolytes/nonelectrolytes body temp digestion/elimination tissue lube

inhalation treatment:

treats pulmonary symptoms, often with inhaled drugs

sensible fluid loss:

urination, defecation, wounds

why and how should a nurse teach a client to pursed lip breathe?

used for patients with dyspnea and are panicked. they exhale through pursed lips, as it creates a smaller opening for air movement, losing expiration

when would mechanical ventilation be used?

used on patients with endotracheal or tracheostomy tubes; when patient has limited or no control over respiratory system

when would a chest tube be used?

when negative pressure in pleural space is disrupted from surgery or trauma, or when fluid, blood or air is in chest

examples of hypotonic fluids:

• 0.45% sodium chloride • 0.33% sodium chloride • 0.225% dextrose in water.

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe."

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?

"You will be asked to forcefully exhale into a mouthpiece."

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream

adolescent/adult (>12 yo) respirations and heart rates:

12-20 respirations 60-100 bpm

school age (6-12 yo) respirations and heart rates:

20-24 respirations 75-118 bpm

preschooler (3-5 yo) respirations and heart rates:

20-24 respirations 80-120 bpm

toddler (1-3 yo) respirations and heart rates:

20-30 respirations 98-140 bpm

HCO3 range:

22-26 mEq/L

infant (1-12 months) respirations and heart rates:

25-40 respirations 100-190 bpm

neonate respirations and heart rates:

30-50 respirations 100-205 bpm

PCO2 range:

35-45 mmHg

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl

The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence.

Which category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?

Bronchodilators

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Electrolyte management Nutrition management Intravenous therapy

Which disease may result in decreased lung compliance?

Emphysema

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

Explain to the client why this is needed.

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance?

Infant

In what age group would a nurse expect to assess the most rapid respiratory rate?

Infants

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?

Initiate interventions to help relieve the symptoms.

A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?

Isotonic

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

Perform a respiratory assessment.

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?

Perform respiratory assessment.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?

SpO2 92%

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply.

Stop the infusion immediately. Restart the IV at another site. Apply warm compresses as ordered by the primary care provider.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?

Verify the orders for type of solution and amount of infusion.

How can defects within the conduction system of the heart (SA/AV nodes) impact perfusion?

When the electrical impulses are interrupted, perfusion is interrupted as well.

cardiac output:

amount of blood pumped in 1 minute, and it is dependent on heart rate, contractility, preload, and afterload. (stroke volume x heart rate)

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

Potassium is needed for neural, muscle, and:

cardiac function.

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

how does heart failure (pump failure) impact perfusion?

damage to cardiac muscle interferes with effective contractions

what is hypoxia?

deficiency in the amount of oxygen reaching the tissues

surfactant:

detergent like phospholipid that reduces surface tension of the fluid lining the aveoli

hypoxia symptoms:

dyspnea, elevated BP with small pulse pressure, increased respiratory and PR, pallor, cyanosis, anxiety, restlessness, confusion, and drowsiness

While reading a physician's progress notes, a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find?

dyspnea, tachycardia, cyanosis

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:

fluid volume excess.

respiration:

gas exchange between the atmospheric air in the alveoli and blood in the capillaries

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to:

increase her fluid intake to thin secretions.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

The home care nurse visits a client with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of:

infection.

pulmonary ventilation:

movement of air into and out of the lungs

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

nasal cannula

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

pursed-lip breathing diaphragmatic breathing

what can decrease perfusion?

renal or cardiac disorders

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire

what are the components of the lower airway system?

trachea, r/l main stem bronchi, segmental bronchi, and terminal bronchioles