NCLEX Challenge 3

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A patient who has diarrhea A patient who is vomiting A patient taking a thiazide diuretic Apatient who has salicylate intoxication

A client who has diarrhea Diarrhea can cause metabolic acidosis due to the loss of bicarbonate.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)

Bicarbonate excess Circumoral paresthesia Bicarbonate excess is a clinical manifestation for a client experiencing metabolic alkalosis. Circumoral paresthesia is a clinical manifestation for a client experiencing metabolic alkalosis.

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? metabolic acidosis respiratory acidosis metabolic alkalosis respiratory alkalosis

Metabolic acidosis A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.

A nurse is admitting a client who reports flue-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that that the client is experiencing which of the following conditions ? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

Metabolic alkalosis

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Respiratory Acidosis With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be

dysphagia. Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness.

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a)"I will be able to tell how much oxygen I'm getting by looking at the flowmeter." b)"I should call my doctor if I find it harder to concentrate. "c)"I will make sure my visitors smoke outside. "d)"I will wear synthetic clothing and woolen socks when using my oxygen."

"I will wear synthetic clothing and woolen socks when using my oxygen." Woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

"It is no longer possible for you to choke on or aspirate food." The surgical procedure of total laryngectomy provides complete anatomical separation of the trachea and esophagus. Choking and aspiration of food and liquids is no longer possible.

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

"The rate and rhythm of breath are irregular in newborns." Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats. Secure the oxygen tubing to the bed sheet near the client's head. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Attach a humidifier bottle to the base of the flow meter. Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

Cardiac dysrhythmias This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Check the client's IV infusion every 8 hr. The nurse should assess the client's IV infusion site and the infusion to monitor for infiltration, extravasation or phlebitis every hr.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Kussmaul respirations Apneustic respirations Cheyne-Stokes respirations Stridor

Cheyne-Stokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds Clear breath sounds indicate that there are no remaining secretions obstructing or potentially obstructing the client's airway.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the *long-term inadequate oxygenation*? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

Clubbing of the fingers The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.

A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? Decreased pH and metabolic acidosis decreased pH and respiratory acidosis elevated pH and metabolic alkalosis elevated pH and respiratory alkalosis

Decreased pH and metabolic acidosis This client would have a decreased pH and be in metabolic acidosis. Other findings would include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? 1. Decreased brain natriuretic peptide (BNP). 2. Elevated central venous pressure (CVP). 3. Increased pulmonary artery wedge pressure (PAWP). 4. Decreased specific gravity

Elevated central venous pressure (CVP).

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? Hypernatremia Hyperuricemia Hypercalcemia Hyperchloremia

Hyperuricemia The nurse should monitor the client who is receiving IV furosemide for hyperuricemia. The nurse should instruct the client to notify the provider for any tenderness or swelling of the joints.

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

Hypokalemia If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrhythmia.

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?

Loud, scratchy sounds Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?

N/V A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level.

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?

Naloxone The nurse should plan to administer naloxone, which is an opiate antagonist that competes with opioids at opiate receptor sites making the opioid ineffective.

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?

Need for suctioning. Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

PaCO2 50 mm Hg This laboratory value is an expected finding for a client who has respiratory acidosis.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed. Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values.pH 7.22PaCo2 68mmHgBase excess -2PaO2 78mmHgSaturation 80%Bicarbonate 26mEq/LWhich of the following is an appropriate analysis of the ABGs? a. Respiratory acidosis b. Metabolic acidosis' .cRespiratory alkalosisd. D Metabolic alkalosis

Respiratory acidosis

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

Sodium polystyrene Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes. Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect? Widened QRS complexes, hyperactive deep tendon reflexes, bounding peripheral pulse, warm flushed skin

Widened QRS complexes A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block.

A nurse is planning to teach a client about a low potassium diet. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) Butter Poulty Yogurt Frozen Veggies Orange Juice

Yogurt Orange Juice

A nurse is preparing to provide tracheostomy care for a client who has a nondisposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

clean gloves sterile basin sterile cotton tipped applicators

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

hoarseness Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply.) aApply pressure to the nares. b. Place ice to the bridge of the client's nose. c. Instruct the client to blow his nose. d. Tilt the client's head backward. e. Move the client into high-Fowler's position.

move the client into high fowlers position place ice to the bridge of the client's nose apply pressure to the nares

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

pH 7.26, HCO3 14, PaCO2 30 AKI causes metabolic acidosis because the kidneys cannot adequately process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is low, the bicarbonate is low, and the PaCO2 is low or in the expected range, as in these results.

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH<7.35 HCO3 >26 PaO2 <70 PaCO2 >45

pH below 7.35 With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.

A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take?

provide humidified air for the client. The nurse should provide humidification to loosen secretions and prevent crust formation.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

respiratory acidosis

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?

respiratory acidosis A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL).

A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?

1 cup milk Of the four choices, milk contains the most calcium per serving. Milk contains 276 mg calcium per one cup serving.

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28% The nurse should recognize that a flow rate of 2 L/min via nasal cannula delivers an oxygen concentration of about 28%.

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Administer oxygen via face mask. The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.