exam #4
1.The provider orders calcium 1.5 g orally twice a day (1 g in the morning and 500 mg at bedtime). The patient asks why she must drink extra fluids with this medication. What is the best response by the nurse?
Increased fluid intake helps prevents the formation of calcium-based urinary stones.
As the RN is assessing a patient with Grave's disease, which finding requires immediate attention? A.Elevated temperature B.Elevated blood pressure C.Change in respiratory rate D.Irregular heart rate and rhythm
a
During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention? A. Communicate the discrepancy to the surgical team immediately. B. Complete appropriate documentation concerning the error in sponge count. C. Examine the environmental distractions, refocus, and count the sponges again. D. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively.
a
Following surgery, a patient is wearing pneumatic compression devices. The patient asks, "Why do I have to wear these?" What is the most appropriate nursing response? A. "This helps to prevent blood clots." B. "It will make your legs feel more comfortable." C. "This prevents skin breakdown from immobility." D. "It will make it easier on you when you start to ambulate."
a
The client's nurse asks the student nurse to apply a thromboembolic device (TED) hose and a sequential compression device (SCD) on him. What is the purpose of each device? A. To prevent thrombus and emboli B. To promote respirations C. To promote pain relief D. To promote wound healing E. All of the above
a
The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present? A. Diabetes mellitus B. Age greater than 65 C. Impaired liver function D. Insertion of a surgical drain
a
When developing a postoperative plan of care for a client after a total thyroidectomy, the RN knows the plan should include which intervention? A.Avoiding extending the patient's neck B.Assessing the patient's voice once per shift-more than once per shift C.Encouraging the patient to be out of bed in a chair-semi fowlers D.Administering oxygen via nasal cannula as needed-humidified oxygen
a
a patient presents with a pot belly but smaller on extremities. what does the nurse term this as? a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
a
a pt has respiratory acidosis. what type of electrolyte imbalance occurs? a. hyperkalemia b. hyponatremia c. hypomagnesemia d. hypokalemia
a
a student nurse is looking at doctors orders for a client to go to surgery during her clinical rotations. she notices that their is an order for an antibiotic. what should the SRN do? a. understand this is standard practice b. research to see if pt has an infection c. question the order d. call the doc to d/c the order
a
bone is a living, changing tissue that is constantly undergoing changes in a process referred to as: a. bone remodeling b. osteopenia c. osteomalacia d. bone mineral density
a
how is SaO2 obtained? a. pulse ox b. abg c. blood pressure d. allen test
a
how soon does respiratory changes affect blood pH? a. rapidly b. one hour c. 24 hours d. 30 minutes
a
lack of protein quantity and quality in the presence of adequate calories. body weight is more normal, and serum proteins are low. a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
a
on assessment, the patient is noted to have conjunctival xerosis, dry skin, follicular hyperkeratosis, and a bright magenta (purple) tongue. which vitamin deficiency does the nurse suspect? a. vit a b. vit c c. vit d d. vit k
a
pt comes to ED with symptoms that include fever, tachycardia, and systolic htn. pt also has abdominal pain, n/v, and diarrhea. the doctors have realized the pt is having a thyroid storm. what will the nurse plan to do next? a. admit pt to ICU b. send pt home c. ask doc for medication to lower temp d. place pt on a med sure unit
a
severe intellectual disability is determined by what? a. IQ scores of 25-40 b. IQ scores of <25 c. IQ scores of 55-70 d. IQ scores of 40-55
a
the nurse caring for a client who has been receiving iv diuretics suspects that the client is experiencing fluid volume deficit. which assessment finding would the nurse note in a client with this condition? a. weight loss and poor skin turgor b. lung congestion and increased heart rate c. decreased hematocrit and increased urine output d. increase resp and increased bp
a
the nurse is assessing a client with a suspected diagnosis of hypocalcemia. which clinical manifestation would the nurse expect to note in the client? a. twitching b. hypoactive bowel sounds c. negative trousseau's sign d. hypoactive deep tendon reflexes
a
the nurse is assigned to care for a group of clients. on review of the clients medical records, the nurse determines that which client is most likely at risk for fluid volume deficit? a. a client with an ileostomy b. a client with heart failure c. client with long term corticosteroid therapy d. client receiving frequent wound irrigations
a
the nurse is looking at the cholesterol level of a pt that is malnourished. what does the nurse suspect it to be at? a. <160 b. >160 c. 200-240 d. 300-315
a
the nurse reviews a clients laboratory report and notes that the client's serum phosphorus level is 1.8. which condition most likely caused this serum phosphorus level? a. malnutrition b. renal insufficiency c. hypoparathyroidism d. tumor lysis syndrome
a
this drug is approved for women at least 5 years postmenopausal when alternative drug therapy is not appropriate. it is given with a nasal spray or subq. a. salmon calcitonin (miacalcin/fortical) b. teriparatide (forteo) c. denosumab (prolia) d. biphosphonates
a
which client is at risk for development of a sodium level at 130? a. client who is taking diuretics b. client with hyperaldosteronism c. client with cushings d. client taking corticosteroids
a
a nurse knows that a person with hyper magnesia is at greatest risk for what? a. cardiac arrest b. coma c. kidney failure d. seizures
a *hypermag has no direct effect on the lungs, however when he resp muscles are weak, respiratory insufficiency can lead to resp failure and death.
what medication should the RN question with a pt who has alkalosis? a. digoxin b. metoprolol c. lisinopril d. coreg
a +hypokalemia increases heart sensitivity to digoxin, which increases the risk for digoxin toxicity
a pt presents with malnourishment. what does the nurse suspect the hematocrit level to be at for a woman? a. <37% b. 38%-40% c. <52% d. 42%-52%
a 37%-47% in women 42%-52% in males
During a community education program the nurse is asked about the risk of a woman breaking a bone due to osteoporosis after age 50. The nurse knows which of the following is the risk? A. 1 in 2 women B. 1 in 5 women C. 1 in 7 women D. 1 in 10 women
a One in two women over the age of 50 will break a bone because of osteoporosis. A woman's risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian, and uterine cancer combined. Women have lighter, thinner bones than men. Many women also lose bone quickly after menopause. Up to one in four men over the age of 50 will break a bone because of osteoporosis. A man older than age 50 is more likely to break a bone due to osteoporosis than he is to get prostate cancer. +doesn't just affect women, but it is more prominent in women.
the new grad rn needs further education when she states: a. vital signs will determine if the ph has changed first b. change in vital signs will occur after the alter in ABG c. carbon dioxide and oxygen will be abnormal with vs changed d. increased hr is a early compensatory mechanism
a long before the outward signs of changed in vs occur, the oxygen, carbon dioxide, and ph of a pt blood will have become abnormal
a pt present with malnourishment. what does the nurse suspect the hemoglobin level to be at for a male? a. <12 b. <14 c. >16 d. 16-20
a norm levels are 12-16 women and 14-18 males
pt presents with symptoms of hyperthyroidism. the RN is looking at the lab values of the thyroid. which one indicates hyperthyroidism? a. serum t3 210 b. serum t3 70 c. serum t4 5 d. serum t4 10
a norm t3 levels are 70-205
Which assessment data would the nurse expect in a patient diagnosed with osteomalacia? A. Lack of Vitamin D B. Decreased bone mass C. Lack of estrogen D. Elevated blood sugar
a osteomalacia KEY thing is lack of vitamin D. osteoporosis is decreased bone mass.
a nurse is taking care of a pt whose radiographs show osteopenia and fractures. what indications would lead her to the assumption this is osteoporosis? a. calcium level is 8.0 b. phosphate is low c. parathyroid hormone is normal d. vitamin d level low
a osteoporosis indications include: calcium low/normal, phosphate normal, parathyroid normal, alkaline phosphatase normal.
the nurse is wanting to know more about a pt nutritional status over the last few weeks. which test should she look at? a. serum albumin b. TLC c. thyroxine binding prealbumin d. cholesterol
a plasma protein that reflect the nutrition status of the pt a few weeks before testing. NOT a sensitive test. +pt who are dehydrated have increased levels of albumin and fluid excess have lowered.
what is a base?
a base binds free hydrogen ions in solutions and lowers the amount of free hydrogen ions in solution. strong bases bind hydrogen ions easily. *sodium hydroxide, ammonia +weak bases binds hydrogen ions less readily, such as bicarbonate. although it is a weak base, the many bicarbonate ions in the body are critical in preventing major changes in body fluid ph.
what is the allen test?
a test to assess collateral circulation +failure to do the allen test prior to ABG draws could result in severe ischemic injury to the pt hand if damage to the radial artery occurs with arterial pressure. +radial & ulnar pressure must be intact to draw ABG from that particular hand
acidosis can be caused from: sata a. co2 retention b. hco3 loss or h+ retention c. co2 loss d. hco3 excess or h+ loss
a, b
roles of circulating nurse: sata a. creates and maintains sterile work environment b. assist all staff including scrub nurse c. acts as assistant to pt and surgeon d. passes instruments and complex assistive tasks
a, b
roles of circulating nurse: sata a. involved in assessment of client before and after operations b. opens sterile packing c. passes instruments and completes assistive tasks d. ensures needed medical equipment is necessary
a, b
what does SaO2 measure? a. oxyhemoglobin saturation b. adequacy of arterial blood oxygenation c. amount of oxygen carried in the blood
a, b
agents that cause acidosis: sata a. ethyl alcohol b. methyl alcohol c. acetylsalicylic acid d. acetaminophin
a, b, c
To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication about the patient includes which elements? (Select all that apply.) A. Providing a recent patient history B. Communicating vital signs, allergy, and medication updates C. Verbally verifying that the operating room nurse understands the report D. Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE) E. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report
a, b, c, d DO NOT ENCOURAGE INTERUPTING.
the nurse is preparing to intervene with a pt who has hyperthyroidism. what are nonsurgical interventions the nurse recognizes? a. reduce stimulation b. promote comfort c. drug therapy d. total thyroidectomy e. iodine and RAI
a, b, c, e
a patient is to undergo an endoscopy. what are the doctors looking for with this exam? a. mucosal inflammation b. crypt hyperplasia c. bowel obstruction d. villous atrophy e. stomach ulcers
a, b, d
what is the reason for keeping the difference of sodium levels in extracellular and intracellular fluid? SATA a. muscle contraction b. cardiac contraction c. fluid balance d. nerve impulse transmission f. brain function
a, b, d
where is ABG analysis usually obtained? sata a. radial b. brachial c. carotid d. femoral
a, b, d
members of the inter professional team who collaborate most closely for the patient with malnutrition include: SATA a. health care provider b. nurse c. respiratory therapist d. dietitian
a, b, d for patient who experience psychological impact from or related to malnutrition, a psychologist or therapist will also have an important role in care.
s/s of hyponatremia. SATA a. cerebral edema b. increased intracranial pressure c. decreased contractility of the heart d. general muscle weakness e. deep tendon reflexes diminish f. tremors
a, b, d, e
which nursing interventions promote oral nutrition intake? SATA a. delegating a UAP to feed the patient b. providing mouth care before each meal c. placing a small-bore nasoduodenal tube d. assisting the patient to sit up in a chair e. ordering foods that the patient like to eat
a, b, d, e
older adult mortality is caused from: SATA a. unintentional injury b. malignant neoplasm c. suicide e. respiratory disease f. heart disease
a, b, e
to help to be free from injury, what should be included? SATA a. basic needs b. physical and psychosocial factors that influence or affect life and survival c. money d. love e. safe environment that helps protect optimal function
a, b, e
a patient just got prescribed an iron supplement. the RN is expected to inform the patient about what with iron? a. take with plenty of fluids b. may cause constipation c. can cause dehydration d. poop will change colors e. poop will be black and tarry f. take iron with meals
a, b, e, f
what are classic symptoms of celiac disease? SATA a. wt loss b. anorexia c. infertility d. protein calorie malnutrition e. vomiting f. steatorrhea
a, b, e, f infertility and protein calorie malnutrition are ATYPICAL symptoms of celiac disease
what are classic symptoms of celiac disease? SATA a. abdominal pain b. abdominal distention c. migrains d. depression e. diarrhea f. constipation
a, b, e, f migraines and depression are atypical symptoms of celiac disease
where should the nurse look for nutrient deficiencies? a. hair b. eyes c. stools d. urine e. oral cavity f. skin g. neurologic systems
a, b, e, f, g
middle adult mortality is caused from: SATA a. unintentional injury b. malignant neoplasm c. suicide e. homicide f. heart disease
a, b, f
EKG changes with hyperkalemia. SATA a. tall peaked T waves b. prolonged PR intervals c. st-segment depression d. flat or inverted T waves e. increased U waves f. flat or absent p waves g. wide QRS complex
a, b, f, g
a patient comes in severely anxious. when the RN talks with the pt, the pt states, "I have celiac disease and I was told that I will have cancer." the nurse knows that a primary complication of CD is what? SATA a. GI cancer b. irritable bowel syndrome c. non-hodgkins lymphoma d. nutrient deficiencies
a, c, d
risk factors for women for cognitive impairment: sata a. poor health status b. decreased estrogen c. dependency d. lack of social support e. anemia f. insomnia
a, c, d, f
the nurse recognizes what as the influence for pt safety? a. pt developmental level b. culture c. mobility, sensory, and cognitive status d. lifestyle choices e. gender f. knowledge of common safety precautions
a, c, d, f
where should the RN expect to first see symptoms of acidosis? a. abg value b. musculoskeletal changes c. cardiac changes d. vs changes e. respiratory changes f. PNS changes g. cns changes
a, c, e, g
what are the parafollicular cells? a. TCT b. t4 c. t3 d. calcitonin regulate hormones
a, d
in early compensation for ABG, when vital signs will the nurse expect to see? sata a. increased hr b. decreased hr c. decreased rr d. norm bp e. increased bp
a, d you will see and increased hr, increased rr, and the b/p will be normal.
a doctor prescribes a pt with hypokalemia medications that are potassium sparing. what meds would the nurse recognize as potassium sparing? a. spironolactone b. lasix c. bumetanide d. triamterene e. amiloride
a, d, e
teenager mortality is mainly caused from: SATA a. MVA b. congenital anomalies c. unintentional injury d. homicide e. suicide
a, d, e
risk factors for men for cognitive impairment: sata a. diabetes b. decreased testosterone c. dependency d. lack of social support e. stroke f. insomnia
a, e
the nurse is educating a pt who is taking oral potassium chloride. what would be the most appropriate for the nurse to tell the patient? a. do not take on an empty stomach b. take it first thing in the morning c. take with other medication d. limit intake of potassium supplements
a. potassium chloride can cause nausea and vomiting
what is the difference between acute hypocalcemia and chronic hypocalcemia?
acute: results in the rapid onset of life-threatening symptoms chronic: occurs slowly over time, and excitable membrane symptoms may not be severe because the body has adjusted to the gradual reduction of serum calcium levels
a pt has a hard time seeing with and without his glasses on and complains about how sometimes it is hard to move around and see in his house. how should the nurse help?
adjust lighting, assess furniture layout and use of rugs
primary risk factor for cognitive impairment is?
advancing age
when excess carbon dioxide is produced, what does it cause?
an increase in hydrogen ions and a decrease in ph.
causes of resp depression
anesthetic agents opioids poisons brain tumor cerebral aneurysm stroke fluid overload
priorities for nursing care of the pt with hyperkalemia
assess for cardiac complications pt safety for fall prevention monitoring the pt response to therapy health teaching
behavior for cognitive functioning:
assess the loc. facial expressions should be appropriate and consistent with the situation. flat expressions could be associated with dementia. not the quality of speech. individuals with impaired cognition may have trouble recalling words, blocking, distorted speech, disconnected sentences, or loose associations. confabulation (the fabrication of events to fill in memory gaps) may also be demonstrated.
The student nurse is going over the client's preoperative checklist. The informed consent form has been signed. The student nurse knows that it is the responsibility of the _____ to tell the client about the surgery, including risks, benefits, expected outcomes, and alternatives. A. preoperative nurse B. surgeon C. anesthesiologist D. circulating nurse
b
a client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him too hyperventilate. what is the nurse's BEST response? a. "even your exhaled breath still has some oxygen in it, and rebreathing this air ensures that you won't pass out from lack of oxygen." b. "when you breathe fast, you lose too much carbon dioxide, and rebreathing this air keeps you from becoming dizzy and falling." c. "rapid breathing can lead to dehydration from excessive fluid loss, and rebreathing this air helps you retain fluid in the form of vapor moisture." d. "breathing into the bag for several minutes helps you become distracted from whatever is making you anxious and allows you to calm down."
b
a condition of low bone mass that occurs when there is a disruption in the bone remodeling process. a. bone remodeling b. osteopenia c. osteomalacia d. bone mineral density
b
a female is wanting to better her nutrition and meal management. how many meals would be expected of the nurse to tell the pt? a. 3 meals a day is good b. 6 small meals a day c. breakfast and lunch only d. drink meal replacement shakes
b
a nurse suspects someone coming in with impaired gas exchange. what type of imbalance will the nurse suspect most? a. intake and output b. acid base c. activity level d. weight
b
a patient presents and has an older appearance with loose, wrinkled skin. what does the nurse term this as? a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
b
a pt is asking the nurse who was recently diagnosed with CD how long it will take his intestinal mucosa to recover with him managing his diet. what is the nurses best response? a. 3 years b. 2 years c. 1 year d. 6 months
b
a teenage mother is coming in for an ultrasound. the teen stated, "I am so excited. we finally have a car seat. I am scared, though, that I do not know the proper way to use the clip such as where it should be placed." the nurse educates the teen when she states it needs to be placed where? a. upper sternum b. middle sternum c. lower sternum
b
an elderly person comes in very confused. the family has stated this is very out of the normal for him. what is the best thing for the nurse to do at this time? a. take vital signs b. ask about any recent med changes c. admit pt d. ask pt to remember 3 words.
b
calorie malnutrition in which body fat and protein are wasted. serum proteins are often preserved. a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
b
how is PaO2 obtained? a. pulse ox b. abg c. blood pressure d. allen test
b
how often should a pt respiration be monitored in resp acidosis? a. q2h b. q1h c. q30min d. once a shift
b
how soon does it take kidney changes to affect acid base balance? a. immediately b. 24-48 hours c. one week d. 30 minutes
b
profound intellectual disability is determined by what? a. IQ scores of 25-40 b. IQ scores of <25 c. IQ scores of 55-70 d. IQ scores of 40-55
b
the RN is assigned a pt diagnosed with celiac disease. the nurse understands that this is an inflammatory reaction that occurs in the intestines because of what? a. lactose b. gluten c. fat d. protein
b
the RN is giving instructions to a new mother on creating a safe sleep environment for her infant. what should the nurse needs more education when she states which of the following? a. place baby on a firm, flat, mattress designed for babies b. place toys and other objects in bed with baby c. share room with your baby and keep the baby close d. always place baby on back when taking naps
b
the most appropriate nursing interventions to prevent a fall for a wandering client would include: a. raise all four side rails when darkness falls b. use an electronic bed monitoring device c. place the patient in a room close to the nursing station d. use a loose-fitting vest-type jacket restraint
b
the nurse is preparing to care for a client with a potassium deficit. the nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a. sustained tissue damage b. requires nasogastric suction c. has a hx of Addison's disease d. uric acid level of 9.4
b
this drug is for bone building and is given subq and can only be used up to 2 years. a. salmon calcitonin (miacalcin/fortical) b. teriparatide (forteo) c. denosumab (prolia) d. biphosphonates
b
what additionally safety teaching is needed when a caregiver states: a. teenagers need to practice safe sex b. a 3 year old can safely sit in the front seat of the car c. children need to wear safety equipment when bike riding d. children need to learn to swim, even if they do not have a pool.
b
what electrolyte imbalance occurs with acid base imbalance? a. sodium b. potassium c. calcium d. magnesium
b
which dietary item should be removed from the patients nutritional tray with loose and poor fitting dentures? a. applesauce b. granola cereal c. scrambled eggs d. toast with butter
b
which food items selected by a client who must restrict potassium because of continuing risk for hypokalemia indicated to the nurse that more teaching is needed? a. strawberries, cheerios, eggs b. cantaloupe, broccoli, sweet potatoes c. apple pie, black coffee with sugar, carrot sticks d. whose wheat toast with butter, canned pineapple chunks.
b
which test is a more sensitive indicator of protein status? a. serum albumin b. serum transferrin c. cholesterol d. prealbumin
b
The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate? A. Teach her to cut down on her cigarette smoking. B. Recommend walking for 30 minutes three to five times a week. C. Suggest a diet that is high in protein and calcium but low in vitamin D. D. Tell her to include high-impact activities, such as running, in her exercise regimen.
b The single most effective exercise for osteoporosisis walking 30 minutes three to five times a week. Patients should include increased vitamin D along with calcium in the diet. Smoking should be avoided, as should high-impact exercises, which may cause vertebral compression fractures.
a pt is 76 years old. the nurse is looking over the PaO2 and determines that their level is 64. what should the nurse do? a. notify hcp b. interpret this as a normal finding c. give the pt oxygen d. redraw ABG
b for every year about 60, the PaO2 drops 1 mmHg. the normal value is 80-100. this pt is 76 years old. 76-60=16. 80-16=64.
When assessing the laboratory work of a 65-year-old patient scheduled for surgery, the nurse understand which laboratory value may result in cancellation of the surgery? A. Hemoglobin 10.5 g/dL B. Serum potassium 2.7 mEq/L C. Serum sodium level 149 mEq/L D. Fasting blood glucose 120 mg/dL
b normal hemoglobin: 12-16 females, 14-18 males normal potassium: 3.5-5 sodium: 136-145 blood sugar: 74-106
how often should the nurse assess the respiratory status of a pt with hypokalemia? a. q1h b. q2h c. q30 min d. once a shift
b resp insufficiency is a major cause of death
a nurse is taking care of a pt who has had a fracture. when reviewing his labs, she notices that his phosphate is low, parathyroid hormone is high, and alkaline phosphatase is high. what does the nurse believe the fracture is a result from? a. decreased calcium, estrogen, and testosterone b. lack of vitamin d c. decreased bone mass caused by multiple fractures d. bone loss
b these are indications of osteomalacia
a pt is being treated for hypernatermia. which fluids would the nurse expect to be used for this pt? sata a. 0.45% ns b. D5W in 0.45% ns c. 0.9% ns d. 5% dextrose in water
b, c
roles of a scrub nurse: sata a. create and maintain sterile work environment b. prepares client for surgery c. acts as assistant to surgeon d. opens sterile packing
b, c
the RN understands that which people are at highest risk for developing celiac disease? a. cancer b. RA c. DM type 1 d. vitiligo
b, c
the nurse is caring for a client who has celiac disease. which food will the nurse remove from the client's dietary tray? SATA a. rice b. graham crackers c. croissant d. fresh peaches e. chicken breast
b, c
the nurse is taking care of a school age child in the ED. the nurse needs further education when she thinks that this age groups mortality is caused mainly from: SATA a. unintentional injury (accidents) b. homicide c. suffocation d. malignant neoplasms/suicide e. congenital anomalies
b, c
what are the follicular cells? SATA a. TCT b. t4 c. t3 d. tpp
b, c
what does PaO2 measure? sata a. oxyhemoglobin saturation b. adequacy of arterial blood oxygenation c. amount of oxygen carried in the blood
b, c
what medications would the nurse expect to be d/c'd from the pt medical record who has hypercalcemia? a. lasix b. calcium with vitamin d c. ringers lactate d. metoprolol
b, c
which population are at risk for developing celiac disease? SATA a. type 2 diabetes b. type 1 diabetes c. RA d. OA
b, c
during the first 12 hours postop, what would the nurse NOT expect? a. hypothermia b. hyperthermia c. resp infection d. asleep bladder
b, c, d
roles of scrub nurse: sata a. assist surgical staff present, including circulating nurse b. hands on assistant with pt and surgeon c. ensures medical equipment is available d. if break in sterile field/technique is witnessed, must acknowledge it and correct immediately
b, c, d
The patient is diagnosed with possible osteoporosis. Which diagnostic tests should the nurse anticipate will be ordered? (Select all that apply.) A. Sodium B. Phosphorus C. Serum calcium D. Thyroid function tests E. Dual x-ray absorptiometry (DXA)
b, c, d, e
What important teaching points should the RN include in discharge teaching for the person with hypothyroid? (Select all that apply.) A."Your diet should be low-fiber, but with plenty of fluids." B."Note how many hours you sleep in a 24-hour period." C."Report any difficulty with orientation to time, place, or person." D."Be sure that you take your medication every day at the same time." E."Call the provider if you develop an unsteady gait or tremors in your hands."
b, c, d, e
an older female has kidney failure causing hyperkalemia. what lab values go with this cause of hyperkalemia? data a. increased h&h b. normal or low h&h c. increased BUN d. increased creatinine e. decreased blood ph f. increased electrolytes
b, c, d, e
the nurse is reviewing at risk pt for hyperkalemia. the RN notices that which are at greatest risk for hyperkalemia? a. intake and output adequate b. hospitalized and going through tx c. chronic illness d. increased output e. debilitated f. older pt g. infants
b, c, e, f
which assessment data finding for a client schedule for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? sata a. o2 sat 97% b. serum potassium 3.0 c. client took a total of 1300 mg aspirin yesterday d. client request to talk with RDA about wt loss e. client took regularly scheduled antiHTN drug with a sip of water 2 hours ago f. after receiving preop meds, clients tells nurse that he lied on the assessment from and that he really is a current smoker
b, c, f
a pt is receiving lithium due to inappropriate secretion of adh. what should the nurse monitor for every hours? sata a. increased potassium levels b. excessive fluid loss c. decreased sodium levels d. increased sodium levels
b, d
drugs that disrupt acid-base balance. sata a. acetaminophen b. diuretics c. MAOs d. aspirin
b, d
what is MH crisis commonly triggered by? sata a. local anesthesia b. succinylcholine c. regional anesthesia d. general anesthesia
b, d
which blood lab values does the nurse need to evaluate to determine whether the client's acidosis has respiratory origin or a metabolic origin? sata a. calcium b. hco3 c. lactic acid d. paco2 c. pao2 f. ph g. k+
b, d, e
young adult mortality is NOT caused from: SATA a. unintentional injury b. malignant neoplasm c. suicide e. homicide f. heart disease
b, f
how is celiac disease diagnosed?
based on the presence of flattened villi as well as specific antibodies in the blood.
why is the scope of cognition on a continuum?
because the level of cognition is not a matter of "all or none." it can change over time, and the degree of impairment can be mild to severe.
why is serum potassium level high in acidosis?
body attempts to maintain electroneutrality during buffering +as the blood hydrogen ion level rises, some of the excess hydrogen ions enter red blood cells for intracellular buffering. +movement of hydrogen ions into the cells creates an excess of positive ions inside the cells. +to balance extra positive charges, an equal number of potassium ions move from the cells into the blood.
drug therapy for respiratory acidosis
bronchodilators, anti-inflammatories, and mucolytics
what is a buffer?
buffers are critical to keeping body fluid ph at normal levels because they can react either as an acid (releasing a hydrogen ion) or as a base (binding a hydrogen ion). how a buffer reacts depends on the existing ph of that fluid. +buffers act like hydrogen ion sponges, soaking up hydrogen ions when too many are present and squeezing out hydrogen ions when too few are present.
a client was originally scheduled for surgery at noon. the surgeon is delayed, and the surgery has been rescheduled for 3:00 pm. how will the nurse plan to administer the prep prophylactic antibiotic? a. give at noon as originally prescribed b. cancel orders; preop prophylactic antibiotics are given optionally c. adjust the administration time to be given within 1 hour before surgery d. hold the preop antibiotic so it can be administered immediately following surgery
c
a mother comes into the clinic for her toddler. the toddler is 3 years of age. the RN recognizes that the leading cause of death in this age group is what? a. MVA b. suffocating c. drowning d. pediatric cancer
c
a patient presents and the nurse can tell that metabolic stress has imposed on a chronically starved patient. what does the nurse term this as? a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
c
a pt presents to the ED with exceedingly foul smelling stools and steatorrhea. what does the nurse suspect? a. depression b. celiac flare up c. impaired fat absorption d. impaired nutrient absorption
c
an adult has diabetic ketoacidosis and chronic copd. what acidosis does he have? a. respiratory b. metabolic c. both
c
combined protein and energy malnutrition. a. kwashiorkor b. marasmus c. marasmic-kwashiorkor
c
the RN administers an incorrect medication to a client. this error can be classified as: a. a poisoning accident b. an equipment related accident c. a procedure-related accident d. an accident related to time management
c
the RN is planning care in the patient who is diagnosed with CD. who should the RN refer the patient to? a. physician b. charge nurse c. dietitian d. nutritionist
c
the RN is planning care in the patient who is diagnosed with CD. who should the RN refer the patient to? a. physician b. charge nurse c. registered dietitian d. nutritionist
c
the nurse is caring for a client with heart failure who is receiving high doses of a diuretic. on assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. the nurse suspects hyponatremia. what additional signs would the nurse expect to note in a client with hyponatremia? a. muscle twitches b. decreased urinary output c. hyperactive bowel sounds d. increased specific gravity of the urine
c
the nurse is caring for a client with heart failure. on assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. what additional manifestations would the nurse expect to not in this client if excess fluid volume is present? a. weight loss and dry skin b. flat neck and hand veins and decreased urinary output c. an increase in blood pressure and increased resp d. weakness and decreased central venous presssure
c
the nurse is reading a hcp progress notes in the clients record and reads that the hcp has documented "insensible fluid loss of approximately 800 mL daily." the nurse makes a notation that insensible fluid loss occurs through which type of excretion? a. urinary output b. wound drainage c. integumentary output d. gi tract
c
the nurse is reviewing orders from the doctor for a patient that has been diagnosed with malnutrition. which medication should the nurse question? a. multivitamin b. zinc c. adipex d. iron
c
the nurse recognizes that the normal lab values of thyroxine binding albumin is what? a. 14-30 b. 10-12 c. 15-36 d. 16-37
c
this medication is approved for tx of osteoporosis when other drugs are not effective. this drug decreases bone loss, increases bone mass and strength. it is given subs 2x yearly. a. salmon calcitonin (miacalcin/fortical) b. teriparatide (forteo) c. denosumab (prolia) d. biphosphonates
c
what client teaching will the nurse provide regarding postop leg exercises to minimize the risk for development of dvt after surgery? a. only perform each exercise one time to prevent overuse b. begin exercises by sitting at a 90 degree angle on the side of bed c. point toes of one foot toward bottom of bed; then point toes of same leg toward his or her face. repeat several times; then switch legs d. bend knee, and push heel of foot into the bed until calf and thigh muscles contract. repeat severe times; then switch legs
c
an older patient comes is admitted to the ER for severe hyponatremia. the nurse is looking over the patients medications. which medication sticks out to the nurse for a cause of the hyponatremia? a. propranolol b. xanax c. lasix d. oxybutynin
c *a common cause of low na levels is prolonged use of diuretics, especially in older populations.
what is a loss of bone related to lack of vitamin D, which causes bone softening? a. bone remodeling b. osteopenia c. osteomalacia d. bone mineral density
c +vitamin D is needed for calcium absorption in the small intestines. as a result of vitamin d deficiency, normal bone building is disrupted, and calcification does not occur to harden the bone.
the nurse knows that there is a test a person can have done that reflects the nutrition status of the pt a few weeks before testing. what test is this? a. albumin b. serum glucose c. serum albumin d. transferrin
c 3.5-5f
a pt with severe hyponatremia is ordered to receive hypertonic saline. the nurse should question the order when the order says to choose which saline? a. 3% saline b. 5% saline c. 5% dextrose d. 10% dextrose in water
c 5% dextrose is a hypotonic solution
which results support a diagnosis of malnutrition? a. hematocrit 37% b. hemoglobin 12 g/dL c. prealbumin 13 mg/dL d. serum albumin 3.5 g/dL
c Serumalbumin, hematocrit,and hemoglobin are all low normal values that could indicate malnutrition. A serum albumin value of 3.5 g/dL is low and reflects nutritional status a few weeks before testing, so it is not the most sensitive protein study. A 13 mg/dL prealbumin level is low and is a more sensitive indicator of protein deficiency because of its short half-life of 2 days.
which person is most likely to acquire celiac disease? a. 16 year old asian female b. 64 year old African American female c. 21 year old European female d. 24 year old American male
c celiac disease is most commonly seen among eurpean and american adult female
a nurse is talking with her friend one afternoon. her friend states, "I think I am going to quit eating gluten." the nurse responds, "why?" the friend then states, "because every time i eat something with gluten in it, my stomach starts to hurt. my sister said that she stopped eating gluten and she feels a lot better also, so I felt like is should try it too." how should the nurse respond? a. "good for you!" b. "you should figure out what works best for you." c. "you really should diagnose yourself. maybe going to your doctor would be a better option." d. "do not be stupid. gluten is good for you."
c if a person diagnoses themselves, it could skew the results that the doctors are trying to search for.
a UAP is bringing a postop pt a gatorade. which color should she not give this patient? a. yellow b. orange c. red d. blue
c if the pt throws up, you will not know if it is blood or the drink
a patient comes in with another flare up of her celiac disease. what is the first thing the nurse should question? a. fluid intake b. exercise c. diet d. intake of red meat
c pt with cd have varying s/s with cycles of remission and exacerbation, usually related to how well they monitor their diet.
mild intellectual disability is determined by what? a. IQ scores of 25-40 b. IQ scores of <25 c. IQ scores of 55-70 d. IQ scores of 40-55
c represents 85% of the population with intellectual disability
if serum mg is low, what other electrolyte will the nurse suspect to be low as well? sata a. na b. k c. ca
c, b calcium occurs most likely with it then potassium. if a person is prescribed meds for low mg, drugs for low ca will be prescribed too.
alkalosis can be caused from: sata a. co2 retention b. hco3 loss or h+ retention c. co2 loss d. hco3 excess or h+ loss
c, d
EKG changes with hypokalemia. sata a. tall peaked T waves b. prolonged PR intervals c. st-segment depression d. flat or inverted T waves e. increased U waves f. flat or absent p waves g. wide QRS complex
c, d, e *dysrhythmias can lead to death, particularly in older adults who are taking digoxin
a pt has been told to eat a low sodium diet. which food should the nurse suggest eating? SATA a. pickled foods b. smoked foods c. fresh fish d. mustard e. fresh vegetables f. fresh fruits
c, e, f
calcium and phosphorus balance takes place partly through actions of what?
calcitonin
carbohydrate metabolism forms what?
carbon dioxide
what should the nurse assess first in a patient at risk for acidosis? a. respiratory b. cardiovascular c. neuro d. skeletal
cardiovascular acidosis can lead to cardiac arrest from the accompanying hyperkalemia. if cardiac changes are present, respond by reporting these changes immediately to the hcp.
oxygen therapy for resp acidosis
carefully monitor oxygen sat levels to ensure that the lowest flow of oxygen that prevents hypoxemia is used to avoid oxygen-induced tissue damage
the RN informs the family of a child with celiac disease that the child needs an annual evaluation. why is this?
celiac disease can cause impaired growth, delayed puberty, nutritional deficiencies, reduced bone mineral density.
causes of airway obstruction
clothing neck edema local lymph node enlargement aspiration of foreign objects bronchoconstriction mucus edema
the nurse recognizes that the hallmark for hypothyroidism is:
cold intolerance
a woman is post menopausal. what is the most important thing to instruct her to do to prevent the effects of hypocalcemia?
continue weight bearing exercises.
what type of substitutes would the nurse expect the RDA so suggest for a pt with celiac disease?
corn and rice
when excess hydrogen ions are present, what happens?
creates more carbon dioxide
After the surgery, the client is taken to the PACU, the endotracheal tube is removed, and he responds to his name. During the time in the PACU, the student nurse monitors respiratory status closely due to what factors? A. Anesthesia can have a depressing effect on respirations. B. He has a history of smoking. C. The client has an abdominal incision. D. All of the above.
d
Which client statement indicates that further nursing teaching is needed about hypothyroidism? A."When I go homeI should check my heart rate and BP every day." B."I will be sure to include fiber in my diet and drink plenty of water." C."I will call my provider if I notice any change in level of consciousness." D."When I am feeling better in a few months, I will no longer need to take the Synthroid pills."
d
a pt comes in with symptoms of malnutrition and muscle wasting. what does the nurse suspect? a. impaired fat absorption b. depression c. anxiety d. impaired nutrient absorption
d
a pt has metabolic alkalosis. what electrolyte imbalance occurs? a. hyperkalemia b. hyponatremia c. hypomagnesemia d. hypokalemia
d
a pt is malnourished. what lab value would the RN suspect their TLC to be at? a. 1600-1650 b. 1800-2000 c. >2200 d. <1500
d
on review of the clients medical records, the nurse determines that which client is at risk for fluid volume excess? a. taking diuretics and has tennis of the skin b. ileostomy from recent and surgery c. requires intermittent go suctioning d. kidney disease and 12 year hx of dm
d
the quality of bone that determines bone strength. it peaks between 30-35 years of age, when both bone resorption activity and bone-building activity occur at a constant rate. when bone resorption activity exceeds bone-building activity, bone density decreases. a. bone remodeling b. osteopenia c. osteomalacia d. bone mineral density
d
the student nurse needs more education when she states: a. early ambulation increases micturition b. the pt needs to stay in bed to prevent dizziness c. peristalsis is increases d. pt needs to be up and in chair ASAP
d
which client is at risk for the development of a potassium level of 5.5? a. client with colitis b. client with cushings c. overusing laxatives d. sustained a traumatic burn
d
a client is receiving 250 ml of 3% sodium chloride solution iv for severe hypernatremia. which signs or symptoms indicate to the nurse that this therapy is effective? a. the client reports hand swelling b. bowel sounds are present in all four abdominal quadrants c. serum potassium level has decreased from 3.3 to 4.2 d. bp has increased from 100/50 to 112/70
d *not c because hyponatremic means the pt is hypervolemic so they will already have swollen hands.
Which patient statement about self-care indicates a need for further teaching by the nurse? A. "I am going to swim at the YWCA." B. "Low-fat yogurt is on my grocery list." C. "My husband is getting rid of our throw rugs." D. "Joining a bowling team will help me exercise."
d Bowling should be avoided for patientswith osteoporosis because it can contribute to compression fractures. Swimming, eating yogurt,and eliminating throw rugs in the house are all appropriate considerations for the patient with osteoporosis.
when determining the leading cause of infant mortality, what does the nurse consider? a. suffocation b. MVA c. pediatric cancer d. congenital anomalies
d OTHER injuries include suffocation
how are blood hydrogen ion levels and blood carbon dioxide levels related? a. these two blood values are negatively related to the extent that, as carbon dioxide levels rise, the concentration of hydrogen ions decreases b. carbon dioxide is attached to and becomes part of hydrogen ions in the blood so the loss of one always leads to the loss of the other. c. there is no relation between blood hydrogen ion level and carbon dioxide, making the concentration of each substance independent of the other. d. blood hydrogen ion levels and blood carbon dioxide levels are directly related so, when the level on of increases, the level of the other increases to the same degree.
d blood hydrogen ion levels helps determine the amount of acid, where carbon dioxide helps release it??
moderate intellectual disability is determined by what? a. IQ scores of 25-40 b. IQ scores of <25 c. IQ scores of 55-70 d. IQ scores of 40-55
d represents 10% of the population with intellectual disability
serum potassium levels are elevated in which acidosis? a. metabolic acidosis b. normal respiratory acidosis c. chronic respiratory acidosis d. acute respiratory acidosis
d they or normal or low in chronic respiratory acidosis when kidney compensation is present
this morning Kramer woke up and grabbed a donut. he brushed his teeth and ran outside, late for work. on his way there, he took a multivitamin which contained a starch filler. he has never been one to eat a balanced diet with real food. in fact, the most balanced thing he had eaten this week was a nacho plate with green onions and salsa after his beer binge the night before. which items exposed him to gluten?
donut multivitamin with starch nacho plate beer
interventions for respiratory acidosis
drug therapy oxygen therapy pulmonary hygiene ventilatory suppor
which diagnostic test is most promising when testing for osteoporosis? a. dxa b. x-ray c. ct based absorptiometry d. vertebral imaging e. MRI
e •X-ray-only present on x-ray after large amount of bone loss has occurred. Can identify bone fractures with this •DXA-dual x-ray absorptiometry. Spine and hip mostoftenassessed. Begin at age 40. •CT-basedabsorptiometry-volume of bone density and strength of vertebral spine •Vertebral imaging
what can a nurse do postop to prevent thrombus formation?
early ambulation, tcdb, ted hose, scd
what foods are low in potassium?
eggs, bread, cereal grains
primary age group at risk for cognitive impairment
elderly *no difference in impairment have been found across populations based on race, ethnicity, or gender; however, correlated risk factors among women and men differ.
TRUE/FALSE leading causes of injury/death is the same for each age group.
false. it is fluid i.e. changing all the time
fat metabolism forms what?
fatty acids and ketoacids
what nutrient is not being digested in celiac disease?
gliadin
the nurse is educating new RN students about hyperthyroidism. what should the nurse include in her teaching as the hallmark sign of hyperthyroidism?
heat intolerance
how often should the nurse assess the pt for symptoms of excessive losses of fluid, sodium, or potassium?
hourly
how often should the nurse assess the site infusing potassium?
hourly. ask the pt whether he or she feels burning or pain at the site
how can malignancy cause hypercalcemia?
hypercalcemia occurs due to systemic secretion of parathyroid hormone related protein by a malignant tumor. pthrp increases bone resorption and limits renal clearance of calcium, resulting in hypercalcemia.
an amnestic disorder can lead to what?
impaired social and occupational function
what is the main difference between respiratory acidosis and metabolic acidosis?
in resp acidosis, PaCO2 is high because the pulmonary problem impairs gas exchange causing co2 retention. +HALLMARK OF RESPIRATORY ACIDOSIS ARE A DECREASING PAO2, COUPLE WITH A RISING PACO2*
benefits of ambulating early:
increases rate and depth of breathing micturition circulation metabolism peristalsis
what happens when there is high serum sodium levels?
inhibit aldosterone secretion and stimulate secretion of ADH and NP. *together, these hormones increase kidney sodium excretion and water reabsorption
what happens when there are low serum sodium levels?
inhibits secretion of ADH and NP and trigger aldosterone secretion. *together, these compensatory actions increase serum sodium levels by increasing kidney reabsorption of sodium and enhancing kidney loss of water.
a pt is having an MH crisis. the nurse takes the temperature and the temperature is 110 degrees F. what does the nurse interpret about this fever?
it is a late sign
hco3 comes from?
kidneys
paco2 comes from?
lungs
a patient has lost 10% of her total body weight in 6 months. what does this indicate?
malnutrition
a patient has lost 5% of her total body in the past 30 days. what does this indicate?
malnutrition
what foods are high in potassium?
meat, fish, veggies, fruit
when the kidneys fail, the resulting imbalance is:
metabolic
why is continuous cardiac monitoring important for hypercalcemia?
needed to identify dysrhythmias and decreased cardiac output. compare recent ECG tracings with the pt baseline tracings. especially look for changes in the t waves and the qt interval and changes in rate and rhythm.
a pt ABG reveals that their pH level in 7.4. does the nurse consider this to be an emergency? y/n
no
how can the nurse promote safety in the home?
no toys smaller than a toilet paper roll, proper water temp, locking doors, putting up chemicals in a safe place
how is diagnosis of celiac disease made?
obtaining a screening blood test and endoscopy
what is the difference between PCM and PEM
pcm-protein calorie malnutrition pea-protein energy malnutrition
what happens when acid-base problems are fully compensated with kidney compensation?
ph of blood returns to normal, even though levels of oxygen and bicarbonate may be abnormal
what three things are needed to measure abg?
ph, co2, o2
causes of reduced alveolar diffusion
pneumonia pneumonitis tuberculosis emphysema acute resp distress syndrome chest trauma pulmonary emboli pulmonary edema drowning
general appearance for cognitive functioning:
posture and body movements should be relaxed, coordinated, and smooth. slumped posture, slow movements while walking, and dragging feet may be indicative of dementia. observe the patient's dress and overall hygiene, and consider if it is appropriate for the weather, setting, gender, and age. individuals with cognitive impairment may present with inappropriate dress and/or poor hygiene.
a resident with delirium and is agitated would benefit most in what type of environment?
private room, soft music, relaxation tapes playing, or massage
how can the nurse promote safety and injury prevention with MVA?
proper use of car seats, air bags, and wearing seat belts.
when the lungs fail, the resulting imbalance is:
respiratory
so acid-base balance is mainly regulated by_____________ & __________ systems; but you need an intact ________ & __________ *fill in the blanks
respiratory & renal CV & nervous
what is the acid base balance mainly regulated by?
respiratory and renal systems, but an intact CV system and nervous system is vital.
what medicine would the nurse expect to be prescribed to promote the excretion of water and retain sodium?
samsca (tolvaptan) conivaptan (vaprisol)
how can the nurse promote teaching infant CPR?
show the need for it. educate using a babysitter or older sibling
causes of inadequate chest expansion
skeletal trauma deformities resp muscle weakness external constriction cast tight scar tissue around chest obesity internal condition of ascites
a nurse is giving education to a patient who has celiac disease about the importance of not having lactose. what is this for?
so that way the mucosal lesions can heal. once they have healed, they can slowly introduce back lactose.
what is the main controller of potassium in the ECF?
sodium-potassium pump. this moves extra sodium ions from the ICF and moves extra potassium ions from the ECF back into the cell. in this way the serum potassium level remains low, and the cellular potassium remains high. at the same time, this action also helps the serum sodium level remain high and the cellular sodium level remain low.
a pt is experiencing excessively large, pale, oily, frothy stools. what is this termed as?
steatorrhea
what is an acid?
substances that release hydrogen ions when dissolved in water or body fluids, increasing the amount of free hydrogen ions in that solution. +a weak acid releases only some, not all, of its hydrogen ions.
protein metabolism forms what?
sulfuric acid
The student nurse is developing the client's care plan and adds the nursing diagnosis potential for infection. Why would he be at high risk for developing an infection?
the pt has diabetes
why do sodium imbalances often occur with fluid imbalances?
the same hormones regulate both sodium and water balance
what is the pH level when the lungs fully compensate for kidney problems?
they are normal
too much calcium is present in the plasma. what hormone if secreted?
thyrocalcitonin. tct. causes plasma calcium level to decrease by inhibiting bone resorption of calcium, inhibiting vitamin D associated intestinal uptake of calcium, and increasing kidney excretion of calcium in the urine.
1.Normal Pulmonary Function requires a balanced relationship among the respiratory, cardiovascular, nervous, and renal systems t/f
true
If the pH drops below 7.0 or rises above 8.0 death usually occurs t/f
true
Normal PaCO2is 35 -45 t/f
true
Normal pH is 7.35 - 7.45 t/f
true
The O2level only indicates how well the patient is obtaining oxygen and does not indicate the acid/base status t/f
true
The carbonic acid - Bicarbonate buffer system is the major buffer system of the body t/f
true—kidney and lungs are major buffer system
a person who has celiac disease can experience atypical symptoms of celiac disease. why?
undiagnosed celiac disease or not following the regimen
five symptoms of failure to thrive
weakness slow walking speed low physical activity unintentional weight loss exhaustion
a nursing home struggles with a resident who wanders a lot that has dementia. this resident would benefit most from what?
wearing an identification bracelet or wander guard device
what weight loss can indicate malnutrition?
weight loss of 5% or more in 30 days, a weight loss of 10% in 6 months, or a weight that is below ideal
when does acute PEM develop?
when patients who were adequately nourished before hospitalization but experience starvation while in a catabolic state from infection, stress, or injury.
when does chronic PEM develop?
when pt has cancer, end stage kidney or liver disease, or chronic neurologic disease
when are surgeries imperative ?
when something can't be fixed with medications ◦Surgery addresses diseases, conditions and traumatic injuries that are difficult or impossible to treat only with medicine. (before during and after)
a pt ABG reveals that their pH level is 6.9. does the nurse consider this to be an emergency? y/n
yes
a pt ABG revels that their pH level is 7.8. does the nurse consider this to be an emergency? y/n
yes
Normal HCO3is 20- 30 mEq/L t/f
*false--22-26
Carbonic acid concentration is maintained by the kidneys t/f
*false-maintained by the lungs. Bicarb is the kidneys
The major effect of alkalosis on the CNS is depression false
*false—stimulates
When the kidneys fail, the resulting imbalance is metabolic t/f
*true—lungs fail will be respiratory
nursing priorities for metabolic acidosis
+continuously monitoring the patient for indications either that he or she is responding to the tx or the acidosis is becoming worse +cardiovascular and skeletal muscle systems are sensitive to acidosis and the most important systems to monitor. +interpret ABG
the nurse is taking care of someone with COPD. how will the kidneys play a role with this patient concerning blood gas levels?
+excrete hydrogen ions +increase movement of bicarbonate back into the blood
what happens if the fluid is basic?
+few free hydrogen ions the buffer releases hydrogen ions into the fluid.
interventions for metabolic acidosis
+hydration +drugs/tx to control problem causing acidosis i.e. acidosis as a result of aka, insulin is given to correct the hyperglycemia and halt the production of ketone bodies. i.e. rehydration and antidiarrheal drugs are given if the acidosis is a result of prolonged diarrhea.
goals for respiratory acidosis
+improve gas exchange -arterial ph approaching 7.35, pa02 above 90, paco2 levels below 45 or at lest 15 mmhm below pt admission level
what happens if the fluid is acidic?
+many free hydrogen ions the buffer binds some of the excess hydrogen ions.
As part of the student nurse's assignment, she is observing the client's surgery. She is to follow the circulating nurse. What will the student nurse learn about the role of the circulating nurse during the surgery?
+review preop assessment +establishandimplementinteropcareplan +createoproomenvironment +assistwithinfusion +veryspongeandinstrument count
+carbon dioxide is a gas that can be eliminated during exhalation, and this action is important for acid base balance. +when any condition causes the hydrogen ion concentration of body fluids to increase, extra co2 is produced in the same proportion. the extra co2 is eliminated during exhalation, helping to bring the hydrogen ion concentration down to normal.
.
CHEMICAL BUFFERS ALONE CANNOT PREVENT CHANGES IN BLOOD PH, the resp system is the second line of defense against changes
.
cognitive changes can also be considered from a time perspective--that is, temporary state or a chronic (permanent) state. depending on the underlying cause, chronic states of impaired cognition can remain stable or can be associated with study decline over time.
.
increasing potassium excretion helps reduce hyperkalemia if kidney function is normal. potassium excreting diuretics are prescribed. when kidney problems exist, more invasive interventions may be needed. . generally in ICU areas, IV fluids with glucose and insulin are prescribed. strict monitoring for hypoglycemia and hypokalemia. (usually 100 mL of 10% to 20% glucose with 10-20 units of regular insulin.) these are hypertonic and are infused through a central line or in a vein with a high blood flow to avoid local vein inflammation.
.
the effects of hypomagnesium are caused by increased membrane excitability and the accompanying serum calcium and potassium imbalances. excitable membranes, especially nerve cell membranes, may depolarize spontaneously.
.
+less co2 is lost through the lungs, and more co2 is retained in arterial blood. this retention of already-formed co2 together with the normal production of co2 from metabolism, results in a rapid return of the arterial co2 levels (and hydrogen ion levels) back up to normal. when these levels are normal, the rate and depth of breathing is also returned to normal levels.
..
Culture of Safety is EVERYONE'S responsibility Nurses have accountability to challenge the "unsafe" Nurses have accountability to practice safely Nurses in leadership and management roles have additional opportunities to implement best evidence
..
acid base balance occurs by matching the rate of hydrogen ion production (which is a continuous normal process) with hydrogen ion loss.
..
an increase in bicarbonate causes the amount of hydrogen ions to decrease and the ph to increase, becoming more alkaline (basic.) a decrease in bicarbonate causes the free hydrogen ion level to increase and the ph to decrease, becoming more acidic
..
breathing controls the amount of free hydrogen ions by controlling the amount of carbon dioxide in arterial blood. because co2 is converted into hydrogen ions with the carbonic anahydrase reaction, the co2 level is DIRECTY related to the hydrogen ion level. breathing rids the body of any excess co2 +because the amount of co2 in room air is nearly zero, co2 can continue to be exhaled even when breathing is impaired
..
if infiltration of solution containing potassium occurs, stop the IV solution immediately, remove the venous access, and notify the health care provider or rapid response team. document these actions along with a complete description of the IV site
..
malnutrition results when meals are different from what the patient usually eats. be sure to identify specific food preferences that the patient can eat and enjoy the are in keeping with his or her cultural practices. older adults in the community or in any health care setting are most at risk for poor nutrition, especially PEM. risk factors include physiologic changes of aging, environmental factors, and health problems.
..
the nurse needs to understand that managing a school age Childs diet is EXTREMELY difficult. make sure to be patient with the parents and help with as many resources as possible to make it a little easier on them to manage their child with celiac disease.
..
when assessing for malnutrition, assess for difficulty or pain chewing or swallowing. unrecognized dysphagia is a common problem among nursing home residents and can cause malnutrition, dehydration, and aspiration pneumonia. ask the patient whether any foods are avoided and why. ask UAP to report any choking while the patient eats. record the occurrence of n/v, heart burn, or any other symptoms of discomfort with eating.
..
when a pt has hypothyroidism and is prescribed medication, stress to the patient that this is lifelong home management..
...
A client is admitted to the hospital after taking an overdose of aspirin. A nasogastric tube is inserted for lavage. Which solution should the nurse obtain for the gastric lavage? 1 Normal saline 2 Lactated Ringer 3 Citrate magnesium 4 Sodium bicarbonate
1 A saline solution of 0.9% is considered a physiological or isotonic solution appropriate for gastric lavage because it will not detrimentally influence the client's acid-base balance. Lactated Ringer contains sodium chloride, potassium chloride, and calcium chloride in purified water; it is an intravenous solution. Citrate magnesium affects the lower bowel, not the stomach. Sodium bicarbonate is used to counteract acidosis in some instances of salicylate toxicity, but it is undesirable for lavage because as a systemic alkalinizer, it can precipitate metabolic alkalosis.
the nurse is reviewing lab results and notes that a clients serum sodium level is 150. the nurse reports the serum sodium level to the hip and the hcp prescribes dietary instructions based on the sodium level. which acceptable food items does the nurse instruct the client to consume? sata 1. peas 2. nuts 3. cheese 4. cauliflower 5. proceeded oat cereals
1, 2, 4
potassium chloride iv is prescribed for a client with hypokalemia. which actions should the nurse take to plan for preparation and administration of the potassium? sata 1. obtain iv infusion pump 2. monitor urine output during admin 3. prepare the med for bolus admin 4. monitor the iv site for signs of infiltration or phlebitis 5. ensure that the med is diluted in the appropriate volume of fluid 6. ensure that the bag is labeled so that it reads the volume of potassium in solution
1, 2, 4, 5, 6
a nurse reviews a clients electrolyte lab report and notes that the potassium level is 2.5. which patterns should the nurse watch for on the ECG as a result of the lab value? sata 1. u waves 2. absent p waves 3. invertes t waves 4. depressed st segments 5. widened qrs complex
1, 3, 4
what is the ratio of bicarbonate to carbonic acid?
1:20 +constant ratio is related to balancing the production and elimination of carbon dioxide and hydrogen ions.
A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased Pco 2 levels
2 Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco 2 level will increase in profound shock.
the nurse provides instruction to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? sata 1. peas 2. raisins 3. potatoes 4. cantaloupe 5. cauliflower 6. strawberries
2, 3, 4, 6
An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance? 1 Retention of potassium in the cells 2 Loss of fluid by way of the kidneys 3 Loss of chloride ions through vomiting 4 Reduction of blood supply to body cells
3
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing? 1 Kidney failure 2 Mild dehydration 3 Metabolic acidosis 4 Respiratory alkalosis
3 Metabolic acidosis occurs with loss of alkaline fluid through diarrhea and is manifested by lethargy and Kussmaul breathing; all of the assessments indicate severe dehydration. The infant has not urinated because excessive amounts of fluid have been lost in the loose stools; this indicates that the kidneys are functioning by compensating for the fluid loss. All data indicate a severe, not mild, fluid volume deficiency. Respiratory alkalosis is caused by an excessive loss of carbon dioxide, not diarrhea.
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis [1] [2]. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 35 mm Hg, and HCO 3 is 20 mEq/L (20 mmol/L). Which client should the nurse consider is most likely to exhibit these results? 1 A 54-year-old with vomiting 2 A 17-year-old with panic attacks 3 A 24-year-old with diabetic ketoacidosis 4 A 65-year-old with advanced emphysema
3 The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic attacks most likely will experience metabolic alkalosis from hyperventilation. A 65-year-old with advanced emphysema most likely will experience respiratory acidosis.
the nurse reviews the electrolyte results of an assigned client and notes that the potassium level 5.7. which patterns would the nurse watch for on the cardiac monitor as a result of the lab value? 1. st depression 2. prominent u wave 3. tall peaked t waves 4. prolonged st segment 5. widened qrs complexes
3, 5
Which would the nurse claim is a cardiovascular manifestation of alkalosis? 1 Anxiety 2 Seizures 3 Hyperreflexia 4 Increased digitalis toxicity
4
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? 1 PCO 2: 49, HCO 3: 32, pH: 7.50 2 PCO 2: 26, HCO 3: 20, pH: 7.52 3 PCO 2: 54, HCO 3: 28, pH: 7.30 4 PCO 2: 28, HCO 3: 18, pH: 7.28
4 ketoacidosis: METABOLIC!!
the nurse is caring for a client with hypocalcemia. which patters would the nurse watch for on the egg as a result of the lab value? 1. u waves 2. widened t wave 3. prominent u wave 4. prolonged qt interval 5. prolonged st segment
4,5
1.The patient also asks why she can't just take the calcium once a day. What is the best response by the nurse?
A third of the daily dose should be given at bedtime because calcium is most readily utilized by the body when the patient is fasting and immobile.
A 64-year-old woman is seen in the adult outpatient clinic. She was measured as standing 65 inches tall last year. The nurse observes that the patient now measures 64 inches. She has mild kyphosis. What assessment questions should the nurse ask at this time?
ANS: Ask the patient if she feels she has gotten shorter.Ask if she experiences pain with lifting, bending, or stooping. Ask if the pain is worse with activity and relieved by rest.
