Lewis Med-Surg Ch 17 Fluid, Electrolytes + Acid-Base Imbalances

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? o 1.Sodium level of 145 mEq/L o 2.Potassium level of 3.0 mEq/L o 3.Magnesium level of 2.0 mg/dL o 4.Phosphorus level of 4.0 mg/dL

Potassium level of 3.0 mEq/L Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe? o 1.Respirations that cease for several seconds o 2.Respirations that are regular but abnormally slow o 3.Respirations that are labored and increased in depth and rate o 4.Respirations that are abnormally deep, regular, and increased in rate

Respiration that are abnormally deep, regular, increased in rate Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance? o 1.Metabolic acidosis o 2.Metabolic alkalosis o 3.Respiratory acidosis o 4.Respiratory alkalosis

Respiratory acidosis Respiratory acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base disturbances can occur in a client with COPD during exacerbation of the disease, but the most likely imbalance is respiratory acidosis. The remaining options are incorrect. COPD is a respiratory condition, not a metabolic one. Respiratory alkalosis is associated with hyperventilation.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PCO2 is 90 mm Hg, and is 22 mEq/L. The nurse interprets the results as indicating which condition? o 1.Metabolic acidosis with compensation o 2.Respiratory acidosis with compensation o 3.Metabolic acidosis without compensation o 4.Respiratory acidosis without compensation

Respiratory acidosis without compensation The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate () level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore the condition is without compensation. The remaining options are incorrect interpretations

Which pH value respresents acidosis? a. 7.26 b. 7.35 c. 7.4 d. 7.49

a

An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply): a. weight loss b. dry oral mucosa c. full bounding pulse d. engorged neck veins e. decreased central venous pressure

a, b, & e Rationale: Body weight loss, especially sudden change, is an excellent indicator of overall fluid volume loss. Other clinical manifestations of dehydration include dry mucous membranes and a decreased central venous pressure, which reflect fluid volume loss.

The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions (select all that apply)? a. Lung sounds b. Bowel sounds c. Blood pressure d. Serum sodium level e. Serum potassium level

a, c, & d BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? a. The potassium level may be increased if the patient has renal nephropathy. b. The patient may be excreting extra sodium and retaining potassium because of malnutrition. c. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. d. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. e. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.

a, c, & d Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.

What is an adequate intake of sodium for an adult aged 71 or older? 1. 1.2g 2. 1.3g 3. 1.5g 4. 2.3g

1

Which of the floowing intravenous solutions is isotonic? (select all that apply) 1. 0.9% saline 2. 5% dextrose in water (D5W) 3. 0.45% NaCl 4. Dextrose in 0.255% NaCl

1

The nurse working on a medical unit recognizes that which of the following individuals are a risk for hyponatremia? Select all that apply. 1. A 19-year-old drowning victim rescued from a nearby lake. 2. A 52-year-old with congestive heart failure taking diuretics who is NPO for a cardiac catheterization. 3. A 68-year-old with bowel obstruction receiving nasogastric suction 4. A 92-year-old who is receiving total parenteral nutrition 5. A 55-year-old who takes calcium supplements for osteoporosis 6. A 42-year-old with chronic renal failure.

1, 2, 3, 4

The nurse is caring for a patient with suspected hypokalemia. Which of the following are signs and/or symptoms for which the nurse should be vigilant? Select all that apply. 1. Weak thready pulse 2. Shallow breathing 3. Increased gastrointestinal motility 4. Muscle weakness 5. Nausea 6. Pinpoint pupils

1, 2, 4, 5

The nurse is caring for a patient who is very anxious and hyperventilating. Which of the following are signs and symptoms of respiratory alkalosis for which to observe? Select all that apply. 1. Increased heart rate 2. Increased PaCO2 level 3. Slow deeps respirations 4. Rapid shallow respirations 5. Decreased heart rate 6. Lightheadedness

1, 4, 6

The nurse is caring for an older adult patient who presents to the emergency room complaining of severe vomiting and diarrhea, sweating, and rapid heartbeat. The body temperature is normal. Which of the following assessments should the nurse complete next? 1. Evaluate the presence of leg edema 2. Check skin turgor 3. Listen for crackles 4. Assess capillary refill

2

What percentage of an older adult's body weight is water? 1. 30% 2. 50% 3. 60% 4. 70%

2

A positive Chvostek's sign and a positive Trousseau's sign are classic signs of hypocalcemia and of what other electrolyte imbalance? 1. Hypermagnesemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypokalemia

3

Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.2 mEq/L? 1. Lungs 2. Kidneys 3. Liver 4. Heart

4

Which of the following are functions of sodium in the body? Select all that apply. a. Maintenance of serum osmolarity b. Formation of bones and teeth c. Control of bronchodilation d. Control of serum glucose e. Maintenance of cellular function

A,E Sodium is the major cation in the blood and helps maintain serum osmolarity. Sodium is also important for cell function, especially in the central nervous system.

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

ANS: A An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

ANS: A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

ANS: A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

ANS: A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.

ANS: A The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids

ANS: A The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

ANS: A The patient should be placed near the nurse's station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

ANS: A The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

ANS: A This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

ANS: B An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

ANS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

ANS: B Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

ANS: B Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

ANS: B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness

ANS: B The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

ANS: B The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.

ANS: B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

ANS: B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

ANS: C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

ANS: C Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. "There is a decreased risk for infection when 25% dextrose is infused through a central line." b. "The prescribed infusion can be given much more rapidly when the patient has a central line." c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." d. "The required blood glucose monitoring is more accurate when samples are obtained from a central line."

ANS: C The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

ANS: C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

ANS: C The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight

ANS: C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

ANS: C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

ANS: D Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

ANS: D Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.

ANS: D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift

The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? o 1.Metabolic acidosis o 2.Metabolic alkalosis o 3.Respiratory acidosis o 4.Respiratory alkalosis

Metabolic acidosis Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? o 1.Metabolic acidosis o 2.Metabolic alkalosis o 3.Respiratory acidosis o 4.Respiratory alkalosis

Metabolic alkalosis Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. o 1.Nausea o 2.Confusion o 3.Bradypnea o 4.Tachycardia o 5.Hyperkalemia o 6.Lightheadedness

Nausea confusion tachycardia lightheadedness Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b, Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chxostek's sign

a, d, & e Rationale: Inadvertent removal of a portion of or injury to the parathyroid glands during thyroid or neck surgery can result in a lack of parathyroid hormone, leading to hypocalcemia. A positive Chvostek sign, confusion, and circumoral numbness are manifestations of low serum calcium levels.

Which serum potassium result best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.9 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L

a. 3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side.

a. Administer oxygen. The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.

A patient is being discharged following hospitalization for fluid imbalance. Which instruction by the nurse should take priority? a. "Weigh yourself at the same time every day and report changes." b. "Call your doctor immediately if you feel weak or fatigued." c. "Drink eight glasses of water a day." d. "Measure everything you drink, and measure how much you urinate each day."

a. Daily or every-other-day weights are easy to keep track of at home.

When caring for a patient with fluid excess, which of the following interventions will best help relieve respiratory distress? a. Elevate the head of the bed b. Encourage the patient to cough and deep breathe. c. Increase fluids to promote urine output. d. Perform percussion and postural drainage.

a. Elevating the head of the bed will provide more room for lung expansion and provide the quickest relief for shortness of breath.

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? a. Renal dialysis b. IV potassium chloride c. IV furosemide (Lasix) d. IV normal saline at 250 mL per hour

a. Renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output which is the major route of excretion for magnesium.

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? a. Sodium 136 mEq/L, potassium 4.5 mEq/L b. Sodium 145 mEq/L, potassium 4.8 mEq/L c. Sodium 135 mEq/L, potassium 3.6 mEq/L d. Sodium 144 mEq/L, potassium 3.7 mEq/L

a. Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors

a. Weakness Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

The nursing care for a patient with hyponatremia includes: a. fluid restriction b. administration of hypotonic IV fluids c. administration of a cation-exchance resin d. increased water intake for patients on nasogastric suction

a. fluid restriction Rationale: In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.

The lungs act as an acid-base buffer by: a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. Rationale: As a compensatory mechanism, the respiratory system acts on the CO2 + H2O side of the reaction by altering the rate and depth of breathing to "blow off" (through hyperventilation) or "retain" (through hypoventilation) CO2.

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is: a. osmosis b. diffusion c. active transport d. facilitated diffusion

a. osmosis Rationale: Osmosis is the movement of water between two compartments separated by a semipermeable membrane. Water moves through the membrane from an area of low solute concentration to an area of high solute concentration.

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as a. within normal limits. b. slight metabolic acidosis. c. slight respiratory acidosis. d. slight respiratory alkalosis.

a. within normal limits. The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? o 1.A decreased pH and an increased CO2 o 2.An increased pH and a decreased CO2 o 3.A decreased pH and a decreased HCO3 o 4.An increased pH with an increased HCO3

an increased pH with an increased HCO3 Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition

Which patient is at risk for respiratory acidosis? a. The patient with uncontrolled diabetes mellitus b. The patient with chronic pulmonary disease c. The patient who is very anxious d. The patient who overuses antacids

b

A 93-year-old patient with diarrhea and dehydration is admitted to the hospital from an extended care facility. For which of the following symptoms of dehydration should the nurse assess? a. Pale-colored urine, bradycardia b. Disorientation, poor skin turgor c. Decreased hematocrit, hypothermia d. Lung congestion, abdominal discomfort

b Dehydration is associated with poor skin turgor because of loss of water in the tissues, and with disorientation because of loss of blood volume in the brain.

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)? a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. e. Treatment of heartburn can best be managed with Tums as needed.

b, c, & d A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

A patient is being placed on a potassium-losing diuretic. Which foods are high in potassium and should be recommended to the patient by the nurse? Select all that apply. a. Bread b. Potato c. Tomato juice d. Banana e. Gelatin

b, c, d Potatoes, tomatoes and bananas are highest in potassium.

The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline

b. 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.

The patient is admitted with metabolic acidosis. Which system is not functioning normally? a. Buffer system b. Kidney system c. Hormone system d. Respiratory system

b. Kidney system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives

b. Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

Which nursing intervention is most appropriate when caring for a patient with dehydration? a. Auscultate lung sounds every 2 hours. b. Monitor daily weight and intake and output. c. Monitor diastolic blood pressure for increases. d. Encourage the patient to reduce sodium intake.

b. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypoxemia d. Normal acid-base balance with hypercapnia

b. Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

The nurse anticipates treatment of the patient with hyperphosphatemia secondary to renal failure will include: a. fluid restriction b. calcium supplements c. loop diuretic therapy d. magnesium supplements

b. calcium supplements Rationale: The major conditions that can lead to hyperphosphatemia are acute kidney injury and chronic kidney disease that alter the ability of the kidneys to excrete phosphate. For the patient with renal failure, measures to reduce serum phosphate levels include calcium supplements, phosphate-binding agents or gels, fluid replacement therapy, and dietary phosphate restrictions.

When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient? a. 500 to 1500 mL b. 1200 to 2200 mL c. 2000 to 3000 mL d. 3000 to 4000 mL

c. 2000 to 3000 mL Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

Which patient would be at greatest risk for the potential development of hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking Beta-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

c. 42-year-old woman with systemic lupus erythematosus and renal failure Rationale: Causes of hypermagnesemia include renal failure (especially if the patient is given magnesium products), excessive administration of magnesium for treatment of eclampsia, and adrenal insufficiency.

Which of the following is the most reliable way to monitor a patient's fluid status? a. I&O b. Skin turgor c. Daily weights d. Lung sounds

c. Daily weights are the best way to monitor fluid imbalances. They are easier to monitor accurately than intake and output.

The nurse should be alert for which manifestations n a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

c. Weak, irregular pulse and poor muscle tone Rationale: Loop diuretics may result in renal loss of potassium (i.e., hypokalemia). Clinical manifestations of hypokalemia include fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, soft, muscle flab, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia, and electrocardiographic changes.

The typical fluid replacement for the patient with a fluid volume deficit is: a. dextran b. 0.45% saline c. lactated Ringer's d. 5% dextrose in 0.45% saline

c. lactated Ringer's Rationale: Administration of an isotonic solution expands only the extracellular fluid (ECF). There is no net loss or gain from the intracellular fluid (ICF). An isotonic solution is the ideal fluid replacement for a patient with an ECF volume deficit. Examples of isotonic solutions include lactated Ringer's solution and 0.9% NaCl.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? a. 60 mL urine output in 90 minutes b. 1200 mL urine output in 24 hours c. 300 mL urine output per 8-hour shift d. 20 mL urine output for 2 consecutive hours

d. 20 mL urine output for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial spaces into the cells c. Fluid movement from the blood vessels into interstitial spaces d. Fluid movement from the interstitial space into the blood vessels

d. Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume? a. Polyuria b. Decreased pulse c. Difficulty breathing d. General restlessness

d. General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

A patient is being treated for hypokalemia. When evaluating his response to potassium replacement therpy, which of the following changes in his assessment should the nurse observe for? a. Improving visual acuity b. Worsening constipation c. Decreasing serum glucose d. Increasing muscle strength

d. Hypokalemia is associated with muscle weakness.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Notify the physician and complete an incident report. b. Slow the rate to keep vein open until next bag is due at noon. c. Obtain a new bag of IV solution to maintain patency of the site. d. Listen to the patient's lung sounds and assess respiratory status.

d. Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the physician for further orders.

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorus falling to 2.1 mg/dL

d. Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

Which patient is most at risk for fluid excess? a. An infant with pneumonia b. A teen with multiple injuries following and automobile accident. c. A middle-aged man who has just had surgery d. An elderly patient receiving IV therapy

d. The elderly have reduced kidney function and may not be able to handle excess fluids

A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mmHg; HCO3- 24 mEq/L. The nurse determines that these results indicate: a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

d. respiratory alkalosis Rationale: Respiratory alkalosis (carbonic acid deficit) occurs with hyperventilation. The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, central nervous system (CNS) disorders, and mechanical overventilation also increase ventilation rate and decrease the partial pressure of arterial carbon dioxide (PaCO2). This leads to a decrease in carbonic acid level and to alkalosis.

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to: a. apply warm moist compresses to the insertion site b. attempt to force 10mL of normal saline into the device c. place the patient on the left side with head-down position d. instruct the patient to change positions, raise arm, and cough.

d. instruct the patient to change positions, raise arm, and cough. Rationale: Interventions for catheter occlusion include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking of the tube; flushing the catheter with normal saline through a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site of occlusion; and instilling anticoagulant or thrombolytic agents.

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because: a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults

d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults Rationale: In the older adult, body water content averages 45% to 55% of body weight.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1.pH 7.25, PCO2 50 mm Hg 2.pH 7.35, PCO2 40 mm Hg 3.pH 7.50, PCO2 52 mm Hg 4.pH 7.52, PCO2 28 mm Hg

pH 7.24, PCO2 50 mm Hg Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? o 1.Metabolic acidosis, compensated o 2.Respiratory alkalosis, compensated o 3.Metabolic alkalosis, uncompensated o 4.Respiratory ac

respiratory alkalosis, compensated The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.