unit 4 NCLEX

A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client's serum albumin is 1.5 g/dL (150 mg/dL), the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL (300 mg/dL). When evaluating the client's response to fluid replacement, what determines when the nurse should prepare to administer a colloid? 1 Globulin is 3 g/dL (300 mg/dL) Correct 2 Albumin is below 2 g/dL (200 mg/dL) 3 Hematocrit is below 32% 4 Urine specific gravity is 1.018

Administration of a colloid is indicated when the serum albumin decreases below 2 g/dL (200 mg/dL); then, albumin must be administered to increase the level to the expected range of 3.5 to 5.5 g/dL (350 to 550 mg/dL). This increases the oncotic pressure and prevents the shift of fluid out of the intravascular compartment. A globulin of 3 g/dL (300 mg/dL) is within the expected parameters of 2.3 to 3.4 g/dL (230 to 430 mg/dL). A hematocrit level of 32% is low and indicates overhydration; administration of a colloid will increase this problem. The urine specific gravity is within the expected limits of 1.010 to 1.030.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that applyOlive oil Correct 2 Chicken broth Correct 3 Enriched whole milk Correct 4 Red meats, such as beef 5 Vegetables and whole grains Correct 6 Liver and other glandular organ meats

Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.

After reviewing the laboratory reports, the nurse anticipates that the client has renal impairment. Which test reports support the nurse's concern? Select all that apply. 1 Serum albumin: 4.7 g/dL(6.815 µmol/L) Correct 2 Serum creatinine: 2.0 mg/dL (176.8 µmol/L) Correct 3 Serum potassium: 5.9 mEq/L (5.9 mmol/L) 4 Serum cholesterol: 120 mg/dL (3.108 mmol/L) Correct 5 Blood urea nitrogen: 32 mg/dL (11.424 mmol/L)

Renal impairment is marked by increased serum creatinine concentration, blood urea nitrogen, and potassium ion concentration levels. The normal serum creatinine concentration lies between 0.5 and 1.5 mg/dL (44.2-132.6 µmol/L). A serum creatinine value of 2.0 mg/dL (176.8 µmol/L) indicates renal impairment. The normal concentration of potassium ions in serum ranges from 3.5 to 5 mEq/L (3.5-5 mmol/L). A potassium ion concentration of 5.9 mEq/L(5.9 mmol/L) indicates kidney dysfunction. The normal value of blood urea nitrogen (BUN) lies between 7 and 20 mg/dL (2.45-7.14 mmol/L). A BUN value of 32 mg/dL (11.424 mmol/L) indicates renal impairment. The normal range of serum albumin concentration lies between 3.5 to 5.5 g/dL (5.075-7.975 µmol/L). A cholesterol value less than 200 mg/dL (5.18 mmol/L) is normal.

The primary healthcare provider has prescribed an intravenous piggyback (IVPB) to be administered every 4 hours. The prescription is 1200 mg vancomycin, which must be added to 50 mL D5W after being diluted according the pharmacy's instructions. After the nurse dilutes the powdered medication with the correct amount of saline, the resulting solution contains 1 gram of drug per 3 mL. How much antibiotic solution should be added to the 50 mL of D5W? Record your answer using one decimal place. ___ mL

The prescribed dose is 1200 mg. The available concentration of drug is 1 g/3 mL. The prescribed dose should first be converted to the available concentration. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be added to 50 mL D 5W.

A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply. Correct 1 Lethargy Correct 2 Thready, weak pulse Correct 3 Muscle weakness 4 Hyperactive deep tendon reflexes Incorrect 5 Numbness and tingling of the hands and feet

Altered mental status, including lethargy, occurs with hypokalemia; a thready, weak pulse occurs in hypokalemia because of an impaired conduction system in the cardiac muscle. Muscular weakness may occur with hypokalemia because impulse conduction of skeletal muscles is impaired. An adequate level of potassium is necessary for effective functioning of the sodium-potassium pump. Hyperactive reflexes and numbness and tingling of the hands and feet indicate hyperkalemia, not hypokalemia.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list? Select all that apply. Correct 1 Epistaxis Correct 2 Hematuria Correct 3 Hemarthrosis Correct 4 Easy bruising 5 Frequent fevers 6 Fast clotting of injuries Correct 7 Dark-colored tarry stools

Epistaxis, also known as nosebleeds, is a common symptom of a lack of clotting factor. Hematuria (blood in the urine) may be grossly apparent. The child may experience joint pain and deformities from bleeding into joints. Excessive bruising will occur from bleeding into tissue with seemingly minor injuries. Dark-colored tarry consistency stools are indicative of gastrointestinal bleeding. Frequent fevers are not associated with hemophilia. Prolonged clotting times occur with this condition.

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply. Smoker Correct 2 Twin gestation 3 Hemoglobin of 12 g/dL (120 mmol/L) Incorrect 4 Term delivery 2 years ago 5 Caffeine intake of 180 mg/day 6 Fasting blood sugar of 80 mg/dL (4.4 mmol/L)

Smokers generally have a nutrient-poor diet and are at risk for continuing the same diet through pregnancy. Multifetal pregnancies require nutrition above the normal requirements for pregnancy. A hemoglobin reading of 12 g/dL (120 mmol/L) and fasting blood sugar of 80 mg/dL (4.4 mmol/L) are normal values. Caffeine intake of 180 mg/day is less than the daily recommended intake.

When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. 1 Diarrhea 2 Seizures 3 Chvostek sign 4 Cardiac dysrhythmias 5 Increased temperature

Sodium is the most abundant cation in the extracellular fluid and functions as part of the sodium/potassium pump. In the presence of a deficit, the client will exhibit confusion, lethargy, diarrhea, and seizures. Spasm of the facial muscles following a tap over the facial nerve (Chvostek sign) indicates hypocalcemia. Cardiac dysrhythmias are associated with increases or decreases in potassium and calcium. An increase in body temperature reflects a possible infection, not an electrolyte imbalance.

The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care? Sensory deprivation Correct 2 Urinary tract infection 3 Frequent use of diuretics 4 Inaccessibility of a bathroom

Urinary incontinence in older adults can be a sign of urinary tract infection. Urinary tract infections affect the genitourinary tract and interfere with voluntary control of micturition. Sensory deprivation is a neurologic, not a genitourinary, factor. Frequent use of diuretics is an iatrogenic, not genitourinary, factor. Inaccessibility of a bathroom is an environmental, not genitourinary, factor.