med surg chapter 13 nur113o questions
Which is an insensible mechanism of fluid loss? A.Breathing B.Urination C.Nausea D.Bowel elimination
A >>>Loss of fluid from sweat or diaphoresis is referred to as insensible loss because it is unnoticeable and immeasurable. Losses from urination and bowel elimination are measurable. Nausea does not result in fluid loss, however if the client would develop emesis ( vomiting) this would be considered loss of body fluids and would need measured.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? A. 0.45% NaCl B. 5% NaCl C. 0.9% NaCl D. Lactated Ringer solution
A >>Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
Which nerve is implicated in the Chvostek's sign? A.Optic B.Facial C.Spinal accessory D.Hypoglossal
B >>Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.
Early signs of hypervolemia include A.moist breath sounds. B. increased breathing effort and weight gain. C. thirst. D.a decrease in blood pressure.
B >>Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
Which of the following is a factor affecting an increase in urine osmolality? A.Alkalosis B.Fluid volume excess C.Syndrome of inappropriate antidiuretic hormone release (SIADH) D.Myocardial infarction
C >>Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? A.1500 ml B.500 ml C.1250 ml D.1 L
D >>A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: A. insert a nasogastric tube (NG) as ordered. B.administer acetaminophen as ordered. C.administer antibiotics as ordered. D. instruct the client to breathe into a paper bag.
D >>A client recovering from an acute asthma attack who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). An NG tube would be indicated for a client with metabolic alkalosis secondary to ingestion of toxic substances; there is no reason to believe that this has occurred. Fever may cause metabolic (not respiratory) alkalosis and would be treated with acetaminophen. A client with sepsis also may have metabolic alkalosis and probably would receive antibiotics; however, this clinical situation doesn't suggest sepsis.
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A.Hypernatremia B.Hypophosphatemia C.Hyperkalemia D.Hypokalemia
D >>Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.
Which is a correct route of administration for potassium? A.Intramuscular B.IV (intravenous) push C.Subcutaneous D.Oral
D >>Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.
What foods can the nurse recommend for the patient with hypokalemia? A.Nuts and legumes B.Green, leafy vegetables C.Milk and yogurt D.Fruits such as bananas and apricots
D >>Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? A. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. B.A 79-year-old client admitted with a diagnosis of pneumonia. C.A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. D.An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.
D >>The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? A.dehydration B.hyperkalemia C. hypercalcemia D.hypervolemia
A >>Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? A.Chest pain B.Jaundice C.Slow pulse D.Hypertension
A >>Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? A.Arterial blood gas (ABG) B.analysis Sputum culture C.Red blood cell count D.Total hemoglobin
A >>Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: A.bowel sounds. B. electrocardiogram (ECG) results. C.neuromuscular function. D. respiratory rate.
B >>>Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? A.Magnesium B.Calcium C.Phosphorus D.Potassium
B >>Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? A.Serum bicarbonate of 21 mEq/L B.Serum bicarbonate of 28 mEq/L C.pH 7.30 D. pH 7.26
B >>Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? A.Vasodilation B.Tachycardia C.Increased urine output D.Bradycardia
B >>Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? A.<136 mOsm/kg B.275-300 mOsm/kg C.350-544 mOsm/kg D.>408 mOsm/kg
B >>In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? A."A good breakfast for me will include milk and a couple of bananas." B."I can use laxatives and enemas but only once a week." C."I will be sure to buy frozen vegetables when I grocery shop." D"I will take a potassium supplement daily as prescribed."
B >>The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.
A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond? A.Renin-angiotensin-aldosterone system B. Bicarbonate-carbonic acid buffer system C. Sodium-potassium pump D.ADH-ANP buffer system
B >>The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. Therefore options A and C are incorrect. Option D does not exist, it is only a distractor for this question.
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? A.Hypovolemia B.Dehydration C.Hypervolemia D.Fluid volume excess
B >>The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. A.A low urine specific gravity B.Electrolyte imbalance C.Low protein level in the urine D.Absence of ketones in urine E.An elevated hematocrit level
B,E >>>Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? A.evaporation B.active transport C.osmosis D.filtration
C >>>Osmosis is the movement of water through a semipermeable membrane; one that allows some but not all substances in a solution to pass through from a diluted area to a more concentrated area. Filtration promotes the movement of fluid and some dissolved substances through a semipermeable membrane according to pressure differences. Evaporation is the process of converting water into a vapor. Active transport requires the energy source ATP to drive dissolved chemicals from an area of low concentration to an area of higher concentration; the opposite of passive diffusion.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? A.Temperature B.Respirations C.Pulse D.Blood pressure
C >>An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
A priority nursing intervention for a client with hypervolemia involves which of the following? A. Drawing a blood sample for typing and crossmatching. B. Encouraging the client to consume sodium-free fluids. C. Monitoring respiratory status for signs and symptoms of pulmonary complications. D. Establishing I.V. access with a large-bore catheter.
C >>Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
A priority nursing intervention for a client with hypervolemia involves which of the following? A.Encouraging the client to consume sodium-free fluids. B.Drawing a blood sample for typing and crossmatching. C.Monitoring respiratory status for signs and symptoms of pulmonary complications. D.Establishing I.V. access with a large-bore catheter.
C >>Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? A.Metabolic alkalosis B.Respiratory acidosis C.Metabolic acidosis D.Respiratory alkalosis
C >>Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? A. Neutral B.Basic C.Acidic D.Alkaline
C >>Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? A. Potassium B.Calcium C.Sodium D.Magnesium
C >>Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? A.Hyperkalemia B.Hypokalemia C.Hypercalcemia D.Hypocalcemia
C >>The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? A.Confusion and depression B.Hyperactive bowel sounds. C.Dyspnea and laryngospasm D.Tingling or twitching sensation in the fingers
D >>All the choices are signs and symptoms of hypocalcemia, but tetany is the most characteristic manifestation that occurs when the calcium level is less than 4.4 mg/dL.