Electrolytes Q's

21. In reviewing the results of the clients blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is: 1. Calcium 3.9 mEq/L 2. Sodium 140 mEq/L 3. Potassium 3.5 mEq/L 4. Magnesium 2.1 mEq/L

ANS: 1 A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L. A sodium level of 140 mEq/L is within the normal range of 135 to 145 mEq/L. A potassium level of 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. A magnesium level of 2.1 mEq/L is within the normal range of 1.5 to 2.5 mEq/L.

When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? 1. Neurological 2. Gastrointestinal 3. Pulmonary 4. Hepatic

ANS: 1 Because sodium is necessary for nerve impulse transmission, the priority nursing assessment with hyponatremia is the neurological system.

A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

ANS: 1 Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the bodys fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids.

15. A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of: 1. Cardiac dysrhythmias 2. Severe diarrhea 3. Hyperactive reflexes 4. Peripheral cyanosis

ANS: 1 Lasix is a nonpotassium-sparing diuretic. Without a potassium supplement the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias. Clients with hypokalemia from diuretic use may experience intestinal distention and decreased bowel sounds. Severe diarrhea may be a cause of hypokalemia, not a result of hypokalemia. Clients with hyperactive reflexes may have hypocalcemia. Lasix and digoxin do not predispose a client to hypocalcemia. Peripheral cyanosis is not a potential problem related to the clients medication regimen.

2. A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results? 1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L 2. pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L 3. pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L 4. pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L

ANS: 1 Metabolic acidosis may be found in cases of starvation. The clients pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition.

35. Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

ANS: 1 Physical examination of a hypernatremic client may reveal extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability. The remaining options are examples of hyponatremia, hypokalemia, and hyperkalemia.

40. The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor: 1. Urine output 2. Intake of sodium 3. Activity level 4. Oxygen level

ANS: 1 Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved. For example, the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and ADH are increasingly secreted, causing sodium and chloride retention, potassium excretion, and decreased urinary output. The clients diet most likely has not advanced enough to be concerned about excess sodium intake. The clients activity level is important, and the nurse should encourage her to increase her activity level. The clients oxygen level is also important to monitor, but has no direct effect on the fluid, electrolyte, and acid-base alterations

38. A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of: 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypocalcemia

ANS: 1 Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics.

30. Which of the following foods will have the greatest impact on the water balance of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

ANS: 1 Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food. The remaining options are good sources of potassium, calcium, and magnesium.

8. A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is: 1. 0.45% normal saline (NS) 2. 10% dextrose 3. 5% dextrose in lactated Ringers 4. Dextrose 5% in NS

ANS: 1 The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringers are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.

When the water absorption in the renal tubules becomes greater than normal, the nurse anticipates that the urine will become: 1. more concentrated 2. less concentrated 3. more alkaline 4. less alkaline

ANS: 1 When more water is kept back in the body, the water left to form urine is less; therefore, the urine is more concentrated.

2. A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.) 1. A respiratory rate of 36 breaths per minute 2. Complaints of numbness in fingers and toes 3. Dizziness when attempting to sit upright 4. Difficulty holding a cup because of tremors 5. An irregular heartbeat on an electrocardiogram (ECG) 6. Warm, flushed skin

ANS: 1, 2, 3, 4 Physical examination of a client experiencing respiratory alkalosis may reveal dizziness, confusion, dysrhythmias, tachypnea, numbness and tingling of extremities, convulsions, and coma.

4. A client experiencing diabetic ketoacidosis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Red, flushed skin 2. Verbally aggressive 3. Complaints of dry mouth 4. Crackles in both lung fields 5. Oral temperature of 102.8 F 6. Requiring frequent linen changes

ANS: 1, 2, 3, 5, 6 Physical examination of a client experiencing diabetic ketoacidosis may reveal dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temperature, irritability, convulsions, and coma. The remaining option is not reflective of diabetic ketoacidosis.

1. A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.) 1. Water vapor that is lost through the skin that is burned 2. Plasma and interstitial fluids that are lost as burn exudate 3. Blood leakage via damaged capillaries in the dermis 4. Respiratory acidosis resulting from altered respiratory function 5. Plasma that leaves the intravascular space and becomes trapped in blisters 6. Sodium and water shift that out of the vessels because of increased permeability

ANS: 1, 2, 3, 5, 6 The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume.

6. Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply.) 1. 50-year-old with hypertension 2. 36-year-old with schizophrenia 3. 40-year-old with a fractured femur 4. 15-month-old with diarrhea for 2 days 5. 76-year-old with advanced Alzheimers disease 6. 25-year-old with partial-thickness burns over 40% of the body

ANS: 1, 3, 4, 5, 6 When there is a loss of body fluids because of burns, illnesses, or trauma, the client is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or a clients inability to communicate fluid needs, resulting in acid-base disturbances. Trauma, disease, and medications (e.g., diuretics) all contribute to alterations in fluid, electrolyte, and acid-base balance. Schizophrenia itself is not a risk for fluid, electrolyte, or acid-base imbalances.

26. A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

ANS: 2 A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids.

The nurse assesses that the patient's urine has become much more concentrated, which results from the effect of: 1. adrenaline. 2. aldosterone. 3. antidiuretic hormone (ADH). 4. insulin.

ANS: 2 Aldosterone acts on the kidney tubules, affecting water retention and its attendant urine concentration.

39. A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The childs rectal temperature is 101.1 F. The nurse knows the child is probably dehydrated and should do which of the following first? 1. Give the child some juice to drink. 2. Prepare to start an IV. 3. Get an order for an antipyretic. 4. Sponge the child to bring down the fever.

ANS: 2 Children ages 2 through 12 have less stable regulatory responses to imbalance, and in childhood illnesses they tend to operate within a more narrow range with less tolerance for severe fluid and electrolyte imbalance. Clients who have been exposed to temperature extremes may have clinical signs of fluid and electrolyte alterations. Exposure to environmental temperatures exceeding 28 to 30 C (82.4 to 86 F) results in excessive sweating with weight loss. A body weight loss over 7% decreases the ability of the cooling mechanism to conserve water. The nurses first priority is fluid volume replacement, then an antipyretic (because the fever is not dangerously high). If the child has been vomiting, she is likely to vomit the juice.

14. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? 1. Weak, thready pulse 2. Hypertension 3. Dry mucous membranes 4. Flushed skin

ANS: 2 Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.

A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately? 1. Check the vital signs. 2. Stop the blood transfusion. 3. Slow down the rate of blood flow. 4. Notify the health care provider and blood bank personnel.

ANS: 2 If a blood reaction is suspected, the nurse stops the blood transfusion immediately. The nurse should take the clients vital signs, but the initial action should be to stop the blood transfusion. Once the transfusion is stopped, the nurse could notify the health care provider and blood bank personnel.

Which of the following clients is at greatest risk for insensible water loss? 1. A 37-year-old with a superficial burn to the left hand 2. A 15-year-old experiencing an asthmatic attack 3. A 50-year-old with type 2 diabetes 4. A 73-year-old with a history of pneumonia

ANS: 2 Insensible water loss is continuous and occurs through the skin and lungs. A person does not perceive the loss, but it can significantly increase with fever or burns. This insensible water loss increases in response to changes in respiratory rate and depth. In addition, devices for administering oxygen increase insensible water loss from the lungs. The teenager experiencing the asthmatic attack is at greatest risk because of the increased respiratory involvement and possible fever. Type 2 diabetes does not necessarily increase insensible water loss, and the remaining clients may have a small risk.

The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is: 1. 0.45% saline 2. Lactated Ringers 3. 5% dextrose in normal saline 4. 5% dextrose in lactated Ringers

ANS: 2 Lactated Ringers is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringers are both hypertonic solutions.

37. Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

ANS: 2 Physical examination of a hyperkalemic client may reveal anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea. The remaining options are examples of hypernatremia, hyponatremia, and hypokalemia.

31. Which of the following foods will have the greatest impact on the hearts conductivity of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

ANS: 2 Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food. The remaining options are good sources of sodium, calcium, and magnesium.

12. A client has intravenous therapy for the administration of antibiotics and is stating that the IV site hurts and is swollen. Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? 1. Intensity of the pain 2. Warmth of integument surrounding the IV site 3. Amount of subcutaneous edema 4. Skin discoloration of a bruised nature

ANS: 2 Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.

3. A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Tingling fingers 2. Difficult to arouse 3. Warm, flushed skin 4. Tremors in the hands 5. Reporting a terrible headache 6. Repeatedly asking Where am I?

ANS: 2, 3, 4, 5, 6 Physical examination of a client experiencing respiratory acidosis may reveal confusion, dizziness, lethargy, headache, ventricular dysrhythmias, warm and flushed skin, muscular twitching, convulsions, and coma. The remaining option is not reflective of respiratory acidosis.

5. A client experiencing acute congestive heart failure (CHF) is likely to present with which of the following clinical signs? (Select all that apply.) 1. Flat neck veins 2. Bilateral crackles 3. +2 ankle edema bilaterally 4. Urine output of 790 mL in 24 hours 5. History of a 5-pound weight gain in 3 days 6. Systemic blood pressure 15 mm Hg above usual baseline

ANS: 2, 3, 5, 6 Physical examination of a client experiencing CHF may reveal rapid weight gain, edema (especially in dependent areas), hypertension, polyuria (if renal mechanisms are normal), neck vein distention, increased blood and venous pressure, crackles in lungs, and confusion. The remaining options are not reflective of CHF.

An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as: 1. 32 gtt/min 2. 60 gtt/min 3. 125 gtt/min 4. 250 gtt/min

ANS: 3 (60 gtt/mL 60 min) x 125 mL = 125 gtt/min.

10. The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be: 1. 12 gtt/min 2. 22 gtt/min 3. 32 gtt/min 4. 42 gtt/min

ANS: 3 1000 mL 8 hr = 125 mL/hr; (15 gtt/mL 60 min) x 124 mL = 32 gtt/min.

. A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced: 1. Decreased muscle tone 2. Hypertension 3. Diarrhea 4. Fever

ANS: 3 A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting. Decreased muscle tone is a symptom of hypokalemia. A client with adrenal insufficiency is not likely to experience hypertension. Resultant hyponatremia with adrenal insufficiency may be exhibited as postural hypotension. Fever is a symptom of hypernatremia, not hyponatremia. Hypernatremia is not caused by adrenal insufficiency.

47. Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBCs), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is: 1. 24 gauge 2. 22 gauge 3. 20 gauge 4. 18 gauge

ANS: 3 A large cannula such as an 18 gauge or 19 gauge is preferred because blood is more viscous than IV fluids, although smaller gauge sizes will accommodate transfusions. However, a catheter no smaller than a 20 gauge should be used to transfuse blood; 22- and 24-gauge cannulas are not recommended because they are too small to allow the viscous blood to flow freely through them. An 18 gauge is considered ideal, but the minimum-size cannula that should be used is a 20 gauge.

The patient's IV has been infusing at a very high rate and now the patient appears to be in fluid volume overload, as indicated by: 1. hypotension. 2. tachycardia. 3. pulmonary edema. 4. kidney failure.

ANS: 3 An IV infusing at a high rate is used to increase intravascular fluid volume, but there is an equalization level, after which the patient goes into fluid overload; this results in pulmonary edema.

32. Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

ANS: 3 Calcium is necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction. Milk is a high-calcium food. The remaining options are good sources of sodium, potassium, and magnesium.

A rapid infusion of citrated blood has been given to the client. The nurse observes for: 1. Diaphoresis 2. Anxiety 3. Chvosteks sign 4. Nausea and vomiting

ANS: 3 Chvosteks sign is seen with hypocalcemia. Rapid administration of blood transfusions containing citrate may cause hypocalcemia. Citrate solution is used to prevent clotting of the blood so that it can be stored in the refrigerator until it is needed for transfusion. Also, if blood that is cold is administered too rapidly, it may cause cardiac dysrhythmias. If a client receives a rapid blood transfusion, the kidneys may not be able to excrete phosphorus quickly enough and the phosphorus level increases while the calcium level decreases. Sepsis may also increase the risk for developing hypocalcemia. The client who has a rapid blood transfusion of citrated blood would not be expected to experience excessive sweating. The client who experiences an anaphylactic reaction or sepsis typically has cool, clammy skin. Anxiety may be related to an anaphylactic or febrile, nonhemolytic reaction to a blood transfusion. However, it is not the best indication of a possible reaction because the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion. Nausea and vomiting may or may not indicate a reaction to a blood transfusion.

The nurse anticipates that the client with a fluid volume excess will manifest a(n): 1. Increased urine specific gravity 2. Decreased body weight 3. Increased blood pressure 4. Decreased pulse strength

ANS: 3 Hypertension is manifested with fluid volume excess. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit, as well as an increase in body weight and an increase in pulse strength.

34. Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

ANS: 3 Physical examination of a hyponatremic client may reveal apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions, and coma. The remaining options are examples of hypernatremia, hypokalemia, and hyperkalemia.

44. The nurse is preparing to replace a bag of IV fluids for a client receiving fluid therapy. When assessing the client, the nurse notes that the IV solution is not dripping. Which of the following should the nurse do to assess the patency of the site? 1. Lower IV container below level of IV site for presence of blood return. 2. Use a large-volume syringe to apply negative pressure to achieve a blood return. 3. Carefully adjust the roller clamp to see an increase in flow rate. 4. Massage the clients arm proximal to where the catheter is inserted.

ANS: 3 The catheter may be lodged against the vein wall; allowing additional pressure from the bag of fluid to flow into the vein may float the catheter into the vein, allowing the instillation of fluids. Using a large-volume syringe could cause the vein to collapse, and massaging the clients arm could dislodge a clot, causing an embolus.

. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: 1. A 6-month-old learning to drink from a cup 2. A 12-year-old who is moderately active in 80 F weather 3. A 42-year-old with severe diarrhea 4. A 90-year-old with frequent headaches

ANS: 3 The client at greatest risk for a fluid volume deficit is the client who has severe diarrhea. Any condition that results in the loss of gastrointestinal (GI) fluids predisposes the client to dehydration and a variety of electrolyte disturbances. The very young are at risk for a fluid volume deficit because their body water loss is proportionately greater per kilogram of weight. A 12-year-old who is moderately active in warm weather will lose body water through sweating. The very old are at increased risk for fluid volume deficit as they have a decreased thirst sensation and a decreased number of filtering nephrons.

48. The nurse is discontinuing a clients IV line in preparation for the clients discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first thing that the nurse should do is: 1. Notify the health care provider immediately 2. Apply pressure to the IV site 3. Apply a tourniquet high on the extremity 4. Ask another nurse to double-check the cannula

ANS: 3 The first priority of the nurse is to apply a tourniquet high on the extremity to restrict mobility of catheter embolus. The health care provider needs to be notified after the tourniquet is applied.

41. Which of the following clients is most at risk for fluid volume deficit? 1. 25-year-old male near-drowning victim 2. 56-year-old woman with salicylate poisoning 3. 45-year-old woman with second-degree burns over 20% of her body 4. 13-year-old boy with an oral temperature of 103.4 F

ANS: 3 The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. A near-drowning victim may suffer from hypoxia and respiratory acidosis but would not be as likely to be at risk for fluid volume deficit as the burn victim. Salicylate poisoning may cause some insensible fluid loss through the bodys hyperventilation to compensate for the increased PaCO2. Adolescents have increased metabolic processes and increased water production because of the rapid changes that occur in the anatomical and physiological process.

46. The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurses first action should be to: 1. Immediately discontinue the IV line and remove the cannula 2. Put cool compresses on the IV site to decrease the edema 3. Notify the health care provider of the situation 4. Put warm compresses on the IV site to decrease the pain

ANS: 3 The nurse should notify the health care provider to determine if the health care provider would like to culture the IV cannula. (Confirm before removal of IV line.) Wrapping the extremity in a warm, moist towel for 20 minutes promotes venous return, increases circulation, and reduces pain and edema. Heat therapy can be repeated three to four times during the day.

client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should: 1. Administer an antipyretic 2. Begin an infusion of epinephrine 3. Run normal saline through the blood tubing 4. Obtain and send a urine specimen to the laboratory

ANS: 4 After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the laboratory to determine the presence of hemoglobin as a result of red blood cell (RBC) hemolysis. In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic. The nurse should be prepared to administer emergency drugs, such as diuretics, per the health care providers order. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).

When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: 1. Rales 2. A bounding pulse 3. Engorged peripheral veins 4. An elevated hematocrit level

ANS: 4 An elevated hematocrit level would be expected with a deficit of body fluid in the intravascular compartment. When an excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected. Crackles (in lungs) are consistent findings with fluid volume excess. An assessment finding associated with fluid volume excess is a bounding pulse. Engorged peripheral veins may be seen with fluid volume excess.

A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematoma, the nurse needs to hold pressure on the IV site for: 1. 1 to 2 minutes 2. 2 to 3 minutes 3. 3 to 5 minutes 4. 5 to 10 minutes

ANS: 4 Because the client is on a low-dose aspirin, it takes longer for his blood to form a clot, so the nurse needs to hold pressure for 5 to 10 minutes. Holding pressure for 2 to 3 minutes would be appropriate for a client who is not on anticoagulant therapy.

45. A client has been hospitalized following a myocardial infarction. The client has an IV line running with multiple drips. The nurse assesses the clients medical record to determine the last time the IV tubing was changed, because the nurse knows that the Centers for Disease Control and Prevention (CDC) recommends that IV tubing be changed: 1. Every shift 2. Daily 3. Every 48 hours 4. Every 72 hours

ANS: 4 CDC and INS recommend tubing change no more often than 72-hour intervals or whenever tubing has been compromised. The more frequently a closed sterile system is opened, the more opportunities there are for microorganisms to be introduced into the system.

The single best indicator of fluid status is the nurses assessment of the clients: 1. Skin turgor 2. Intake and output 3. Serum electrolyte levels 4. Daily weight

ANS: 4 Daily weights are the single most important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status; however, daily weights are the single best indicator of a clients fluid status.

. The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the clients assessment? 1. Serum potassium 2. Serum sodium 3. Serum magnesium 4. Serum calcium

ANS: 4 Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.

27. A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells

ANS: 4 Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge. The remaining options describe the function of other types of fluids.

The nurse recognizes which of the following clients is at the greatest risk for dehydration? 1. A 35-year-old client diagnosed with Crohns disease 2. A 15-year-old client who is following a low-carbohydrate diet 3. A 2-year-old client diagnosed with an allergy to milk proteins 4. A 79-year-old client who has been diagnosed with advanced Alzheimers disease

ANS: 4 Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration.

33. Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it? 1. A pickle 2. A banana 3. A milkshake 4. A spinach salad

ANS: 4 Magnesium is essential for enzyme activities, neurochemical activities, and cardiac and skeletal muscle excitability. Spinach is a high-magnesium food. The remaining options are good sources of sodium, potassium, and calcium.

42. A 66-year-old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted on the daily intake and output (I&O)? 1. IV fluids 2. Cream of mushroom soup 3. Gelatin 4. Mashed potatoes

ANS: 4 Mashed potatoes do not contain enough liquid to be counted in the fluid intake of the client, whereas IV fluids are part of the liquid intake of the client and should be counted. Soups are high in the percentage of water that they contain, as is gelatin, and both should be counted in the daily fluid intake.

36. Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics? 1. Dry, sticky tongue 2. Increased anxiety 3. Nausea and vomiting 4. Decreased bowel sounds

ANS: 4 Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. The remaining options are examples of hypernatremia, hyponatremia, and hyperkalemia.

1. The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should: 1. Start with the most proximal site 2. Look for hard, cordlike veins 3. Use the dominant arm 4. Avoid sites on the extremity away from a dialysis graft

ANS: 4 The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins.

The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first? a. Place the patient on a cardiac monitor. b. Insert a retention catheter. c. Administer Kayexalate 15 g orally. d. Give IV furosemide (Lasix) 40 mg.

Correct Answer: A Rationale: Because cardiac dysrhythmias are a common and potentially fatal complication of hyperkalemia, the first action should be to initiate cardiac monitoring. The other orders are also appropriate and should be accomplished as quickly as possible.

When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. mental status. b. skin turgor. c. capillary refill. d. heart sounds.

Correct Answer: A Rationale: Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.

The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. There are crackles audible throughout both lung fields. b. The patient's radial pulse is 105 beats/minute. c. The blood pressure increases from 120/80 to 142/94. d. There is sediment and blood in the patient's urine.

Correct Answer: A Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

The long-term-care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Absence of peripheral edema b. Good skin turgor c. Hematocrit 28% d. Blood pressure 110/72 mm Hg

Correct Answer: A Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. generalized weakness. b. facial muscle spasms. c. frequent loose stools. d. personality changes.

Correct Answer: A Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. peripheral pulses. b. lung sounds. c. peripheral edema. d. urinary output.

Correct Answer: B Rationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include is a. monitor intake and output hourly. b. restrict oral free water intake. c. ambulate patient at least once per shift. d. use incentive spirometer every 2 hours.

Correct Answer: B Rationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I can have low-fat cheese." b. "I will have apple juice instead of orange juice." c. "I will drink at least 8 glasses of water every day." d. "I can use a salt substitute."

Correct Answer: B Rationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.

The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. Oral fluid intake is 100 ml for the last 8 hours. b. The blood pressure is 90/40 mm Hg. c. Urine output is 30 ml over the last hour. d. There is prolonged skin tenting over the sternum.

Correct Answer: B Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately? a. The patient reports feeling "sick to my stomach." b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The bibasilar breath sounds are decreased.

Correct Answer: B Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

A diabetic patient with poor glucose control develops diabetic ketoacidosis. The nurse notes that a patient with diabetic ketoacidosis has rapid, deep respirations. Which collaborative intervention will the nurse anticipate implementing? a. Oxygen at 2 to 4 L/min b. IV sodium bicarbonate 50 mEq c. IV 50% dextrose 50 ml d. IV lorazepam (Ativan) 1 mg

Correct Answer: B Rationale: The rapid, deep (Kussmaul) respirations are a compensatory mechanism to "blow off" excessive CO2 generated by the high levels of ketoacids. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of 50% dextrose will increase serum glucose level. Ativan administration will slow the respiratory rate and increase the level of acidosis.

A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question? a. Administer 3% saline if serum sodium drops to less than 128 mEq/L. b. IV morphine sulfate 4 mg every 2 hours prn. c. Infuse 5% dextrose in water at 125 ml/hr. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.

Correct Answer: C Rationale: Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict a. intake of green, leafy vegetables. b. the amount of high-fat foods. c. ingestion of dairy products. d. the quantity of fruits and juices.

Correct Answer: C Rationale: Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted.

A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. metoprolol (Lopressor) 12.5 mg orally daily. b. lantus insulin 24 U subcutaneously q-evening. c. oral digoxin (Lanoxin) 0.25 mg daily. d. ibuprofen (Motrin) 400 mg every 6 hours.

Correct Answer: C Rationale: Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. confusion. b. restlessness. c. edema. d. pallor.

Correct Answer: C Rationale: Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. rapid and unexpected weight loss. b. increased total urinary output. c. decreased serum sodium level. d. elevation of serum hematocrit.

Correct Answer: C Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information that a. to give adequate doses of IV insulin, a centrally located IV catheter is needed. b. blood glucose testing is more accurate when samples are obtained from a central line. c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose. d. the 50% dextrose is less likely to produce infection when given through a PICC line.

Correct Answer: C Rationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines.

A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The laboratory data that will be of most concern to the nurse is a. K+ 3.4 mEq/L (3.4 mmol/L). b. Ca+2 7.8 mg/dl (1.95 mmol/L). c. Na+ 154 mEq/L (154 mmol/L). d. HPO4- 3 4.8 mg/dl (1.55 mmol/L).

Correct Answer: C Rationale: The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. respiratory acidosis. b. respiratory alkalosis. c. metabolic acidosis. d. metabolic alkalosis.

Correct Answer: C Rationale: The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of 100/60, pulse 62, and respirations 10. The nurse notes that the patient has been taking an aluminum hydroxide/magnesium hydroxide suspension (Maalox) for indigestion. The nurse anticipates that management of the patient will include IV administration of a. magnesium sulfate. b. potassium chloride. c. calcium gluconate. d. sodium chloride.

Correct Answer: C Rationale: The patient has a history and symptoms consistent with hypermagnesemia, so calcium gluconate or calcium chloride will be the initial therapy to oppose the effects of excess magnesium on cell function. Magnesium sulfate infusion is contraindicated because it will increase the serum magnesium level. Potassium chloride and sodium chloride will not impact the patient's symptoms and should be avoided in a patient with renal insufficiency.

Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is a a. weight gain of 2 pounds above the preoperative weight. b. an oral temperature of 100.1° F with bibasilar lung crackles. c. gradually decreasing level of consciousness (LOC). d. serum sodium level of 138 mEq/L (138 mmol/L).

Correct Answer: C Rationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.

A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bedrest to prevent pathologic fractures. b. monitoring for Trousseau's and Chvostek's signs. c. encouraging fluid intake up to 4000 ml every day. d. auscultate breath sounds every 4 hours.

Correct Answer: C Rationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of breath sounds, although these would be assessed every shift.

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. when the patient feels thirsty. b. in the late evening hours. c. as soon as changes in LOC occur. d. if the oral mucosa feels dry.

Correct Answer: D Rationale: An alert elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age, and is not an accurate indicator of volume depletion. Many prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.

When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. d. daily weight.

Correct Answer: D Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age; considerable fluid-volume excess may be present before fluid moves into the interstitial space and causes edema; and hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level will ask the patient about a. intake of dietary protein. b. use of OTC laxatives. c. multivitamin/mineral use. d. daily alcohol intake.

Correct Answer: D Rationale: Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamins mineral supplements would tend to increase magnesium level.

To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is a. weak hand grips. b. confusion. c. constipation. d. lip numbness.

Correct Answer: D Rationale: Numbness and tingling around the lips or in the fingers are early signs of hypocalcemia. Muscle weakness, confusion, and constipation may also occur, but these are later signs of low calcium levels.

ntravenous potassium chloride (KCl) 40 mEq is ordered for treatment of a patient with hypokalemia. In administering the potassium solution, the nurse is aware that a. the KCl should be administered as an IV bolus so that the hypokalemia will be corrected before complications occur. b. the amount of KCl added to IV fluids should not exceed 20 mEq/L to prevent hyperkalemia from developing. c. the KCl should be given only through central lines to avoid venospasm and inflammation at the IV insertion site. d. to reduce the risk for cardiac dysrhythmia, the maximum amount of KCl to be administered in 1 hour is 20 mEq.

Correct Answer: D Rationale: Rapid IV administration of KCl can cause cardiac arrest; KCl is administered at a maximal rate of 20 mEq/hr. Bolus administration of KCl is contraindicated. The rate of administration, not the amount of KCl added to IV fluids, is important. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement? a. Disconnect the nasogastric tube until the pH is within the normal range. b. Administer the prescribed sodium bicarbonate 50 mEq intravenously. c. Teach the patient about the importance of taking slow, deep breaths. d. Give the patient the ordered morphine sulfate 4 mg intravenously.

Correct Answer: D Rationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

Correct Answer: D Rationale: The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. elevated serum potassium level. b. decreased thyroid hormone level. c. bleeding on the patient's dressing. d. the presence of Chvostek's sign.

Correct Answer: D Rationale: The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial oxygen saturation 91% b. Serum potassium is 5.1 mEq/L c. Arterial blood pH is 7.32 d. Serum calcium is 18 mEq/L

Correct Answer: D Rationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they do not indicate the need for immediate intervention.