Exam 1 Medsurg
A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on?
Maintaining the patients hope
Below which serum sodium concentration might convulsions or coma occur?
135 mEq/L (135 mmol/L)
Which is an insensible mechanism of fluid loss?
Breathing
What is the second most common cause of death in the United States?
Cancer
Which electrolyte is a major anion in body fluid?
Chloride
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?
Dehydration
The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate which initial intervention to correct this problem?
Encourage the pt to breathe in & out slowly into a paper bag.
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations?
Fatigue, cramps and weakness
A patient is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?
Fluid volume excess
What foods can the nurse recommend for the patient with hypokalemia?
Fruits such as bananas and apricots
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following?
Hyperkalemia
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?
Hypocalcemia
When caring for the patient with cancer, what does the nurse understand as the response of the immune system to antigens of the malignant cells? Metastasis Tumor angiogenesis Immunologic escape Immunologic surveillance
Immunologic surveillance
The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing?
Intracellular fluid deficit
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?
Presence of Trousseau sign
What is the highest incidence of cancer in men?
Prostate cancer
The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care?
Restrict Fluids
A pregnant patient is admitted with excessive thirst, urination, and has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following diagnoses as most appropriate?
Risk for imbalanced fluid volume
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? Acute pain Hypothermia Powerlessness Risk for infection
Risk for infection
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused?
Risk of dehydration
A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?
Sodium level of 150 mEq/L
You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you?
Start IV fluids and blood products
The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? The medications the patient is taking The nutritional supplements that will help the patient How much time is needed to provide the patient's care The time the nurse spends at what distance from the patient
The time the nurse spends at what distance from the patient
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?
Third spacing
The nurse counsels the patient receiving radiation therapy or chemotherapy that
after successful treatment, a return to the persons previous functional level can be expected
The patient who has a serum magnesium level of 1.4 mg/dl is being treated with dietary modification. Which foods should the nurse suggest? Select all the apply.
bananas seafood chocolate.
What is the highest incidence of cancer in women? (not deaths just incidence)
breast cancer
When caring for a group of pts, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis?
bulimia
A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an imbalance of which of the following electrolytes?
calcium
A pt is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing?
cerebral bleeding
An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes that this pt is at risk for developing
dehydration.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt?
distended neck veins
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her:
electrocardiogram (ECG) results
The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are very deep. The metabolic disorder this pt might be demonstrating is which of the following?
increasing carbon dioxide in the blood
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the
malignancy is causing the electrolyte imbalance.
A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered
mixed in the prescribed intravenous fluid.
The blood gases of a pt with an acid-base disorder show a blood pH outside of normal limits. The nurse realizes that this pt is
partially compensated.
The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder?
potassium
The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood pH? Select all that apply.
renal and buffers
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?
Confusion and seizures
An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding these symptoms?
"Are you using a salt substitute?"
The nurse is caring for an 18-yr-old female patient with acute lymphocytic leukemia that is scheduled for hematopoietic stem cell transplantation (HSCT). Which patient statement indicates a correct understanding of the procedure? "I understand the transplant procedure has no dangerous side effects." "After the transplant, I will feel better and can go home in 5 to 7 days." "My brother will be a 100% match for the cells used during the transplant." "Before the transplant, I will have chemotherapy and possibly full-body radiation."
"Before the transplant, I will have chemotherapy and possibly full-body radiation."
Which patient is statistically and medically at the highest risk of developing cancer? A 68-yr-old white woman who has BRCA-1 gene and is obese A 56-yr-old African American man with hepatitis C who drinks alcohol daily An 18-yr-old Hispanic man who eats fast food once per week and drink alcohol An 80-yr-old Asian woman with coronary artery disease on blood pressure medication.
A 56-yr-old African American man with hepatitis C who drinks alcohol daily
Which is the most common cause of symptomatic hypomagnesemia?
Alcoholism
An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated?
Assess the urine for osmolality.
A patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin? Use Dial soap to feel clean and fresh. Scented lotion can be used on the area. Avoid heat and cold to the treatment area. Wear the new bra to comfort and support the area.
Avoid heat and cold to the treatment area.
Patients may reduce the risk of developing cancer using health promotion strategies. Identify strategies which can reduce the risk of developing cancer (select all that apply.). Control weight Genetic testing Immunizations Use sunscreen Stop smoking Limit alcohol intake
Control weight Genetic testing Immunizations Use sunscreen Stop smoking Limit alcohol intake
A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem?
Corticosteroid
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.
Drink water as an inexpensive way to meet fluid needs Respond to thirst Drink at least eight glasses of fluid each day
What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? (Select all that apply.).
Hematocrit level of greater than 47% Urine specific gravity of 1.027 Urine osmolality of greater than 450 mOsm/kg
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
Hypothalamus
When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up?
Irregular heart rate
The patient is told that her adenoma tumor is not encapsulated but has normally differentiated cells and surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? It will recur. It has metastasized. It is probably benign. It is probably malignant.
It is probably benign
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?
Limit salt and water intake
What type of cancer is highest cause of death by site and gender?
Lung and bronchus cancers
What cancer is the highest cause of death in woman?
Lung cancer
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?
Magnesium
A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this pt?
Milk & milk-based products will ensure an adequate calcium intake.
The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply.
Monitor the injection site for redness. Use an infusion controller for the IV. Monitor fluid intake & output.
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted
The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this pt? Select all that apply.
weakness dysrhythmias
Which is a correct route of administration for potassium?
Oral
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?
Osmosis
The calcium concentration in the blood is regulated by which mechanism?
Parathyroid hormone (PTH)
A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care?
Request a dietitian consult for selecting foods high in phosphorous
A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will most likely need which of the following precautions implemented?
Seizure
A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? Weight gain of 6 lb Nausea and vomiting Urine specific gravity of 1.004 Serum sodium level of 118 mEq/L
Serum sodium level of 118 mEq/L
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale cool skin, and decreased urine output. the nurse realizes these findings are most likely a direct result of which of the following?
The body's natural compensatory mechanisms
The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure?
The pt breathes rapidly to eliminate carbon dioxide.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?
Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad
A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances?
hypernatremia
An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following?
hyponatremia
A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for which of the following electrolyte imbalances?
hypophosphatemia
A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this pt is demonstrating is which of the following?
metabolic alkalosis
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:
muscle weakness
A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous fluids will most likely be which of the following?
normal saline
When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?
other electrolyte disturbances
The nurse explains to a patient undergoing brachytherapy if the cervix that she
requires the use of radioactive precautions during nursing care
An elderly postoperative pt is demonstrating lethargy, confusion, & a resp rate of 8 per minute. The nurse sees that the last dose of pain medication administered via a pt controlled anesthesia (PCA) pump was within 30 minutes. Which of the following acid-base disorders might this pt be experiencing?
respiratory acidosis
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate
The primary protective role of the immune system related to malignant cells is?
surveillance for cells with tumor-associated antigens
The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this pt? Select all that apply.
IV normal saline calcium containing antacids
Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels?
A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use
A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this pt?
Assist the pt to move into different positions in stages.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?
Confusion
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
In dehydration, only extracellular is depleted.
Clients diagnosed with hypervolemia should avoid sweet or dry food because it
Increases the clients desire to consume fluid
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?
Insensible fluid loss
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?
The kidneys retain bicarbonate.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?
Urine pH of 3.0
Which pts are at risk for the development of hypercalcemia? Select all that apply.
the pt with a malignancy the pt taking lithium the pt with hyperparathyroidism the pt who overuses antacids
A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is
to help regulate acid-base balance
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?
Provide oral care every 2-3 hours.
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? A) 7 year old with a tibia fracture B) 52 year old with diarrhea C) 72 year old with a knee replacement D) 65 year old with myocardial infarction
A 52-year-old with diarrhea
A patient on chemotherapy for 10 weeks started at a weight of 121 pounds. She now weighs 118 pounds and has no sense of taste. Which nursing intervention would be a priority?
Advise the patient to experiment with spices and seasonings to enhance the flavor of food
The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?
I will not salt my food; instead I'll use salt substitute.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?
Sodium
An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia?
hypotension, warmth, & sweating
Early signs of hypervolemia include.
increased breathing effort and weight gain.
A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will have a need for which of the following electrolytes?
magnesium
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?
"I can use laxatives and enemas but only once a week."
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
Jugular vein distention
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?
Calcium
Which statement by the nurse most facilitates patient cancer prevention during the promotion stage of cancer development? "Exercise every day for 30 minutes." "Follow smoking cessation recommendations." "Following a vitamin regime is highly recommended." "I recommend excision of the cancer as soon as possible."
"Follow smoking cessation recommendations."
The nurse assesses a 76-yr-old man with chronic myeloid leukemia receiving chemotherapy using a kinase inhibitor medication. Which question is most important for the nurse to ask? "Have you had a fever?" "Have you lost any weight?" "Has diarrhea been a problem?" "Have you noticed any hair loss?"
"Have you had a fever?"
The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says he still has pain in his leg and it is getting worse. Which question would best determine treatment measures for the patient's pain? "Where is the pain?" "Is the pain getting worse?" "What does the pain feel like?" "Do you use medications to relieve the pain?"
"What does the pain feel like?"
A female patient is having chemotherapy for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? "When your hair grows back, it will be patchy." "Don't use your curling iron, and that will slow down the loss." "You can get a wig now to match your hair so you will not look different." "You should contact "Look Good, Feel Better" to figure out what to do about this."
"You can get a wig now to match your hair so you will not look different."
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend? A bland, low-fiber diet A high-protein, high-calorie diet A diet high in fresh fruits and vegetables A diet emphasizing whole and organic foods
A bland, low-fiber diet
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be most appropriate to increase the patient's nutritional intake? Increase intake of liquids at mealtime to stimulate the appetite. Serve three large meals per day plus snacks between each meal. Avoid the use of liquid protein supplements to encourage eating at mealtimes. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?
Cardiac volume intolerance
The laboratory reports that the cells from the patient's tumor biopsy are grade II. What should the nurse know about this histologic grading? Cells are abnormal and moderately differentiated. Cells are very abnormal and poorly differentiated. Cells are immature, primitive, and undifferentiated. Cells differ slightly from normal cells and are well-differentiated.
Cells are abnormal and moderately differentiated.
What features of cancer cells distinguish them from normal cells?
Cells lack contact inhibition Cells return to a previous undifferentiated state New protein characteristics of embyronic stage emerge on cell membrane
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
Dark, concentrated urine
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
Elevated blood pressure
A 70 year old male patient has multiple myeloma. HIs wife calls to report that he sleeps most of the day, is confused when awake and complains of nausea and constipation. Which complication of cancer is this most likely caused by?
Hypercalcemia
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance
Hypercalcemia
The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation (select all that apply.)? Maintain hope. Exhibit a caring attitude. Plan realistic long-term goals. Give them antianxiety medications. Be available to listen to fears and concerns. Teach them about the types of cancer that could be diagnosed.
Maintain hope. Exhibit a caring attitude. Be available to listen to fears and concerns.
A 64-yr-old male patient who is receiving radiation to the head and neck as treatment for an invasive malignant tumor complains of mouth sores and pain. Which intervention should the nurse add to the plan of care? Provide ice chips to soothe the irritation. Weigh the patient every month to monitor for weight loss. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide. Provide high-protein and high-calorie, soft foods every 2 hours.
Provide high-protein and high-calorie, soft foods every 2 hours.
A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation?
Tingling or twitching sensation in the fingers
The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? Ask the patient if the site hurts. Turn off the chemotherapy infusion. Call the ordering health care provider. Administer sterile saline to the reddened area.
Turn off the chemotherapy infusion.
An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do?
Wear support hose.
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?
Weight
A 33-yr-old patient has recently been diagnosed with stage II cervical cancer. Which statement by the nurse best explains the diagnosis? "The cancer is found at the point of origin only." "Tumor cells have been identified in the cervical region." "The cancer has been identified in the cervix and the liver." "Your cancer was identified in the cervix and has limited local spread."
Your cancer was identified in the cervix and has limited local spread."
The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.).
vomiting drinking milk urination infusion of intravenous solution
