Exam 1 - Adult Health/Med Surg I (Pro-Nurse, Electrolyte Balance, Acid/Base, Pain)

A nurse is collecting data from an older adults who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (select all that apply) A. Crackles in lung bases B. Periorbital edema C. Bounding radial pulse D. Swelling at the IV site E. Flat neck veins when supine

ANS: A, B, C Rationale: Crackles in bases of lungs, periorbital edema, bounding radial pulse

A nurse assesses a client who is admitted for treatment to fluid overload. Which sign and symptom does the nurse expect to find? A. Increased pulse rate B. Distended neck veins C. Decreased blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances

ANS: A, B, E, F Rationale: Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is normal finding

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

ANS: A, D, F Rationale: The most important body fluid compartment to maintain for function is the plasma volume of circulating blood. The most reliable indicators for effectiveness of IV fluid replacement to increase this volume are blood pressure and pulse. Urine output is also very sensitive to changes in plasma volume and is a reliable indicator of adequacy of fluid replacement therapy. Skin turgor changes do not occur quickly enough to use for evaluation of fluid replacement adequacy. Hand-grip strength and deep tendon reflex changes are less reliable and are affected by other factors.

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching? A. "It's unfortunate that I have to be in the hospital for this treatment." B. " I wish I didn't have to attach the electrodes to my skin" C. "I will need to shave the hair off the skin where I place the electrodes" D. " I hope I don't have to take as many pain pills"

ANS: A. "It's unfortunate that I have to be in the hospital for this treatment." Rationale: TENS are portable; do have to be attached to skin/hair should be removed/reasonable to expect less pharmacological intervention

The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine (5 mg) IV approximately 30 minutes earlier. What action must the nurse be prepared to take? A. Administer naloxone (Narcan). B. Administer oxygen. C. Assist with intubation. D. Monitor pain level.

ANS: A. Administer naloxone (Narcan). Rationale: A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider? A. BUN 25 mg/dL B. Creatinine 0.9 mg/dL C. Hematocrit 45% D. Urine specific gravity 1.028

ANS: A. BUN 25 mg/dL

A high school student arrives at the local blood drive to donate blood for the first time. As the site is prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instruct the student to do? A. Breathe into cupped hands. B. Pant using rapid, shallow breaths C. Use a rapid deep breathing pattern D. Hold the breath for as long as possible

ANS: A. Breathe into cupped hands. Rationale: Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia? A. Decreased deep-tendon reflexes B. Hyperactive bowel sounds C. Restlessness D. Bounding peripheral pulses

ANS: A. Decreased deep-tendon reflexes

A nurse is planning care for a group of supercentenarians in an assisted living facility. The nurse considers which of the following? A. Most super-centenarians are functionally independent or require minimal assistance with activities of daily living B. The majority of super-centenarians have cognitive impairment C. The number of super-centenarians is expected to decrease in coming years as a result of heart disease and stroke D. It is theorized that super-centenarians survived as long as they have due to genetic mutations that made them less susceptible to common diseases

ANS: A. Most super-centenarians are functionally independent or require minimal assistance with activities of daily living Rationale: Research supports that most super-centenarians are functionally and cognitively intact, requiring minimal assistance with ADLs. The number of super-centenarians is expected to increase in coming years as the number of older adults increases. The reason why individuals survived as long as they have is not known.

A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider? A. Potassium 2.3 mEq/L B. Sodium 136 mEq/L C. Calcium 10 mg/dL D. Magnesium 1.4 mEq/L

ANS: A. Potassium 2.3 mEq/L

What level of prevention is reflected by administering flu vaccines to older adults in a senior center? A. Primary B. Tertiary C. Secondary D. Quaternary

ANS: A. Primary Prevention Rationale: Administering flu vaccines is an example of primary prevention. Primary prevention promotes health and protects against threats to health. Tertiary prevention tries to limit the damaging effects of a health problem. Secondary prevention detects and treats health problems in early stages. Quaternary is not a level of prevention.

In which situation is the public health nurse assisting people in the community with primary prevention? A. Providing free measles immunizations to children B. Screening a group of people who have per-hypertension C. Treating patients in the community who have active tuberculosis D. Giving out healthy snacks and exercise plans to people who are obese

ANS: A. Providing free measles immunizations to children Rationale: Primary prevention promotes health and protects people against threats to health. Vaccinations and immunizations are primary prevention strategies. Treating patients in the community who have active tuberculosis is an example of tertiary prevention because the people already have the disease. Screening people who have pre-hypertension is an example of secondary prevention because the risk is already there, but actions may be taken to prevent hypertension. Giving out healthy snacks and exercise plans to people who are obese is an example of tertiary prevention because the problem (obesity) has already been identified and confirmed.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? A. Reports having a bowel movement daily. B. ECG shows an inverted T wave. C. Fasting blood glucose level is 106 mg/dL. D. Two lb weight gain during the past week.

ANS: A. Reports having a bowel movement daily. Rationale: Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics? A. Sedation B. Anxiety B. Diarrhea D. Insomnia

ANS: A. Sedation

An older adult with gastric cancer with bone metastases is being discharged from the hospital after beginning a regimen of opioid analgesics to control the metastatic pain. What should be included in the discharge teaching plan? A. The development of a plan to prevent constipation B. Benefits of grief counseling C. Increasing calories in the diet D. Preventing pressure ulcers

ANS: A. The development of a plan to prevent constipation Rationale: Side effects of opioids are significant to older adults and include constipation. Because constipation is almost universal when opioids are used, the nurse should ensure that an appropriate bowel regimen is taken at the same time as the opioids. The remaining options are not specifically related to the management of the client's pain or the effects of opioid treatment.

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? A. Visceral pain B. Referred pain C. Cutaneous pain D. Somatic pain

ANS: A. Visceral pain Rationale: Visceral pain arises from a stimulus (distention, inflammation, and ischemia) acting on an abdominal organ. Somatic is a form of parietal pain. Parietal pain, from the parietal peritoneum, is more localized and intense than visceral pain, which arises from the organs themselves. Referred pain is visceral pain felt at some distance from a diseased or affected organ

A nurse is collecting data from a client who has hypokalemia a a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Weak, irregular pulse​ B. Paresthesia C. Extreme thirst D. Hyperactive reflexes

ANS: A. Weak, irregular pulse​

A nurse is caring for a client who has just received an epidural. Which side effect is the most common in epidural anesthesia? A: Maternal hypotension, which can lead to fetal bradycardia B. Tachycardia C. Dizziness D. Pain

ANS: A: Maternal hypotension, which can lead to fetal bradycardia Rationale: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia

The physician orders Lanoxin(digoxin) 0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient? A. 8 mL B. 7.5 mL C. 7 mL D. 5.5 mL

ANS: B. 7.5 mL Rationale: Need: 0.375 mg Have: 0.25mg/5mL 5mL x 0.375 = 1.875 1.875/0.25 = 7.5 mL

A nurse is collecting data from a client who has a calcium level of 12 mg/dL. Which of the following manifestations should the nurse expect? A. Diarrhea B. Decreased deep tendon reflexes C. Increased appetite D. Hypotension

ANS: B. Decreased deep tendon reflexes

A nurse is collecting data from a client who has sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect? ​A. Increased salivation B. Decreased level of consciousness C. Cool, clammy skin D. Hypertension

ANS: B. Decreased level of consciousness

The nurse is preparing to assess the pain of a developmentally and cognitively delayed 8-year-old. Which pain rating scales should the nurse choose? A. Visual Analog and Numerical Scales B. FACES pain rating scale C. Adolescent Pediatric Pain Tool D. Word Graphic Rating Scale

ANS: B. FACES pain rating scale Rationale: The nurse should select the pain assessment tool that is appropriate for the child's cognitive abilities. The FACES pain rating scale is designed for use with children ages 3 and up. A child with limited reading skills or vocabulary may have difficulty with some of the words listed to describe pain on the word graphic scale. Some of the concepts might be too difficult on the visual analog and numerical scales for a developmentally disabled child. The base age for the Adolescent pediatric pain tool is 8 years, but its use would likely be inappropriate for an 8-year-old with cognitive delays.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? A. Nose and ears have a slightly yellow-tinged appearance. B. Neck veins are now distended in the sitting position. C. Breath sounds can be heard in the right lower lung lobe. D. Weight is unchanged from that obtained yesterday

ANS: B. Neck veins are now distended in the sitting position.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Monitor the client's heart rhythm. B. Prepare to assist with ventilation. C. Obtain a urine specimen for drug screening. D. Prepare for gastric lavage.

ANS: B. Prepare to assist with ventilation.

The nurse administers an opioid analgesic to a patient. What serious side effect should the nurse carefully monitor for? A. Renal toxicity B. Respiratory depression C. Seizure activity D. Hypertension

ANS: B. Respiratory depression

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? A. The AP's ability to prioritize B. The AP has the knowledge and skill to perform the task C. The AP's rapport with clients D. The AP's ability to complete the task without assistance

ANS: B. The AP has the knowledge and skill to perform the task Rationale:

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Distended neck veins B. Urine specific gravity 1.034 C. Bounding pulse D. BP 146/94 mm Hg

ANS: B. Urine specific gravity 1.034

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? A. PaCO 36 B. pH 7.48 C. HCO 21 mEq/L D. O saturation 95%

ANS: B. pH 7.48

Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery? A. "Instruct your visitors to press the button for you when you are sleeping." B. "Push the button every 15 minutes whether you feel pain at that time or not." C. "Push the button when you first feel pain instead of waiting until pain is severe." D. "Try to go as long as you possibly can before you press the button."

ANS: C. "Push the button when you first feel pain instead of waiting until pain is severe." Rationale: Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA.

The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? A. 3 Tablets B. 1 Tablet C. 1.5 Tablets D. 2.2 Tablets

ANS: C. 1.5 Tablets Rationale: 60 divided by 40 = 1.5 Tablets

The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? A. 30 seconds B. 150 seconds C. 60 seconds D. 15 seconds

ANS: C. 60 seconds Rationale: Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

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

ANS: C. Metabolic alkalosis

The patient develops respiratory depression after the nurse administer his fentanyl for pain. What medication can the nurse anticipate administering to counteract the effects of the fentanyl? A. Nalbuphine hydrochloride B. Morphine C. Naloxone D. Lidocaine

ANS: C. Naloxone

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

ANS: C. Pulse rate and rhythm Rationale: Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias. It is the most important assessment to perform for a client with an elevated serum potassium level. Respiratory rate and depth are more affected by hypokalemia because of the accompanying muscle weakness. The reduction then affects oxygen saturation. Although deep tendon reflexes may be increased with hyperkalemia, cardiac changes are more critical.

A client's blood gas results are pH 7.48, PaCO2 30 mmHg, HCO3 23 mEq/L. What will the nurse suspect that the client is at risk for? A. Respiratory alkalosis, compensated B. Metabolic alkalosis, uncompensated C. Respiratory alkalosis, uncompensated D. Metabolic alkalosis, compensated

ANS: C. Respiratory alkalosis, uncompensated Rationale: The client's pH is high, indicating alkalosis. The PaCO2 is abnormal, indicating a respiratory basis. The HCO3 is normal, indicating that compensation has not started. The HCO3 level would decrease with compensation. The primary disturbance is respiratory, as indicated by the decrease in the PaCO2 parameter.

A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the provider? A. Magnesium 1.9 mg/dL B. Chloride 99 mEq/L C. Sodium 126 mEq/L D. Potassium 3.6 mEq/L

ANS: C. Sodium 126 mEq/L

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? A. Sodium 132 mEq/L (mmol/L) B. Potassium 3.5 mEq/L (mmol/L) C. Sodium 148 mEq/L (mmol/L) D. Potassium 5.3 mEq/L (mmol/L)

ANS: C. Sodium 148 mEq/L (mmol/L)

An older woman asks a nurse, "You always seem to be telling me that I need to drink more water. How much water do I really need to drink?" The nurse bases her response on the knowledge that older adults should consume at least: A. 2000 mL of fluid per day B. 1000 mL of fluid per day C. 2500 mL of fluid per day D. 1500 mL of fluid per day

ANS: D. 1500 mL of fluid per day

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

ANS: D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis Rationale: Insulin increases the activity of the sodium-potassium pump and forces more potassium from the extracellular fluid into the intracellular fluid. Although this is a desired response when managing hyperkalemia, the drug can cause hypokalemia in a client whose serum potassium level is initially normal. Spironolactone is a potassium-sparing diuretic that has the potential to raise serum potassium levels, not lower them. Ringer's lactate contains potassium and would not dilute serum potassium below normal. Infusions of red blood cells usually raise serum potassium levels, not lower them, because some blood cells are damaged during the infusion and release intracellular potassium.

A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremeia. Which of the following laboratory findings should the nurse also expect to be below the expected reference range? A. Magnesium B. Calcium C. Potassium D. Chloride

ANS: D. Chloride

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? A. Urge the client to drink more water B. Notify the primary health care provider C. Assess the client's deep tendon reflexes D. Document the finding as normal

ANS: D. Document the finding as normal Rationale: The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

Compared with acute pain, persistent pain requires the nurse to: A. Monitor vital signs more frequently. B. Document the character of the pain as burning. C. Administer analgesics at least every 4 hours. D. Educate the client to the benefit of specific lifestyle changes.

ANS: D. Educate the client to the benefit of specific lifestyle changes. Rationale: Persistent pain can manifest itself as depression, eating and sleeping disturbances, and impaired function, all of which can lead to lifestyle changes. Persistent pain usually does not lead to markedly altered vital signs. Acute or persistent pain can manifest itself as a burning pain. Persistent pain has no time frame; it is continually persistent at varying levels of intensity.

A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect? A. Increased appetite B. Hyporeflexia C. Constipation D. Headache

ANS: D. Headache

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding? A. Decreased BUN B. Decreased hematocrit C. Increased urine ketones D. Increased urine specific gravity

ANS: D. Increased urine specific gravity

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A. Nausea or vomiting B. Abdominal pain or diarrhea C. Hallucinations or tinnitus D. Light-headedness or paresthesia

ANS: D. Light-headedness or paresthesia

A nurse of a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Deliver meal trays to clients in their rooms B. Assisting a client who has difficult seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused

ANS: D. Observing a postoperative client who is confused

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? A. pH 7.26 B. Serum bicarbonate of 21 mEq/L C. pH 7.30 D. Serum bicarbonate of 28 mEq/L

ANS: D. Serum bicarbonate of 28 mEq/L

The nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Hypoactive bowel sounds B. Skeletal muscle weakness C. Decreased deep-tendon reflexes D. Tingling of the lips

ANS: D. Tingling of the lips

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? A. Hypoxemia B. Hypocapnia C. Compensated metabolic acidosis D. Uncompensated respiratory acidosis

ANS: D. Uncompensated respiratory acidosis Rationale: The increased PaCO2 indicates respiratory acidosis, and the low pH indicates that the respiratory acidosis is uncompensated. The PaO2 is normal, indicating that the client is not hypoxemic. The elevated PaCO2 indicates hypercapnia. The HCO3 is normal, indicating that there is no metabolic acidosis.

When taking care of an older adult client, you realize that when assessing his pain level that all of the following considerations would apply EXCEPT: A. He might not be able to express pain. B. He might be depressed. C. Sedation will affect how he expresses his pain. D. You will have to take his culture into consideration. E. You realize that because he is older, he does not feel pain as much.

ANS: E. You realize that because he is older, he does not feel pain as much.