Physiological Aspects of Care EAQ

A physician orders guaifenesin (Humibid) 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. ____ mL

7.5 300mg/x = 200mg/5mL X = 7.5 mL

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1 Incisional pain 2 Absent bowel sounds Correct3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing

Correct3 Urine output of 20 mL/hour A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1 apple juice. 2 grape juice. 3 orange juice. Correct4 cranberry juice.

Correct4 cranberry juice. Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? Correct1 Interstitial 2 Intercellular 3 Intravascular 4 Intracellular

Correct1 Interstitial Edema is defined as the accumulation of fluid in the interstitial spaces. The incorrect answer options occur in other compartments: intercellular means between or among cells; intravascular means within a vascular space; and intracellular means within a cell.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse Correct2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

Correct2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1 Respiratory acidosis Correct2 Respiratory alkalosis 3 Respiratory compensation 4 Respiratory decompensation

Correct2 Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess carbon dioxide (CO2) retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? 1 Only at bedtime, when famotidine is not taken. 2 Only if famotidine is ineffective. 3 At the same time as famotidine, with a full glass or water. Correct4 One hour before or two hours after famotidine.

Correct4 One hour before or two hours after famotidine. Antacids interfere with complete absorption of famotidine; therefore, antacids should be administered at least one hour before or two hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken one hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the health care provider first.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Correct1 Clear breath sounds 2 Positive pedal pulses 3 Normal potassium level 4 Increased urine specific gravity

Correct1 Clear breath sounds Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. While it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will decrease, not increase.

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? 1 Prone 2 High-Fowler's Correct3 On the right side 4 Trendelenburg

Correct3 On the right side Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation. There is no indication that the other three positions are beneficial or appropriate for the client.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.) Correct1 Clients have a right to refuse treatment. Correct2 Nurses are required to answer clients truthfully. Correct3 The health care provider should have been notified. 4 The client had insufficient knowledge to make such a decision. 5 Legally prescribed medications are administered despite a client's objections.

Correct1 Clients have a right to refuse treatment. Correct2 Nurses are required to answer clients truthfully. Correct3 The health care provider should have been notified. Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. Client's questions must always be answered truthfully. The health care provider should be notified when a client refuses an intervention so that an alternate treatment plan can be formulated. This is done after the nurse explores the client's reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over the health care provider's prescription.

The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to UAP? (Select all that apply.) Correct1 Performing a bed bath for a client on bed rest. 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3). 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered. Correct4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy.

Correct1 Performing a bed bath for a client on bed rest. Correct4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. Performing a bed bath for a client on bed rest is within the scope of practice of UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1 Hypernatremia Correct2 Hyponatremia 3 Hyperkalemia 4 Hypokalemia

Correct2 Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L; hyperkalemia results when serum potassium is greater than 5.0 mEq/L; hypokalemia results when serum potassium is less than 3.5 mEq/L.

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1 Sprinkle the powder from the capsule into a cup of water. 2 Insert a rectal suppository containing 100 mg of phenytoin. Correct3 Contact the prescriber to determine if a change to a suspension form would be possible. 4 Obtain a change in the administration route to allow an intramuscular (IM) injection.

Correct3 Contact the prescriber to determine if a change to a suspension form would be possible. When an oral medication is available in a suspension form, the nurse can discuss this with the prescriber for clients who cannot swallow capsules. Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the health care provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1 Portal hypotension 2 Kidney malfunction Correct3 Decreased liver function 4 Decreased production of potassium

Correct3 Decreased liver function The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathological condition. It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's Correct3 End-stage renal 4 Gastroesophageal reflux

Correct3 End-stage renal One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? 1 Colitis 2 Stomatitis Correct3 Paralytic ileus 4 Gastrocolic reflux

Correct3 Paralytic ileus After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis , and gastrocolic reflux are not postoperative complications related to anesthetic agents.

The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 1 Chemically stimulate the loop of Henle 2 Diminish the thirst response of the client Correct3 Prevent reabsorption of water in the distal tubules 4 Cause fluid to move toward the interstitial compartment

Correct3 Prevent reabsorption of water in the distal tubules Sodium absorbs water in the kidneys' renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced. A decrease in sodium will prevent the reabsorption of water. Furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules. Adequate hydration is the major factor that diminishes the thirst response. A low-sodium diet will help move fluid from the interstitial compartment to the intravascular compartment.

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? 1 Notify the primary healthcare provider. 2 Consult an audiologist. Correct3 Stop the infusion. 4 Document the finding and continue to monitor the client.

Correct3 Stop the infusion. The first action the nurse should take is to stop the infusion immediately. Vancomycin can cause temporary or permanent hearing loss. The nurse should stop the medication infusion and then notify the physician at once if a client reports any hearing problems or ringing in their ears. The nurse should document the findings; however, it is not first best action. An audiologist may need to be consulted at a later date, but this is not the best first action.

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1 "You need to try to be patient. The client is going through a lot right now." 2 "I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3 "Just ignore it and get on with your work. I'll assign someone else to take a turn." Correct4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

Correct4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take." The correct response interprets the client's behavior without belittling the UAP's feelings; it encourages the UAP to get involved with plans for future care. Telling the UAP to be patient recognizes the client's feelings, but it does not address the UAP's feelings or help the UAP cope with the client's behavior. The nurse should not assume the UAP has nothing to contribute and that only the nurse can deal with the problem. Saying "Just ignore it" does not help the UAP understand the client's behavior, nor does it demonstrate an understanding of the client's feelings.

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1 Apply pressure to the site. 2 Obtain vital signs. 3 Change the client's gown and bed linens. Correct4 Assess the catheterization site.

Correct4 Assess the catheterization site. Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized