EAQ Module 1 NSG 1140

Which IV solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration?

0.9% sodium chloride

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? a. Skin condition b. Fluid and electrolyte balance c. Food intake d. Fluid intake and output

B. Fluid and electrolyte balance

I high finding by the nurse when assessing a client who is receiving IV fluids indicates need for a change in the fluid infusion rate?

Crackles in lungs

The nurse gave a client the prescribed sodium polystyrene sulfonate. Which assessment finding indicates that the medication has been effective? a. Control of diarrhea b. An increase in serum sodium level c. An increase in serum calcium level d. A decrease in serum potassium level

D. A decrease in serum potassium level

Which action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and a blood pressure pressure of 102/56 mm Hg?

Offer oral fluids at frequent intervals

When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia?

Paresthesias

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Use lemon juice to season meat.

Which action would the circulating nurse classify as a priority during surgery?

- protecting clients privacy - assessing blood loss and urine - providing supplies and equipment on the basis of the surgical team's needs

Symptoms that indicate hyperthermia

- vasodilation - dry and flushed skin - decreases urinary output

Which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client?

Increased expired carbon dioxide

Which process is responsible for the shift of body fluids associated with the IV administration of albumin?

Osmosis

Which physiological function is the last function lost during anesthesia induction? Gag reflex Eyelid reflexes Voluntary control Respiratory movement

Respiratory movement Rationale: There is no respiratory movement in stage 4 of anesthesia; before this stage, respirations are depressed but present. The gag reflex is lost in stage 3 of anesthesia. Eyelid reflexes are lost in stage 2 of anesthesia. Voluntary control is lost in stage 2 of anesthesia.

Which clinical manifestation would the nurse expect when a client develops internal bleeding after abdominal surgery? - pallor - polyuria - bradypnea - tachycardia - hypertension

- pallor - tachycardia RATIONALE: Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.

For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply. 1. Thirst 2. Anorexia 3. Leg cramps 4. Rapid, thread pulse 5. Dry mucous membranes

2. Anorexia 3. Leg cramps RATIONALE: The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased Peristalsis [1] [2]. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst is associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia. Dry mucous membranes are associated with hypernatremia.

Which actions will the nurse take when preparing a client before thoracentesis? Select all that apply. One, some, or all responses may be correct. A. Assist the client to sit up on the edge of the bed. B. Remind the client not to eat before the procedure. C. Instruct the client to rest the arms on the bedside table. D. Verify that the client has signed the informed consent form. E. Educate the client about when to cough during the procedure.

ANS: A, C, D Rationale: A- The client is usually positioned sitting up at the side of the bed or seated facing backward on a chair so that the posterior thorax is exposed. C- The client will rest the arms on the bedside table, which increases the size of the intercostal spaces. D- Informed consent is needed before thoracentesis. B- Because no sedation or general anesthesia is needed for thoracentesis, the client does not need to refrain from eating before the procedure. E- The client should be instructed to avoid coughing or moving during the procedure to decrease risk for pneumothorax.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. Diplopia Skin rash Leg cramps Tachycardia Muscle weakness

Ans: leg cramps, muscle weakness Rationale: Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.

Which response by the nurse asked "How will they know me out for this colonoscopy?" Described the route of administration for conscious sedation?

"You will receive medication through an IV catheter"

A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? (Select all that apply.) 1.Weight loss 2.Negative nitrogen balance 3.Increased urine specific gravity 4.Excessive loss of potassium ions 5.Pronounced retention of sodium ions

1.Weight loss 4.Excessive loss of potassium ions

Which adverse effect would a nurse monitor for when caring for a client receiving furosemide to relieve edema?

Hypokalemia

A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience:

sore throat

As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse as a leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply.

Surgery procedures Name of the surgeon Description of the risks

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? A. Seizures B. Confusion C. Thirst D. Erythema E. Constipation

A. Seizures B. Confusion RATIONALE: Confusion and seizures are associated with hyponatremia. Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures. Thirst is a symptom of hyper-natremia; it may indicate dehydration. Erythema is not associated with hyponatremia. Diarrhea is associated with hyponatremia.

Nursing action after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

Atelectasis

Which symptom in a client receiving hydrochlorothiazide would cause a nurse to notify the health care provider? A. Insomnia B. Nasal congestion C. Increased thirst D. Generalized weakness

D. Generalized weakness Rationale: Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy. Insomnia is not known to be related to hypokalemia or hydrochlorothiazide therapy. Although a stuffy nose is unrelated to hydrochlorothiazide therapy, it can occur with other antihypertensive medications. Increased thirst is associated with hypernatremia. Because this medication increases excretion of water and sodium in addition to potassium and chloride, hyponatremia, not hypernatremia, may occur.

The nurse is reviewing the blood test reports of a child whose blood sample was tested after receiving a general anesthetic. The nurse finds that the client has increased intracellular calcium levels. What medication would be beneficial to the client? Aspirin (Anacin) Naproxen (Aleve) Ibuprofen (Advil) Dantrolene (Dantrium)

Dantrolene (Dantrium) Rationale The administration of general anesthetic sometimes causes malignant hyperthermia in clients. Malignant hyperthermia is characterized by increased levels of intracellular calcium in the body. Dantrolene sodium (Dantrium) reduces the muscle tone and metabolism and thereby decreases the calcium levels in the body. Therefore dantrolene is used to antagonize the effects of malignant hyperthermia in this client. Aspirin (Anacin) should not be given to children because it increases the risk of Reye syndrome. Drugs such as naproxen (Aleve) and ibuprofen (Advil) may not reduce calcium levels in the body and thus may not be used to reverse the effects of malignant hyperthermia in the client.

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low sodium diet?

Decreased fluid retention

Which initial action would the nurse take when obtaining consent for surgery?

Determine whether the client's knowledge level is sufficient to give consent

Which prescription would the nurse question when a client's serum sodium is 123 mEq/L?

Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h

A client with parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the clients clinical manifestations?

hypercalcemia