np2 med surg exam 2

Which client will the nurse assess for potential metabolic acidosis? (Select all that apply) A.A client in the ER who has had severe diarrhea for 7 days B.A young adult following an aspirin overdose C.An older adult with asthma D.An older client who takes sodium bicarbonate for gastroesophageal reflux disease (GERD)

a, b (Rationale:One cause of acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. Severe diarrhea is another cause of metabolic acidosis. The client with an overdose of aspirin has ingested excess acid. In the client with asthma, acid-base status will be determined by a combination of depth of respirations and oxygen saturation. Excessive intake of sodium bicarbonate may increase the risk of metabolic alkalosis)

An older adult is admitted to the medical unit with GI bleeding. Assessment findings that occur with fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. orthostatic f. hypotension. g. increased central venous pressure.

a, b, e (Rationale: An adult patient who is fasting may lose 1 to 2 lb/day. A weight loss exceeding this is likely due to loss of body fluid. Other clinical manifestations of fluid volume deficit include dry mucous membranes and a decreased central venous pressure, which reflect fluid volume loss. In mild to moderate fluid volume deficit, pulses may be weak and thready. A change in position from lying to sitting or standing may decrease BP or further increase the heart rate (orthostatic hypotension). In more severe deficits, hypotension may be present. In fluid volume excess, the pulse is full, bounding, and not easily obliterated. Increased volume causes distended neck veins (jugular venous distention), increased central venous pressure, and high BP.)

Which action would the nurse take when caring for a patient who has a central venous access device (CVAD)? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Position the patient's face toward the CVAD during injection cap changes. d. Obtain a prescription from the health care provider to change CVAD dressing.

b (The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. the dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider's order is not necessary. the patient should turn away from the CVAD during cap changes.)

After receiving change-of-shift report, which patient would the nurse assess first? a. Patient with serum sodium level of 145 mEq/L who is asking for water b. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates

c (The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. the other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.)

Ricky's grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown? A) Respiratory Alkalosis, Uncompensated B) Respiratory Acidosis, Partially Compensated C) Metabolic Alkalosis, Uncompensated D) Metabolic Alkalosis, Partially Compensated

c (The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.)

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

d (Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.)

a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action would the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed fluid bolus and insulin.

d (The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.)

You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at 10 mEq/hr. The client complains of burning along their vein. What should you do? A) Change the electrolyte. B) Switch to an oral formulation. C) Increase the speed of transfusion. D) Dilute the infusion.

d (Treatment of severe hypokalemia requires treatment with IV infusion of potassium. Clients may experience burning along the vein with IV infusion of potassium in proportion to the infusion's concentration. If the client can tolerate the fluid, consult with the physician about diluting the potassium in a larger volume of IV solution. Oral potassium may not be enough in severe cases hypokalemia. Hypokalemia requires treatment with potassium and not any other electrolyte.)

A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: A) electrocardiogram (ECG) results. B) neuromuscular function. C) bowel sounds. D) respiratory rate.

a (Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.)

A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy would the nurse question? a. Infuse 5% dextrose in water intravenously at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. d. administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.

a (Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.)

A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action would the nurse take first? a. Check the patient's blood pressure. b. Observe the oral mucosa for dryness. c. Draw blood for serum electrolyte levels. d. Ask about extremity numbness or tingling.

a (Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. the other actions are also appropriate but are not as essential as determining the patient's perfusion status.)

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 (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. Patients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.)

A patient with renal failure is on a low phosphate diet. Which food would the nurse remove from the patient's food tray? a. Skim milk b. Grape juice c. Mixed green salad d. Fried chicken breast

a (Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.)

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

a (Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.)

A priority nursing intervention for a client with hypervolemia involves which of the following? A) Monitoring respiratory status for signs and symptoms of pulmonary complications. B) Establishing I.V. access with a large-bore catheter. C) Encouraging the client to consume sodium-free fluids. D) Drawing a blood sample for typing and cross-matching.

a (Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.)

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. Stridor b. Fatigue c. Constipation for 4 days d. Numbness around the lips

a (Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. the other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.)

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. the nurse would alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Ibuprofen 400 mg every 6 hours c. Lantus insulin 24 U every evening d. Metoprolol (Lopressor) 12.5 mg/day

a (Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. the nurse will need to do more assessment about the other medications, but they are not of as much concern with the potassium level.)

A patient has a magnesium level of 1.3 mg/dL. Which information from the patient's health history would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Daily multivitamin use d. Occasional laxative use

a (Hypomagnesemia is associated with alcohol use. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.)

Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A) pH, 7.25; PaCO2 50 mm Hg B) pH, 7.35; PaCO2 40 mm Hg C) pH, 7.40; PaCO2 35 mm Hg D) pH, 7.5; PaCO2 30 mm Hg

a (In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A pH value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.)

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

a (Rationale: As a compensatory mechanism, the respiratory system acts on the CO2 + H2O side of the reaction by altering the rate and depth of breathing to "blow off" (through hyperventilation) or "retain" (through hypoventilation) CO2.)

On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? A.Inspiratory crackles at the bases B.Expiratory wheezes in both lungs C.Abnormal lung sounds in the apices of both lungs D.Pleural friction rub in the right and left lower lobes

a (Rationale: Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.)

The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.

a (Rationale: In hyponatremia caused by water excess, fluid restriction often is all that is needed to treat the problem. The patient would only need an indwelling urinary catheter if the patient is unable to help with maintaining an accurate output record.)

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is (recognize) a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.

a (Rationale: Osmosis is the movement of water between 2 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. Whenever dissolved substances are contained in a space with a semipermeable membrane, they can pull water into the space by osmosis. Diffusion is the movement of molecules from an area of high concentration to low concentration. Facilitated diffusion involves the use of a protein carrier in the cell membrane. The protein carrier combines with a molecule and helps move the molecule across the membrane from an area of high to low concentration. Active transport is a process in which molecules move against the concentration gradient.)

The nurse administers Proscar to a 75-year-old male client. The nurse instructs the client that the effect of Proscar is to A.decrease size of prostate. B.relax the smooth muscle of the bladder. C.increase force of urinary stream. D.decrease production of testosterone.

a (Rationale: Proscar works by reducing the size of the prostate gland. The drug results in regression of hyperplastic tissue through suppression of androgens)

When the nurse is assessing a client, what findings would indicate early hypoxia? A.Client is anxious B.Lips are cyanotic C.Intercostal retractions D.Coarse lung crackles

a (Rationale: The presence of hypoxemia from any cause may be reflected by rapid breathing, gasping, apprehension, restlessness and a rapid or thready pulse.)

The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 6.8mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first? A.Place the patienton a cardiac monitor. B.Insert a retention catheter. C.Administer Kayexalate 15 g orally. D.Give IV furosemide (Lasix) 40 mg

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

A 55-year-old man tells the nurse he has been having increasing problems with erectile dysfunction (ED) and is interested in using Viagra (sildenafil). What should the nurse do first? A.Ask the patient about any prescription drugs he is taking. B.Tell the patient that Viagra does not always work for ED. C.Discuss the common adverse effects of erectogenic drugs. D.Assure the patient that ED is commonly associated with aging.

a (Rationale:Because some medications can cause ED and patients using nitrates should not take Viagra, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of Viagra therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease in a 55-year-old)

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? A.Observe for distended neck veins. B.Auscultate for abnormal sounds C.Palpate for heaves or thrills over the heart. D.Review hemoglobin and hematocrit values

a (Rationale:Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased)

A 69-year-old male has been diagnosed with benign prostatic hypertrophy. The client asks the nurse if he can avoid having surgery. The nurse is correct in telling the client that A.emptying the bladder on a regular schedule will help minimize symptoms and the need for surgery. B.most men with benign prostatic hypertrophy will eventually need surgery. C.this will depend on whether or not it progresses to prostate cancer. D.usually physicians will not recommend surgery unless the client is going into renal failure.

a (Rationale:Regular voiding, avoiding ETOH and medications can postpone surgery in many patients. Most men do not need surgery but surgery would be performed before severe damage is done to the urinary system)

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? A.Auscultate breath sounds. B.Administer the PRN morphine. C.Have the patient cough forcefully. D.Notify the patient's health care provider

a (Rationale:The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider)

A client is admitted to the hospital with respiratory difficulty and wheezing on expiration. The physician orders an intravenous infusion of aminophylline (Theophylline). What will the nurse teach the client about the way this medication works? A.It relaxes the bronchial smooth muscle. B.It increases the tone in the respiratory passages. C.It causes bronchoconstriction. D.It will decrease the inflammatory response.

a (Rationale:Theophylline relaxes the smooth muscles of the bronchi, bronchioles and the pulmonary blood vessels by inhibiting the enzyme phosphodiesterase, resulting in an increase in cAMP which promotes bronchodilation)

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action would the nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the history of gastrointestinal upset on the chart. d. Teach the patient about magnesium-containing antacids.

a (The health care provider should be notified immediately. the patient has a history and manifestations consistent with hypermagnesemia. As the serum magnesium level increases, deep tendon reflexes are lost, followed by muscle paralysis and coma. Respiratory and cardiac arrest can occur. the nurse should check the chart for a recent serum magnesium Test Bank - Lewis's Medical Surgical Nursing, 12th Edition (Harding, 2023) level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia. Dialysis should correct the high magnesium levels. the patient needs teaching about the risks of taking magnesium-containing antacids and further investigation of indigestion symptoms.)

The nurse observes that the patient's central venous catheter insertion site is red and tender to touch. the patient's temperature is 101.8F. What should the nurse plan to do? a. Discontinue the catheter and culture the tip. b. Use the catheter only for fluid administration. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

a (The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.)

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

a (The normal pH is 7.35 to 7.45. Normal PaCO2levels are 35 to 45 mm Hg and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.)

Which of the following serum potassium results best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 ml of NSS over 2 hours? A) 3.1 mEq/L B) 3.9 mEq/L C) 4.6 mEq/L D) 5.3 mEq/L

a (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 lowest value shown is 3.1 mEq/L.)

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 of the following serum laboratory values, documented on this same patient, best supports 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 (The normal range for serum sodium is 135 to 145 mEq/L, whereas 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 who is lethargic with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How would the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a (The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.)

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action would the nurse expect to take first? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

a (This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. the other actions may be needed if the ionized calcium is also decreased.)

It is important for the nurse to assess for which 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 sign

a, d, e (Rationale: Inadvertent removal of a part 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's sign, confusion, and circumoral numbness are manifestations of low serum calcium levels.)

Which IV solution would the nurse anticipate administering to a patient with an extracellular fluid (ECF) deficit who requires isotonic fluid replacement? (Select all that apply.) a. Saline 0.9% b. Saline 0.45% c. Dextrose 10% d. Lactated Ringer's e. Dextrose 5% in saline 0.25%

a, d, e (Saline 0.9%, Lactated Ringer's, and Dextrose 5% in saline 0.25% are isotonic solutions. An isotonic solution has an osmolality similar to plasma. Giving an isotonic solution expands only extracellular fluid (ECF) and the fluid does not move into cells, which makes isotonic solutions that ideal fluid replacement for patients with ECF volume deficits. Which isotonic solution would be prescribed is based on electrolyte levels and types of fluid losses. Saline 0.45% is hypotonic, which would cause fluid to move out of the ECF and into cells. Dextrose 10% is hypertonic, which would cause fluid to move out of cells into the ECF.)

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? a. Titrate vasoactive IV medications. b. Flush a saline lock with normal saline. c. Remove the central venous catheter. d. Verify and administer blood products.

b (A LPN/VN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.)

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

b (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.)

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/min. b. There are crackles throughout both lung fields. c. There is sediment and blood in the patient's urine. d. The patient's blood pressure increases to 142/94 mm Hg.

b (Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. the increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.)

A nurse, when caring for a client, notes that the specific gravity of the client's urine is low. What could have lead to the low specific gravity of urine? A) Repeated diarrhea B) Excess fluid intake C) Frequent vomiting D) Urine retention

b (Excess fluid intake results in low specific gravity of urine. Excessive fluid intake will result in formation of dilute urine. When the urine is diluted, it results in low specific gravity of urine. Frequent vomiting, repeated diarrhea, and urine retention will result in high specific gravity of urine. (The normal range of specific gravity in urine is from 1.003 to 1.030.))

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? A) Bradycardia B) Tachycardia C) Increased urine output D) Vasodilation

b (Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguria, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.)

IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action would the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a maximum rate of 10 mEq/hr. c. Discontinue cardiac monitoring during the infusion. d. Monitor deep tendon reflexes during the infusion.

b (IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Cardiac monitoring would be continued while patient is receiving potassium because of the risk for dysrhythmias. Deep tendon reflexes are monitored during magnesium infusions, not potassium infusions.)

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? A."I will avoid being outdoors whenever possible." B."My husband will be sleeping in the guest bedroom." C."I will take the bus instead of driving tovisit my friends." D."I will keep the windows closed at home to contain the germs."

b (Rationale: Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infectedperson spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation)

The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.

b (Rationale: 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, long-term measures to reduce serum phosphate levels include phosphate-binding agents or gels, such as calcium carbonate, fluid replacement therapy, and dietary phosphate restrictions.)

The nurseanalyzes the patient's arterial blood gas(pH: 7.26, PaCO256 mmHg, HCO324 mEq/L)to determine the patient isexperiencing: A.respiratoryalkalosis B.respiratory acidosis C.metabolic alkalosis D.metabolic acidosis

b (Rationale: pH is < 7.35 making it an acidotic state; PaCO2is high, indicating respiratory acidosis; HCO3is normal; It is an uncompensated ABG, because the kidneys shave not started compensatingby retaining bicarbonate)

A client is admitted to the hospital with chronic bronchitis in the early stages. When taking the client's history, what will the nurse expect the client to describe? A.Dyspnea on minimal exertion. B.Frequent respiratory infections. C.Swollen feet and legs. D.Large abdomen with tender right upper quadrant.

b (Rationale:Acute bronchitis is an inflammation of the bronchi in the lower respiratory tract usually due to infection. It is one of the most common conditions seen in primary care. it usually occurs as a sequela to an upper respiratory tract infection)

A client is admitted to the hospital following a motor vehicle accident. On admission, the client's BP is 110/80 and heart rate 90. The nurse rechecks the vital signs 15 minutes later and the BP is now 90/60 and heart rate 140. What should the nurse suspect as the main cause of this client's vital sign changes? A.Fluid volume overload B.Fluid volume deficit C.Acute pain D.Hypoxia

b (Rationale:The decreasing blood pressure and increasing heart rate are indications of fluid loss, possibly hemorrhage. Fluid overload and acute pain would increase BP. The changes in BP would not be explained by hypoxia)

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A.Teach about treatment for drug-resistant tuberculosis. B.Ask the patient if medications have been taken as directed. C.Schedule patient for directly observed therapy three times weekly. D.Discuss with the health care provider the need for the patient to use an injectable antibiotic.

b (Rationale:The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed)

The client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure and the nurse finds an ecchymotic area on the client's right lower back. Which is the nurse's priority action? A.Notify the physician B.Apply ice to the site C.Place the client in the prone position D.Auscultate the lungs

b (Rationale:The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Thisis an expected finding not a complication requiring physician notification. Placing the client in the prone position or listening to the lungs are not needed with this assessment data)

A patient asks the nurse why a peripherally inserted central catheter is needed to begin receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when there is a central line." b. "The hypertonic solution is more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."

b (The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered through a peripheral IV. Blood glucose testing is not more accurate when samples are obtained from a central line. the infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.)

A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding would the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

b (The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and would be reported, but they are not as significant as the loss of deep tendon reflexes. the decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.)

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? A) Hypovolemia B) Dehydration C) Hypervolemia D) Fluid volume excess

b (The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.)

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation would the nurse expect? a. Pallor b. Edema c. Confusion d. Restlessness

b (The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.)

A patient with new-onset confusion and hyponatremia is being admitted. Which action would the charge nurse take when making room assignments? a. Assign the patient to a semiprivate room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves.

b (The patient would be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient would not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.)

a patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature increased to 100.1F b. Decreased alertness since admission c. Weight gain of 2 pounds (1 kg) over 2 days d. Serum sodium level of 138 mEq/L (138 mmol/L)

b (The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. the weight gain, elevated temperature, and serum sodium level will be reported but do not indicate a need for rapid action to avoid complications.)

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. the patient reports anxiety and incisional pain. the patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis with a normal arterial oxygen level. Which action would the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient to take slow, deep breaths when anxious.

b (The patient's respiratory alkalosis is likely caused by the increased respiratory rate associated with pain and anxiety. the nurse's first action would be to medicate the patient for pain. the health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. the patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.)

Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which action would the nurse complete first? a. Verify the serum potassium level. b. Test for presence of Chvostek's sign. c. Observe for blood on the neck dressing. d. Confirm a prescription for thyroid replacement.

b (The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of an urgent need to check the potassium level, the thyroid replacement, or for bleeding.)

A patient is admitted to the emergency department with severe fatigue and confusion. Which laboratory value requires the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

b (The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. the nurse should start cardiac monitoring and notify the health care provider. the potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.)

A patient with multiple draining wounds is admitted for hypovolemia. Which information would provide the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence

b (rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.)

A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium of 120 mg/dL c. Urinary output of 280 mL in 8 hours d. Reported weight gain of 2.2 pounds (1 kg)

b (rationale: Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.)

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data would be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for 8 hours. d. Skin tenting over the sternum is prolonged.

b (rationale: The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss from the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.)

Which client has the greatest need of Potassium replacement? A) A client in renal failure with a post-dialysis serum K+ of 3.4 B) A client with a large NG output who is receiving Kayexalate with serum K+ of 5.5 C) A client with cardiac disease who is about to receive furosemide with a K+ of 3.5 D) A client with cardiac disease who is about to receive spironolactone with a K+ of 3.5

c (A) is incorrect because generally patients with renal failure have trouble excreting K+. In the days before the next dialysis treatment, the K+ increases. B) is incorrect because this pt's K+ is already too high. More K+ is not needed. C) is correct because clients with cardiac disease are vulnerable to arrhythmia when serum potassium is low. Furosemide will cause K+ loss. It is important to replace K+ before furosemide is given. D) is incorrect. Spironolactone is a K+ sparing diuretic.)

Baby Angela was rushed to the Emergency Room following her mother's complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant's respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean? A) Respiratory Alkalosis, Fully Compensated B) Metabolic Acidosis, Uncompensated C) Metabolic Acidosis, Fully Compensated D) Respiratory Acidosis, Uncompensated

c (Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.)

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

c (Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient.)

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

c (Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.)

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. the patient seems confused and short of breath with peripheral edema. Which assessment would the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

c (Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.)

A client with a potassium level of 5.8 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 (Kayexalate causes K+ to be exchanged for Na+ in the intestines and excreted through bowel movements. If patient does not have stools, the drug cannot work properly. BP and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia.)

Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A) Metabolic Acidosis B) Metabolic Alkalosis C) Respiratory Acidosis D) Respiratory Alkalosis

c (One of the risk factors of having respiratory acidosis is hypoventilation which may be due to brain trauma, coma, and hypothyroidism or myxedema. Other risk factors include COPD, Respiratory conditions such as pneumothorax, pneumonia and status asthmaticus. Drugs such as Morphine and MgSO4 toxicity are also risk factors of respiratory acidosis.)

Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-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 (Rationale: Causes of hypermagnesemia include renal failure (especially if the patient is given magnesium products), excess magnesium administration for treatment of eclampsia, and adrenal insufficiency.)

The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's solution. d. 5% dextrose in 0.45% saline.

c (Rationale: Giving 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. Replacement therapy depends on the severity and type of volume loss. If the deficit is more severe, we replace volume with blood products or balanced IV solutions, such as isotonic (0.9%) sodium chloride or lactated Ringer's solution.)

The nurse should be alert for which manifestations 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 (Rationale: Loop diuretics may result in renal loss of potassium and hypokalemia. Therefore, the manifestations of hypokalemia involve changes in cardiac and muscle function. Clinical manifestations of hypokalemia include fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia, and ECG changes.)

A client comes from the emergency room with a diagnosis of renal calculi. Which assessment data, if found, should the nurse communicate immediately to the physician? A.Cloudy urine B.Burning on urination C.Scanty urine output D.Sediment in urine

c (Rationale: Urinary stones cause clinical manifestations when they obstruct urinary flow and could indicate a complete obstruction. All other options indicate a UTI)

To prevent the recurrence of renal calculi, the nurse teaches the patient to A.avoid all sources of dietary calcium. B.drink diuretic fluids such as coffee. C.drink 2000 to 3000 ml of fluid per day. D.use a filter to strain all urine

c (Rationale:A fluid intake of 2000 to 3000 ml daily is recommended help flush out minerals before stones can form. Patients are not advised to avoid all calcium-containing foods and a high calcium intake may decrease the incidence of some types of stones. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones)

During assessment of a client with asthma, the nurse notes wheezing and dyspnea, recognizing that these symptoms are related to the pathophysiologic feature of A.laryngospasm. B.pulmonary edema. C.airway narrowing. D.overdistention of the alveoli

c (Rationale:As a result of bronchospasm, edema and mucous in the bronchioles, the airway becomes narrower than usual. This produces the characteristic wheezing, air trapping and hyperventilation. The primary pathophysiologic process in asthma is chronic inflammation. The inflammatory process results in vascular congestion; edema formation; production of thick, tenacious mucus; bronchial muscle spasm; thickening of airway walls and increased bronchial hyperresponsiveness.)

When administering oxygen to the client with COPD for the first time, which precaution should the nurse take? A.Administer oxygen only when the client demonstrates cyanosis. B.Utilize a non-rebreather at 100% only. C.Start oxygen at 1-2 liters per nasal cannula. D.Administer oxygen at intermittent intervals.

c (Rationale:It is critical to start O2 at a low flow rate until ABG's can be obtained)

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, thirst and weakness. Which laboratory result should the nurse report to the health care provider immediately? A.K+ 3.3 mEq/L (3.4 mmol/L) B.Ca+2 7.9 mg/dL (1.95 mmol/L) C.Na+ 157 mEq/L (154 mmol/L) D.PO4-3 4.7 mg/dL (1.55 mmol/L)

c (Rationale:The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal)

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? A.Foul-smelling urine B.Complaint of flank pain C.Blood pressure 88/45 mm Hg D.Temperature 100.1° F (37.8° C)

c (Rationale:The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.)

Which information about continuous bladder irrigation (CBI) should the nurse teach a patient who is scheduled for a transurethral resection ofthe prostate (TURP)? A.Bladder irrigation decreases the risk of postoperative bleeding. B.Hydration and urine output are maintained by bladder irrigation. C.Bladder irrigation prevents obstruction of the catheter after surgery. D.Antibiotics are infused on a continuous basis with bladder irrigation.

c (Rationale:The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation)

An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result would the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

c (The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. the potassium, phosphate, and calcium levels vary slightly from normal and should be reported, but do not require immediate action.)

After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action would the nurse take first? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give prescribed PRN morphine sulfate IV.

c (The initial action would be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. the other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.)

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which action would the nurse include in the plan of care? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Encourage fluid intake up to 4000 mL daily. d. Monitor for Trousseau's and Chvostek's signs.

c (To decrease the risk for renal calculi, the patient would have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.)

The home health nurse cares for an alert and oriented older adult patient who has a history of dehydration. Which instruction would the nurse give this patient? a. "Drink more fluids in the late evening." b. "More fluids are needed if you feel thirsty." c. "Increase the fluids if your mouth feels dry." d. "If you feel confused, you need more fluids."

c (rationale: An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.)

The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

d (ABGs with a decreased pH and increased PaCO2 indicate uncompensated respiratory acidosis and should be reported to the health care provider. the other values are normal, close to normal, or compensated.)

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 (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.)

When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is A) skin turgor. B) presence of edema. C) hourly urine output. D) daily weight.

d (Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age; considerable fluid-volume excess may be present before fluid moves into the interstitial space and causes edema; and hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.)

A patient who is taking a potassium-depleting diuretic for treatment of hypertension reports generalized weakness. Which action would the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

d (Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.)

A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d (Rationale: Alkalosis occurs with a decrease in carbonic acid (respiratory alkalosis) or increase in HCO3− (metabolic alkalosis). Respiratory alkalosis (carbonic acid deficit) occurs with hyperventilation. The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, central nervous system disorders, and mechanical overventilation also increase ventilation rate and decrease the partial pressure of arterial carbon dioxide (PaCO2). This leads to a decrease in carbonic acid level and to alkalosis.)

A postop client is receiving an IV of 1/2 NS (normal saline) at 100ml/hr. What findings would indicate a complication related to the IV therapy? A.Client has dry, flushed skin. B.Client complains of thirst and is restless. C.Client has diminished bowel sounds. D.Client complains of headache and dizziness.

d (Rationale: Hypotonic solutions pull fluid into the cells causing them to become edematous and burst. Cerebral cells in particular love hypotonic fluid, leading to cerebral edema which is manifested as headache, confusion, dizziness, etc. Use ofhypotonic solutions (including hypotonic parenteral solutions) overtime can also lead to hyponatremia (especially in pediatric patients), as those solutions reduce the serum sodium concentration. Manifestations of hyponatremia include irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma, headache, apathy, muscle spasms. Hypotonic IV solutions like 1/2 NS can cause hyponatremia)

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. try to force 10 mL of normal saline into the device. c. place the patient on the left side with the head down. d. have the patient change positions, raise arm, and cough.

d (Rationale: Interventions for catheter occlusion include having the patient 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); and instilling anticoagulant or thrombolytic agents.)

During the postoperative 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. older adults are more likely than younger adults to lose extracellular fluid during surgeries. c. water accounts for a greater percentage of body weight in the older adult than in younger adults. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

d (Rationale: Older adults also tend to have less lean body mass, resulting in a lower percentage of body water when compared to younger adults. In older adults, body water content averages 45% to 50% of body weight. This places them at a higher risk for fluid-related problems than young adults. The older adult has normal physiologic changes that increase susceptibility to fluid and electrolyte imbalances. Structural changes to the kidneys and a decrease in the renal blood flow lead to decreased glomerular filtration rate and loss of the ability to concentrate urine and conserve water.)

Which pathophysiological mechanism that occurs in the lung allows pneumonia to develop in the post-op client? A.pulmonary edema B.pleuritis C.bronchiectasis D.atelectasis

d (Rationale:Common causes of respiratory problem for postoperative patients in the clinical unit are atelectasis and pneumonia, especially after abdominal and thoracic surgery. without intervention atelectasis can progress to pneumonia when microorganisms grow in the stagnant mucus and an infection develops)

The nurse understands that which client would be at greatest risk for a fluid imbalance? A.A 15-year-old mowing the lawn on a hot day. B.A healthy 65-year-old with a fractured wrist. C.A 52-year-old client who is vomiting. D.An infant with diarrhea.

d (Rationale:Infant has higher body fluid content than older clients. Infant's fluid status would be affected more rapidly than the others.)

While caring for a client with generalized edema and low albumin, what type foods might the nurse recommend? A.Low in salt B.High in vitamins A & C C.Low in zinc D.High in protein

d (Rationale:The lack of plasma protein is allowing the fluid to leave the vascular space and enter the interstitial space. A diet high in protein would be recommended)

How should the nurse interpret the following arterial blood gas results: pH 7.49, PaO2 86 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mEq/L? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis

d (Rationale:The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3)

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

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

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How would the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d (The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.)