N120 Ch 16: (Evolve)

You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W? __________

800 pm Divide the 500 mL left in the IV bag by the hourly rate of 125 mL to calculate that the present solution will remain infusing for another 4 hours. If you made this notation at 4:00 PM, the bag is due to be changed at 8:00 PM.

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? A. 3.1 mEq/L B. 3.9 mEq/L C. 4.6 mEq/L D. 5.3 mEq/L

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

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? A. Administer oxygen B. Notify the health care provider C. Rapidly administer more IV fluid D. Reposition the patient on the right side

A. Administer oxygen The cap off the central line could allow entry of air into the circulation, causing an air embolus. To manage an air embolus, oxygen is administered; the catheter is clamped, and the patient is positioned on the left side with the head down. Then the health care provider is notified.

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? A. D5W B. 0.9% saline C. Packed red blood cells D. Lactated Ringer's solution

A. D5W IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)? A. Lung sounds B. Bowel sounds C. Blood pressure D. Serum sodium level E. Serum potassium level

A. Lung sounds C. Blood pressure D. Serum sodium level Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

A patient is admitted with metabolic acidosis. Which system is not functioning normally? A. Renal system B. Buffer system C. Endocrine system D. Respiratory system

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

You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? A. The potassium level may be increased if the patient has nephropathy. B. The patient has been eating excessive amounts of foods that increase potassium levels. C. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A. The potassium level may be increased if the patient has nephropathy. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an nasogastric tube and not be eating.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? A. Weakness B. Paresthesia C. Facial spasms D. Muscle tremors E. Depressed reflexes

A. Weakness E. Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

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

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

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? A. Antibiotics B. Loop diuretics C. Bronchodilators D. Antihypertensives

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

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

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

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

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

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? A. Have patient restrict fluid intake to less than 2000 mL/day. B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake to 3000 to 4000 mL. E. Any heartburn can be managed with an as needed calcium-containing antacid.

B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake to 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is A. malted milk. B. orange juice. C. tomato juice. D. hot chocolate.

B. orange juice. Orange juice would be the safest option because it has the least amount of sodium (~2 mg in 8 oz). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 oz. Malted milk has approximately 625 mg sodium in 8 oz.

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

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

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is A. 500 to 1500 mL. B. 1200 to 2200 mL. C. 2000 to 3000 mL. D. 3000 to 4000 mL.

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

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? A. Change the injection cap after the administration of IV medications. B. Use a 5-mL syringe to flush the catheter between medications and after use. C. During removal of the catheter, have the patient perform the Valsalva maneuver. D. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

C. During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? A. Slow the rate to keep vein open until next bag is due at noon. B. Notify the health care provider and complete an incident report. C. Listen to the patient's lung sounds and assess respiratory status. D. Asses the patient's cardiovascular status by checking pulse and blood pressure.

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

Which nursing intervention is most appropriate when caring for a patient with dehydration? A. Monitor skin turgor every shift. B. Auscultate lung sounds every 2 hours. C. Monitor daily weight and intake and output. D. Encourage the patient to reduce sodium intake.

C. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? A. Polyuria B. Bradycardia C. Restlessness D. Difficulty breathing

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

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? A. Limit foods high in potassium B. Calcium gluconate IV piggyback C. Spironolactone (Aldactone) daily D. Administer intravenous insulin and glucose

C. Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

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

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

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A. A patient with a traumatic brain injury B. A patient with type 1 diabetes mellitus C. A patient with acute respiratory failure D. A patient with nasogastric tube suction

D. A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

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

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

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

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

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

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