Elevate Module 1

Paste results of the arterial blood gases (ABG's) What imbalance does the nurse understand the client to be exhibiting? Exhibit: pH 7.35, paO2 95%, paCO2 49, HCO3 30 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated

1 Rationale 1 correct: the pH is normal but on the acidic side of normal. The paco2 is elevated causing acid formation. The hco3 is alkalotic and is increased to buffer the acid. The pH in paco2 match so the original problem was respiratory acidosis compensation has occurred since the pH is now normal. 2, 3, 4 incorrect: the pH is normal but on the acidic side of normal the paco2 is acid. The hco3 is alkalotic. Did pH in the paco2 match so the original problem was respiratory acidosis but the compensation has occurred since the pH is now low. Let's Talk You will need to know how to interpret blood gases in order to answer this question but first notice that there are opposites in these options. We know automatically that the problem is acidosis and since every option includes this word. We also know that compensation is happening but we do not yet know if it is partial or complete. The other opposite options are either metabolic or respiratory. So let's interpret the pH of 7.35 (normal 7.35 to 7.45). This result is normal but it is on the low or acidosis side of normal. Remember 7.4 is perfect. Anything below 7.4 is on the acidosis side of normal. Anything above 7.4 is on the alkalotic side of normal. Since the pH is within the normal range we know that total compensation has occurred. So options 2 and 4 can be eliminated. With partial compensation, the pH would still be abnormal. Now we are left with options 1 and 3. What other chemical says acid? If paCO2 of 49 (normal 35 to 45) says acid. The hco3 of 30 (normal 22 to 26) says alkaline. So option one is correct respiratory acidosis compensated.

Which client would the nurse monitor for the development of cardiogenic shock? 1. Admitted with pericardial tamponade 2. Admitted with pulmonary embolism 3. Diagnosed with Cushing's Disease 4. Diagnosed with left sided heart failure 5. Admitted with multiple wasp stings

1, 2, 4 Rationale 1, 2, 4 Correct: These clients are at risk for cardiogenic shock. 3. Incorrect: I would worry about fluid volume excess with this client. 5. Incorrect: Wasp stings, especially multiple stings, can lead to anaphylactic shock. Let's Talk There are different types of shock, but this question wants you to identify clients at risk for cardiogenic shock. Cardiogenic shock occurs when the heart is unable to supply enough blood to the vital organs of the body. Option 1 is true, With pericardial tamponade, think cardiogenic shock. Option 2 is true. A sudden blockage of a blood vessel in the lung increases the workload of the heart. If increased too much, then cardiogenic shock can occur. Option 3 is false. With Cushing's disease, the client is retaining too much sodium and water in the vascular space which can lead to fluid volume excess. Option 4 is true. Heart failure can reduce the heart's ability to deliver oxygen-rich blood to your organs, leading to cardiogenic shock. Option 5 is false. Wasp stings, especially multiple stings, can lead to anaphylactic shock.

Which clinical manifestations would validate to the nurse that a client has developed an electrolyte imbalance due to malabsorption from celiac disease? 1. Anorexia 2. Arrhythmia 3. Doll's eyes 4. Paralysis 5. Seizure

1, 2, 5 Rationale 1, 2, 5 Correct: Low magnesium is typically due to decreased absorption of magnesium in the gut or increased excretion of magnesium in the urine. Conditions that increase the risk of magnesium deficiency include gastrointestinal (GI) disease, such as Celiac disease, advanced age, type 2 diabetes, use of loop diuretics, and alcohol dependence, Early signs of low magnesium include nausea, vomiting, weakness, and decreased appetite. As magnesium deficiency worsens, symptoms may include numbness, tingling, muscle cramps, seizures, muscle spasticity, personality changes, dysrhythmias, tremors, hyperactive deep tendon reflexes, hyperreactivity to sensory stimuli, positive Chvostek and Trousseau signs, tetany, and nystagmus. 3. Incorrect: Typically the doll's eyes refelx is elicited by turning the head of the unconscious patient while observing the eyes. The eyes will normally move as if the patient is fixating on a stationary object. If there is a negative doll's eyes reflex then the eyes remain stationary with respect to the head. 4. Incorrect: A low magnesium level goes muscle to become hyperactive.

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress what assessment findings would indicate to the nurse that treatment has been effective? 1. CVP 6 mmhg 2. 3.8 kg weight loss in 24 hours 3. Pink frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/ 8 hours 6. Dyspnea on exertion

1, 2, 5 Rationale 1, 2, 5 correct. These are all signs that the client is getting better. This is a normal CVP value which would indicate the client is improving. A weight loss of 3.8 kg in 24 hours is a good thing. Excess fluid is being removed from the body. A urinary output of 320 ml in 8 hours is good. That averages out to 40 ml per hour. 3 Incorrect: Pink frothy sputum commands that there is fluid in the lungs; this is not a sign of improvement. 4 incorrect: A S3 heart sound is often an indication of heart failure. 6 incorrect: Dyspnea on exertion is not a sign of improvement. Let's Talk Check the clues in this question: bedrest, new onset heart failure, assessment findings, successful treatment. So you are looking for signs and symptoms that indicate heart failure is improving. Treatment has been successful so signs and symptoms of heart failure will be absent. When a client is in heart failure the heart muscles are weak so cardiac output goes down, perfusion of the vital organs goes down, so urinary output goes down. If you are not putting out urine as you used to, where are all the fluids staying? In the vascular space. So which options indicate that the client is no longer in fluid volume excess? Option 1 is true. The normal CVP is 226 mm Hg. The client's CVP is 6 mm Hg. Option 2 is true. The weight loss of 3.8 kg is good. The client is getting rid of fluid. Remember a rapid weight gain or loss is fluid, not fat. Option 3 is false. Pink frothy sputum and or persistent cough indicates that there is still fluid in the lungs. This is an abnormal finding; it indicates fluid volume excess continues. When the heart is weak it cannot pump well so fluid backs up into the lungs. Option 4 is false. An S3 heart sound is often an indication of heart failure; the 3rd heart sound is known as an intercooler gallop and occurs just after as to when the mitral valve opens allowing the passive filling of the left ventricle. The S3 sound is actually produced by a large amount of blood striking a very compliant left ventricle. And S3 can be an important sign of systolic heart failure. Option 5 is true. UOPof 320 ml in 8 hours translates to 40 mL per hour. We want to see at least 30 ml per hour so this is good. Option 6 is false. Dyspnea on exertion indicates that there is still fluid in the lungs.

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? 1. Atrial fibrillation 2. Capillary refill 2 seconds 3. Eyes appear sunken 4. Hematocrit 55% 5. Several small furrows on tongue

1, 3, 4, 5 Rationale 1, 3, 4, 5 Correct: These are signs and symptoms indicating that a client is dehydrated (fluid volume deficit). 2 Incorrect: This is a normal capillary refill. Let's Talk Lack of electrolytes in the blood associated with dehydration, especially potassium, can trigger A-fib symptoms. Normal capillary refill time is 1 to 2 seconds. This is consistent with a normal blood volume and perfusion. A CRT longer than 2 seconds suggests poor perfusion due to peripheral vasoconstriction. The client eyes appear sunken with severe dehydration and the skin is pale. This hematocrit is high which would indicated fluid volume deficit. Dilute decreases hematocrit, sodium, and specific gravity. Concentrated volume would make these numbers go up. The tongue normally has one main furrow. With dilute volume deficit there will be several small furrows on the tongue.

A client has been admitted with Advanced cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches and an increase in 6 lb since yesterday's measurements. The client reports decrease desire to eat due to gastric reflux and is having steatorrhea. Which interventions would the nurse expect to see in this client's plan of care? 1. Administer pantoprazole 40 mg by mouth every morning 2. Prepare client for thoracentesis Infuse albumin human 25% 50 ml / 1 hour 3. Provide diet of 1500 calories per day 4. Administer vitamins a d and e in water-soluble form

1, 3, 5 rationale 1, 3, 5 correct: pantoprazole is a proton pump inhibitor that increases the amount of acid produced in the stomach. Im acute liver failure albumin human 25% solution helps stabilize vascular circulation by moving fluid into the vascular space. Clients who have fatty stools (steatorrhea) are losing fat soluble volumes. They need to receive water soluble forms of fat soluble vitamins a d and e. 2 incorrect: This client would need to be prepared for a paracentesis not a thoracentesis. 4 incorrect: This client needs 3000 calories per day. Let's Talk Option one is true. Pantoprazole is a proton pump inhibitor that could increase the amount of acid produced in the stomach. This will help the client's ability to eat small frequent meals. Remember the client needs a diet high in calories up to 3000 calories per day. Option 2 is false. What is a thoracentesis? Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid known as a pleural effusion around the pleural space to help the client breathe easier. But where is this client's excess fluid? It's in the abdominal cavity. So what is needed? A paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. Option three is true. An acute liver failure albumin (human) 25% solution serves the triple purpose of stabilizing the circulation, correcting an oncotic deficit, and binding excessive serum bilirubin. It increases blood volume if circulatory instability follows the withdrawal of ascitic fluid. Option four is false. This client is in a hypermetabolic state and needs more calories. Up to 3000 calories per day. 1500 calories is not adequate for this client's needs. However with all the fluid in the abdominal cavity, this client may not be able to eat much at a meal. 6 small high-calorie moderate to low-fat meals spread throughout the day should be provided. Option five is true. Provide clients who have fatty stools with water-soluble forms of fat-soluble vitamins a d and e and give folic acid and iron to prevent anemia.

The community health nurse has been educating their group of college students living in a dormitory about receiving an immune globulin injection for Hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? 1. Immune globulin contains antibiotics that destroy HAV, preventing infection. 2. Immune globulin protectionist temporary. 3. Common side effects of the immune globulin include soreness and swelling around the injection site. 4. It is important to take IG within four weeks of any exposure to hepatitis A 5. Crowded living environments such as dormitories place people at risk for HAV.

1, 4 Rationale 1, 4 Correct: Immune globulin contains antibodies that destroy HAV, preventing infection. It is important to take IG within two weeks of any exposure to hepatitis A. 2, 3, 5, Incorrect: These are correct statements about immune globulin for Hepatitis A indicating that the teaching has been effective. Let's Talk The clues in this question include immune globulin and hepatitis A. You need to know that immune globulin provides passive immunity which is temporary protection against the disease. When an immune globulin is given the client received antibodies immediately to fight against the disease. The body does not have to do anything for this protection. This is why it's called passive immunity. In contrast active immunity provides the client with a small dose of the antigen. The body that has to actively produce the antibodies. It takes several weeks for the client to produce these antibodies. During this time the client is not protected. Option one is true. Further teaching is necessary. The client gets the antibodies not antibiotics immediately. Option 2 is false. This is a correct statement: immune globulin protection is temporary. Option three is false. The statement is accurate. Even if the test taker did not know this most injections cause some discomfort and swelling at the site. Option four is true. Further teaching is needed. It is important to take IG within four weeks of any exposure to hepatitis A. Option 5 is false. Further teaching is not needed with the statement. The most common method of transmission for Hepatitis A is through the fecal-oral route. People living in a crowded confined places are at higher risk for contracting hepatitis A.

How should the nurse interpret the arterial blood gas (ABG) report? Exhibit: pH 7.32, paO2 93%, paCO2 33, HCO3 19 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1, 6 Rationale 1, 6 Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and CO2 are all abnormal, so compensation is beginning. Since the pH is not normal yet total compensation has not occurred. There is only partial compensation. 2 Incorrect: The pH remains low (acidic) so acidosis rather than alkalosis is occurring. 3 Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and CO2 are all abnormal, so compensation is beginning. Since the pH is not normal yet total compensation has not occurred. The pH and bicarb match indicating a metabolic problem initially. The lungs are attempting to compensate by blowing off CO2. 4 Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The original problem is not a lung problem but a metabolic problem 5 Incorrect: With uncompensated metabolic acidosis the lungs have not decreased the CO2 (acid) level in the blood yet 7 Incorrect: Full compensation occurs when the pH has reached within the normal range.

A client weighing 155 lb (70 kg) is admitted to the burn unit with second and third-degree burns covering 50% total body surface area. Normal saline IV fluid resuscitation is ordered at 4 ml per kg per percentage of total body surface area burned within the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answers using numbers in decimal points only.

14000 Rationale 4 mL * 70 kg = 280 280 mL * 50 tbsa = 14000 mL in the first 24 hours Let's Talk The prescription is 4 mL * weight in kg * tbsa

What is the nurse's priority when treating a client admitted with a full thickness thermal burn over 30% of the body? 1. Insert a urinary catheter 2. Establish IV access of Normal Saline 3. Administer fentanyl (1mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns

2 Rationale 2 Correct: The priority action for this client is fluid resuscitation. 1. Incorrect: The kidneys need to be monitored, but fluid resuscitation should begin first. 3. Incorrect: IV pain medication can be given after the IV is started. 4. Incorrect: The other three options take priority.

What should the nurse assess when examining a client who has had a fasciotomy of the forearm? 1. Brachial pulse 2. Capillary refill 3. Color 4. Presence of thrill 5. Skin turgur

2, 3 Rationale 2, 3 Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the burse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored. 1. Incorrect: We want to know if circulation below the fasciotomy is impaired or not. So check distal pulses. 4. Incorrect: If you want to check for a thrill, you are thinking about a shunt, like a dialysis shunt. You check patency by feeling for a thrill and listening for a bruit. 5. Incorrect: checking skin turgur is a hydration check.

An elderly bedbound client receiving G tube feedings at home is admitted to the unit after onset of Behavioral changes and hallucinations. What action should the nurse initiate? 1. Administer furosemide 20 mg IVP 2. Frequent mouth care 3. Provide 250 ml water via Gtube every 6 hours 4. Seizure precautions 5. Start IV of 0.9% normal saline

2, 3, 4 Rationale 2, 3, 4 correct: Oral mucous membranes become dry and sticky due to loss of fluid in the interstitial spaces so mouth care should be provided frequently. The client is dehydrated with a high sodium level because of the high solute tube feeding. The client needs water and a sodium free IV fluid. High sodium levels in the blood leads to dehydration of brain cells resulting and changes in mental status ranging from drowsiness, restlessness, confusion, and lethargy to seizures and coma. Seizure precautions are necessary. 1 incorrect: the client is dehydrated. A diuretic would make it worse. 5 Incorrect: this is an isotonic sodium fluid. The client does not need more sodium.

The clients arterial blood gas report has arrived at the nurses station. Based on the results what interventions are required by the nurse? Exhibit: pH 7.47, paCO2 29, HCO3 23, PO2 95% 1. Start oxygen at 2 liters per minute 2. Instruct the client on taking slow deep breaths 3. Monitor serum sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP

2, 4 Rationale 2, 4 Correct: This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give them an anxiolytic if necessary. Safety precautions are needed because this dizziness and faintness can occur with respiratory alkalosis. 1 Incorrect: This client does not have an oxygen problem, they have a CO2 problem. Their O2 is normal. 3 Incorrect: Potassium rather than sodium needs to be monitored. Hypokalemia may occur as potassium is lost (urine) or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis. 5 Incorrect: The bicarb is normal. A benzodiazepine or an anxiolytic medication can be given to slow the client's respiration rate. Let's Talk This question requires the test taker to go through a two-step process. First, the ABG's have to be interpreted correctly in order to look at the responses to see what fits the results. The pH of 7.47 is high so it indicates alkalosis. The paCO2 of 29 is low which also indicates alkalosis. The HCO3 of 23 is normal. So the client is in respiratory alkalosis. How did this happen? This client was breathing too fast. Note the paO2 of 95%. Now you must look at interventions that will fix this problem. Option 1 is false. More CO2 is needed, not more oxygen. Option 2 is true. When breathing slows down more CO2 is retained. Option 3 is false. Serum potassium rather than sodium is to be monitored. Option 4 is true. Safety precautions are needed because dizziness and fainting can occur with respiratory alkalosis. Option 5 is false. Anxiolytics or sedatives will decrease respirations so that more CO2 is retained.

A nurse is caring for a client who has a cholecystectomy 4 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? Exhibit: pH 7.31, PaCO2 49, HCO3 22, O2 99% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2, 5 Rationale 2, 5 Correct: The pH is 7.31 (normal 7.35- 7.45) which means acidosis. The paCO2 of 49 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis. The HCO3 is normal. This means that the client is in uncompensated respiratory acidosis 1. Incorrect: This is a respiratory problem. The bicarb is within normal limits, eliminated a metabolic problem. 3. Incorrect: the pH is low which indicates acidosis. The bicarb is within normal limits, eliminated a metabolic problem. 4 Incorrect: The pH is low, which indicates acidosis. 6: Incorrect: Compensation has not begun because the bicarb is normal. To compensate the bicarb would need to decrease to bring the pH down to normal. 7 Incorrect: Fully compensated would occur if the pH is normal with abnormal CO2 and bicarb. Let's Talk You need knowledge of ABG interpretation, There are opposite in these options. You need to first decide if the client is in acidosis or alkalosis. So look at the pH of 7.31 (normal 7.34-7.45). This pH indicated acidosis since it is low. You can eliminate options 3 and 4 since these are alkalosis. That leaves options 1 and 2. Which other chemical says acidosis? The paCO2 of 49 (normal 35-45) is high which indicated acidosis. The HCO3 is normal. This means that option 2, respiratory acidosis is correct. How did this happen? The client must have been breathing slowly and shallowly, retaining CO2, an acid. Since the HCO3 is normal, compensation has not begun, so this is uncompensated respiratory acidosis.

Based on the results of the arterial blood gases (ABGs), which imbalance does the nurse understand the client to be exhibiting? Exhibit: pH 7.36, PaCO2 55, HCO3- 32, O2 93% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2, 7 Rationale 2, 7 Correct: The pH is 7.36 normal (normal 7.35-7.45). But the paCO2 of 55 (normal 35-45) indicates acidosis. The HCO3 is also abnormal at 32 (normal 22-26), indicating alkalosis. Since both chemicals are abnormal, but the pH is normal, compensation must have occurred. A perfect pH is 7.4. A pH of 7.36 is on the acid side of normal. So the original problem was acidosis. Which chemical abnormality matches acidosis? The CO2 is acid. This means that the client is in fully compensated respiratory acidosis. 1. Incorrect: This is a respiratory problem. The bicarb is high, which is alkalosis. The kidneys are compensating. 3. Incorrect: The pH is on the acid side of normal. The bicarb is high. They don't match. 4. Incorrect: The pH is low normal, which indicated acidosis. 6. Incorrect: Compensation is complete because the pH is normal. 7. Incorrect: Fully compensated has occurred because the pH is normal with abnormal CO2 and bicarb.

A new nurse asked the charge nurse persistence and interpreting the arterial blood gases ABG's for a client. What acid base imbalance should the charge nurse tell the new nurse these ABGs indicate and the client? Exhibit: pH 7.46, paO2 97%,paCO2 47, HCO3 28 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3, 6 Rationale 3, 6 Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH of 7.46 normal (7.35 - 7.45) is high which means alkalosis. The paco2 is 47 (normal 35 to 45) which is high. Greater than 45 is acidosis from too much CO2. The hco3 is 28 (normal 22 to 26) which is high. High bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis. 1 incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis so this option is incorrect. 2 incorrect: The paco2 would be low rather than high if the problem was respiratory alkalosis. 4 incorrect: A pH of greater than 7.45 indicate alkalosis better than acidosis so this option is incorrect. 5 incorrect: If the abg's indicated that conversation had not begun then the CO2 would be normal since it is high the lungs are attempting to compensate for the metabolic alkalosis retaining more acid. Decrease breathing to hold on to acid 7 incorrect: Full compensation does not occur until the pH is normal. The pH is still abnormal here.

The nurse is reviewing morning laboratory results for multiple clients which client laboratory results should the nurse immediately report to the healthcare provider? 1. Client with chronic obstructive pulmonary disease COPD and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L) 3. Cardiac client on furosemide with potassium of 3.1 mEq/L (3.1 mmol/L) 4. Client with sepsis and total white blood cell count of 16000 mm3 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L)

3,5 Rationale 3,5 Correct: Although all the laboratory results are outside of standard accepted levels to particular clients are the most concerning. The cardiac clients potassium level 3.1 is extremely concerning since normal potassium level should be between 3.5 to 5.0 meq/L. Hypokalemia can cause muscle weakness in heart arrhythmias such as PVCs. Secondly, after the client's thyroidectomy their calcium level is 8.0 mg/dL (normal 9.0 to 10.5 mg/dL) indicating possible removal of the parathyroid gland. Because hypocalcemia places the client at risk for seizures and laryngospasms as well as arrhythmias, the primary health care provider needs to be notified immediately so that corrective therapy can be initiated. 1 incorrect: While the client's pCO2 of 50 is elevated (normal is 35 to 45 mm Hg) neither is unexpected or unusual for a client with COPD. The client will frequently experience elevated levels of pCO2. Therefore, the nurse should just continue monitoring for any changes in respiratory status. 2 incorrect: The diabetic client has a fasting blood sugar of 145, which is elevated above normal levels of 70 to 110. However it is not uncommon for diabetics to occasionally have elevated glucose levels even early in the morning. The nurse can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary health care provider. 4 incorrect: It is expected that client diagnosed with sepsis will have extremely elevated white blood cell counts despite the fact this lab result is outside of the normal values 45 mm to 10000 mm H3. This level is not concerning enough to immediately contact the healthcare provider

A client arrives in the emergency department in a postictal state after having a seizure for the first time. The nurse notes peripheral edema to the lower extremities. BP 100/68, Resp 18, HR 86. Family reports client has taken "a lot of antacids for indigestion over the past 48 hours." Current health history includes chronic renal failure. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4 Rationale 4 Correct: The client's condition indicates metabolic alkalosis. Antacid use won't normally lead to metabolic alkalosis, but if you have weak or failing kidneys and use a nonabsorbable antacid, it can bring on alkalosis. Nonabsorbable antacids contain aluminum hydroxide or magnesium hydroxide. The client has had a seizure for the first time which is a sign of metabolic alkalosis when combine with the rest of the client's history. 1 Incorrect: This client has no respiratory symptoms. This is not respiratory acidosis. 2. Incorrect: This client has no respiratory symptoms. This is not reparatory alkalosis. 3. Incorrect: This client's condition is related to chronic renal failure.

What should the nurse monitor for when caring for a client receiving an IV infusion of 5% normal saline? 1. Hypotension 2. Fluid volume deficit 3. Hyponatremia 4. Phlebitis

4 Rationale 4 Correct: 5% normal saline is a hypertonic solution. Hypertonic fluids contain a higher concentration of solute compared to the plasma and interstitial fluid. This creates an osmotic gradient and drives fluid from the interstitial space into the intravascular space which causes fluid to stay in the vascular space. Hypertonic Solutions are irritating to veins and can cause phlebitis. 1 incorrect: Hypertension can occur with isotonic and hypertonic IV Solutions. Hypotension can occur with hypotonic IV solutions such as ½ normal saline. 2 incorrect: fluid volume excess can occur with isotonic and hypertonic Solutions. 3 incorrect hypernatremia can occur with isotonic and hypertonic Solutions.

An Intubated client has been admitted to the emergency department via ambulance with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? 1. Obtain a blood pressure for arterial blood gases. 2. Connect clients' endotracheal tube to a ventilator. 3. Administer 1000 mL of lactated Ringer's (LR). 4. Assessed for head and neck injuries.

4 Rationale 4 correct: Once the client's Airway is protected with an endotracheal tube then the nurse can perform an assessment. In addition to the burns the client may have a neck injury. So the client should be elevated for any neck or head injuries. 1 incorrect: arterial blood gases can be ordered but assess the client first. 2 incorrect: The client can be connected to a ventilator if needed but at present the airway is being protected by the 82. Nothing was said to indicate that the ventilation assistance is needed at present. 3 incorrect: fluid resuscitation is needed, however assess the client for injuries first.

Educator has completed an educational program on interpreting arterial blood gases. The educator recognizes that education was successful when a nurse selects which set of abg's as compensated respiratory alkalosis? 1. pH 7.46, paCO2 30, HCO3 26 2. pH 7.45, paCO2 35, HCO3 25 3. pH 7.36, paCO2 43, HCO3 24 4. pH 7.43, paCO2 31, HCO3 20

4 rationale 4 correct: This set of abg's indicates compensated respiratory alkalosis. The pH is normal but on the alkalotic side of normal (normal 7.35 to 7.45; perfect to 7.4). The paco2 is low indicating alkalosis so it matches the alkalotic pH. The bicarb is low at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred. 1 incorrect: pH 7.46, paco2 30, hco3 26. The pH is high. The paco2 is low. The bicarb is normal. This is uncompensated respiratory alkalosis. 2 incorrect: pH 7.45, paco2 35, HCO3 25. All of these values are normal; there is no acid-base problem here. 3 incorrect: ph 7.36, paco2 43, hco3 24. the pH is normal. The paco2 is normal and the bicarb is normal.

The elderly confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)? 1. Perform a physical assessment 2. Start an IV of NS with KCL 20 meq at 50 mL/hr 3. Insert a urinary catheter 4. Weigh the client

4 rationale 4 correct: the UAP can weigh clients. 1 incorrect: This is a new client admit. The RN should perform the physical assessment. 2 incorrect: the RN should start an initial IV with a potassium supplement. The LPN can hang a maintenance bag with premixed potassium supplements after that. 3 incorrect: the LPN or RN can insert an indwelling urinary catheter.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? Exhibit: pH 7.48, paCO2 30, HCO3 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4, 5 Rationale 4, 5 Correct: The blood gases confirm respiratory alkalosis. The pH is 7.48 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 30 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis. 1 Incorrect: The blood gases confirm respiratory alkalosis. The bicarb is normal, so the problem is not metabolic. 2 Incorrect: The blood gases confirm respiratory alkalosis. The paCO2 of 30 (normal 35-45) is low which indicates alkalosis. For this client to be in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The bicarb is normal, so the problem is not metabolic. 6. Incorrect: Compensation has not begun because the bicarb is normal. To compensate the bicarb would need to decrease to bring the pH down to normal. 7. Incorrect: Fully compensated would occur if the pH is normal with abnormal CO2 and bicarb. Let's Talk You need knowledge of ABG interpretation, There are opposite in these options. You need to first decide if the client is in acidosis or alkalosis. So look at the pH of 7.48 (normal 7.34-7.45). This pH indicates alkalosis since it is high. You can eliminate options 1 and 2 since these are acidosis. That leaves options 3 and 4. Which other chemical says alkalosis? The PaCO2 of 30 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that option 4, respiratory alkalosis is correct. How did this happen? The client must have been breathing too fast, blowing off CO2, an acid. Since the HCO3 is normal compensation has not begun, so this is uncompensated respiratory alkalosis.

An adult client has partial and full thickness burns over the anterior trunk, the anterior and posterior aspect the left leg, the anterior aspect of the right leg, and the peritoneal area. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.

46 Rationale The anterior trunk counts for 18% of the body, the entire left leg counts 18%, the anterior right leg counts 9%, and the peritoneal area counts 1%. The body surface on this client is 46%.

A nurse is assigned to care for five adult clients. In what order should the nurse care for these clients? 1. The client with full-thickness Burns to the posterior chest who has a temperature of 102 F and a blood pressure of 88/52. 2. The client admitted with electrical Burns 8 hours ago and has a serum potassium level of 5.2 meq / L 3. The patient with partial-thickness arm Burns who has a temperature of 99F and a blood pressure of 92 / 66. 4. The client with facial Burns 3 days ago who's been crying since recent visitors left. 5. The client who is to receive an analgesic 30 minutes prior to wound debridement in 2 hours

this is the correct order. rationale The nurse should first see the client with full-thickness Burns to the posterior chest who has a temperature of 102 F and a blood pressure of 88 / 52. The client's vital organs are not going to be perfusing properly with this BP and shock is a major concern. The client's temperature is also too high so we worry about infection. The nurse should see the client admitted with electrical Burns 10 hours ago and has a serum potassium level of 5.2 meq / L next the potassium is high normal placing the client at risk for heart problems and dysrhythmias. The nurse should see the planet with the partial thickness arm Burns who has a temperature of 99 F and a blood pressure of 92 over 66 third. This client has a low-grade fever and a low normal BP. The client needs to be monitored closely for the risk of shock. But at present, this client is more stable than the client with high potassium. The fourth client the nurse should see is a client who has been crying. Don't let facial Burns through you. The burn is three days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is more stable than the first two that should be seen however the client scheduled for wound debridement does not need pain medication for 1 and 1/2 hours and can be the last client seen