345 exam 1

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the client's mobility when selecting a site. C) Have the client briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes.

Consider potential effects on the client's mobility when selecting a site.

Baroreceptors in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A) Decrease in the release of aldosterone B) Increase of filtration in the Loop of Henle C) Decrease in the reabsorption of sodium D) Decrease in glomerular filtration

Decrease in glomerular filtration

The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration

Diffusion

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

Diminished deep tendon reflexes

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A) Maintain a low sodium diet B) Encourage the use of over-the-counter calcium supplements C) Ensure the client has sufficient potassium intake D) Encourage fluid intake

Ensure the client has sufficient potassium intake

Diagnostic testing has been prescribed to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill client. What health problem often precedes normal anion gap acidosis? A) Metastases B) Excessive potassium intake C) Water intoxication D) Excessive administration of chloride

Excessive administration of chloride

The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? A) Extravasation of the medication B) Discomfort to the client C) Blanching at the site D) Hypersensitivity reaction to the medication

Extravasation of the medication

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status

Fluid volume status

One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal? A) Help distinguish hyponatremia from hypernatremia B) Help evaluate pituitary gland function C) Help distinguish reduced renal blood flow from decreased renal function D) Help provide an effective treatment for hypertension-induced oliguria

Help distinguish reduced renal blood flow from decreased renal function

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

Hydrostatic pressure resulting from the pumping action of the heart

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

Hypercalcemia

The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? A) Hypocalcemia B) Hyponatremia C) Hyperchloremia D) Hypophosphatemia

Hyperchloremia

The perioperative nurse has completed the presurgical assessment of an 82-year-old female client who is scheduled for a left total knee replacement. When planning this client's care, the nurse should address the consequences of the client's aging cardiovascular system. These include an increased risk of which of the following? A) Hypervolemia B) Hyponatremia C) Hyperkalemia D) Hyperphosphatemia

Hypervolemia

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

Hypocalcemia

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

Hypocalcemia

The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

Hypovolemia

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

Hypovolemic shock

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

Increased serum sodium

The nurse is performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in clients over 70.

Inelastic skin turgor is a normal part of aging.

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should you document this complication related to IV therapy? j A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

Infiltration

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. What assessment finding would suggest that the client's potassium levels are too low? A) Diarrhea B) Large amounts of dilute urine C) Increased muscle tone D) Joint pain

Large amounts of dilute urine

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, 1cI stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. 1d What would be the nurse's best response? A) 1cI will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup. B) Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids. C) It is normal to be a little confused following surgery, and it is safe not to urinate at night. 1d D) If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. 1d

Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids.

The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's admission total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly? A) Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. D) Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate.

Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.

The emergency-room nurse is caring for a trauma client. Your client has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

Metabolic acidosis with a compensatory respiratory alkalosis

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

Metabolic alkalosis

The nurse is providing discharge teaching to a client who had hypophosphatemia during his time in hospital. The client has a diet prescribed that is high in phosphate. What foods should you teach this client to include in his diet? Select all that apply. A) Milk B) Beef C) Poultry D) Green vegetables E) Liver

Milk Poultry Liver

The ICU nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 23 mEq/L. The nurse should recognize the likelihood of what acid-base disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acid-base disorder

Mixed acid-base disorder

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

Osmosis and osmolality

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

Respiratory acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

Respiratory alkalosis

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations

Shallow respirations

The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change? A) Substantially reduced renal function B) Acute kidney injury C) Decreased cardiac output D) Alterations in ratio of body fluids to muscle mass

Substantially reduced renal function

A nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, A client in kidney disease partially loses the ability to regulate changes in pH. 1d What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

A client comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. D) The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? A) The client's calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the client's intracranial pressure and create confusion. C) Oxygen may cause the client to hyperventilate and become acidotic. D) Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should A) ensure that anticoagulants are placed on hold for the duration of IV therapy. B) replace the IV dressing with a new, clean dressing if it is soiled. C) ensure that the tubing is firmly anchored to the client's skin. D) periodically remove hair from 2 cm around the IV site.

ensure that the tubing is firmly anchored to the client's skin.