232 EXAM 2
Which should the nurse include when teaching a client with clostridium difficile about decreasing the risk of transmission to family members? A. Increase fluid intake B. A high-fiber diet C. Soap and water for handwashing D. Wash hands with an alcohol-based hand sanitizer
C
Which site would the nurse use to insert Vitamin K to a newborn? A. Deltoid muscle B. Rectus femoris C. Vastus Lateralis D. Gluteus Maximus
C
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? A. Metabolic alkalosis caused by excessive production of acid metabolites B. Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide C. Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid D. Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
C
A client is receiving furosemide. For which sign for hypokalemia will the nurse monitor the client? A. Chvostek Sign B. Muscle Weakness C. Anxious behavior D. Abdominal cramping
B
Which clinical manifestation is indicative of the fluid and electrolyte imbalance associated with a parathyroidectomy? A. Constipation B. Muscle spasms C. Hypoactive reflexes D. Increased specific gravity
B
Which finding for a client who has potassium level 2.8 mEq/L(2.8 mmol/L) would be of most concern to the nurse? A. Abdominal cramps B. irregular heart rate C. Decreased reflexes D. Muscle weakness
B
Which statement by the student nurse indicated the need for further education about medication administration? A. "I should set up and prepare medications in distraction-free areas?" B. "I should advise the certified medical assistant to administer intravenous medication." C. "I should be vigilant during the entire process of medication administration." D. " I should identify each client using at least two identifiers before administering medication"
B
The nurse is caring for an infant whose vomiting is intractable. Which complication is likely to occur? A. Acidosis B. Alkalosis C. Hyperkalemia D. Hypernatremia
B. Alkalosis
How do the kidneys regulate sodium in the ECF?
By excreting or retaining water under the influence of ADH (aldosterone)
Which action would a nurse anticipate taking when a client with anxiety begins hyperventilating and reports feeling dizzy? A. Administering oxygen B. Offering an incentive spirometer C. Having the client breathe in and out of a paper bag D. Administering intravenous sodium bicarbonate
C
After the nurse has taught a client about a 2-gram sodium diet, which client statement indicated that the teaching has been effective? A. "My fluid intake should be restricted" B. "I should limit the number of daily food servings" C. "Cheese can be added to my luncheon meat sandwiches" D. "I will read labels on prepackages food products before purchase"
D
The clients serum sodium is 123 mEq/L(123 mmol/L). Which prescription would the nurse question? A. Add table salt to each meal B. Fluid restriction of 1000 mL per day C. Assess neurological status every 2 hours D. Provide 0.45% sodium chloride (NaCl) intravenously at 125 mL/h.
D
Coarse crackles in the lower long fields
overhydration
Furosemide(Lasix) 40 mg PO daily
overhydration
The medication prescribed for an infant is to be given intramuscularly. Which site will the nurse select for administration of the medication? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid
A
The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicated effective learning? A. Administering sodium polystyrene sulfonate B. Instructing a client to increase potassium and sodium intake C. Monitoring glucose levels hourly D. Providing potassium-sparing diuretics
A
Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L(6.7 mmol/L)? A. Monitor for cardiac dysrhythmias B. Inquire about changes in bowel patterns C. Assess for leg muscle twitching or weakness D. Assess for signs and symptoms of dehydration
A
A health care provider prescribes enoxaparin 30 mL subcutaneously daily. Which measure would the nurse take when administering this medication? A. Push over 2 minutes B. Administer in the abdomen C. Massage site after administration D. Remove air pocket from prepackaged syringe before administration
B
Based on the electrocardiogram (ECG) , a client is suspected to have hypokalemia. Which test would be used to confirm hypokalemia? A. Complete blood count B. Serum potassium level C. Arterial blood gas panel D. Urine osmolality test
B
Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? A. Respiratory acidosis B. Respiratory alkalosis C. Respiratory compensation D. Respiratory decompensation
B
Which category of isolation would the nurse implement for a client who is positive for clostridium difficile? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Protective environment
C
A critically ill 5-year-old child exhibits Kussmaul Respirations. Which would the nurse suspect may be causing an increasing acid-base imbalance? A. Metabolic alkalosis caused by an increase in base bicarbonate B. Respiratory alkalosis caused by excess carbon dioxide (CO2) output C. Respiratory acidosis caused by an accumulation of CO2 D. Metabolic acidosis caused by a concentration of cations in body fluids
D
An intravenous solution containing potassium inadvertently infused too rapidly. The client is prescribed insulin added to a solution 10% dextrose in water. Which would the nurse identify the purpose of the insulin? A. Glucose with insulin increases metabolism, which accelerates potassium excretion B. Increased potassium causes a temporary slowing of the pancreatic production of insulin C. Increased insulin accelerates the excretion of glucose and potassium, thereby decreasing the potassium serum level. D. Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level.
D
Fluid restriction of 1500 mL/Day(may be ordered if fluid overloaded)
overhydration
edema
overhydration
local infection
pathogens are limited to a small area of the body
contact precautions have what
wash hands, gloves, gown
A client has been admitted with a diagnosis of intractable vomiting and can tolerate only sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). The client is likely experiencing which condition? A. Hypernatremia B. Hyponatremia C. Hyperkalemia D. Hypokalemia
B. Hyponatremia
The nurse teaches a client about the dangers of using sodium bicarbonate regularly. Which effect of sodium bicarbonate is the nurse trying to prevent? A. Gastric distention B. Metabolic alkalosis C. Chronic constipation D. Cardiac dysrhythmias
B. Metabolic alkalosis
Which clinical finding would the nurse evaluate before continuing the administration of intravenous (IV) magnesium sulfate therapy? A. Temperature and respirations B. Patellar reflexes and urinary output C. Urinary glucose and specific gravity D. Level of consciousness and funduscopic appearance
B. Patellar reflexes and urinary output
Which change in arterial blood gases does the nurse expect to occur as a result of hyperventilation due to anxiety? A. Respiratory acidosis B. Respiratory alkalosis C. Respiratory compensation D. Respiratory decompensation
B. Respiratory alkalosis
When preparing to assess a client with active Tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room? A. Isolation gown B. Surgical mask C. Shoe covers D. N95 respiratory mask
D
The nurse places a school aged child with bacterial meningitis in isolation with droplets precautions. Which is the purpose of these precautions? A. They keep the child away from uninfected people B. The infectious process is interrupted as quickly as possible C. The child is protected from contracting a secondary infection D. They prevent the development of a hospital-acquired infection
A
Which findings are consistent with hypercalcemia after prolonged immobility? select all that apply. A. Bone pain B. Convulsions C. Muscle spasms D. Tingling of extremities E. Depressed deep tendon reflexes
A and E
The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would the infection belong to? A. Primary B. Secondary C. Superinfection D. Nosocomial
D
Which consideration would the nurse make when preparing to give a preschooler an intramuscular injection in the vastus lateralis site? A. The anterior third of the vastus lateralis is used to give an injection B. The vastus lateralis site is used to inject volumes greater than 10 mL C. The child should keep the knee straight to receive an injection at the vastus lateralis site D. The maximum recommended length of the needle insertion at the vastus lateralis site is 1 inch for preschoolers
D
A client with the diagnosis of Cushing syndrome has the following laboratory results: Na+(sodium) 149 mEq/L (149 mmol/L; K+ (potassium) 3.2 mEq/L(3.2 mmol/L); Hg (hemoglobin) 17g/dL (170 mmol/L); and glucose 90mg/dL (5 mmol/ L). Based on these lab results, which instructions would the nurse include in the teaching plan for this client? A. Avoid foods high in salt B. Restrict your fluid intake C. Eat foods high in potassium D. Limit your carbohydrate intake E. Continue your regular diet as before
A and C
___ serum calcium levels stimulate the release of calcitonin from the parathyroid gland. Calcitonin has the _____________ effect of PTH. It lowers the serum calcium level by increasing calcium _______________ into bone, increasing renal calcium excretion, and decreasing GI absorption.
high, opposite, deposition
droplet precautions
influenza, mumps, rubella, pertussis, diphtheria
A________ relationship exists between phosphorous and______.
inverse, calcium
Serum sodium 149 mEq/L(increased)
underhydration
Sticky mucous membranes
underhydration
Supine position(to help with low BP)
underhydration
Urine output 50mL in 2 hours(decreased urine output)
underhydration
Which statement made by a student nurse indicates the need for further learning about assessing for respiratory system manifestations of alkalosis? select all that apply A. "I should assess for an increased rate of ventilation in respiratory alkalosis" B. "I should assess for a decreased depth of ventilation in respiratory alkalosis" C. "I should assess for a decreased rate of ventilations in respiratory alkalosis" D. "I should assess for an increased depth of ventilation in respiratory alkalosis" E. " I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis"
B and C
Bacteremia
bacteria in the blood
Where is most phosphorous found in the body?
bones and teeth
Clinically, hypomagnesemia resembles hypo____
calcemia
acute infection
comes on rapidly, with severe but short-lived effects
Endogenous
originate from clients themselves
Exogenous
originate from hospital environment and hospital personnel
3 G sodium restriction (may be ordered to not hold onto more fluid)
overhydration
BP 155/98(hypertension)
overhydration
We all know that calcium is important for bones and teeth. What other functions does calcium have?
- Blood __Clotting (coagulation)_________ - Transmission of ____Nerve________ impulses - Myocardial (heart) ___contraction________________ - ____Muscle___________ contractions
Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer?
2 tablets
Levothyroxine 25 mcg daily is prescribed for a client with hypothyroidism. The pharmacy dispensed levothyroxine 12.5 mcg per tablet. How many tablets will the nurse instruct the client to take daily?
2 tablets
Nitrofurantoin 0.1 g is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets will the nurse administer?
2 tablets
Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1 mg scored tablets. How many tablets will the nurse administer?
2.5 tablets
Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets should the nurse administer?
3 tablets
A nurse prepares to administer oxybutynin 30 mg orally. Each tablet contains 5 mg. How many tablets will the nurse administer?
6 tablets
A healthcare provider prescribes guaifenesin 300 mg four times a day. The dosage strength is 200 mg/5 mL. How many mL will the nurse administer for each dose?
7.5 mL
Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How many mL will the nurse administer?
8 mL
The nurse is teaching a client who is taking a loop diuretic about foods that are high in potassium. Which foods would the nurse emphasize? select all that apply A. Bananas B. Apricots C. Roasted chicken D. Macaroni and cheese E. Baked potatoes with skins
A, B and E
Which food would the nurse recommend for a client who is to begin a 2-g sodium diet? A. Beef steaks B. Mushrooms C. Aged cheese D. Luncheon meats E. Cooked broccoli
A, B, E
The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicated effective learning? A. Administering sodium polystyrene sulfonate B. Instructing a client to increase potassium and sodium intake C. Monitoring glucose levels hourly D. Providing potassium-sparing diuretics
A. Administering sodium polystyrene sulfonate
An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which psychologic imbalances would the nurse most likely encounter? Select all that apply. A. Hypovolemia B. Hyperkalemia C. Hypercalcemia D. Metabolic Acidosis E. Decreased Hematocrit
A. Hypovolemia and D. Metabolic Acidosis
What does the nurse consider to be the priority nursing intervention for a client on diuretic therapy who has developed metabolic alkalosis? A. preventing falls B. Monitoring electrolytes C. Administering antiemetics D. Adjusting the diuretic therapy
A. Preventing falls
Potassium also plays a role in _________-__________ balance
Acid-base
Which information must be clearly documented in the medication administration record (MAR) before administering a medication? Select all that apply. A. Dosage and route B. Clients full name C. Time to be administered D. Frequency of administration E. Full name and prescribed medication
All are correct
chronic infection
An infection of long duration
A client has a prescription for a sublingual nitroglycerin tablet. Which technique will the nurse teach the client to use? A. Place the pill inside the cheek and let it dissolve B. Place the pill under the tongue and let it dissolve C. Chew the pill thoroughly and then swallow it D. Swallow the pill with a full glass of water
B
Which clinical manifestations would the nurse expect to find in a client with hypokalemia? Select all that apply. A. Thirst B. Anorexia C. Leg cramps D. Rapid, thready pulse E. Dry mucous membranes
B and C
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? select all that apply A. Diplopia B. Skin rash C. Leg cramps D. Tachycardia E. Muscle weakness
C and E
Which client indicator(s) would the nurse expect a client with hyperkalemia to exhibit? select all that apply. A. Tetany B. Seizures C. Confusion D. Weakness E. Dysrhythmias
C, D and E
Which clinical manifestations will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? select all that apply A. Anorexia B. Constipation C. Muscle weakness D. Irregular Heart Rhythm E. Hyperactive bowel tones
C, D and E
A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness and lethargy. Which is the primary nursing concern? A. Acute pain B. Risk for injury C. Metabolic alkalosis D. Ineffective breathing
C. Metabolic alkalosis
Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis? A. Assessing the nail beds B. Listening to breath sounds C. Monitoring breathing status D. Checking muscle contractions
C. Monitoring breathing status
Which intravenous fluid is a hypertonic solution? A. Ringer solution B. 5% dextrose in water C. Lactated ringer solution D. 5% dextrose in normal saline
D. 5% dextrose in normal saline
A critically ill 5-year-old child exhibits Kussmaul Respirations. Which would thee nurse suspect may be causing an increasing acid-base imbalance? A. Metabolic alkalosis caused by an increase in base bicarbonate B. Respiratory alkalosis caused by excess carbon dioxide(CO2) output C. Respiratory acidosis caused by an accumulation of CO2 D. Metabolic acidosis caused by a concentration of cations in body fluids
D. Metabolic acidosis caused by a concentration of cations in body fluids
Daily weights(to watch weight gain)
overhydration
Hematocrit 34%(decreased)
overhydration
Intake 4000 mL, output 500 mL
overhydration
Perform daily weights
overhydration
Semi-fowler position(help with increased BP)
overhydration
Serum sodium 130 mEg/L (decreased)
overhydration
Proper phosphate balance requires adequate function of what organs?
Renal, mainly kidneys
A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates administering which intravenous(IV) solution? A. 3% sodium chloride B. 0.9 sodium chloride C. 5% dextrose and 0.9% sodium chloride D. 5%dextrose and lactated ringer solution
B. 0.9% sodium chloride
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? A. Metabolic alkalosis caused by excessive production of acid metabolites B. Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide C. Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid D. Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
C. Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid
Sodium imbalances are typically associated with imbalances in ______ ____________.
ECF Volume
Is potassium mostly in the ICF or the ECF?
ICF
The________ and GI system regulate serum magnesium
Kidneys
What is the primary route for potassium loss?
Kidneys
contact precautions
MRSA, VRE, CRE, scabies, RSV
Compromised Clients Precautions have what
Mask, gown, gloves
Airborne precautions have what
N94 respiratory mask, door closed, wash hands before leaving room, mask on client when leaving room
Weight gain of 5 pounds
Overhydration
droplet precautions have what
PPE, hand hygiene, patient placement, patient transport
Why are neuromuscular and cardiac functions so commonly affected by potassium imbalances?
The ratio of ECF potassium to ICF potassium is the major factor in the resting membrane potential of nerve and muscle cells
Sodium influences _________ distribution between ECF and ICF.
Water
Community infection
acquired in the community, not hospital
nasocomial infection
an infection acquired during hospitalization
systemic infection
an infection throughout the body
Iatrogenic
direct result of diagnostic or therapeutic procedures
septicemia
infection because of the bacteremia that makes you sick
Compromised Clients Precautions
leukemia, chemotherapy, major burns
____ serum calcium levels stimulate the parathyroid glands to produce and release PTH. PTH increases ________ resorption (movement of calcium out of bones), increases GI absorption of calcium, and increases renal tubule reabsorption of calcium.
low, bone
Sodium plays an important role in what three processes:
· Generation and transmission of nerve impulses. · Muscle contractility · Regulation of acid-base balance
In what three forms does sodium leave the body?
· Urine · Sweat · Feces
Airborne precautions
tuberculosis, varicella until dry/crusted, and rubeola
AAO times 2(confusion)
underhydration
BP 95/60(hypotension)
underhydration
BUN 35 mg/dL (D/T dehydration; increased)
underhydration
Hematocrit 50.2%(increased)
underhydration
Increased HR
underhydration
JVD
underhydration
Order for 0.45% NS at 100 mL/HR (to help correct dehydration/dehydrated cell)
underhydration
Patient placed on 3 G sodium restriction
underhydration