9

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gas

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis - Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

Ask the patient about allergies to latex or iodine

A patient is admitted with a diagnosis of renal failure, That patient complains of stomach distress and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having?

B. 5 mEq/L

Which medication does the nurse anticipate administering to antagonize the effects potassium on the hear for a patient in severe metabolic acidosis?

B. magnesium sulfate

What clinical indication of hypophosphatemia does the nurse assess in a patient?

B. paresthesia

What food would the nurse provide for a patient who has hypokalemia?

Bananas

D. 135 mEq/L (135 mmol/L) Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.

Below which serum sodium concentration might convulsions or coma occur? A. 145 mEq/L (145 mmol/L B. 140 mEq/L (140 mmol/L) C. 142 mEq/L (142 mmol/L) D. 135 mEq/L (135 mmol/L)

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? PO2 Carbonic acid Bicarbonate PaO2

Bicarbonate

Bicarbonate - Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system - The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system.

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system - The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. Therefore options A and C are incorrect. Option D does not exist, it is only a distractor for this question.

The most common buffer system in the body is the

Bicarbonate-carbonic acid-buffer system

Which of the following are the insensible mechanisms of fluid loss?

Breathing

A patient is admitted with severe vomiting for 24 hours as well as weakness and feeling exhausted. The nurse observes flat T waves and ST segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete?

C. 2.0 mEqL

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patients laboratory work was returned?

C. calcium

With which condition should the nurse expect that a decrease in serum osmolality will occur?

C. kidney failure

Calcium

Trousseau's sign is elicited by which of the following?

Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Renal failure Red blood cell crenation Red blood cell hydrolysis Cerebral edema

Cerebral edema

You are instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?

Cheese

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest Pain - Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

Which electrolyte is a major anion in body fluid? Potassium Chloride

Chloride

A. Increases the clients desire to consume fluid Explanation: The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.

Clients diagnosed with hypervolemia should avoid sweet or dry food because it A. increases the client's desire to consume fluid. B. can lead to weight gain. C. an cause dehydration. D. obstructs water elimination.

How are calcium levels regulated?

Combined actions of parathyroid hormone and vitamin D.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion

The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following?

Confusion

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

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

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Correct response: Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Correct response: Lactated Ringer's solution Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

Correct response: active transport Explanation: Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Decreased blood pressure Bradycardia Crackles in the lung fields Shortness of breath Distended neck veins

Crackles in the lung fields Shortness of breath Distended neck veins

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

Dark, concentrated urine

A 73-year-old male client was admitted to your hospital unit after 2days of vomiting and diarrhea. His wife became alarmed when he demonstrated confusion and elevated temperature and reported "dry mouth."You suspect the client is experiencing which of the following conditions?

Dehydration

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?

Dehydration

A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

Distended neck veins

C. increased breathing effort and weight gain. Explanation: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

Early signs of hypervolemia include A. moist breath sounds. B. thirst. C. increased breathing effort and weight gain. D. a decrease in blood pressure.

"I can use laxatives and enemas but only once a week."

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? "I'll drink cranberry juice with my breakfast instead of coffee." "I need to check to see whether my cola beverage has potassium in it." "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them."

"I will not salt my food; instead I'll use salt substitute."

Factors that contribute to hypercalcemia

*Hyperparathyroidism *malignant tumors *immobilization because of multiple fractures *thiazide diuretics

Factors that contribute to hyperphosphatemia

*Kidney failure *neoplastic disease chemotherapy

Factors that contribute to hypomagnesemia

*alcohol abuse *diarrhea *gentamicin administration *untreated ketoacidosis

Factors that contribute to Hypokalemia

*alkalosis *vomiting *gastric suction *anorexia nervosa *hyperaldosteronism *furosemide (Lasix) administration *steroid administration *penicillin administration

Factors that contribute to hypophosphatemia

*hyperparathyroidism *major thermal burns *alcohol withdrawal

Things respiratory alkalosis causes

*hypoxemia *gram-negative bacterial infection

Factors that contribute to hypermagnesemia

*kidney failure

Things Metabolic acidosis causes

*lactic acidosis *ketoacidosis *diarrhea

Factors that contribute to hypocalcemia

*massive administration of citrated blood *pancreatitis *kidney failure * aminoglycoside administration

Things respiratory acidosis causes

*sedative overdose *severe pneuomonia *acute pulmonary edema

Factors that contribute to Hyperkalemia

*tourniquet too tight when collecting a blood sample *leukocytosis *kidney failure *adrenal steroid deficiency

Factors that contribute to Hyponatremia

*vomiting *diarrhea *diuretics *adrenal insufficiency *syndrome of inappropriate antidiuretic hormone *excessive parenteral administration of dextrose and water solution

Things metabolic alkalosis causes

*vomiting *hypokalemia

Factors that contribute to Hypernatremia

*watery diarrhea *Inability to quench thirst *burns over a large surface area *heat stroke *status post-therapeutic abortion *diabetes insipidus with water restriction

Isotonic Solutions:

-0.9% NS (crystalloid) -Lactated Ringers (crystalloid)

Hypotonic Solutions (<0.9% NS)

-5% Dextrose in water (crystalloid, starts as hypotonic, becomes iso) -0.45% NS (crystalloid)

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply.

-Blood urea nitrogen (BUN) of 23 mg/dL -Serum osmolality of 310 mOsm/kg -Serum sodium of 148 mEq/L -Urine specific gravity of 1.03

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.

-pH -HCO3 -PaCO2

A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering?

0.45% NaCl

Which of the following solutions is hypotonic?

0.45% NaCl

Which solution is hypotonic?

0.45% NaCl

Which solution is hypotonic? 0.9% NaCl 0.45% NaCl Lactated Ringer solution 5% NaCl

0.45% NaCl

A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer?

0.45% sodium chloride A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. An isotonic solution (0.9%) is not desirable as a supplement because it provides Na and CL.

Which is considered an isotonic solution?

0.9% normal saline

Which of the following is considered an isotonic solution?

0.9% normal saline

A 77-year-old retired male client visits your general practice office twice monthly to maintain control of his congestive heart failure. He measures his weight daily and phones it to your office for his medical record. In a 24-hour period, how much fluid is this client retaining if his weight increases by 2 lb?

1 L

The average daily urinary output in an adult is

1.5 L

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects? 135 mEq/L 148 mEq/L 114 mEq/L 130 mEq/L

114 mEq/L

A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1600 mg of sodium daily?

12a

A 42-year-old client has chronic hypo natremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur?

135 mEq/L

BELOW which serum sodium level may convulsions or coma can occur?

135 mEq/L

Below which serum sodium level may convulsions or coma can occur?

135 mEq/L

A patient who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue and a body temperature of 99.3°F. The urine specific gravity is 1.020. What is the most likely serum sodium value for this patient?

155 mEq/L

The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following?

155 mEq/L

A 160-pound patient, diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the patient loses 1,000 mL of fluid in 24 hours. Choose the weight that would be consistent with this amount of fluid loss.

158 lbs

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 165 mEq/L 145 mEq/L 110 mEq/L 130 mEq/L

165 mEq/L

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 minutes

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

280 mOsm/kg

Hypertonic Solutions (>0.9%)

3% Saline 5% Saline 5% Dextrose in 0.45% Saline 5% Dextrose in 0.9% Saline 5% Dextrose in Lactated Ringers 10% Dextrose in water

The normal serum value for potassium is

3.5 to 5.5 mEq/L.

About ____ % of the 6 liters of total blood volume is plasma

50 %

The upper and lower blood pH levels that are incompatible with life are _____ and ______ ?

6.8 on lower range; 7.8 on upper range

About ______ of total body fluid is in the intracellular space

66%

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.35 7.45 7.50 7.30

7.50

A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following?

7.50

Cardiac effects of hyperkalemia are usually present when the serum potassium level reaches

8 mEq/L

serum calcium level

8.5-10

It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL.

9.8 mg/dL

A normal oxygen saturation value for arterial blood is

95%

A. Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesiu

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. Potassium B. Phosphorous C. Sodium D. Chloride

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

D. No, sodium intake should be restricted Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? A. No, start with the sodium chloride IV. B. Yes, along with the hypotonic IV. C. Yes, this will correct the sodium deficit. D. No, sodium intake should be restricted.

D. Third-spacing Explanation: Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anascara is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? A. Anascara B. Hypovolemia C. Pitting-edema D. Third-spacing

Presence of Trousseau sign Explanation: After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? A. Muscle weakness B. Negative Chvostek sign C. Presence of Trousseau sign D. Slurred speech

D. Serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A. Serum creatinine level of 0.4 mg/dl B. Hematocrit of 52% C. Serum blood urea nitrogen (BUN) level of 8.6 mg/dl D. Serum sodium level of 124 mEq/L

C. electrocardiogram (ECG) results Explanation: 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 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.respiratory rate. B. neuromuscular function. C. electrocardiogram (ECG) results. D. bowel sounds.

B. 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? A. Lactated Ringer solution B. 0.45% NaCl C. 0.9% NaCl D. 5% NaCl

A. Drink water as an expensive way to meet fluid needs D. Respond to thirst E. Drink at least eight glasses of fluid each day Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. A. Drink water as an inexpensive way to meet fluid needs B. Drink carbonated beverages to help balance fluid volume. C. Drink caffeinated beverages to retain fluid. D. Respond to thirst E. Drink at least eight glasses of fluid each day.

D. malignancy is causing the electrolyte imbalance. Explanation: The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the A. client may be developing hyperaldosteronism. B. client has a history of alcohol abuse. C. client's diet is lacking in calcium-rich food products. D. malignancy is causing the electrolyte imbalance.

C. 280 mOsm/kg. Explanation: Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of: A. 230 mOsm/kg. B. 250 mOsm/kg. C. 280 mOsm/kg. D. 210 mOsm/kg.

A. Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? A. Jugular vein distention B. Polyuria C. Weight loss D. Tetanic contractions

A.Provide oral care every 2-3 hours. Explanation: Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? A. Provide oral care every 2-3 hours. B. Assess the client's weight daily for trends. C. Teach the client about increased fluid intake. D. Monitor for signs and symptoms of dehydration.

D. Hypercalcemia Explanation: The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? A. Hyperkalemia B. Hypokalemia C. Hypocalcemia D. Hypercalcemia

D. Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? A. Specific gravity of 1.02 B. Absence of protein C. Absence of glucose D. Urine pH of 3.0

C. Calcium Explanation: Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

B. Tingling or twitching sensation in the fingers Explanation: All the choices are signs and symptoms of hypocalcemia, but tetany is the most characteristic manifestation that occurs when the calcium level is less than 4.4 mg/dL

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? A. Hyperactive bowel sounds. B. Tingling or twitching sensation in the fingers C. Dyspnea and laryngospasm D. Confusion and depression

B. Fatigue, cramps and weakness Explanation: A serum potassium level of 2.7 mEq/L constitutes hypokalemia. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), arrhythmias, and increased sensitivity to digitalis. Respiratory symptoms, dysphagia, and tetany are not typically associated with hypokalemi

A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? A. Confusion and decreased level of consciousness B. Fatigue, cramps, and weakness C. Shortness of breath, rales, and peripheral edema D. Dysphagia, tetany, and emotional lability

D. Sodium level of 150 mEq/L Explanation: Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? A. Potassium level of 3.8 mEq/L B. Sodium level of 137 mEq/L C. Potassium level of 6 mEq/L D. Sodium level of 150 mEq/L

C. 275-300 mOsm/kg Explanation: In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c)

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? A. <136 mOsm/kg B. 350-544 mOsm/kg C. 275-300 mOsm/kg D. >408 mOsm/kg

B. Lactated Ringers Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? A.5% Dextrose in NS B. Lactated Ringers C. 0.45% NS D. 10% dextrose in water

A. Monitoring respiratory status for signs and symptoms of pulmonary complications Explanation: 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 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. Encouraging the client to consume sodium-free fluids. C. Drawing a blood sample for typing and crossmatching. D. Establishing I.V. access with a large-bore catheter.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?

A. .45% sodium chloride

The nurse notes that a patient's urine osmolality is 980 mOsm/kg. What should the nurse assess as a possible cause of this finding?

A. acidosis

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient?

A. assessing for symptoms of nausea and malaise C. monitoring neurologic status D. restricting tap water intake

What foods can the nurse recommend for the patient with hypokalemia?

A. fruits such as bananas and apricots

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic

The human body is an intricate mechanism which maintains homeostasis through a multitude of chemical reactions. The measureable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid?

Acids - Acids are substances that release hydrogen into fluid. The delicate balance of fluid, electrolytes, acids, and bases is ensured by an adequate intake of water and nutrients, physiologic mechanisms that regulate fluid volume, and chemical processes that buffer the blood to keep its pH nearly neutral.

You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful?

Administer Sodium Bicarbonate IV - When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered.

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? Administer small volumes of a hypertonic solution. Restrict fluids and salt for 24 hours. Correct the sodium deficit rapidly with salt. Monitor the serum sodium for changes hourly.

Administer small volumes of a hypertonic solution

Which is the most common cause of symptomatic hypomagnesemia?

Alcoholism

D. Hypokalemia Explanation: Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A. Hyperkalemia B. Hypernatremia C. Hypophosphatemia D. Hypokalemia

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? A)Intracellular fluid B)Extracellular fluid C)Interstitial fluid D)Intravascular fluid

Ans: A Feedback: About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? A) Potassium: 5.8 mEq/L B) Sodium: 138 mEq/L C) Magnesium: 2 mEq/L D) Calcium: 10 mg/dL

Ans: A Feedback: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.

Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? A)Metabolic acidosis B)Respiratory alkalosis C)Metabolic alkalosis D)Respiratory acidosis

Ans: A Feedback: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) - (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state? A)Compensated respiratory alkalosis B)Uncompensated respiratory alkalosis C)Compensated metabolic acidosis D)Compensated metabolic alkalosis

Ans: A Feedback: The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27 mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).

The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression? A)Decreased abdominal girth B)Increased level of consciousness C)Weight maintenance D)Pulse rate decrease

Ans: A Feedback: Third-spacing is the translocation of fluid from the intravascular to intercellular space to tissue compartment. Anasarca is the general edema in the organ cavities such as the abdomen. Monitoring the abdominal girth provides data on the localization of the fluid in the interstitial space. A decrease in girth, in particular, notes improvement. Level of consciousness is not affected unless shock occurs. Weight remains the same as there is a shifting in fluid; pulse rate could fluctuate according to fluid movement.

You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should you do? A)Seek a physician's order to dilute the infusion. B)Switch to an oral formulation. C)Increase the speed of transfusion. D)Change the electrolyte.

Ans: A Feedback: 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.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. A)An elevated hematocrit level B)A low urine specific gravity C)Electrolyte imbalance D)Low protein level in the urine E)Absence of ketones in urine

Ans: A, C Feedback: Dehydration is a common primary or secondary diagnosis in healthcare. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.

A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply. A)Drink at least eight glasses of fluid each day. B)Drink caffeinated beverages to retain fluid. C)Drink carbonated beverages to help balance fluid volume. D)Drink water as an inexpensive way to meet fluid needs. E)Respond to thirst.

Ans: A, D, E Feedback: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits

The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a class of sixth graders. Which action by bases keeps the blood pH nearly neutral? A)Bases cast off acids. B)Bases bind with hydrogen. C)Bases hold acidic properties. D)Bases have no contact with acids.

Ans: B Feedback: Acids are substances that release hydrogen into fluid, bases are substances that bind with hydrogen. The delicate balance between acids and bases, as well as fluids and electrolytes, maintains the nearly neutral blood pH.

The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students that the average daily fluid intake for an adult is? A)2000 mL B)2500 mL C)3000 mL D)3500 mL

Ans: B Feedback: In healthy adults, oral fluid intake averages about 2500 mL/day; however, it can range between 1800 and 3000 mL/day, with a similar volume of fluid loss.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A)Low heart rate B)Elevated blood pressure C)Rapid respiration D)Subnormal temperature

Ans: B Feedback: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur? A)Respiratory alkalosis B)Metabolic alkalosis C)Respiratory acidosis D)Metabolic acidosis

Ans: B Feedback: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.

The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis? A)A blood pressure elevation upon rising or activity B)A drop in systolic blood pressure (15 mmHg) upon rising C)A pulsating headache D)A drop in diastolic blood pressure (25 mm Hg) upon rising

Ans: B Feedback: Postural hypotension occurs when the client rises from a supine or semi-Fowler's position to a standing position and the systolic blood pressure drops by 15 mm Hg. The client has symptoms of dizziness or a near syncopal episode.

Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing? A)Initiate an IV of an isotonic solution. B)Initiate an IV of albumin. C)Manage an infusion of plasma. D)Manage an infusion of total parenteral nutrition.

Ans: B Feedback: The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin. Administration of albumin pulls the trapped fluid back into the intravascular space. An isotonic solution will not pull water from the intercellular space. Blood products are used for third-spacing management; however, albumin is the product of choice. The management of total parenteral nutrition is not associated with third-spacing.

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid? A)Isotonic fluid B)No intravenous solution C)Hypertonic solution D)Hypotonic solution

Ans: B Feedback: There are three types (tonicity) of intravenous fluids, which are isotonic, hypotonic, and hypertonic solutions. By process of osmosis and diffusion, solutes are moved through the body. A hypertonic solution is used to pull water back in to circulation as a hypertonic solution has more particles than the body's water. An isotonic solution is the same concentration as the body's water and is used as an intravenous volume expander. A hypotonic solution has fewer particles than the body's water thus shifting water from the vascular space to the tissue.

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? A)Abnormal potassium level B)Elevated hematocrit level C)Low white blood count D)Low urine specific gravity

Ans: B Feedback: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? A)Endocrine system B)Gastrointestinal system C)Neurological system D)Musculoskeletal system

Ans: C Feedback: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A) A 7-year-old with a fracture tibia B) A 65-year-old with a myocardial infarction C) A 52-year-old with diarrhea D) A 72-year-old with a total knee repair

Ans: C Feedback: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic patients will not likely have an electrolyte imbalance. Myocardial infarction patients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage? A)A grilled chicken sandwich with mayonnaise B)A natural fruit salad with nuts C)A hot dog with catsup D)A fresh grilled tuna entrée with fresh asparagus

Ans: C Feedback: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.

You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition? A)Dehydration B)Hypokalemia C)Hypocalcemia D)Hypomagnesemia

Ans: C Feedback: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding.

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia? A)Hypervolemia B)Hypercalcemia C)Hypomagnesemia D)Hypermagnesemia

Ans: C Feedback: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? A)Similar causes are present in both conditions. B)Hypovolemia contains only low blood volume. C)In dehydration, only extracellular is depleted. D)Both conditions result in abnormal laboratory studies.

Ans: C Feedback: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? A)Kidney and liver B)Heart and lungs C)Lungs and kidney D)Pancreas and stomach

Ans: C Feedback: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate? A)Call the physician with the report. B)Encourage the client to deep breath. C)Complete a head-to-toe assessment. D)Obtain an ECG.

Ans: C Feedback: The nurse realizes that a pH level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.

What is one process by which dissolved chemicals from one area of the body to another? A)Passive osmosis B)Free flow C)Passive elimination D)Active transport

Ans: D Feedback: Active transport requires an energy source, a substance called adenosine triphosphate (ATP), to drive dissolved chemicals from an area of low concentration to an area of higher concentration—the opposite of passive diffusion.

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? A)Osmosis B)Passive diffusion C)Facilitated diffusion D)Active transport

Ans: D Feedback: Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? A)PaO2 B)PO2 C)Carbonic acid D)Bicarbonate

Ans: D Feedback: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? A)Vital signs B)Edema C)Intake and output D)Weight

Ans: D Feedback: Daily weight provides the ability to monitor fluid status. A 2-lb weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output don't account for insensible fluid loss.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? A)Cool and pale skin B)Crackles in the lung fields C)Distended jugular veins D)Dark, concentrated urine

Ans: D Feedback: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? A)Lung function B)Summer allergies C)Cardiovascular compromise D)Insensible fluid loss

Ans: D Feedback: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.

. The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH? A)The lungs are unable to breathe in sufficient oxygen. B)The lungs are unable to exchange oxygen and carbon dioxide. C)The lungs have ineffective cilia from years of smoking. D)The lungs are not able to blow off carbon dioxide.

Ans: D Feedback: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system. Although individuals with COPD frequently have a history of smoking, cilia is not the cause of the acidosis.

The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid? A)Eight to 10 glasses of water per day B)Foods high in sodium C)Potassium-rich fruit D)Beverages with alcohol or caffeine

Ans: D Feedback: The nursing management of clients with hypovolemia is to restore fluid balance. The nurse provides nutritional information and instructs the client to avoid beverages with alcohol and caffeine, which increases urination and contributes to the fluid deficits. The clients should drink 8 to 10 glasses of water daily, include sodium in the diet, and eat potassium-rich fruit.

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? A)Yes, this will correct the sodium deficit. B)Yes, along with the hypotonic IV. C)No, start with the sodium chloride IV. D)No, sodium intake should be restricted.

Ans: D Feedback: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? A)Suggest a fluid restriction. B)Encourage oral fluids. C)Remove the Hemovac. D)Offer a prescribed antiemetic medication.

Ans: D Feedback: When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration. A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation.

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client? A)Slow heart rate B)Kidney stones and blood clots C)Imbalance in electrolytes D)Elevated central venous pressure (CVP)

Ans: B Feedback: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below 4 cm H2O.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Elevated blood pressure Rapid respiration Low heart rate Subnormal temperature

Elevated blood pressure

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Elevated hematocrit level Low urine specific gravity Low white blood count Abnormal potassium level

Elevated hematocrit level

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Respiratory acidosis Altered blood urea nitrogen (BUN) value Extracellular fluid volume deficit Metabolic alkalosis SUBMIT ANSWER

Extracellular fluid volume deficit

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme Anxiety - Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Myasthenia gravis Type 1 diabetes mellitus Opioid overdose Extreme anxiety

Extreme anxiety

Which nerve is implicated in the Chvostek's sign?

Facial

B. Osmosis Explanation: Osmosis is the movement of water through a semipermeable membrane; one that allows some but not all substances in a solution to pass through from a diluted area to a more concentrated area. Filtration promotes the movement of fluid and some dissolved substances through a semipermeable membrane according to pressure differences. Evaporation is the process of converting water into a vapor. Active transport requires the energy source ATP to drive dissolved chemicals from an area of low concentration to an area of higher concentration; the opposite of passive diffusion.

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? A. Filtration B. Osmosis C. Active transport D. Evaporation

When an elderly client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing

Fluid overload

B. muscle weakness. Explanation: Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: A. diaphoresis B. muscle weakness C. constipation D. tremors.

What foods can the nurse recommend for the patient with hypokalemia?

Fruits such as bananas and apricots

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? a) Generalized b) Dependent c) Brassy d) Pitting

Generalized, there may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca. Options B and D are not part of the process of third-spacing fluid. Option C is a distractor for this question.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?

Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a HIGH-sodium diet, and should be restricted (2 to 3 g/day)?

Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings?

Hypercalcemia

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? Hyperglycemia Hypernatremia Hyperkalemia Hypercalcemia

Hyperkalemia

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance? Hypocalcemia Hyponatremia Hyperchloremia Hypermagnesemia

Hypocalcemia

The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances?

Hypocalcemia

You are caring for a client that has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia - Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings?

Hypokalemia

A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances?

Hypokalemia

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia

During his annual physical exam, your 72-year-old male client complains of muscle cramps in his calves and that he feels "tired a lot." He is taking ethacrynic acid (Edecrin) for his hypotension. Your client will be evaluated for which of the following electrolyte imbalance based on his symptoms?

Hypokalemia

D. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Hypomagnesemia is particularly troublesome during treatment of alcohol withdrawal. Therefore, the serum magnesium level should be routinely measured in patients undergoing withdrawal from alcohol. TPN, heart disease, and lymphoma are not identified as central risk factors for the development of hypomagnesemia.

Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? A. A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL) B. An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction C. A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery D. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use

Which could be a potential cause of respiratory acidosis? Hypoventilation Hyperventilation Diarrhea Vomiting

Hypoventilation

Which of the following may occur with respiratory acidosis?

Increased Intracranial Pressure (ICP) - If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increased arterial pH - Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? Decreases arterial pH Provides long-term pH regulation Increases arterial pH No effect

Increases arterial pH

You are doing an admission assessment on an elderly patient newly admitted for end-stage liver disease. You must assess the patient's skin turgor. What should you remember when evaluating skin turgor?

Inelastic skin turgor is a normal part of ageing

Insensible fluid loss

Instruct the client to breathe into a paper bag.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer an ordered decongestant. Administer ordered supplemental oxygen. Offer the client fluids frequently. Instruct the client to breathe into a paper bag.

Instruct the client to breathe into a paper bag.

Instruct the client to breathe into a paper bag. - The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

Explain why the administration of a 3% to 5% sodium chloride solution requires intense monitoring.

Intense supervision is required because only small volumes are needed to elevate the serum sodium from dangerously low levels

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Extracellular fluid Intravascular fluid Interstitial fluid Intracellular fluid

Intracellular fluid

Third space fluid shift

Intravascular fluid volume deficit

What is blood urea nitrogen?

It is made up of urea. It is an end product of protein(muscle and dietary) metabolism by the liver.

What is urine specific gravity?

It measures the kidney's ability to excrete or conserve water.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

JVD

The nurse monitors a patient who is being evaluated for hyperkalemia. She is aware that ECG changes and serum potassium levels are diagnostic. Which of the following are the earliest changes that the nurse should report?

K+ = 7 mEq/L; peaked T waves

With which condition should the nurse expect that a decrease in serum osmolality will occur? Hyperglycemia Uremia Kidney failure Diabetes insipidus

Kidney failure

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia - The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidney

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Phosphorus Potassium Magnesium Calcium

Magnesium

The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely?

Magnesium

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic Acidosis - This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic Acidsosis - The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic Alkalosis - A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

Metabolic Alkalosis - Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

Metabolic acidosis

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic alkalosis Respiratory alkalosis Respiratory acidosis Metabolic acidosis

Metabolic acidosis

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Metabolic acidosis

A 75-year-old client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which of the following acid-base imbalances?

Metabolic alkalosis

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis SUBMIT ANSWER

Metabolic alkalosis

Name the primary complication of hyperphosphatemia which occurs when the calcium-magnesium product exceeds 70mg/dL?

Metastatic calcification of soft tissue, joints, and arteries

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications

What is the mathematical formula that a nurse would use to approximate the value of serum osmolality?

Na * 2 = glucose divided by 18 + BUN divided by 3

When teaching a patient about foods that affect fluid balance, the nurse would advise the patient to decrease:

Na+

No, sodium intake should be restricted

A nurse monitoring a patient's IV infusion auscultates the patient's lung sounds and finds crackles in the bases in lungs that were previously clear. What would be the appropriate intervention in this situation?

Notify primary care provider immediately for possible fluid overload

Which is a correct route of administration for potassium?

Oral

Which of the following is a correct route of administration for potassium?

Oral

A. Hypothalamus Explanation: Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus

Oral intake is controlled by the thirst center, located in which of the following cerebral areas? A. Hypothalamus B. Cerebellum C. Brainstem D. Thalamus

Sodium, the most abundant electrolyte in extracellular fluid, is primarily responsible for maintaining fluid _____, which ______________________________.

Osmolality; affects the movement of water between fluid compartments.

The calcium concentration in the blood is regulated by which mechanism? Parathyroid hormone (PTH) Thyroid hormone (TH) Androgens Adrenal gland

Parathyroid hormone (PTH)

The major positively charged ion in intracellular fluid is

Potassium

Which electrolyte is a major cation in body fluid?

Potassium

Which of the following electrolytes is a major cation in body fluid?

Potassium

Which of the following electrolytes is a major cation in body fluid?

Potassium is a major cation that affects cardiac muscle functioning. Chloride is an anion. Bicarbonate is an anion. Phosphate is an anion.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEq/L

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

Potassium: normally 3.5-5.0.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation. - Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Muscle weakness Presence of Trousseau sign Slurred speech Negative Chvostek sign

Presence of Trousseau sign

A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance?

Presence of Trousseau's sign

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?

Provide oral care every 2-3 hours.

A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant?

Provide oral care every 2-3 hours.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/l). The nurse determines that which of the following is a possible cause for these findings?

Pulmonary embolus.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Pulse Respirations Blood pressure Temperature

Pulse

In a patient who loses bicarbonate from the body, how does it get replaced?

Renal tubular cells generate new bicarbonate.

Bicarbonate is stored in which structure when the body needs a buffer?

Renal tubule

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory Alkalosis - A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory Alkalosis - Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Respiratory Alkalosis - This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition?

Respiratory acidosis

Respiratory alkalosis

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis - A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

Respiratory alkalosis - Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

Respond to thirst Drink water as an inexpensive way to meet fluid needs. Drink at least eight glasses of fluid each day.

Respond to thirst. Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs.

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?

Send the client for a chest x-ray.

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? Obtain written consent for the procedure. Send the client for a chest x-ray. Assess the client's blood pressure (BP) on the right arm. Administer the prescribed IV fluids.

Send the client for a chest x-ray.

Osmoreceptors

Sense changes in sodium concentration

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L - Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum creatinine level of 0.4 mg/dl Serum blood urea nitrogen (BUN) level of 8.6 mg/dl Serum sodium level of 124 mEq/L Hematocrit of 52%

Serum sodium level of 124 mEq/L

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Shock - Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Potassium level of 3.8 mEq/L Potassium level of 6 mEq/L Sodium level of 150 mEq/L Sodium level of 137 mEq/L

Sodium level of 150 mEq/L

What foods can the nurse recommend for the patient with hypokalemia?

Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains

List four of six symptoms associated with air embolism, a complication of intravenous therapy.

Symptoms include dyspnea, cyanosis, a weak pulse, hypotension, unresponsiveness, and pain (chest, shoulder, low back ).

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Tachycardia

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

Tachycardia

The nurse is caring for a 12-month-old infant with dehydration and metabolic acidosis. What symptom does the nurse document as congruent with dehydration and metabolic acidosis?

Tachypnea.

What is osmotic pressure?

The amount of hydrostatic pressure needed to stop the flow of water by osmosis. It is primarily determined by the concentration of solutes.

D. Parathyroid hormone (PTH) Explanation: The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.

The calcium concentration in the blood is regulated by which mechanism? A. Adrenal gland B. Androgens C. Thyroid hormone (TH) D. Parathyroid hormone (PTH)

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago.

What is creatinine?

The end product of muscle metabolism, is a better indicator of renal function than blood urea nitrogen

The lungs are not able to blow off carbon dioxide

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? The lungs are not able to blow off carbon dioxide. The lungs are unable to breathe in sufficient oxygen. The lungs have ineffective cilia from years of smoking. The lungs are unable to exchange oxygen and carbon dioxide.

The lungs are not able to blow off carbon dioxide.

The body of a critically ill client may use which of the following mechanisms to maintain normal pH?

The lungs eliminate carbonic acid by blowing off more CO2.

B. Insensible fluid loss Explanation: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? A. Summer allergies B. Insensible fluid loss C. Cardiovascular compromise D. Lung function

D. "I can use laxatives and enemas but only once a week." Explanation: The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? A. "A good breakfast for me will include milk and a couple of bananas." B. "I will take a potassium supplement daily as prescribed." C. "I will be sure to buy frozen vegetables when I grocery shop." " D. "I can use laxatives and enemas but only once a week."

B. Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A. Rapid respiration B. Elevated blood pressure C. Subnormal temperature D. Low heart rate

C. Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? A. Phosphorus B. Calcium C. Magnesium D. Potassium

C. Hypocalcemia Explanation: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? A. Hypokalemia B. Hypomagnesemia C. Hypocalcemia D. Dehydration

C. Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? A. Headache B. Seizures C. Confusion D. Hallucinations

C. Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? A. Distended jugular veins B. Crackles in the lung fields C. Dark, concentrated urine D. Cool and pale skin

D. A 52-year-old with diarrhea Explanation: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A. A 72-year-old with a total knee repair B. A 65-year-old with a myocardial infarction C. A 7-year-old with a fracture tibia D. A 52-year-old with diarrhea

B. Cardiac volume intolerance Explanation: The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? A. An increased sense of thirst B. Cardiac volume intolerance C. Increase in nephrons in the kidneys D. Increased renal blood flow

B. In dehydration, only extracellular is depleted. Explanation: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? A. Similar causes are present in both conditions B. In dehydration, only extracellular is depleted. C Hypovolemia contains only low blood volume. D. Both conditions result in abnormal laboratory studies.

D. The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? A. Urine becomes more diluted. B. The client has a decreased sensation of thirst. C. The frequency of voiding increases. D. The renal system retains more water.

A. "I will not salt my food; instead I'll use salt substitute." Explanation: The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? A. "I will not salt my food; instead I'll use salt substitute." B. "I need to check to see whether my cola beverage has potassium in it." C. "I'll drink cranberry juice with my breakfast instead of coffee." D. "Bananas have a lot of potassium in them; I'll stop buying them."

A, B, C & E Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.) A. vomiting B. drinking milk C. urination D. eating a sandwich E. infusion of intravenous solution

C. The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

B. Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? A. Magnesium:2 mEq/L B. Potassium: 5.8 mEq/L C. Sodium: 138 mEq/L D. Calcium: 10 mg/dL

A nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values for a client diagnosed with heatstroke. Blood gas values are pH 7.48, pCO2 34, pO2 95, CO2 23, HCO3 22, and SO2 98%. What nursing interventions demonstrate the nurse's understanding of the patient's ABG's and knowledge of Maslow's hierarchy of needs when providing care for this patient?

The nurse prepares for endotracheal intubation and mechanical ventilation for the client.

A. 115 mEq/L Explanation: Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? A. 115 mEq/L B. 160 mEq/L C. 145 mEq/L D. 130 mEq/L

A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements?

The patient's malignancy is causing the electrolyte imbalance

D. 0.45% Sodium chloride Explanation: Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? A. 5% glucose in normal saline solution B. 0.9% sodium chloride C. 5% glucose in water D. 0. 45% sodium chloride

A. sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

The primary extracellular electrolytes are: A. sodium, chloride, and bicarbonate. B. magnesium, sulfate, and carbon. C. phosphorous, calcium, and phosphate. D. potassium, phosphate, and sulfate.

A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see peaks.

The second hump

B. 1 L Explanation: A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? A. 500 ml B. 1 L C. 1500 ml D. 1250 ml

What are baroreceptors?

They are responsible for monitoring the circulating volume. They are small nerve receptors that detect changes in pressure within blood vessels.

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

Third-spacing

This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid...(more) This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation?

Tingling or twitching sensation in the fingers

B. Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Explanation: Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? A. Three ounces of sliced ham, beets, and a salad B. Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad C. A frozen, packaged low-fat dinner with a side salad D. Tomato juice, low-fat cottage cheese, and three slices of bacon

Hypocalcemia causes what sign

Trousseau's sign in the hands and Chvostek sign in the face

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Absence of protein Absence of glucose Urine pH of 3.0 Specific gravity of 1.02

Urine pH of 3.0

Which of the following may be the first sign of respiratory acidosis in anesthetized patients?

Ventricular fibrillation

D. Fruits such as bananas and apricots Explanation: Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains (Crawford & Harris, 2011b).

What foods can the nurse recommend for the patient with hypokalemia? A. Nuts and legumes B. Green, leafy vegetables C. Milk and yogurt D. Fruits such as bananas and apricots

D. Hematocrit level of greater than 47% E. Urine specific gravity of 1.027 A. Urine osmolality of greater than 450 mOsm/kg Explanation: Hypovolemia is associated with a hematocrit level that is greater than normal because there is a decreased plasma volume and a BUN elevated out of proportion to the serum creatinine (ratio greater than 20:1). Urine specific gravity is increased in relation to the kidneys' attempt to conserve water. Urine osmolality can be greater than 450 mOsm/kg because the kidneys try to compensate by conserving water. Hypovolemia is not associated with blood in the urine.

What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? (Select all that apply.) A. Urine osmolality of greater than 450 mOsm/kg B. Urine positive for blood C. BUN: serum creatinine ratio of greater than 12.1 D. Hematocrit level of greater than 47% E. Urine specific gravity of 1.027

B. 80 Explanation: To maintain the potassium balance, the renal system must function, because 80% of the potassium excreted daily leaves the body by way of the kidneys. The other numerical values are incorrect.

What percentage of potassium excreted daily leaves the body by way of the kidneys? A. 40 B. 80 C. 20 D. 60

B. Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority.

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? A. Weight loss of 4 lb B. Irregular heart rate C. Blood pressure 96/53 mm Hg D. Mild confusion

B. Chloride Explanation: Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are cations.

Which electrolyte is a major anion in body fluid? A. Calcium B. Chloride C. Sodium D. Potassium

C. Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? A. Tetany and increased blood urea nitrogen (BUN) levels C. Confusion and seizures C. Flaccidity and thirst D. Sunken eyeballs and spasticity

A. Infant Explanation: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances.

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? A. Infant B. School-age child C. Adolescent D. Young adult

D. Oral Explanation: Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.

Which is a correct route of administration for potassium? A. Subcutaneous B. Intramuscular C. IV (intravenous) push D. Oral

D. Breathing Explanation: Loss of fluid from sweat or diaphoresis is referred to as insensible loss because it is unnoticeable and immeasurable. Losses from urination and bowel elimination are measurable. Nausea does not result in fluid loss, however if the client would develop emesis ( vomiting) this would be considered loss of body fluids and would need measured.

Which is an insensible mechanism of fluid loss? A. Urination B. Nausea C. Bowel elimination D. Breathing

C. 0.9% NS Explanation: An isotonic solution is 0.9% normal saline (NaCl). Dextran in normal saline is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.

Which is considered an isotonic solution? A. 3% NaCl B. Dextran in NS C. 0.9% NS D. 0.45% NS

A. Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia

Which is the most common cause of symptomatic hypomagnesemia? A. Alcoholism B. Burns C. Intravenous drug use D. Sedentary lifestyle

B. Sodium Explanation: Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? A. Potassium B. Sodium C. Calcium D. Magnesium

B. Dehydration Explanation: 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.

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

A. Start IV fluids and blood products Explanation: This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.

You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you? A. Start IV fluids and blood products B. Restrict fluids C. Administer a diuretic D. Increase sodium intake

A. Limit salt and water intake Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? A. Limit salt and water intake B. Teach client behaviors that decrease urination C. Assess for dehydration D. Give medications that promote fluid retention

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. a)PaCO2 b)HCO3 c)K+ d)Glucose e)Na+ f)pH

a,b,f

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. a)Cyanosis b)Hypertension c)Tachycardia d)Dyspnea e)Crackles on auscultation f)Shoulder pain

a,c,d,f

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. a)Respond to thirst b)Drink carbonated beverages to help balance fluid volume. c)Drink water as an inexpensive way to meet fluid needs. d)Drink caffeinated beverages to retain fluid. e)Drink at least eight glasses of fluid each day.

a,c,e

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. a)Tachypnea b)Hypotension c)Weakness d)Dehydration e)Lethargy

a,c,e

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level ?

a. 115 mEq/L

What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient?

a. hematocrit level of >47% c. urine specific gravity of 1.027 d. urine osmolality of >450 mOsm/kg

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer? free flow passive elimination passive osmosis active transport

active transport

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

alcoholism

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs:

are unable to blow off carbon dioxide.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. a)Administer IV bicarbonate. b)Document presenting signs and symptoms. c)Maintain intake and output records. d)Compare ABG findings with previous results. e)Suction the client's airway.

b,c,d,

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be ?

b. 275-300 mOsm/kg

What does the nurse recognize as one of the indicators of the patient's renal function?

b. serum creatinine

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations?

b.oliguria, c. tachycardia, e. tachypnea

Which of these ions plays an important role in pH homeostasis?

bicarbonate

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system

bicarbonate-carbonic acid buffer system

The primary concentration of phosporus (85%) is located in the ______ with about 15% located in _______

bones; soft tissue

A patient who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue and a body temperature of 99.3F. The urine specific gravity is 1.020. What is the most likely serum sodium value for this patient?

c. 155 mEq/L

In a patient with excess fluid volume, hyponatremia is treated by restricting fluids to how many milliliters in 24 hours ?

c. 800 mL

The nurse is caring for a patient with hypernatremia. What complication of hypernatremia should the nurse continuously monitor for?

c. cerebral edema

A patient with mild volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this patient?

c. hydroDiuril

THe nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and low plasma bicarbonate concentration should the nurse assess for

c. metabolic acidosis

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 130 mEq/L (130 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is consistent with the client's symptoms? calcium 12.9 mg/dL (3.2 mmol/L) chloride 94 mEq/L (94 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) sodium 137 mEq/L (137 mmol/L)

calcium 12.9 mg/dL (3.2 mmol/L)

A client with emphysema is at a greater risk for developing what acid-base imbalance?

chronic respiratory acidosis

A client with emphysema is at a greater risk for developing which acid-base imbalance?

chronic respiratory acidosis

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

electrocardiogram (ECG) results

comprises the intravascular, interstitial, and transcellular fluid

extracellular fluid compartment

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? no intravenous solution hypertonic solution isotonic fluid hypotonic solution

hypertonic solution

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

hypocalcemia

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hyperkalemia hypocalcemia hypercalcemia hypokalemia

hypokalemia

Which finding would be expected in a client with chest trauma, rib fractures, and respiratory acidosis?"

hypoventilation due to inability to take deep breaths because of pain

Early signs of hypervolemia include

increased breathing effort and weight gain

Early signs of hypervolemia include:

increased breathing effort and weight gain

Early signs of hypervolemia include: thirst. a decrease in blood pressure. increased breathing effort and weight gain. moist breath sounds.

increased breathing effort and weight gain

comprises fluid surrounding cell

interstitial space

comprises about 60% of body fluid

intracellular space

Space where plasma is contained

intravascular space

A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for which symptom?

irritability

Clients diagnosed with hypervolemia should avoid sweet or dry food because

it increases the client's desire to consume fluid

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the client's diet is lacking in calcium-rich food products. client has a history of alcohol abuse. malignancy is causing the electrolyte imbalance. client may be developing hyperaldosteronism.

malignancy is causing the electrolyte imbalance.

malignancy is causing the lyte imbalance

metabolic acidosis

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

metabolic alkalosis

A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?

metabolic alkalosis and hypokalemia

A male client tells the nurse that he takes antacid tablets several times each day. Knowing that the brand of antacid he uses contains calcium carbonate, the nurse cautions the client that overuse could place him at risk for:

metabolic alkalosis.

Sodium establishes the electrochemical state necessary for ________ and the ____________.

muscle contraction; transmission of nerve impulses

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness

Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid-electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

osmosis

Oncotic pressure refers to the amount of pressure needed to stop the flow of water by osmosis. number of dissolved particles contained in a unit of fluid. osmotic pressure exerted by proteins. excretion of substances such as glucose through increased urine output.

osmotic pressure exerted by proteins

A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood?

The nursing student asks their instructor what the term is for the amount of hydrogen ions in a solution. What should the instructor respond?

pH - The symbol pH refers to the amount of hydrogen ions in a solution; pH can range from 1, which is highly acidic, to 14, which is highly basic. All other options are incorrect.

The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14-

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 - Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg - 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 nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which electrocardiogram changes will the client display? elevated ST segment peaked T waves prolonged T waves shortened PR interval

peaked T waves

A neonate weighing 1,870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding?

resolves the metabolic acidosis

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition?

respiratory acidosis

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?

respiratory acidosis

A patient in the ICU starts complaining of being "short 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?

respiratory acidosis

As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance?

respiratory acidosis

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

respiratory acidosis

respiratory alkalosis

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

respiratory alkalosis

respiratory alkalosis. - This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

The major positively charged ion in extracellular fluid is

sodium ions

The most characteristic manifestations of hypocalcemia and hypomagnesemia is

tetany

Sodium is regulated by

thirst, antidiuretic hormone, and the renin-angiotensin aldosterone system

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? flank pain polyuria tingling sensation in the fingers hypertension

tingling sensation in the fingers

The smallest compartment of the extracellular fluid space

transcellular space

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:

trousseau's sign

The extracellular space is divided into three compartments

vascular, interstitial, and transcellular

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? edema weight vital signs intake and output

weight

Which of the following is a function of calcitonin? Select all that apply

• Reduces bone resorption • Increases urinary excretion of calcium • Increases deposition of calcium in bones

The normal blood pH is ______

7.35-7.45

Which is an insensible mechanism of fluid loss?

Breathing

The calcium concentration in the blood is regulated by which mechanism?

Parathyroid hormone (PTH)

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching?

"I can use laxatives and enemas but only once a week."

For the child diagnosed with an asthma attack, which manifestation would best correlate with the child's arterial blood gas results, which include pH of 7.46, bicarbonate of 21 mEq/L (21 mmol/L), and a partial pressure of carbon dioxide (PCO2) of 33 mm Hg (4.4 kPa)?

tingling sensation in the fingertips

Which of the following solutions is hypotonic

0.45% NaCl

Which of the following is the most common cause of symptomatic hypomagnesemia?

Alcoholism is currently the most common cause of symptomatic hypomagnesemia. IV drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.

To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client's arterial blood gas (ABG) results? Select all that apply.

Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus, Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus.

Which of the following would be a potential cause of respiratory acidosis?

Hypoventilation

If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.

On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L. Based on these values, the nurse should prioritize which nursing diagnosis for this client?

Impaired gas exchange

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.

Which finding may occur with respiratory acidosis?

Increased intracranial pressure (ICP)

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH

Metabolic alkalosis

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

What function does the kidney perform to assist in maintaining acid-base balance within the necessary normal range?

Return bicarbonate to the body's circulation

A priority nursing intervention for a client with hypervolemia involves which of the following?

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.

Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make?

`The client is severely hypoxic.

During shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance is the client most likely experiencing?

compensated respiratory alkalosis

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

extreme anxiety

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube on low continuous suction. Which acid-base imbalance is most likely to occur?

metabolic alkalosis

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate in a client with these arterial blood gas results?

increase in rate and depth of respirations

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

lungs and kidneys

metabolic acidosis

A client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation?

metabolic acidosis

The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client reports headache and nausea. Based on the serum laboratory results, how would the nurse interpret the client's acid-base balance?

metabolic acidosis

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?

metabolic acidosis

A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication?

metabolic alkalosis

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?

metabolic alkalosis

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance?

metabolic alkalosis

Arterial blood gas analysis would reveal which finding related to acute respiratory failure?

pH 7.24

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

The nurse is reviewing the results of a patient's arterial blood gas and pH analysis. Normal findings include: (Select all that apply.)

pH 7.45 PCO2 40 mm Hg Base excess or deficit +2 mmol/L

When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting?

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

partial pressure of arterial oxygen (PaO2)

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

partial pressure of arterial oxygen (PaO2) of 69 mm Hg

A client has these arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?

respiratory acidosis

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance?

respiratory acidosis

respiratory alkalosis.

A client has just been diagnosed as being in status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of:

respiratory alkalosis.

A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases?

serum bicarbonate of 28 mEq/L

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

shock

Which of the following may be the first sign of respiratory acidosis in an anesthetized client?

9

Set pelajaran terkait

Chapter 8- Minerals & Water

Chapter 6

Herbs and Spices

MODULE 1

Social Resp & Ethics Ch 4

Behaviors- Interpersonal Violence

Final Exam

NURS 233- Quiz 1

MKT 6309 Exam 1

MACROECON CH 4

Research Methods Part 1 Ch 2

Ch.9

MYERS Ch.15 Quiz

Chapter 9

PEDS: Practice Questions (Exam 3)

NOBCChE Science Bowl: MATH Set 5

Chapter 9

Biology keystone

Insurance Test

Chapter 1 Quiz