N2209 ##1

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For what other manifestation of hypocalcemia would you want to observe in the patient who is post-op thyroidectomy? A.Dry, rough skin. B.Bradycardia, dysrhythmias. C.Decreased urine output. D.Diarrhea.

B. Bradycardia, dysrhytmias calcium is involved in muscle contractility, a decrease will produce cardiac irregularities.

What is the result of hypoosmolar state? A.Cells shrink. B.Cells swell. C.Cell membrane is destroyed. D.Catabolism of cell protein.

B. Cells swell With the low sodium, water leaves the ECF and moves into the cell.

Which of the following individuals would be most likely to have the highest percentage of body weight as water? A. Elderly male B. Infant C. 50-year old obese female D. 45-year old athletic male

B. Infant Infants have the highest percentage (70-80%) of body weight as water. The elderly and obese individuals have a decreased percentage of body water. An athletic male would equal about 60-80% body water.

The nurse inserts a nasogastric tube and it immediately drains 1000 mL of fluid. Which of the following electrolyte levels is of greatest concern at this time? A. Sodium B. Potassium C. Chloride D. Carbon dioxide

B. Potassium Hypokalemia is almost universal complication of loss of gastric hydrochloric acid. Metabolic alkalosis results. Other electrolytes may be affected, but not to the degree of potassium homeostasis is altered.

Your patient has an elevated serum sodium level. Your assessment is likely to reveal: A.muscle twitching B.confusion C.polyuria D.elevated temperature

B. confusion The cells shrink, and the brain is a primary area for symptoms.

A patient with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this patient could possibly have which of the following electrolyte imbalances? A. hypokalemia B. hypernatremia C. carbon dioxide D. magnesium

B. hypernatremia The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.

A patient is admitted with burns over 50% of his body. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances? A. hypercalcemia B. hypophosphatemia C. hypernatremia D. hypermagnesemia

B. hypophosphatemia Causes of hypophosphatemia include stress responses and extensive burns.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which appropriate action in the care of this client? 1.Obtain a court order for the surgery 2.Send the client to surgery without the consent form being signed. 3.Have the hospital chaplain sign the consent form. 4.Obtain a telephone consent from a family member, following agency policy"

Correct Answer: 4 Rationale: Every effort should be made to obtain consent from a responsible family member to perform the surgery if a client is unable to sign the consent form."

A nurse is conducting preoperative teaching with a client about the use of incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and mouth piece. C. After maximum inspiration, hold teh breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees.

D is correct, must be in high fowler's position for optimal lung expansion. The mouthpiece should be covered tightly and breath holds for 5 seconds.

The nurse should observe for a Trousseau sign in the client with which of the following electrolyte abnormalities? A. Hypokalemia B. Hyponatremia C. Hypochloremia D. Hypocalcemia

D. Hypocalcemia Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of this is seen in the Trousseau sign, a carpopedal spasm.

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

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

What drug will you want to be sure is available on the nursing unit for your post-op patient who has had a thyroidectomy? A.Benadryl B.Epinephrine C.sodium bicarbonate D.calcium gluconate

D. calcium gluconate If there has been injury to the parathyroid gland, the serum calcium will drop. Calcium gluconate would be given intravenously.

A 28-year-old male patient is admitted with diabetic ketoacidosis. The nurse realizes that this patient will have a need for which of the following electrolytes? A. sodium B. potassium C. calcium D. magnesium

D. magnesium One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis.

Which of the following is a factor which influences serum calcium levels? A.vitamin K B.sodium C.potassium D.parathyroid hormone

D. parathyroid hormone he parathyroid hormone regulates calcium and phosphorus.

A nurse plans to assess the skin turgor of a young adult client. In which location should the nurse assess the skin turgor of this client? 1. forehead 2. sternum 3. stomach 4. thigh

How should a nurse include a client's wound drainage when calculating intake and output? 1. Add the total amount to the client's intake. 2. Subtract the amount from the total output. 3. Add the amount to the total output. 4. Subtract the amount from the oral intake.

The patient has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this patient? Select all that apply. A. IV normal saline B. calcium containing antacids C. IV potassium phosphate D. encouraging milk intake E. increasing vitamin D intake

A, B. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate.

Which of the following activities can you delegate to nursing assistive personnel? (select all that apply) A. Measuring oral intake and urine output B. Preparing intravenous (IV) tubing for routine change C. Reporting an IV container that is low in fluid D. Changing an IV fluid container

A, C. The registered nurse cannot delegate working with IV tubing or changing an IV infusion to NAP.

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

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

When analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? A. The kidneys retain bicarbonate. B. The kidneys excrete bicarbonate. C. The lungs will retain carbon dioxide. D. The lungs will excrete carbon dioxide.

A. The kidneys retain bicarbonate. The kidneys will compensate for a respiratory disorder by retaining bicarbonate.

When assessing a client for hypovolemic hypernatremia, the nurse would expect to find: A. Thirst B. Serum sodium level of 135 mEq/L C. Moist mucous membranes D. Hypoactive reflexes

A. Thirst

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which of the following might have contributed to the patient's health problem? A. corticosteroid B. thiazide diuretic C. narcotic D. muscle relaxer

A. corticosteroid Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting diuretics, amphotericin B, and large doses of some antibiotics.

A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need which of the following precautions implemented? A. seizure B. infection C. neutropenic D. high-risk fall

A. seizure Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included.

During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia? a. vitamin A b. vitamin D c. vitamin E d. vitamin K

Answer D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.

Which of the following characteristics is consistent with fluid volume deficit? A. A 1 lb weight loss, pale yellow urine B. Engorged neck veins when upright, bradycardia C. Dry mucous membranes, thready pulse, tachycardia D. Bounding radial pulse, flat neck veins when supine

C. Dry mucous membranes, thready pulse, tachycardia The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow urine rather than pale yellow, which is normal.

To aid in control of potassium, which hormone is essential? A.aldosterone B.ADH C.Thyroxine D.Pitocin

aldosterone Aldosterone promotes K+ loss or gain depending on the serum level of K+.

"While completing the preoperative assessment, the male client tells the nurse that he is allergic to codeine. Which intervention should the nurse implement ﬁrst? 1.Apply an allergy bracelet on the client's wrist. 2.Label the client's allergies on the front of the chart. 3.Ask the client what happens when he takes the drug. 4.Document the allergy on the medication administration record

"1. This is an important step for the nurse to implement, but it is not the ﬁrst intervention. 2.This must be done, but it is not the ﬁrst intervention. CORRECT 3. The nurse should ﬁrst assess the events that occurred when the client took this medication because many clients think that a side effect, such as nausea, is an allergic reaction. 4.This information must be put on the medication administration record (MAR), but it is not the ﬁrst intervention"

"When preparing a client for surgery, which intervention should the nurse implement ﬁrst? "1.Check the permit for the spouse's signature. 2.Take and document intake and output. 3.Administer the "on call" sedative. 4.Complete the preoperative checklist."

"Correct answer: 4 Rationale: 1. The client's signature, not the spouse's, shouldbe on the surgical permit. 2.This would be information that would be im-portant if abnormal, but it is not the ﬁrst inter- vention. 3."On call" sedations should be administeredafter the surgical checklist is completed. 4.Completing the preoperative checklist hasthe highest priority to ensure that all detailsare completed without omissions"

"A patient who is dependent on barbiturates is scheduled for surgery following an automobile accident. The nurse recognizes that this patient "a. may need less pain medication during the postoperative period. b. should be provided with taper doses of barbiturates following surgery. c. may have an immediate onset of withdrawal symptoms when given anesthetic and analgesic agents. d. has a low risk for physical withdrawal symptoms but is likely to experience craving and drug-seeking behavior during the post-operative period."

"answer: b Rationale: withdrawal from sedative hypnotics can be very serious.After 24 hours, the patient may experience delirium, seizures, and respiratory and cardiac arrest, and withdrawal from high doses requires close monitoring in an inpatient setting. Long-acting agents such as diazepam (Valium), chlordiazepoxide (Librium), clonazepam (Klonopin), or phenobarbital may be substituted for the abused drug and gradually tapered after stabilization. Mild to moderate symptoms can persist for 2 to 3 weeks after a 3- to 5-day period of acute symptoms."

"A nurse is developing a POC for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before going into surgery 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Report immediately any slight increase in blood pressure or pulse."

. Have the client void immediately before going into surgery The nurse would assist client to void immediately before surgery so that the bladder will be empty. A slight increase in blood pressure and pulse is common during the preoperative period and usually the result of anxiety. The client usually has a restriction of food and fluids for 6-8 hours before surgery instead of 24.

A client is admitted to the emergency department with a closed head injury and multiple fractures. Which IV solution should a nurse plan to administer? 1. 0.9 % saline solution 2. 0.25 % saline solution 3.0.5 % saline solution 4. Dextrose 5% in water

A client presents to an urgent care center after a reported 3-day history of nausea, vomiting, and diarrhea. A nurse suspects this client is severely dehydrated. Which info is most important for the nurse to obtain when assessing the client? 1. Vital signs 2. Skin turgor 3. Thirst level 4. BUN and creatinine

How should a nurse who is calculating a client's intake and output include the irrigating fluid of the client's continuous bladder irrigation? 1. Add the amount to the total intake. 2. Deduct the amount from the urine output. 3. Subtract the amount from the IV intake. 4. Record the amount in the urine output.

When teaching a client who is breastfeeding a newborn, which instruction should a nurse provide to a new mother to reduce the newborn's risk of developing FVD? 1. Maintain an adequate fluid intake. 2. Limit breastfeeding to every 4 hours. 3. Decrease caloric intake to promote weight loss. 4. Feed from both breasts during each feeding.

A nurse who is assessing intake and output for a client with severe burns notes that the client's intake is 2000 mL greater than output. Which rationales should the nurse associate with this discrepancy? Select all that apply. 1. The client is experiencing vasoconstriction. 2. The client is experiencing increased insensible output. 3. The client has been incontinent of urine and stool. 4. The client has been dangerously overhydrated. 5. The client is experiencing third spacing.

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Which manifestations should a nurse associate with the development of FVD in a client receiving diuretic therapy? Select all that apply. 1. dry oral mucosa 2. hypertension 3. hypotension 4. jugular venous distention 5. tachycardia with peripheral pulses 3+ bilaterally

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A nurse caring for a client who is hypovolemic anticipates orders from a health care provider for IV fluid replacement therapy. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply. 1. Normal saline solution 2. dextrose 5% in water 3. dextrose 5% in normal saline solution 4. 0.45 saline solution 5. 3% sodium chloride solution 6. lactated ringer's solution

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The nurse requests a client to sign the surgical consent form for an emergency appendectomy. Which statement by the client indicates that further teaching is needed? 1. "I will be glad when this is over so that I can go home." 2."I will not be able to eat or drink anything prior to my surgery." 3."I need to practice relaxing by listening to my favorite music." 4."I will need to get up and walk as soon as possible."

1. "I will be glad when this is over so that I can go home" 1. When recuperating from emergency surgery, the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching. 2.Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and after anesthesia. 3.Listening to music and other relaxing techniques can be used to alleviate anxiety and pain. 4.Clients are encouraged to get out of bed as soon as possible and progress until a return to daily activity is achieved.

A 46-year-old woman with a subclavian triple-lumen catheter is transferred from a critical care unit after an extended stay for respiratory failure. Which action is important for the nurse to take? 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.

The nurse assesses a patient's weight loss as being 22 lbs. How many liters of fluid did this patient lose?

10. Each liter of body fluid weighs 1 kg or 2.2 lbs. This patient has lost 10 liters of fluid.

A client diagnosed with liver failure presents to an acute care facility with moderate ascites and reports shortness of breath. Vital signs are as follows: b/p 90/50, heart rate 104 and weak, and respiratory rate, 26 and shallow. The clients skin and mucous membranes are dry. Based on this info, which nursing diagnosis should be the priority? 1. Excess Fluid Volume Related to Third Spacing Fluid Shifts Secondary to Liver Failure 2. deficient fluid volume related to third spacing fluid shifts secondary to liver failure 3.risk for decreased cardiac output related to decreased plasma volume and electrolyte deficits secondary to liver failure 4.risk for shock related to decreased plasma volume secondary to liver failure

A regnant client with hyperemesis gravidarum has had continuous nausea and vomiting for 3 days. IV fluid replacement is planned. A nurse should anticipate orders from the client's obstetrician for which type of IV solution? 1. hypertonic 2. isotonic 3. hypotonic 4. atonic

Which intervention should a nurse include in the plan of care for a client diagnosed with FVD? 1. Offer fluids with meals 2.monitor for an increase in temp 3.administer diuretics as ordered 4.monitor for crackles and orthopnea

Which order given for a client with a closed head injury, multiple fractures, and blood loss should a nurse question? 1. neurological checks every hour 2. vital signs every 4 hours 3. IV normal saline at 150 mL/hr 4. strict intake and output measurement

Which urine output value in an adult client should a nurse associate with the development of FVD? 1. 500 mL/DAY or 20 mL/hr 2. 700, 29 3. 1680, 70 4. 2400, 100

which clinical manifestation should a nurse associate with effective IV fluid replacement therapy for a client diagnosed with FVD? 1. jugular venous distention 2. urine output of 50 mL/hr 3. BP of 90/60 4. T 99.9

A nurse is evaluating IV fluid administration orders for a client with FVD secondary to vomiting. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply. 1. 0.45% saline solution 2. 0.9% saline solution 3. Lactated Ringer's solution 4. Dextrose 5% in normal saline solution 5. Dextrose 5% in lactated Ringer's solution 6. Albumin

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A nurse is caring for a client diagnosed with FVD secondary to DKA who is experiencing nausea, vomiting, and abdominal pain. A health care provider orders NPO status for the client to decrease nausea and vomiting and then starts to write orders for IV fluid replacement therapy. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply. 1. normal saline solution 2. Dextrose 5% in water 3. Dextrose 5% in normal saline solution 4. 0.45% saline solution 5. 3% sodium chloride solution 6. lactated ringer's solution

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The nurse has just finished explaining the necessity of coughing and deep breathing following surgery to a perioperative client. Which of the following responses by the client would indicate his understanding and acceptance of what he has been taught? " 1. ""I thought that spirometry thing was supposed to do the job."" 2. ""When I do the coughing and deep breathing, I reduce my chances of getting pneumonia."" 3. ""It really hurts too much to do that. Deep breathing and coughing are impossible."" 4. ""I guess I'll try to remember to take a couple of deep breaths once and a while.""

2. ""When I do the coughing and deep breathing, I reduce my chances of getting pneumonia. Rationale: Deep-breathing exercises are encouraged. These exercises help remove mucus, which can form and remain in the lungs due to the effects of general anesthetic and analgesics. Deep breathing increases lung expansion and prevents the accumulation of secretions. It helps prevent pneumonia and atelectasis, which may result from stagnation of fluid in the lungs.

A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld? 1) Ferrous sulfate. 2) Prednisone (Deltasone) . 3) Cyclobenzaprine (Flexeril) 4) Conjugated estrogen (Premarin).

2: Prednisone (Deltasone)Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withtand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated strogen is used for hormone replacement therapy in postmenopausal women. These three meds can be withheld before surgery without consequences.

A nurse is a teaching a client to evaluate fluid status by weight. Which is the appropriate instruction to provide this client? 1. Weigh yourself twice a day wearing the same amount of clothing. 2. Weigh yourself 1 hour before meals and before urinating. 3. Weigh yourself at the same time every morning and after urinating. 4. Weigh yourself after breakfast using the same scale.

A nurse receives a phone call from the parent of an infant who is listless and has had vomiting and diarrhea for 2 days. Which is the most appropriate instruction for the nurse to give the parent? 1. Give the infant 2-4 ox of oral electrolyte replacement solution every 1-2 hours. 2. Monitor the infant's urine output for 24 hours. 3. Bring the infant to the pediatrician or emergency department. 4. Withhold all oral intake until vomiting has resolved.

An older adult client presents at a health-care probider's office and reports dizziness and "heart racing" while gardening outdoors. Which question should the nurse include in the initial assessment of this client? 1. "Are you wearing sunscreen when you garden?" 2."Have you noticed an increase in thirst when you garden?" 3."What time of day do you garden, and for how long?" 4."Do you have a plan in place if you pass out while gardening?"

A nurse who is planning care for a client with severe FVD and hyponatremia should anticipate an order for the infusion of which IV solution? 1. 0.45% saline solution 2. 0.25% saline solution 3. 0.9% saline solution 4. 3% saline solution

For which potential complication should a nurse monitor in a client receiving IV hypotonic saline solution? 1. decreased ECF 2. hypernatremia 3. increased urine output 4. mental status changes

Which client info should a nurse associate with a nursing diagnosis of Deficient Fluid Volume Secondary to Dehydration? 1. Decreased pulse rate 2.decreased hemoglobin level and hematocrit 3. jugular venous destention 4.BP 96/54 mm Hg

Which intervention should a nurse include when planning care for a confused client with FVD? 1. Explain to the client the rationale for increasing the fluid intake. 2. Ensure that the certified nursing assistant maintains fresh ice water at the client's bedside at all times. 3. Provide fluids at the client's bedside, at the desired temperature, at all times. 4. Assist the client in drinking fluids every hour.

Which vital sign readings should a nurse associate with the development of FVD? 1. BP 140/70, P 96, RR 24 2.BP 110/80, P 84, RR 24 3. BP 100/70, P 60, RR 20 4. BP 80/60, P 110, RR 24

The typical fluid replacement for the patient with a fluid volume deficit is A. Dextran B. 0.45% saline C. Lactated Ringer's D. 5% dextrose in 0.45% saline

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

The client just had surgery to create an ileostomy. the nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. folate deficiency 2. malabsorption of fat 3. intestinal obstruction 4. fluid and electrolyte imbalance

4. fluid and electrolyte imbalance a frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. the client requires constant monitoring of intake and output to prevent this from occurring. losses require replacement by IV infusion until the client can tolerate a diet orally. intestinal obstruction is a less common complication. fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

"Which of the laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL 2. Bleeding time 2min 3. Hemoglobin 15 g/dL 4. Potassium 2.4 mEq/L

4: Potassium 2.4 mEq/L "1. This laboratory value is within normal limits 2. This laboratory value is within normal limits 3. This laboratory value is within normal limits 4. This potassium levels is low and should be reported to the health care provider because potassium is important for muscle function, including the cardiac muscle"

The patient has been placed on a 1200 mL daily fluid restriction. The patient's IV is infusing at a keep open rate of 10 mL/hr. The patient has no additional IV medications. How much fluid should the patient be allowed from 0700 until 1500 daily?

540 mL. Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case 1200 mL - 240 mL = 960mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening shift, and the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.

A 35-year-old female patient comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this patient? A. Drink one glass of red wine per day. B. Avoid the sun. C. Milk and milk-based products will ensure an adequate calcium intake. D. Red meat is the protein source of choice.

C. Milk and milk-based products will ensure an adequate calcium intake. This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products.

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating: A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." B. "Most older adults get confused in the hospital." C. "The sodium level is low, and the confusion will resolve as the levels normalize." D. "The sodium level is high and the behavior is a result of dehydration."

C. Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize.

The nurse evaluates which of the following clients to have hypermagnesemia? A. A client who has chronic alcoholism and a magnesium level of 0.3 mEq/L B. A client who has hyperthyroidism and a magnesium level of 0.6 mEq/L C. A client who has renal failure, takes antacids, and has a magnesium level of 4.9 mEq/L D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L

C. Normal serum magnesium is 0.8 - 4 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain B. Depressed deep tendon reflexes C. Positive Chvostek's sign D. Nausea

C. Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.

A patient is prescribed spironolactone (Aldactone) for treatment of hypertension. Which foods should the nurse teach the patient to avoid? A. Baked fish B. Low-fat milk C. Salt substitutes D. Green beans

C. Salt subsitutes

What is the normal serum calcium level? A.2.5-3.5 mEq/L B.3.5-4.5 mEq/L C.4.5-5.5 mEq/L D.5.5-6.6 mEq/L

C. The normal serum calcium level is 4.5 - 5.5 mEq/L.

Which patients are at risk for the development of hypercalcemia? Select all that apply. A. the patient with a malignancy B. the patient taking lithium C. the patient who uses sunscreen to excess D. the patient with hyperparathyroidism E. the patient who overuses antacids

A, B, D, E. Patients with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy. Lithium and overuse of antacids can result in hypercalcemia. Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines and retention of calcium by the kidneys. Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines and retention of calcium by the kidneys. Lithium and overuse of antacids can result in hypercalcemia.

An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply) A. Weight loss B. Dry oral mucosa C. Full bounding pulse D. Engorged neck veins E. Decreased central venous pressure

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

The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient? Select all that apply. A. bananas B. seafood C. white rice D. lean red meat E. chocolate

A, B, E. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, and chocolate. White rice & lean red meat are not included.

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

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

The nurse is reviewing a patient's blood pH level. Which of the systems in the body regulate blood pH? Select all that apply. A. renal B. cardiac C. buffers D. respiratory

A, C, D. Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, and the renal system.

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

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

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy? (select all that apply) A. Confusion B. Weight gain C. Depressed reflexes D. Circumoral numbness E. Positive Chvostek's sign

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

"A pre-operative nurse prepares a client for surgery, which nursing interventions should be included in the plan of care? Mark all that apply." a. Maintain NPO status to prevent aspiration. b. Verify the client's signature on the consent prior to surgery. c. Remove dentures and contact lenses prior to surgery. d. Check the client's allergy and blood bands for accuracy. e. Verify the client's mobility in all extremities prior to surgery."

A,B,C,D Rationale: A. Maintaining nothing by mouth prevents the client from aspirating food particles into the lungs during and after surgery. B. Because of legal requirements, the surgical consent must be signed prior to surgery to verify the client's acknowledgement of the content on the consent. C. Dentures, hairpins, glasses, and contacts may interfere with client safety, or compromise the sterile field. D. Allergy, blood, and identification bands should all be checked prior to surgery to prevent medication errors, blood bank errors, and to facilitate proper identification of the client. E. Verifying the client's mobility in all extremities prior to surgery is part of the physical assessment, but not a necessary action prior to surgery.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50 year-old with pneumonia, diaphoresis, and high fevers B. 62-year old with congestive heart failure taking loop diuretics C. 39-year old with diarrhea and vomiting D. 60-year old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

A. 50 year-old with pneumonia, diaphoresis, and high fevers Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50-year-old with pneumonia, diaphoresis, and high fevers B. 62-year-old with congestive heart failure taking loop diuretics C. 39-year-old with diarrhea and vomiting D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone

A. 50-year-old with pneumonia, diaphoresis, and high fevers (Correct Answer) Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

A patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient's primary health care provider with which of the following 24-hour urine output volumes? A. 600 mL B. 750 mL C. 1000 mL D. 1200 mL

A. 600 mL A urine output of less than 30 mL per hour must be reported to the primary health care provider. This indicates inadequate renal perfusion, placing the patient at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? A. Absent patellar reflex B. Diarrhea C. Premature ventricular contractions D. Increase in blood pressure

A. Absent patellar reflex An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.

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

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

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A. Auscultate dependent portions of lungs B. Check color of urine C. Assess muscle strength D. Check skin turgor over sternum or shin

A. Auscultate dependent portions of the lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults.

A patient who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this patient? A. Digoxin toxicity may occur. B. A higher dose of digoxin may be needed. C. A diuretic may be needed. D. Fluid volume deficit may occur.

A. Digoxin toxicity may occur. Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for A. edema B. Pallor C. Confusion D. Restlessness

A. Edema 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.

The nursing care for a patient with hyponatremia includes A. Fluid restriction. B. Administration of hypotonic IV fluids. C. Administration of a cation-exchange resin. D. Increased water intake for patients on nasogastric suction.

A. Fluid restriction. In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.

The phenomenon of third-space fluid shifting involves: A. Fluid shifts into body cavities other than ICF and ECF where the fluid is not available for exchange with plasma volume. B. The three types of fluid volume deficits. C. Fluid shifts into the extracellular fluid. D. Fluid shifts into the lymphatic system.

A. Fluid shifts into body cavities other than ICF and ECF where the fluid is not available for exchange with plasma volume.

The nurse is planning care for a patient with severe burns. Which of the following is this patient at risk for developing? A. Intracellular fluid deficit B. Intracellular fluid overload C. Extracellular fluid deficit D. Interstitial fluid deficit

A. Intracellular fluid deficit Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.

A patient has a serum potassium level of 3.1 mEq/L. It is appropriate for the nurse to take which action? A. Administer sustained-release potassium tablets (K-Dur). B. Offer food and fluids that are low in potassium. C. Prepare an intravenous dose of furosemide (Lasix). D. Give a dose of sodium polystyrene sulfonate (Kayexalate)

A. K-dur is a drug used to treat low potassium

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is A. Osmosis B. Diffusion C. Active transport D. Facilitated Diffusion

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

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A. Provide passive ROM exercises and encourage fluid intake B. Teach the client to increase intake of whole grains and nuts C. Place a tracheostomy tray at the bedside D. Administer calcium gluconate IM as ordered

A. Provide passive ROM exercises and encourage fluid intake A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

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

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

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this patient's plan of care? A. Request a dietitian consult for selecting foods high in phosphorous. B. Provide aluminum hydroxide antacids as prescribed. C. Instruct pt to avoid poultry, peanuts, & seeds. D. Instruct to avoid the intake of sodium phosphate.

A. Request a dietician consult for selecting foods high in phosphorus. Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds and whole grains.

A pregnant patient is admitted with excessive thirst, increased urination, and has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnosis as most appropriate? A. Risk for Imbalanced Fluid Volume B. Excess Fluid Volume C. Imbalanced Nutrition D. Ineffective Tissue Perfusion

A. Risk for Imbalanced Fluid Volume The patient with excessive thirst, increased urination and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the patients excess volume loss that can increase the serum levels of sodium.

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

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

A patient experiencing multisystem fluid volume deficit has symptoms of tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following? A. The body's natural compensatory mechanisms B. Pharmacological effects of a diuretic C. Effects of rapidly infused intravenous fluids D. Cardiac failure

A. The body's natural compensatory mechanisms The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart.

The nurse is caring for a patient diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in patients with renal failure? A. The patient breathes rapidly to eliminate carbon dioxide. B. The patient will retain bicarbonate in excess of normal. C. The pH will decrease from the present value. D. The patient's oxygen saturation level will improve.

A. The patient breathes rapidly to eliminate carbon dioxide. In metabolic acidosis compensation is accomplished through increased ventilation or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis.

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

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

An elderly patient is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this patient to do? A. Wear support hose. B. Keep legs in a dependent position. C. Avoid wearing shoes while in the home. D. Try to sleep without extra pillows.

A. Wear support hose. The home care nurse should instruct this patient about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows.

A patient is diagnosed with hyperphosphatemia. The nurse realizes that this patient might also have an imbalance of which of the following electrolytes? A. calcium B. sodium C. potassium D. chloride

A. calcium Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves and muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, and the ionized serum calcium level falls.

You are caring for a client who has had a sub-total thyroidectomy. What assessment would you make to determine if there has been any trauma to the parathyroid gland? A.Check Chvostek's sign. B.Check capillary refill. C.Monitor urine output. D.Check for edema in the legs.

A. check Chvostek sign If the serum calcium is low, tapping in front of the ear along the facial nerve will cause muscle spasms and twitching of the face.

An elderly patient who is being medicated for pain had an episode of incontinence. The nurse realizes that this patient is at risk for developing A. dehydration. B. over-hydration. C. fecal incontinence. D. a stroke.

A. dehydration Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or who are confused, depressed, tube-fed, on bed rest, or taking medications (such as sedatives, tranquilizers, diuretics, and laxatives), are at greatest risk for fluid volume imbalance.

A patient is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? A. fluid volume excess B. fluid volume deficit C. seizure activity D. liver failure

A. fluid volume excess Antidiuretic hormone and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system.

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which of the following? A. hyperkalemia B. hypokalemia C. hypercalcemia D. hypocalcemia

A. hyperkalemia Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.

Your patient with severe burns is now one day post-injury. Without treatment, what problem is the patient apt to develop? A.hypokalemia B.hypernatremia C.hypoglycemia D.hypermagnesemia

A. hypokalemia Initially after a thermal burn, K+ will be high since the K+ moves out of the injured cells. However, after a few days, the K+ drops as the excess is eliminated by the kidneys and some begins to move back into cells.

An elderly patient with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia? A. hypotension, warmth, and sweating B. nausea and vomiting C. hyperreflexia D. excessive urination

A. hypotension, warmth, and sweating Elevations in magnesium levels are accompanied by hypotension, warmth, and sweating.

Your patient has hyponatremia with dehydration. What would you expect to find on assessment? A.Hypotension, dry mucous membranes, tachycardia B.Hypertension, edema, weight gain C.Hypotention, bradycardia, decreased skin turgor D.Tachycardia, hypertension, edema

A. hypotenstion, dry mucous membranes, tachycardia

The nurse teaches a patient who is taking furosemide (Lasix) about foods and beverages that should be consumed. Which dietary items, if selected by the patient, would indicate an understanding of the instructions? A. Oranges, spinach, and potatoes B. Baked fish, chicken, and cauliflower C. Tomato juice, skim milk, and cottage cheese D. Oatmeal, cabbage, and bran flakes

A. oranges, spinach, and potatoes Furosemide may have the adverse effect of hypokalemia. Hypokalemia can be reduced by consuming foods that are high in potassium, such as nuts, dried fruits, spinach, citrus fruits, potatoes, and bananas.

If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is A. osmosis B. diffusion C. active transport D. facilitated diffusion

A. osmosis

When caring for a patient diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the patient? A. other electrolyte disturbances B. hypertension C. visual disturbances D. drug toxicity

A. other electrolyte imbalances The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.

The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which of the following should be included in this patient's plan of care? A. restrict fluids. B. administer intravenous fluids. C. provide kayexalate. D. administer intravenous normal saline with furosemide.

A. restrict fluids. The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution.

What is the nurse's primary concern regarding fluid and electrolytes when caring for an elderly patient who is intermittently confused? A. risk of dehydration B. risk of kidney damage C. risk of stroke D. risk of bleeding

A. risk of dehydration As an adult ages, the thirst mechanism declines. Adding this in a pateint with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.

When there is a change in the potassium level it changes: A.the ability of cells to fire B.water balance C.ECF osmotic pressure D.hydrostatic pressure

A. the abilty of cells to fire (depolarize)

Which one of the following patients on your unit should be observed closely for indications of excessive loss of potassium? The patient who has: A.the flu with frequent, large amounts of emesis and diarrhea B.renal failure C.excessive intake of bananas D.intravenous potassium

A. the flu with frequent large amounts of emesis and diarrhea With massive vomiting and diarrhea, excessive amounts of K+ will be lost.

An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is A. weight loss B. full bounding pulse C. engorged neck veins D. Kussmaul respiration

A. weight loss

The nurse is aware that the client requires clarification of preoperative instructions when the client says: a. "It is OK to drink some juice in the morning." b. ""I should remove all jewelry before surgery. c. ""I should shower the night before with this soap I was give" d. "I will have an IV put in before surgery.""

Answer A. Juice is not allowed the morning of surgery.

Which of the following is the primary reason for accurately recording the patient's current medications during a preoperative assessment? "A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery."

Answer: C, Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider.

Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be: a. signed consent b. vital signs c. name band d. empty bladder

B Rationale: An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.

An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of: A) Hypovolemia, and needs more fluids B) Hypervolemia, and needs the fluids adjusted C) An acid-base disturbance D) Needing no adjustment in fluid administratio

B) Hypervolemia, and needs the fluids adjusted. Isotonic solutions has the same osmolality as body fluids. Isotonic solutions, such as Normal Saline and Ringer's Lactate, initially remain in the vascular compartment, expanding vascular volume. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, and serum osmolality remains constant.

The nurse should be alert for which manifestation in a patient receiving a loop diuretic? A. Restlessness and agitation. B. Paresthesias and irritability. C. Weak, irregular pulse and poor muscle tone. D. Increased blood pressure and muscle spasms.

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

A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this patient at risk for developing? A. pulmonary edema B. atrial dysrhythmias C. cerebral bleeding D. stress fractures

C. cerebral bleeding The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding.

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

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

The patient, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this patient? Select all that apply. A. tachycardia B. weakness C. dysrhythmias D. Kussmaul's respirations E. cold, clammy skin

B, C, D. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, and Kussmaul's respirations.

The patient is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply. A. Administer the dose IV push over 3 minutes. B. Monitor the injection site for redness. C. Add the ordered dose to the IV hanging. D. Use an infusion controller for the IV. E. Monitor fluid intake & output.

B, D, E.

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A. Notify the health care provider immediately. B. Tap the cheek about two (2) centimeters anterior to the ear lobe. C. Check the serum calcium and magnesium levels. D. Prepare to administer calcium gluconate IVP.

B. (correct) These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency

A 22-year-old male 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/minute, respirations 28 breaths/minute, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? A. 0.9% saline B. 0.45% saline C. Packed red blood cells D. Lactated Ringer's solution

B. 0.45% saline IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. Intravenous 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.

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

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

Which of these patients do you expect will need teaching regarding dietary sodium restriction? A. An 88-year old with a fractured femur scheduled for surgery B. A 65-year old recently diagnosed with heart failure C. A 50-year old recently diagnosed with asthma and diabetes D. A 20-year old with vomiting and diarrhea from gastroenteritis

B. A 65-year old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse.

The nurse anticipates that treatment of the patient with hyperphosphatemia secondary to renal failure will include A. Fluid restriction B. Calcium supplements C. Loop diuretic therapy D. Magnesium supplements

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

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A. Request a physical therapy consult from the physician B. Ensure the client is safe from falls and check the most recent potassium level C. Allow uninterrupted rest periods throughout the day D. Encourage the client to increase intake of dairy products and green leafy vegetables.

B. Ensure the client is safe from falls and check the most recent potassium level. In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? A. Tap water or bottled water B. Fluid that has sodium (salt) in it C. Fluid that has potassium and HCO-3 in it D. Coffee or tea, whichever they prefer

B. Fluid that has sodium (salt) in it Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.

A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? A. Serum sodium level of 138 mEq/L B. Gradually decreasing level of consciousness C. Oral temperature of 100.1 degrees Fahrenheit (37.8C) with bibasilar lung crackles D. Weight gain of 2 pounds above the admission weight

B. Gradually decreasing level of consciousness 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. The weight gain, elevated temperature, and crackles also will be reported, but do not indicate a need for rapid action to avoid complications.

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

B. Hypocalcemia Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.

B. Hypocalcemia. Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 4 to 11 mg/dl.

B. In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

The patient is admitted with metabolic acidosis. Which system is not functioning normally? A. Buffer system B. Kidney system C. Hormone system D. Respiratory system

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

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

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

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

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

Which of the following nursing interventions is most appropriate when caring for a patient with dehydration? A. Auscultate lung sounds equally B. Monitor daily weight and intake and output C. Monitor blood pressure for increases D. Encourage the patient to reduce sodium intake

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

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

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

The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient? A. Malted milk B. Orange juice C. Tomato juice D. Hot chocolate

B. Orange juice Orange juice has the least amount of sodium (approximately 2 mg in 8 ounces). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 ounces. Malted milk has approximately 625 mg sodium in 8 ounces.

The major intracellular fluid (ICF) cation is: A. Sodium B. Potassium C. Chloride D. Bicarbonate

B. Potassium

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen C. Encourage the client to increase the intake of bananas D. Initiate seizure precautions

B. Question the results and redraw the specimen A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

A 50-year-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 be questioned by the nurse? A. Limit foods high in potassium B. Spironolactone (Aldactone) daily C. Calcium gluconate IV piggy back D. Administer intravenous insulin and glucose

B. 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). Collaborative management for patients with hyperkalemia may include limiting foods high in potassium, IV insulin and glucose, administration of calcium gluconate, potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

In the osmolar imbalance of hyponatremia there is: A.a balance of sodium and water B.an imbalance in the ratio of water to sodium C.an increase in both water and sodium D.a deficit of potassium, with water and sodium balanced

B. an imbalance in the ratio of water to sodium

An elderly patient comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this patient is demonstrating which of the following? A. hypernatremia B. hyponatremia C. fluid volume excess D. hyperkalemia

B. hyponatremia This elderly patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level.

The nurse observes a patient's respirations and notes that the rate is 30 per minute and the respirations are very deep. The metabolic disorder this patient might be demonstrating is which of the following? A. hypernatremia B. increasing carbon dioxide in the blood C. hypertension D. pain

B. increasing carbon dioxide in the blood Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain. As a result, both the rate and depth of respiration increase. The increased rate and depth of lung ventilation eliminates carbon dioxide from the body, and carbonic acid levels fall, which brings the pH to a more normal range.

The majority of the body's water is contained in which of the following fluid compartments? A. interstitial B. intracellular C. extracellular D. intravascular

B. intracellular

A patient is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered A. directly into the venous access line. B. mixed in the prescribed intravenous fluid. C. via a rectal suppository. D. via intramuscular injection.

B. mixed in the prescribed intravenous fluid. The intravenous route is the recommended route for diluted potassium.

Which one of these patients is at risk for fluid volume excess? One who has: A.chronic diarrhea B.renal failure C.decrease aldosterone production D.restricted salt intake

B. renal failure

A patient is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the patient is receiving this replacement is A. to sustain respiratory function. B. to help regulate acid-base balance. C. to keep a vein open. D. to encourage urine output.

B. to help regulate acid-base balance. Electrolytes have many functions. They assist in regulating water balance, help regulate and maintain acid-base balance, contribute to enzyme reactions, and are essential for neuromuscular activity.

A patient with a serum magnesium level of 0.5 mEq/L receives an intravenous infusion of 10% magnesium at 1.5 mL/min. The nurse should assess the patient for which adverse effects? A. Skeletal muscle paralysis, bloating, and ileus B. Respiratory paralysis, hypotension, and lethargy C. Muscle twitching, disorientation, and seizures D. Peaked T wave, tingling of the lips, and anxiety

B.Respiratory paralysis, hypotension, and lethargy Rationale: Administration of magnesium may lead to excessive levels of magnesium. Symptoms of hypermagnesemia include muscle weakness, hypotension, sedation, electrocardiographic (ECG) changes, respiratory paralysis, and cardiac arrest. Symptoms of hypomagnesemia include muscle excitability, tetany, disorientation, psychoses, and seizures. Symptoms of hyperkalemia include alterations in the ECG and cardiac rhythm (e.g., peaked T wave, prolonged PR interval, ventricular tachycardia or fibrillation, cardiac arrest), confusion, anxiety, dyspnea, weakness or heaviness of the legs, and numbness or tingling of the hands, feet, and lips. Symptoms of hypokalemia include weakness or paralysis of skeletal muscle, risk of fatal dysrhythmias, intestinal dilation, and ileus.

What is the result of sodium imbalance in hypernatremia (a hyperosmolar state)? A.the cells swell as increased fluid moves in B.the cells shrink as fluid moves out of the cell C.aldosterone is released D.decreased tonicity of the extracellular fluidaldosterone is released Yes,

B.the cells shrink as fluid moves out of the cell In hypernatremia, the ECF becomes hypertonic, water leaves the cell to go to the ECF, and the cell shrink.

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin B. Encourage the client to increase fluid intake C. Call the physician D. Report the urine output E. Report indications of nausea

C, D, E. Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." B. "Most older adults get confused in the hospital." C. "The sodium level is low, and the confusion will resolve as the levels normalize." D. "The sodium level is high and the behavior is a result of dehydration."

C. "The sodium level is low, and the confusion will resolve as the levels normalize." Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

You must prepare the correct IV solution before administration. The order reads for the patient to receive D5½ NS with 40 mEq KCl/L at 125 ml/hr. You must add KCl to the IV because no premixed solutions are available. The unit medication supply has a stock of KCl 3 mEq/ml in multidose vials. Which of the following amounts of KCl should you add to a liter of D5½ NS to obtain the correct solution? A. 10 mL B. 7.5 mL C. 13.3 mL D. 15 mL

C. 13.3 mL

You are caring for a patient receiving D5W at a rate of 125 ml/hr. During the 1600 assessment of the patient, you determine that 500 mL is left in the present IV bag. At which of the following times should the nurse anticipate hanging the next bag of D5W? A. 1800 B. 1900 C. 2000 D. 2200

C. 2000

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

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

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? A. 56-year old with acute kidney renal failure B. 40-year old with appendicitis C. 28-year old who has acute pancreatitis D. 65-year old with hypertension and asthma

C. 28-year old who has acute pancreatitis People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids.

When monitoring an adult client with Fluid Volume Deficit, the nurse is aware that the minimum acceptable urine output is: A. 10 mL/hr B. 20 mL/hr C. 30 mL/hr D. 40 mL/hr

C. 30 mL/hr Minimum adult urinary output is 30mL/hr or 500-700mL/day. Minimum infant urinary output is 2mL/kg/hr.

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

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

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician

C. Assess for signs of fluid overload A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

An elderly patient does not complain of thirst. What should the nurse do to assess that this patient is not dehydrated? A. Ask the physician for an order to begin intravenous fluid replacement. B. Ask the physician to order a chest x-ray. C. Assess the urine for osmolality. D. Ask the physician for an order for a brain scan.

C. Assess the urine for osmolality. The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. The nurse should check the patient's urine for osmolality as a 1st step in determining hydration status before other detailed and invasive testing is done.

A postoperative patient with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this patient? A. Assist the patient to maintain a standing position for several minutes. B. This patient should be on bed rest. C. Assist the patient to move into different positions in stages. D. Contact physical therapy to provide a walker.

C. Assist the patient to move into different positions in stages. The patient needs to be taught how to avoid orthostatic hypotension which would include assisting and teaching the patient how to move from one position to another in stages.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A. Urine output B. Blood pressure C. Bowel movements D. ECG for tall, peaked T waves

C. Bowel movements Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

Evaluate ABG values: PH 7.06, CO2 36, HCO3 8

PH Acidosis, CO2 normal, HCO3 acidosis. Answer: Metabolic acidosis. Metabolic b/c CO2 normal- lungs not contributing to cause.

Evaluate ABG values: PH 7.49, CO2 24, HCO3 22

PH alkalosis, CO2 Alkalosis, HCO3 normal. Answer: Respiratory alkalosis. Respiratory b/c CO2 abnormal, not doing job.

Evaluate ABG values: PH 7.39, CO2 36, HCO3 23

PH normal, CO2 normal, HCO3 normal.

"When completing the assessment for the client in the day surgery unit, the client states,"I am really afraid of having this surgery. I'm afraid of what they will ﬁnd." Which state-ment would be the best therapeutic response by the nurse? "1."Don't worry about your surgery. It is safe." 2."Tell me why you're worried about your surgery." 3."Tell me about your fears of having this surgery." 4."I understand how you feel. Surgery is frightening.""

The correct answer is 3. 1.This statement is giving false reassurance. 2.This statement is requesting an explanation. 3. This statement focuses on the emotion that the client identiﬁed and is therapeutic. 4.This statement belittles the client's fear, andno person understands how another personfeels"

"Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A. Assist patient to bathroom and stay next to door to assist patient back to bed when done. B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room."

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

A nurse has just reassessed the condition of a postoperative patient admitted to the surgical unit 1 hour ago. The nurse plans to monitor which of the following parameters most carefully during the next hour? 1. urinary output of 20 ml/hr 2. Temperature of 37.6 Celsius 3. Blood Pressure of 100/70 mmhg 4. Serous drainage of the surgical dressing

Urine output should be maintained at a minimum of 30 ml/hr for an adult. An output of less than 30ml/hr for each consecutive 2 hours should be reported to a physician.

Edema that forms in clients with kidney disease is due to: a. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues b. Decreased capillary hydrostatic pressures pushing fluid into the interstitial tissues c. Capillaries becoming less permeable, allowing fluid to escape into interstitial tissues

a. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues. The edema is due to low levels of plasma proteins that exist with this disease, altering the oncotic pressure that helps regulate fluid movement in the vascular space moving into interstitial area. Increased capillary hydrostatic pressure is the cause. Capillaries have increased permeability when edema formation is possible. Obstructed lymph flow impairs the movement of fluid from interstitial tissues back into the vascular compartment, resulting in edema.

A nurse is developing a plan of care for a client scheduled for surgery The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before going into surgery 2. Avoid oral hygiene and rinsign with mouthwash 3. Verify that the client has not eaten for the last 24 hours 4. Report immediately any slight increase in blood pressure or pulse.

answer #1The nurse would assist the client to void immediately before surgery so that the bladder will be empty. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. Oral hygeine is allowed, but the client should not swallow any water.

"A preoperative client expresses anxiety to a nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? a) ""If its any help, everyone is nervous before surgery"" b) ""I will be happy to explain the entire surgical procedure to you"" c) ""Can you share with me what you've been told about your surgery?"" d) ""Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"""

c) "Can you share with me what you've been told about your surgery?" Explanations should begin with the info the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are clam and emotionally prepared for surgery withstand anesthesia better and experience fewer post-op complications. Options a, b, and d will produce anxiety in the patient.

"A pre-operative nurse prepares a client for surgery, which nursing interventions should be included in the plan of care? Mark all that apply. "a. Maintain NPO status to prevent aspiration. b. Verify the client's signature on the consent prior to surgery. c. Remove dentures and contact lenses prior to surgery. d. Check the client's allergy and blood bands for accuracy. e. Verify the client's mobility in all extremities prior to surgery.

correct answers: a,b,c,d"Maintaining NPO prevents the client from aspirating food particles into the lungs during and after surgery. Because of legal requirements, the surgical consent must be signed prior to surgery to verify the client's acknowledgement of the content on the consent. Dentures, hairpins, glasses, and contacts may interfere with client safety, or compromise the sterile field. Allergy, blood, and identification bands should all be checked prior to surgery to prevent medication errors, blood bank errors, and to facilitate proper identification of the client. Verifying the client's mobility in all extremities prior to surgery is part of the physical assessment, but not a necessary action prior to surgery.

The Dr has ordered a hypotonic IV solution for a newly admitted client. The nurse obtains which of the following solutions based on the order and the likely type of dehydration? a. 0.9% NaCl for hypotonic dehydration b. 5% dextrose in normal saline for isotonic dehydration. c. Lactated Ringers for hypovolemic dehydration d. 0.45% sodium chloride for cellular dehydration.

d. 0.45% sodium chloride for cellular dehydration. This is a commonly used hypotonic (hydrating) solution that draws fluid from vascular compartment into cells. Normal saline and lactated ringers are isotonic. 5% dextrose in normal saline is hypertonic until the body metabolizes the dextrose.

A 77-year-old client with a history of COPD has undergone a hernia repair. Which of the following expected outcomes should be the priority focus for the nurse? " a.The client ambulates 10 feet with assistance. b.The client tolerates a clear liquid diet. c.The client rates his pain as 2 to 3 on a 10-point scale. d.The client has normal auscultated breath sounds"

d: client has normal breath sounds, is the the biggest priority after major surgery

Which one of the following situation can result in an hyperosmolar state (increased sodium). A.Too much water intake. B.Using hypotonic intravenous solutions. C.Difficulty swallowing or tube feedings. D.Using plain water for nasogastric tube irrigations.

C. difficulty swallowing or tube feedings When an individual is unable to obtain water or swallow water, the risk for hypernatremia exists.

A postoperative patient is diagnosed with fluid volume overload. Which of the following should the nurse assess in this patient? A. poor skin turgor B. decreased urine output C. distended neck veins D. concentrated hemoglobin and hematocrit levels

C. distended neck veins Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit and blood urea nitrogen (BUN); & possible cerebral edema.

A patient has been admitted with a diagnosis of pathological fractures of the left femur and left humerus. This is a manifestation of: A. hypernatremia B.hypokalemia C.hypercalcemia D.hypomagnesemia

C. hypercalcemia Ca++ is moved out of bones by tumors and makes the bones susceptible to fracture.

A patient is receiving Kayexalate. The reason this is given is to: A. lower the serum albumin level B. lower the serum sodium level C. lower the serum potassium level D.lower the serum calcium level

C. lower the serum potassium level Kayexalate pulls potassium and water into the GI tract where it is lost in feces

A patient has been taking osmotic diuretics for some time. You would want to obtain an order for serum: A.calcium B.phosphorus C.potassium D.magnesium

C. potassium

A patient has been admitted with hyperkalemia (excess serum potassium). Which information obtained in the patient's history tells you the probable cause of the hyperkalemia? A.episode of diarrhea B.heart failure C.using salt substitutes D.uses laxative regularly

C. using salt substitutes

5.) Which of the following nursing actions should be given highest priority when admitting the patient into the operating room? A.) Level of consciousness B.) Vital signs C.) Patient identification and correctoperative consent D.) Positioning and skin preparation

C.) Patient identification and correctoperative consent

Which assessment finding would you report as indicative of fluid volume excess? A.flat neck veins B.weak pulse C.moist rales D.low central venous pressure(CVP)

C.Moist rales moist rales would indicate pulmonary edema as a result of fluid overload.

"A client is to have NPO for at least 12 hrs before surgery that same day. A nurse learns the client has half a glass of orange juice 3hr prior to admission. The nurse should... A: Report the incident to the nursing supervisor. B: Inform the surgery department. C: Notify the anesthesiologist. D: Reschedule the surgery."

C: Notify the anesthesiologist. Restriction of fluids and food is designed to minimize the potential risk of aspiration and to decrease the risk of postoperative nausea and vomiting. A client who has not followed this instruction may have surgery delayed of cancelled.

A priority nursing intervention to assist a preoperative patient in coping with fear of pain would be to: a) Inform the patient that pain medication will be available b) teach the patient to use guided imagery to help manage pain. c) Describe the type of pain expected with the patient's partcular surgery. d) Explain the pain management plan, including the use of a pain intensity scale."

Correct answer: d Rationale: If a patient has fear of pain and discomfort during and after surgery, the nurse should reassure the patient that drugs are available for anesthesia and analgesia during surgery. The nurse should teach the patient to ask for medications after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. Instruct the patient on the use of some form of pain intensity scale (e.g., 0-10, FACES) and to request pain medication before the pain becomes severe"

The nurse must obtain surgical consent forms for the following clients who are scheduled for surgery. Which client would not be able to consent to surgery? 1.The 65-year-old client who cannot read or write. 2.The 30-year-old client who does not understand English. 3.The 16-year-old client who has a fractured ankle. 4.The 80-year-old client who is not oriented to the day."

Correct: 3 1.The 65-year-old client who cannot read can mark an "X" on the form and is legally able to sign a surgical permit as long as the client understands the beneﬁts, alternatives, and all potential complications of the surgery. 2.The client who does not speak English can and should have information given and questions answered in the client's native language. 3.A 16-year-old client is not legally able togive permission for surgery unless theadolescent is given an emancipated statusby a judge. This information was not given in the stem. 4.A client is able to give permission unless deter-mined incompetent. Not knowing the day of the week is not signiﬁcant"

An elderly patient with a history of sodium retention arrives to the clinic with the complaints of "heart skipping beats" and leg tremors. Which of the following should the nurse ask this patient regarding these symptoms? A. "Have you stopped taking your digoxin medication?" B. "When was the last time you had a bowel movement?" C. "Were you doing any unusual physical activity?" D. "Are you using a salt substitute?"

D. "Are you using a salt substitute?" The patient has a history of sodium retention and might think that a salt substitute can be used. Advise patients who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C.. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.

D. (correct) Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.

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

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

A patient has a serum potassium level of 6.4 mEq/L and an arterial pH of 7.22. Which medication, if ordered by the physician, should the nurse question? A. Sodium bicarbonate B. Glucose and insulin C. Spironolactone (Aldactone) D. Calcium gluconate

D. Calcium gluconate Rationale: The patient has hyperkalemia (serum potassium is elevated) and acidosis (pH is low). Appropriate treatment for hyperkalemia includes withdrawing potassium-containing foods and drugs that promote potassium accumulation (e.g., potassium supplements, potassium-sparing diuretics [spironolactone]), infusing a calcium salt (e.g., calcium gluconate) to offset the cardiac effects of potassium, infusing glucose and insulin to promote potassium uptake by cells, and infusing sodium bicarbonate if acidosis is present.

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A. Assess for depressed deep tendon reflexes B. Call the physician to report calcium level C. Place an intravenous catheter in anticipation of administering calcium gluconate D. Check to see if a serum albumin level is available

D. Check to see if a serum albumin level is available A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.

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

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

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

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

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to A. Apply warm moist compresses to the insertion site. B. Attempt to force 10 mL of normal saline into the device. C. Place the patient on the left side with head-down position. D. Instruct the patient to change positions, raise arm, and cough.

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

You are caring for an elderly 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. Which of the following is the priority nursing intervention? A. Notify the physician and complete an incident report. B. Slow the rate to keep vein open until next bag is due at noon. C. Obtain a new bag of IV solution to maintain patency of the site. D. Listen to the patient's lung sounds and assess respiratory status

D. Listen to the patient's lung sounds and assess respiratory status.

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

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

"The client presents in the emergency room with constricted pupils, slurred speech, drowsiness, and respirations of 8/min. The person who accompanied the client to the emergency room reports the client had taken an unknown quantity of meperidine (Demerol) tablets 30 minutes earlier. Which medication should the nurse anticipate giving the client?" A. Methadone B. Phenytoin (Dilantin) C. Naloxone (Narcan) D. Diazepam (Valium)

D. Naloxone (Narcan)

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A. A client with osteoporosis and a calcium level of 10.6 mg/dl B. A client with renal failure and a magnesium level of 2.5 mEq/L C. A client with bulimia and a potassium level of 3.6 mEq/L D. A client with dehydration and a sodium level of 149 mEq/L

D. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated.

"While witnessing a preoperative consent, the nurse learns that the client does not understand the risks of the surgery. The nurse's best action is to: A. Notify the surgeon B. Notify the surgical unit C. Notify the anesthetist D. Notify the client's family"

D. Notify the surgeon Rationale: The primary responsibility for informed consent lies with the attending surgeon, not the interdisciplinary team."

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq potassium intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? A. Flat neck veins B. Tachycardia C. Hypotension D. Oliguria

D. Oliguria Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia.

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 41. mEq/L C. Magnesium rising to 2.9 mg/dL D. Phosphorus falling to 2.1 mg/dL

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

The nurse would be most concerned about which lab values obtained from a client receiving furosemide therapy? A. BUN level of 20 B. Potassium level of 3.4 C. Creatinine level of 1.1 D. Potassium level of 3.2

D. Potassium level of 3.2 Furosemide inhibits reabsorption of sodium, water, and potassium leading to diuresis. The most common electrolyte disturbance associated with furosemide administration is hypokalemia.

A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of A. ADH deficit. B. Extracellular fluid loss. C. Insensible water loss. D. Sensible water loss.

D. Sensible water loss

A patient with a cardiac history is taking the diuretic furosemide and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first? A. Serum albumin B. Serum sodium C. Hematocrit D. Serum potassium

D. Serum potassium Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? A. Notify a health care provider B. Insert an indwelling catheter C. Alert the blood bank D. Stop the transfusion

D. Stop the transfusion Development of chills, tachycardia, and flushing during a blood transfusion is an indication of an acute hemolytic reaction. You stop the transfusion immediately so no more of the incompatible blood reaches the patient.

The body's fluid and electrolyte balance is maintained partially by hormonal regulation. You will express an understanding of this mechanism in which of the following statements? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone."

D. The pituitary gland secretes antidiuretic hormone

Your friend played tennis a long time in 100 degree weather. He was careful to drink plenty of water during the match. Later he became ill and went to the hospital where he was admitted in a hypoosmolar state. Your assessment is likely to reveal: A.extreme thirst B.serum sodium 180 mEq/L C.hyporeflexia D.disorientation

D. disorientation He diluted the sodium and water moved into the cells

A patient is admitted for treatment of hypercalcemia. The nurse realizes that this patient's intravenous fluids will most likely be which of the following? A. dextrose 5% & water B. dextrose 5% & ? normal saline C. dextrose 5% & ? normal saline D. normal saline

D. normal saline Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.

The nurse is admitting a patient who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder? A. calcium B. magnesium C. phosphorus D. potassium

D. potassium Because the kidneys are the principal organs involved in the elimination of potassium.

A patient is to recieve ranitidine (Zantac) preoperatively. He tells the nurse that he took his esomeprazole (Nexium) today (as ordered). The nurse explains that these medications will. a.) calm the patient and relieve his anxiety b.) provide sedation and amnesia before surgery c.) prevent aspiration of stomach contents into his lungs d.) work to decrease stomach acids and help avoid nausea after surgery

D.) work to decrease stomach acids and help avoid nausea after surgery Rationale: Ranitidine (Zantac) is a histamine (H2) receptor antagonist, and esomeprazole (Nexium) is a proton pump inhibitor. These drugs decrease stomach acid and postoperative nausea."

A patient is scheduled for a laparoscopic cholecystectomy at an ambulatory surgery center. What do you expect? A. Curative surgery for cancer of the pancreas. B. Palliative surgery for a resection of a tumor. C. Surgery with small incisions for removal of the liver. D. Removal of the gallbladder using a minimally invasive technique.

D: Most surgical procedures are being performed as ambulatory surgery (also called same-day or outpatient surgery). Many of these operations use minimally invasive techniques (e.g., laparoscopic techniques). Cholecystectomy is removal of the gallbladder.

N2209 ##1

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