ATI

A nurse is preparing to provide a client with information concerning an adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following?

Addison's disease - most definitive test

Nursing documentation for the use of restraints

Behaviors making restraint necessary Alternatives attempted and the client's response Type and location of restraint and time applied Frequency and types of assessments Restraints should NEVER: Interfere with treatment Be used because of short staffing or staff convenience

Isotonic - treatment of vascular system fluid deficit

Characteristics: concentration equal to plasma Prevent fluid shift between compartments

Interventions for hypokalemia

ECG monitor Administer K+ Teach dietary sources of K+ Never give potassium bolus; MUST dilute

Interventions for hyperkalemia

ECG monitor Kayexalate 50% glucose with insulin Calcium gluconate Loop diuretics Dialysis

Semi-Fowler's - head of bed elevated to 30 degrees

Gastric feedings, head injury, postoperative cranial surgery, respiratory illness with dyspnea, postoperative cataract removal, increased intracranial pressure

Airborne precautions - diseases known to be transmitted by air for infectious agents smaller than 5 mcg (measles, varicella, pulmonary or laryngeal TB)

Gloves, mask - N95 respirator Negative airflow/private room

A nurse is assessing a client newly diagnosed with Cushing's disease. Which of the following findings should the nurse expect?

Hirsutism - thinning of the skin is an expected finding with Cushing's disease

Nursing Interventions for restraints

Implement non-pharmacological measures such as a distraction, frequent observation, or diversion Prior to application, review manufacturers instructions for correct application. Notify health care provider immediately when restraints are implemented. Remove the restraints and assess client q 2 hrs. Assess neuro vascular and neuro sensory status q 2 hrs. Leave the restraint loose enough to prevent injury. Always tie the restraint loose enough to prevent injury. Always tie the restraint to the bed frame Reassess the need for continued use.

Hyperkalemia - high potassium

Risk factors: Tissue injury K+ sparing diuretics Renal failure Adrenal insufficiency Increased intake

Hypokalemia Low potassium

Risk factors: GI loss, diuretics, aminoglycosides, decreased intake

A nurse is caring for a client who is taking propylthiouracil (PTU). The nurse should recognize that treatment goals have been met when the client reports an increase in which of the following?

Serum calcium of 12.8 mg/dL A client with adrenal insufficiency may have an elevated serum calcium level.

Manifestations of hypokalemia

<3.5 Muscle weakness Nausea and vomiting Dysthymias Flat T waves

A nurse is preparing an adolescent client for a lumbar puncture. Which of the following instructions should the nurse provide to the adolescent?

"cream will be applied to decrease discomfort prior to the procedure." A local topical anesthetic will be applied to the adolescent's back prior to the procedure to decrease pain."

Hypotonic solutions

0.45% normal saline 2.5 % dextrose in 0.45% saline

Magnesium

1.3 - 2.1

Hypertonic solutions

10% dextrose in water (D10W) 50% dextrose in water 5% dextrose in 0.9% saline

Sodium

136 - 145

HCO3

21 - 28

PO4

3.0 - 4.5

Potassium

3.5 - 5

Calcium

9 - 10

Chloride

98 - 106

A child with type 1 DM presents to the clinic with influenza and a fever for the past 4 days. After obtaining a bliod glucose level, which of the following assessments should the nurse recognize as the highest priority assessement?

Ketones in urine The greatest risk to the child is the development of DKA; therefore, the highest assessment is testing the urine for ketones

A nurse is providing discharge instructions to the mother of a preschool-age child regarding his digoxin (Lanoxin). The nurse should instruct the mother that which of the following is a symptom of digoxin toxicity and should be reported to the provider?

Lack of appetite This is a symptom of digoxin (Lanoxin) toxicity.

Hypotonic - treatment of intercellular dehydration

Lower osmolality Shift fluid from ECF to ICF

Function of electrolytes

Maintain homeostasis Promote neuromuscular excitability Maintain fluid volume Distribute water between fluid compartments Maintain cardiac stability Regulate acid-base balance

A nurse is planning care for a newborn who is scheduled for a myelomeningocele repair. Preoperative nursing care should include which of the following?

Maintain the newborn's legs in abduction to counteract hip subluxation, which can occur as a result of the paralysis of the lower extremities.

K+ > 5.0

Muscle cramps Bradycardia Dysrhythmias Tall T waves

Isotonic solutions

Normal saline (0.9 % NS) Ringer's lactate solution 5% dextrose in water (D5W)

Droplet precautions - protect against droplets larger than 5 mcg - streptococcal pharyngitis, pneumonia, scarlet fever, rubella, pertussis, mumps, meningococcal pneumonia/sepsis, pneumonic plague

Nursing interventions: Mask is required when working within 3 ft of patient.

Hypertonic - used only when serum osmolality is critically low

Osmolality higher than the ECF Shift fluid from ICF to ECF