MED SURG fluid and electrolyte balance

If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV? ____________ drops/min

16 Drops per minute = volume drop factor ÷ total minutes 250 X 15 = 15.625 4 (hours) X 60 (minutes/hour)

A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set the infusion pump to deliver how many milliliters per hour? _____________ mL/hr

42 1000 mL divided by 24 hours = 41.6 mL/hr

A client has been placed on a ventilator. The physician has ordered that the ventilator be set to deliver a respiratory rate set of 28 breaths/min. The nurse questions the order, citing concerns about which acid-base problem? a. Acid deficit: alkalosis b. Base excess: alkalosis c. Acid excess: acidosis d. Base deficit: acidosis

A

A client has just experienced a 90-second tonic-clonic seizure and has these arterial blood gas values: pH 6.88, HCO3- 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which intervention by the nurse is most appropriate? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

A

A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is best? a. Review the client's daily hemoglobin and hematocrit. b. Ask the laboratory to rerun today's arterial blood gases. c. Document the finding and notify the physician. d. Apply 2 L of oxygen via nasal cannula.

A

A client has moderate acidosis. Which assessment does the nurse perform first? a. Take the client's pulse and blood pressure, and analyze the electrocardiogram (ECG) strip. b. Assess respiratory rate and depth and work of breathing. c. Perform assessments of musculoskeletal strength. d. Determine whether the client is awake, alert, and oriented.

A

A client has the following arterial blood gases (ABGs): pH 7.30, HCO3- 22 mEq/L, PCO2 55 mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority? a. Assessing the airway b. Administering bronchodilators c. Administering mucolytics d. Providing oxygen

A

A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective? a. "I will avoid excess use of antacids." b. "I'll drink at least three glasses of milk daily." c. "I'll avoid medications containing aspirin." d. "I will not add salt to my food during meals."

A

A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the client's arm has begun to blister around the IV site. This manifestation is consistent with which condition? a. Extravasation b. Infiltration c. Infection d. Phlebitis

A

A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes priority? a. Verifying the client's identity b. Ensuring that the blood bank has enough blood c. Establishing a peripheral IV site d. Feeding the client before starting the blood

A

A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 L/min. The client's respiratory rate is 8 breaths/min. Which action by the nurse is the priority? a. Notify the Rapid Response Team and prepare for intubation. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowler's position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

A

A nurse is changing the administration set on a client's central venous catheter. Which intervention is most important for the nurse to complete? a. Have the client hold his breath during the set change. b. Keep the slide clamp on the catheter extension open. c. Position the client in a high Fowler's position. d. Position in the client in a semi-Fowler's position.

A

A nurse is preparing to administer two drugs at the same time to a client via a double-lumen midline catheter. Which action by the nurse is most important? a. Check the two drugs for compatibility. b. Compare the recommended infusion times. c. Schedule any post-infusion lab draws. d. Flush both lumens with saline before starting the infusion.

A

A nursing administrator is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which action by the administrator would have the biggest impact on decreasing complications? a. Investigate initiating a dedicated IV team. b. Require inservice education for all RNs. c. Limit IV starts to the most experienced nurses. d. Perform quality control testing on skin preparation products.

A

A nursing student asks why midline catheters need strict sterile dressing changes when short peripheral IVs do not. Which answer by the experienced nurse is most accurate? a. "Because of the length of time they stay inserted." b. "They really don't need strict sterile technique." c. "Because the tip is in the right atrium of the heart." d. "The tonicity of the fluids used promotes infection."

A

A postoperative client received six units of packed red blood cells (PRBCs) for intraoperative blood loss. The nurse monitors the client for which acid-base imbalance? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory alkalosis d. Respiratory acidosis

A

A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important? a. "Use the arm that doesn't have the IV site in it." b. "Don't inflate the cuff too high if you use the left arm." c. "Make sure the IV line is secure before taking the BP." d. "While the BP is taken, a little backflow of the IV is okay."

A

In a client with less than the normal amount of bicarbonate in the blood and other extracellular fluids, what response does the nurse anticipate? a. Increased risk for acidosis b. Decreased risk for acidosis c. Increased risk for alkalosis d. Decreased risk for alkalosis

A

The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document findings and continue to monitor. d. Notify the physician as soon as possible.

A

The nurse is assessing several clients receiving intravenous therapy. Which client situation requires immediate intervention? a. Completion of an intermittent medication into a Groshong catheter b. Physician's order to discontinue a peripheral intravenous catheter c. Nonaccessed implanted port placed 1 month ago without problem d. Peripheral IV catheter dated 5 days ago used for once-daily antibiotics

A

The nurse is caring for a client who is receiving an epidural infusion for pain management. Which action has the highest priority? a. Assessing the respiratory rate b. Changing the dressing over the site c. Using various pain management therapies d. Weaning the pain medication

A

The nurse monitors the client with which condition most carefully for metabolic alkalosis? a. A critical illness receiving total parenteral nutrition b. Type 1 diabetes on once-daily insulin therapy c. Metastatic breast cancer on continuous IV morphine d. Asthma using an adrenergic agonist inhaler

A

The nurse preparing to insert an IV on an older adult client notices that the client's skin is extremely fragile. Which action by the nurse is best? a. Use a blood pressure cuff to cause the vein to distend. b. Slap the skin vigorously to cause the vein to rise. c. Place a gauze pad under the tourniquet before tightening. d. Avoid the use of a tourniquet if the vein is already hard.

A

The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment finding is consistent with this condition? a. Deep, rapid respirations b. Respirations with an irregular pattern c. Shallow, grunting respirations d. Use of accessory muscles when breathing

A

To prevent infection when infusing an intermittent "piggyback" line, which intervention does the nurse implement? a. Backpriming the secondary container from the primary line b. Detaching and capping the secondary line after use c. Using a new secondary container with each drug infused d. Using sterile gloves when administering medication

A

What action does the nurse take to prevent infection in the older adult receiving IV therapy? a. Applying skin protectant before applying the dressing b. Avoiding the use of alcohol pads when removing tape c. Shaving the skin before attempting the venipuncture d. Using maximum friction to cleanse the skin

A

What information is most important to teach the client going home with a peripherally inserted central catheter (PICC) line? a. "Avoid carrying your grandchild with the arm that has the IV." b. "Be sure to place the arm with the IV in a sling during the day." c. "Flush the IV line with normal saline daily." d. "You can use the arm with the IV for most of the activities of daily living."

A

When an IV pump alarms because of pressure, what action does the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

A

When assessing the client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. What is the most accurate documentation of this finding? a. Grade 3 phlebitis at IV site b. Infection at IV site c. Thrombosed area at IV site d. Infiltration at IV site

A

Which infusion device does the nurse select for the older adult client with a medical diagnosis of "dehydration"? a. Cassette pump b. Elastomeric balloons c. Volumetric controller d. Syringe pump

A

Which response is an example of compensation for an acid-base imbalance? a. Increase in the rate and depth of respirations when exercising b. Increased urinary output when blood pressure increases during exercise c. Increased thirst when spending time in an excessively dry environment d. Increased release of acids from kidneys during exacerbation of chronic obstructive pulmonary disease (COPD)

A

A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the client's previous or concurrent health problems is most likely to increase the client's risk for hypophosphatemia? a. Chronic alcoholic pancreatitis b. 50-pack-year smoking history c. Prostate cancer history d. Heart surgery 8 years ago

A Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia.

A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has new hyperactive bowel sounds in all four quadrants. What analysis about the client's condition is correct? a. The hyponatremia is worse. b. The hyponatremia is the same. c. The hyponatremia is better. d. The client now has hypernatremia.

A Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy, decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes. Bowel sounds that are more hyperactive than on a previous assessment indicate that the condition is worsening.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? a. Client who is NPO receiving intravenous D5W b. Client taking a sulfonamide antibiotic c. Client taking ibuprofen (Motrin) d. Client taking digoxin (Lanoxin)

A D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? a. 2.9 mEq/L b. 3.8 mEq/L c. 5.0 mEq/L d. 6.0 mEq/L

A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.

A client has been treated for hypokalemia. Which clinical manifestation or condition indicates that treatment has been effective? a. Having a bowel movement daily b. Gaining 2 lb during the past week c. Electrocardiogram (ECG) showing inverted T-waves d. Fasting blood glucose level of 106 mg/dL

A Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia.

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.

A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. Client with heart failure using a salt substitute b. Client taking a thiazide diuretic for hypertension c. Client taking nonsteroidal anti-inflammatory drugs daily d. Client with type 2 diabetes taking an oral antidiabetic agent

A Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.

Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause? a. "Do you take diuretics, or 'water pills'?" b. "What do you normally eat over a day's time?" c. "How many bowel movements do you have daily?" d. "Have you been diagnosed with diabetes mellitus?"

A Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration.

Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L? a. Measuring urine output b. Measuring abdominal girth c. Monitoring fluid intake d. Comparing radial versus apical pulses

A The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client.

The RN is working with an experienced LPN (licensed practical nurse) who has been assigned several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy to the LPN? (Select all that apply.) a. Look up and read the State Nurse Practice Act. b. Check facility policy regarding LPNs and IV therapy. c. Ask the LPN what he or she is comfortable performing. d. Supervise the LPN when performing IV therapy. e. Divide the clients up between the two of them.

A,B

The nurse is preparing to give a client an IV push medication through an intermittent IV set (saline lock) using a needleless system. Which actions by the nurse are most appropriate? (Select all that apply.) a. Cleanse the access port vigorously for at least 30 seconds. b. Use an antimicrobial agent when cleansing the port. c. Clean the ridges in the Luer-Lok connection well. d. Rinse the antimicrobial agent off with saline. e. Allow the antimicrobial agent to dry before using IV.

A,B,C

The nurse is preparing to administer a medication IV push. What information does the nurse need to know before beginning the infusion? (Select all that apply.) a. Any dilution required b. Rate of administration c. Compatibility with infusions d. Other routes of administration e. Specific monitoring needed

A,B,C,E

In the client with alkalosis, the nurse assesses for which clinical manifestations? (Select all that apply.) a. Positive Chvostek's sign b. Positive Trousseau's sign c. Hyporeflexia d. Bradycardia e. Elevated blood pressure f. Elevated urinary output

A,B,D

A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating the care plan. For which common complications does the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation

A,C

When the water absorption in the renal tubules becomes greater than normal, the nurse anticipates that the urine will become: 1. more concentrated 2. less concentrated 3. more alkaline 4. less alkaline

ANS: 1 When more water is kept back in the body, the water left to form urine is less; therefore, the urine is more concentrated.

The nurse assesses that the patient's urine has become much more concentrated, which results from the effect of: 1. adrenaline. 2. aldosterone. 3. antidiuretic hormone (ADH). 4. insulin.

ANS: 2 Aldosterone acts on the kidney tubules, affecting water retention and its attendant urine concentration.

The patient's IV has been infusing at a very high rate and now the patient appears to be in fluid volume overload, as indicated by: 1. hypotension. 2. tachycardia. 3. pulmonary edema. 4. kidney failure.

ANS: 3 An IV infusing at a high rate is used to increase intravascular fluid volume, but there is an equalization level, after which the patient goes into fluid overload; this results in pulmonary edema.

A client has acidosis. Which laboratory finding is of greatest concern to the nurse? a. Sodium 154 mEq/L b. Potassium 5.9 mEq/L c. Calcium 8.9 mg/dL d. Magnesium 2.1 mg/dL

B

A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for which manifestation consistent with this condition? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek's sign

B

A client has just had a central venous access line inserted. What is the nurse's next action? a. Beginning the prescribed infusion as soon as possible b. Confirming placement of the catheter by x-ray c. Having the infusion team start the IV therapy d. Confirming that solutions are appropriate for the central line

B

A client has moderate metabolic alkalosis. What is the priority intervention for the nurse? a. Monitor daily laboratory values. b. Assess the client's muscle strength. c. Determine the cause of the problem. d. Teach the client preventive measures.

B

A client has the following arterial blood results: pH 7.12, HCO3- 22 mEq/L, PCO2 65 mm Hg, PO2 56 mm Hg. The nurse correlates these values with which clinical situation? a. Diabetic ketoacidosis in a person with emphysema b. Tracheal obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

B

A client is being discharged from the emergency department with several broken ribs. For which acid-base imbalance does the nurse provide discharge teaching? a. Respiratory alkalosis from anxiety and hyperventilation b. Respiratory acidosis from inadequate ventilation c. Metabolic acidosis from calcium loss from broken bones d. Metabolic alkalosis from taking base-containing analgesics

B

A client is in the emergency department after an overdose of an unknown substance. Which assessment findings does the nurse correlate with possible salicylate poisoning? a. Increased deep tendon reflexes b. Increased rate and depth of respiration c. Decreased capillary refill d. Decreased intestinal motility and paralytic ileus

B

A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert which type of intravenous catheter? a. Hickman b. Midline c. Nontunneled central d. Short peripheral

B

A client who is having a tunneled central venous catheter inserted begins to report chest pain and difficulty breathing. What action does the nurse take first? a. Administer the PRN pain medication. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Place the client in the Trendelenburg position.

B

A client who was malnourished is being discharged. The nurse evaluates that teaching to decrease risk for the development of metabolic acidosis has been effective when the client states, "I will: a. Increase my milk intake to at least three glasses daily." b. Be sure to eat three well-balanced meals and a snack daily." c. Avoid taking pain medication and antihistamines together." d. Not add salt to food when cooking or during meals."

B

A new nurse is securing the connections on a new IV administration set connected to a peripherally inserted central catheter (PICC) line with tape. Which action by the precepting nurse is most appropriate? a. Make sure the tape being used is from a sterile IV start kit. b. Stop the nurse and confirm that the Luer-Lok connections are tight. c. Help the new nurse document the set change appropriately. d. Show the new nurse how to turn back the corner of the tape for easy removal.

B

After discontinuing a nontunneled, percutaneous central catheter, it is most important for the nurse to record which information? a. Application of a sterile dressing b. Length of the catheter c. Occurrence of venospasms d. Type of ointment used to seal the tract

B

The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to the new nurse? a. "Apply topical anesthetic cream to the area after discontinuing the system." b. "Be aware of a rebound effect when discontinuing the system." c. "Be sure to flush the system with saline after removing the Huber needle." d. "Place pressure over the site to prevent bleeding."

B

The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the client's left arm has been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. Which action by the nurse is most appropriate? a. Notify the physician. b. Administer the prescribed medication. c. Discontinue the PICC line. d. Switch the medication to the oral route.

B

The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3- 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease d. Diabetic ketoacidosis and emphysema

B

The nurse finishes administering an intermittent medication through a Groshong catheter. What is the nurse's next action? a. Clamping the catheter b. Flushing the line with saline c. Flushing with heparin d. Removing the access needle

B

The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a car crash. Which action by the nurse takes priority? a. Ensure that the IV flow rate has been recalculated for an IO infusion. b. Plan to insert another kind of IV line during the shift. c. Determine which IV medications can be given safely via the IO. d. Monitor the site and dressings routinely for hemorrhage.

B

The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump. After programming the pump and attaching the IV to the client, what action by the nurse is most important? a. Start the infusion as ordered. b. Hand-calculate the infusion rate. c. Ensure that the pump is plugged in. d. Place a "time tape" on the IV bag.

B

The nurse prepares to administer bicarbonate intravenously to the client with which clinical manifestations? a. pH 7.28, HCO3- 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma attack b. pH 7.28, HCO3- 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea c. Client with chronic emphysema and bronchitis who has the following arterial blood gases: pH 7.30, HCO3- 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis and emphysema d. pH 7.31, HCO3- 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract infection and type 2 diabetes

B

The nurse wants to find written standards for IV therapy. The nursing manager suggests that the nurse investigate publications from which resource? a. IV Therapy Nursing Society b. Infusion Nurses Society c. Nurse's State Board of Nursing d. Hospital's IV solutions vendor

B

Which client does the nurse assess for potential metabolic acidosis? a. Client admitted after collapsing during a marathon run b. Young adult following a carbohydrate-free diet c. Older adult with asthma who is on long-term steroid therapy d. Older client on antacids for gastroesophageal reflux disease

B

The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication? a. Fluid retention b. Hyperkalemia c. Hyponatremia d. Hypervolemia

B Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.

A client is being discharged and needs to self-monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client? a. Weighing self daily at the same time of day b. Assessing radial pulse for a full minute twice a day c. Ensuring an oral intake of a least 3 L of fluids per day d. Restricting sodium as well as potassium intake

B As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate, rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe. Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction may not be necessary.

A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. "I must drink a quart of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 PM so I won't have to get up at night."

B Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention? a. Document the finding and continue to assess. b. Assess respiratory status immediately. c. Request an order for a serum calcium level. d. Administer a rapid bolus of intravenous phosphorus.

B Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound hyperphosphatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might want to know the calcium level, but this is less important than ensuring that the client has adequate respiratory function. Simply documenting the finding without intervening would not help the client.

Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion? a. Measuring intake and output every four hours b. Applying oxygen by mask or nasal cannula c. Increasing the IV flow rate to 250 mL/hr d. Placing the client in a high Fowler's position

B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe? a. "I will weigh myself at the same time daily wearing the same clothes." b. "When I feel lightheaded, I will drink a full glass of water." c. "I will decrease my fluid intake if my urine output increases." d. "If I forget to take my diuretic, I will take twice the dose next time."

B Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild dehydration can cause these problems, and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse. The other options would not prevent mild dehydration from progressing.

A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? a. "Do you use sugar substitutes?" b. "Do you use diuretics or laxatives?" c. "Do you have any kidney disease?" d. "Have your bowel habits changed recently?"

B Misuse and overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia in older adults and in clients with eating disorders. Sugar substitutes and bowel habits are not related to hypokalemia. The client with kidney disease would be more likely to have hyperkalemia.

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia? a. "I have been weighing myself every day." b. "When I am constipated, I drink more fluids." c. "When my muscles feel weak, I eat a banana." d. "I check my pulse each morning and each night."

B The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations of hypokalemia are decreased peristalsis and constipation.

A client has a calcium level of 14 mg/dL. Which intervention is the priority? a. Forcing fluids to 2 L/day b. Placing the client on a cardiac monitor c. Assessing for Chvostek's sign every 2 hours d. Administering IV calcium chloride

B This client has hypercalcemia. Both forcing fluids and providing cardiac monitoring are appropriate, but because calcium has significant cardiac effects, placing the client on a cardiac monitor takes priority. Assessing for Chvostek's sign and administering calcium would be appropriate for the client with hypocalcemia.

Which ethnic groups should the nurse screen specifically for hypocalcemia? (Select all that apply.) a. Whites b. Blacks c. Asians d. Hispanics e. American Indians

B,C,E Lactose intolerance can lead to hypocalcemia because people avoid milk and dairy products to control their symptoms. Although anyone can have lactose intolerance, the incidence is between 75% and 90% among Asians, blacks, and American Indians.

A client has a prolonged fever. For which acid-base imbalance does the nurse assess the client further? a. Metabolic acidosis from excess bicarbonate production b. Metabolic alkalosis from dehydration and hyperkalemia c. Metabolic acidosis from increased production of hydrogen ions d. Respiratory alkalosis from impaired gas exchange

C

A client has an arterial blood gas pH of 7.48. How does the nurse interpret this client's acid-base status? a. An unknown acid-base balance status b. A normal blood hydrogen ion concentration c. A deficit in blood hydrogen ion concentration d. An excess in blood hydrogen ion concentration

C

A client has metabolic alkalosis. Which laboratory results is the nurse most likely to assess as consistent with this condition? a. Na+ 134 mg/dL b. Mg2+ 1.5 mg/dL c. K+ 3.1 mEq/L d. Ca2+ 11.5 mg/dL

C

A client has respiratory acidosis. The nurse evaluates that treatment is being effective with which arterial blood gas values? a. pH 7.28, HCO3- 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg b. pH 7.32, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg c. pH 7.35, HCO3- 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg d. pH 7.48, HCO3- 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg

C

A client has the following arterial blood gases: pH 7.30, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate? a. Prepare to give intravenous sodium bicarbonate. b. Document the findings and continue to assess. c. Assist the physician in determining the cause. d. Administer oxygen at 2 L per nasal cannula.

C

A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of 90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this client's peripheral IV? a. 24 b. 22 c. 20 d. 18

C

A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis and diabetic ketoacidosis. The nurse evaluates that teaching about the client's confusion was effective when a family member makes which statement? a. "It is too early to tell if the ketoacidosis will cause permanent changes." b. "Her memory will improve, but loss of some brain cells has occurred." c. "The confusion should clear when oxygen and electrolyte levels are normal." d. "The confusion should clear when blood glucose levels and other laboratory tests are normal."

C

A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like "pins and needles." Which action by the nurse is best? a. Document the finding and continue to monitor the IV site. b. Check for the presence of a strong blood return. c. Discontinue the IV and restart it at another site. d. Elevate the extremity above the level of the heart.

C

A new nurse is preparing to start an IV on a client who is dehydrated and needs significant fluid volume. The new nurse selects a butterfly needle for the infusion. What action by the supervising nurse is best? a. Help the new nurse with the procedure as needed. b. Make sure the new nurse has the correct dressing. c. Stop the new nurse and review the procedure in private. d. Get the ultrasonic vein finder to help illuminate veins.

C

In a client 4 minutes post cardiac arrest, the nurse correlates the largest source of excess hydrogen ions with which cause? a. Excess renal retention of carbon dioxide due to hypoxia b. Release of intracellular acids due to widespread tissue destruction c. Anaerobic metabolism, leading to the buildup of lactic acid d. Using fat as a fuel source, resulting in increased fat degradation

C

In clients with any type of acid-base imbalance, the nurse places the priority on monitoring which electrolyte? a. Sodium b. Calcium c. Potassium d. Magnesium

C

In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which ECG change with effectiveness of therapy? a. Small U-waves present after each complex b. Heart rate decreased to 62 beats/min c. T-waves present, normal height d. P-wave preceding the QRS complex

C

In the client with hypoventilation, which change in arterial blood gases does the nurse evaluate to determine whether treatment measures are being effective? a. Decreased arterial blood pH b. Decreased arterial blood carbon dioxide c. Increased arterial blood bicarbonate d. Increased arterial blood oxygen

C

The nurse assesses for acidosis in the client with which assessment data? a. Serum sodium level of 130 mEq per liter and peripheral edema b. Serum sodium level of 144 mEq per liter and tachycardia c. Serum potassium level of 6.5 mEq per liter and flaccid paralysis d. Serum potassium level of 4.5 mEq per liter and hyperactive deep tendon reflexes

C

The nurse has just performed an IV start on a client. After the catheter has been threaded its full length in the client's vein, which action does the nurse perform next? a. Secure the IV with a securement device or tape. b. Dispose of the IV needle in the sharps container. c. Engage the safety mechanism of the IV catheter d. Note the date and time of the dressing application over the insertion site.

C

The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis? a. pH 7.28, HCO3- 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg b. pH 7.45, HCO3- 22 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg c. pH 7.32, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg d. pH 7.48, HCO3- 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg

C

The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago. Which assessment is of greatest concern? a. Length of time catheter is in place b. Poor vascular access in upper extremities c. Affected leg cool to touch d. Site of intraosseous catheter placement

C

The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increased risk for metabolic alkalosis? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

C

The nurse monitors for which acid-base imbalance in a client who has hypoxemia? a. Reduced carbon dioxide production leading to alkalosis b. Reduced carbon dioxide retention leading to alkalosis c. Excess carbon dioxide production leading to acidosis d. Excess carbon dioxide retention leading to acidosis

C

A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned about? a. Na+ 146 mEq/L b. K+ 3.6 mEq/L c. Ca2+ 8.2 mg/dL d. Mg2+ 1.1 mEq/L

C A common cause of hypocalcemia is hypothyroidism. The calcium value is low, correlating with this condition. The sodium level is only slightly high, and hypothyroidism is not related to sodium imbalances. The potassium level is normal. The magnesium level is low, but hypothyroidism can cause hypermagnesemia.

Which action does the nurse teach a client to reduce the risk for dehydration? a. Restricting sodium intake to no greater than 4 g/day b. Maintaining an oral intake of at least 1500 mL/day c. Maintaining a daily oral intake approximately equal to daily fluid loss d. Avoiding the use of glycerin suppositories to manage constipation

C Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

What intervention is most important to teach the client about identifying the onset of dehydration? a. Measuring abdominal girth b. Converting ounces to milliliters c. Obtaining and charting daily weight d. Selecting food items with high water content

C Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home. The other options would not be useful for early detection of dehydration.

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? a. Has had diabetes mellitus for 12 years b. Uses sodium-containing antacids frequently c. Just received 3 units of packed red blood cells d. Had abdominal surgery and has a nasogastric tube

C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

A client with hypophosphatemia is being discharged. Which activity demonstrated by the client indicates that discharge teaching has been effective? a. Assessing radial pulse rate and rhythm b. Interspersing daily activities with periods of rest c. Selecting foods high in phosphorus and low in calcium d. Weighing himself or herself correctly at the same time each day

C Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase his or her ingestion of phosphorus and to decrease ingestion of calcium because phosphorus and calcium exist in the blood in a balanced inverse relationship.

A client has a history of hypocalcemia. What intervention is most important for the nurse to add to this client's care plan? a. Push fluids to 2 L/day. b. Strain all urine output. c. Use nonslip footwear to get out of bed. d. Position the client supine twice a day.

C Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Having the client wear nonslip footwear to get out of bed can help prevent falls. The other interventions would not provide safety for this client.

A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the dietary regimen? a. 1% or 2% milk b. Grilled salmon c. Poached eggs d. Baked chicken

C Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in potassium.

A client in the emergency department has potassium of 2.9 mEq/L. For which disease process or condition does the nurse assess the client? a. Diabetes mellitus b. Addison's disease c. Hyperaldosteronism d. Diabetes insipidus

C Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing excretion of potassium. Therefore, any client with this condition is at high risk for the development of hypokalemia.

When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. Which intervention is most appropriate? a. Administer isotonic intravenous fluids. b. Remove the blood pressure cuff and give oxygen. c. Ensure the client has a patent intravenous line. d. Document the finding in the client's chart.

C Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. Flexion contractions that occur during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign. Client safety is a priority, and the nurse must ensure that the client has a working intravenous line. Seizure precautions and decreasing environmental stimuli are also important.

During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. Which question by the nurse is best? a. "Do you usually drink liquids that are hot or cold?" b. "How much salt do you add to your food?" c. "What kinds of liquids do you usually drink?" d. "Do you drink fluids with meals or between meals?"

C It is just as important to determine the types of fluids ingested as the amount, because fluids vary widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine, can contribute to fluid and electrolyte imbalances.

A client has been taught to increase potassium in the diet. What dietary meal selection indicates to the nurse that teaching has been effective? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a cup of strawberries c. Sausage, one slice of whole wheat toast, cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, cup of sliced peaches, and coffee

C Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client? a. "Weigh yourself every morning and every night." b. "Check your radial pulse twice a day." c. "Read food labels to determine sodium content." d. "Bake or grill the meat rather than frying it."

C Most prepackaged foods have high sodium content. Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia. Daily self-weighing and checking the pulse are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking increases the sodium content of a meal, not the method of cooking.

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority? a. Document the observation in the chart. b. Measure urine specific gravity and volume. c. Assess the pulse and blood pressure. d. Assess the client's deep tendon reflexes.

C Neck veins in the normovolemic person are full in the supine position and flat in the sitting position. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine whether overhydration is present. Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give information on volume status at all. The nurse needs to document the finding, but interventions should not end there.

A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day. Which response by the nurse is best? a. "You are correct. Fruit is usually very high in potassium." b. "If you cook the fruit first, that lowers the potassium." c. "Berries, cherries, apples, and peaches are low in potassium." d. "Fresh fruit is higher in potassium than dried fruit."

C Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated? a. The client has dry, scaly skin on bilateral upper and lower extremities. b. The client states that he gets up three or more times during the night to urinate. c. The client states that he feels lightheaded when he gets out of bed or stands up. d. The nurse observes tenting on the back of the hand when testing skin turgor.

C Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.

A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion? a. Measuring intake and output every shift b. Slowing the IV flow rate to 50 mL/hr c. Administering diuretic agents as prescribed d. Placing the client in Trendelenburg position

C Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating fluid excess is the best way to reduce confusion. The other interventions would not relieve the client's confusion.

Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances? a. "My skin is always so dry, especially here in the Southwest." b. "I often use a glycerin suppository for constipation." c. "I don't drink liquids after 5 PM so I don't have to get up at night." d. "In addition to coffee, I drink at least one glass of water with each meal."

C Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration.

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? a. Notify the physician. b. Examine dependent body areas. c. Assess turgor on the client's forehead. d. Document the finding and continue to monitor.

C Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first? a. Place the patient on a cardiac monitor. b. Insert a retention catheter. c. Administer Kayexalate 15 g orally. d. Give IV furosemide (Lasix) 40 mg.

Correct Answer: A Rationale: Because cardiac dysrhythmias are a common and potentially fatal complication of hyperkalemia, the first action should be to initiate cardiac monitoring. The other orders are also appropriate and should be accomplished as quickly as possible.

When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. mental status. b. skin turgor. c. capillary refill. d. heart sounds.

Correct Answer: A Rationale: Changes in ECF osmolality lead to swelling or shrinking 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 may also be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.

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

Correct Answer: A Rationale: 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 should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

The long-term-care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Absence of peripheral edema b. Good skin turgor c. Hematocrit 28% d. Blood pressure 110/72 mm Hg

Correct Answer: A Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of 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 is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. generalized weakness. b. facial muscle spasms. c. frequent loose stools. d. personality changes.

Correct Answer: A Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. peripheral pulses. b. lung sounds. c. peripheral edema. d. urinary output.

Correct Answer: B Rationale: 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 the most serious of the symptoms of fluid excess listed. 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.

When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include is a. monitor intake and output hourly. b. restrict oral free water intake. c. ambulate patient at least once per shift. d. use incentive spirometer every 2 hours.

Correct Answer: B Rationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I can have low-fat cheese." b. "I will have apple juice instead of orange juice." c. "I will drink at least 8 glasses of water every day." d. "I can use a salt substitute."

Correct Answer: B Rationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.

The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. Oral fluid intake is 100 ml for the last 8 hours. b. The blood pressure is 90/40 mm Hg. c. Urine output is 30 ml over the last hour. d. There is prolonged skin tenting over the sternum.

Correct Answer: B Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This 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.

The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately? a. The patient reports feeling "sick to my stomach." b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The bibasilar breath sounds are decreased.

Correct Answer: B Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also 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.

A diabetic patient with poor glucose control develops diabetic ketoacidosis. The nurse notes that a patient with diabetic ketoacidosis has rapid, deep respirations. Which collaborative intervention will the nurse anticipate implementing? a. Oxygen at 2 to 4 L/min b. IV sodium bicarbonate 50 mEq c. IV 50% dextrose 50 ml d. IV lorazepam (Ativan) 1 mg

Correct Answer: B Rationale: The rapid, deep (Kussmaul) respirations are a compensatory mechanism to "blow off" excessive CO2 generated by the high levels of ketoacids. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of 50% dextrose will increase serum glucose level. Ativan administration will slow the respiratory rate and increase the level of acidosis.

A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question? a. Administer 3% saline if serum sodium drops to less than 128 mEq/L. b. IV morphine sulfate 4 mg every 2 hours prn. c. Infuse 5% dextrose in water at 125 ml/hr. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.

Correct Answer: C Rationale: 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.

When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict a. intake of green, leafy vegetables. b. the amount of high-fat foods. c. ingestion of dairy products. d. the quantity of fruits and juices.

Correct Answer: C Rationale: 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.

A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. metoprolol (Lopressor) 12.5 mg orally daily. b. lantus insulin 24 U subcutaneously q-evening. c. oral digoxin (Lanoxin) 0.25 mg daily. d. ibuprofen (Motrin) 400 mg every 6 hours.

Correct Answer: C Rationale: 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 there is not as much concern with the potassium level.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. confusion. b. restlessness. c. edema. d. pallor.

Correct Answer: C Rationale: 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 recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. rapid and unexpected weight loss. b. increased total urinary output. c. decreased serum sodium level. d. elevation of serum hematocrit.

Correct Answer: C Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information that a. to give adequate doses of IV insulin, a centrally located IV catheter is needed. b. blood glucose testing is more accurate when samples are obtained from a central line. c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose. d. the 50% dextrose is less likely to produce infection when given through a PICC line.

Correct Answer: C Rationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. 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.

A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The laboratory data that will be of most concern to the nurse is 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. HPO4- 3 4.8 mg/dl (1.55 mmol/L).

Correct Answer: C Rationale: 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 the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. respiratory acidosis. b. respiratory alkalosis. c. metabolic acidosis. d. metabolic alkalosis.

Correct Answer: C Rationale: The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of 100/60, pulse 62, and respirations 10. The nurse notes that the patient has been taking an aluminum hydroxide/magnesium hydroxide suspension (Maalox) for indigestion. The nurse anticipates that management of the patient will include IV administration of a. magnesium sulfate. b. potassium chloride. c. calcium gluconate. d. sodium chloride.

Correct Answer: C Rationale: The patient has a history and symptoms consistent with hypermagnesemia, so calcium gluconate or calcium chloride will be the initial therapy to oppose the effects of excess magnesium on cell function. Magnesium sulfate infusion is contraindicated because it will increase the serum magnesium level. Potassium chloride and sodium chloride will not impact the patient's symptoms and should be avoided in a patient with renal insufficiency.

Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is a a. weight gain of 2 pounds above the preoperative weight. b. an oral temperature of 100.1° F with bibasilar lung crackles. c. gradually decreasing level of consciousness (LOC). d. serum sodium level of 138 mEq/L (138 mmol/L).

Correct Answer: C Rationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.

A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bedrest to prevent pathologic fractures. b. monitoring for Trousseau's and Chvostek's signs. c. encouraging fluid intake up to 4000 ml every day. d. auscultate breath sounds every 4 hours.

Correct Answer: C Rationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to 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 breath sounds, although these would be assessed every shift.

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. when the patient feels thirsty. b. in the late evening hours. c. as soon as changes in LOC occur. d. if the oral mucosa feels dry.

Correct Answer: D Rationale: An alert elderly 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 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 LOC occur.

When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. d. daily weight.

Correct Answer: D Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age; considerable fluid-volume excess may be present before fluid moves into the interstitial space and causes edema; and 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.

The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level will ask the patient about a. intake of dietary protein. b. use of OTC laxatives. c. multivitamin/mineral use. d. daily alcohol intake.

Correct Answer: D Rationale: 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 multivitamins mineral supplements would tend to increase magnesium level.

To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is a. weak hand grips. b. confusion. c. constipation. d. lip numbness.

Correct Answer: D Rationale: Numbness and tingling around the lips or in the fingers are early signs of hypocalcemia. Muscle weakness, confusion, and constipation may also occur, but these are later signs of low calcium levels.

ntravenous potassium chloride (KCl) 40 mEq is ordered for treatment of a patient with hypokalemia. In administering the potassium solution, the nurse is aware that a. the KCl should be administered as an IV bolus so that the hypokalemia will be corrected before complications occur. b. the amount of KCl added to IV fluids should not exceed 20 mEq/L to prevent hyperkalemia from developing. c. the KCl should be given only through central lines to avoid venospasm and inflammation at the IV insertion site. d. to reduce the risk for cardiac dysrhythmia, the maximum amount of KCl to be administered in 1 hour is 20 mEq.

Correct Answer: D Rationale: Rapid IV administration of KCl can cause cardiac arrest; KCl is administered at a maximal rate of 20 mEq/hr. Bolus administration of KCl is contraindicated. The rate of administration, not the amount of KCl added to IV fluids, is important. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement? a. Disconnect the nasogastric tube until the pH is within the normal range. b. Administer the prescribed sodium bicarbonate 50 mEq intravenously. c. Teach the patient about the importance of taking slow, deep breaths. d. Give the patient the ordered morphine sulfate 4 mg intravenously.

Correct Answer: D Rationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

Correct Answer: D Rationale: 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.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. elevated serum potassium level. b. decreased thyroid hormone level. c. bleeding on the patient's dressing. d. the presence of Chvostek's sign.

Correct Answer: D Rationale: 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.

A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial oxygen saturation 91% b. Serum potassium is 5.1 mEq/L c. Arterial blood pH is 7.32 d. Serum calcium is 18 mEq/L

Correct Answer: D Rationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) 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 do not indicate the need for immediate intervention.

A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment, the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate? a. Document findings and notify the physician. b. Stop suction and request that the laboratory draw arterial blood gases. c. Prepare to administer lorazepam (Ativan). d. Raise the siderails and notify the physician.

D

A client has severe metabolic alkalosis. Which nursing diagnosis does the nurse choose as the client's priority problem? a. Fluid volume excess related to reduced kidney function b. Fluid volume deficit related to increased insensitive fluid loss through lungs c. Risk for impaired skin integrity related to accompanying peripheral edema d. Risk for injury related to increased neuronal sensitivity from hypocalcemia

D

Before the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care provider's orders? a. Intravenous catheter size b. Osmolarity of the solution c. Vein to be used for therapy d. Specific type of IV fluid

D

Five days after the start of intraperitoneal therapy, the client reports abdominal pain and "feeling warm." The nurse prepares to assess the client further for evidence of which condition? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

D

In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority? a. Applying continuous heat b. Continuing to monitor site c. Elevating the extremity d. Removing the catheter

D

The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis? a. Allergic rhinitis and sinusitis on sulfa antibiotics b. Type 1 diabetes and urinary tract infection c. Emphysema and undergoing nasogastric (NG) tube suctioning d. On patient-controlled analgesia after abdominal surgery

D

The nurse expects to find renal compensation for an acid-base imbalance in which situation? a. Mild to moderate dehydration in a middle-aged client who jogged for 2 hours b. Acute asthma attack with wheezing of 6 hours' duration in an older man c. Food poisoning with vomiting for 12 hours in a middle-aged woman d. Hypoxemia for 4 days from pneumonia in an adult woman

D

The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Checking for heparin in infusion container d. Presence of an ulnar pulse

D

The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess first? a. Client with a newly inserted peripherally inserted central catheter (PICC) line waiting for x-ray b. Client with a peripheral catheter for intermittent infusions c. Older adult client with a nonaccessed implanted port d. Older adult client with normal saline infusion

D

The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for hypertension? a. Acid excess secondary to respiratory acidosis b. Acid deficit secondary to respiratory alkalosis c. Acid excess secondary to metabolic acidosis d. Acid deficit secondary to metabolic alkalosis

D

When a client has an arterial blood pH of 7.48, which buffer action will bring the pH back to normal? a. Absorption of bicarbonate ions from the blood b. Release of bicarbonate ions into the blood c. Absorption of hydrogen ions from the blood d. Release of hydrogen ions into the blood

D

When assessing a client's peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter. d. Stop the infusion of IV fluids.

D

Which IV order does the nurse question? a. Flush Groshong catheter with 10 mL normal saline every 8 hours. b. Infuse 20 mEq potassium chloride in 1000 mL D5W at 50 mL/hr. c. Infuse 500 mL normal saline over 1 hour. d. Infuse 0.9% normal saline at keep vein open (KVO) rate.

D

Which assessment finding for a client with a peripherally inserted central catheter (PICC) line requires immediate attention? a. Initial dressing over site is 3 days old. b. Line has been in for 4 weeks. c. A securement device is absent. d. Upper extremity swelling is noted.

D

Which client is the best candidate to receive hypodermoclysis for IV therapy? a. Client requiring 4000 mL normal saline in 24 hours b. Client with an extensive burn injury c. Client with allergy to hyaluronidase d. Client receiving pain management

D

Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance? a. "I am often cold and need to wear a sweater." b. "I seem to urinate more when I drink coffee." c. "In the summer, I feel thirsty more often." d. "My rings seem to be tighter this week."

D A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance.

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. Chinese take-out, including steamed rice b. A grilled cheese sandwich with tomato soup c. Slices of ham and cheese on whole grain crackers d. A chicken leg, one slice of bread with butter, and steamed carrots

D Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The Chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food—a category of foods often high in sodium.

Which client is at greatest risk for dehydration? a. Younger adult client on bedrest b. Older adult client receiving hypotonic IV fluid c. Younger adult client receiving hypertonic IV fluid d. Older adult client with cognitive impairment

D Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. Notify the physician. b. Assess for a blood return. c. Document the finding. d. Stop the IV infusion.

D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy? a. Tenting of skin on the back of the hand b. Increased urine osmolarity c. Weight loss of 10 pounds d. Pulse rate of 115 beats/min

D Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with dehydration, oxygen therapy is indicated.

A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L. Which intervention by the nurse is most appropriate? a. Prepare to administer IV potassium chloride. b. Ask the lab to redraw and rerun the tests. c. Document findings and continue to assess. d. Prepare to administer aluminum hydroxide.

D The client's calcium is low. Treatment for hypocalcemia includes calcium replacement, administering drugs that increase calcium absorption, and giving medications to control bothersome neuromuscular effects. Aluminum hydroxide helps the body absorb calcium. The client's potassium is normal, so giving potassium is not warranted. Asking the laboratory to rerun the tests will not help the client's problem, although if this seems contradictory to the client's condition, it might be an option. Documenting findings and performing ongoing assessments will not help the client's problem.

Which client is at greatest risk for developing hypercalcemia? a. Client taking furosemide (Lasix) for heart failure b. Client with long-standing osteoarthritis c. Woman who is pregnant with twins d. Client with hyperparathyroidism

D The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing calcium resorption from the bones. All these actions increase the serum calcium level.