Exam 2: Fluid/Electrolyte Review
What is Magnesium?
Which electrolyte disturbance is of concern when caring for a client with alcoholism?
What is Hypokalemia?
Flattened T-waves, prominent U-waves, and/or ST depression may be caused by which electrolyte disturbance?
What are Hypotonic solutions?
0.25%D 0.45%D 0.33% dextrose
What is cerebral edema?
A deadly complication of hyponatremia is ____?
C. Metabolic alkalosis Rationale: A client who has influenza has experienced excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities.
A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis
C. Poor skin turgor D. Flat neck veins E. Hypotension
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Pale yellow urine B. Bradycardia C. Poor skin turgor D. Flat neck veins E. Hypotension
What is Hypercalcemia?
Clinical manifestations of this type of electrolyte imbalance reflect a decreased cell membrane excitability. Possible symptoms can include dysrhythmias, decreased DTRs, Hyporeflexia, abdominal pain, bone pain
What is Lactated Ringer's (LR)?
Contains potassium, don't use with renal failure patients Don't use with liver disease, cant metabolize lactate. Don't give to patients with metabolic alkalosis Will increase bicarbonate levels
What are Hypertonic solutions?
D10. 0.9NS 3% NACI TPN ( amino acids and 15-50% dextrose) D5. 45NS
What are sodium and potassium?
Diuretic therapy are a cause of what two electrolyte abnormalities?
What is Isotonic solution?
Expands volume for hypotensive patient Replace abnormal losses through N/V
1. What is Isotonic solutions? 0.9% sodium chloride (Normal Saline) ( NaCI) 2. What is albumin?
1. Can lead to overload Use with caution in patients with heart failure of edema 2. Provides colloidal oncotic pressure, which serves to mobilize fluid from extravascular tissues back into intravascular space
1. What is K+ 2. What is dextrose and Insulin?
1. This electrolyte follows glucose into the cells of the body. 2. In severe cases of hyperkalemia, these medication may be given to facilitate the diffusion of potassium back into the cells
1. What is Pulmonary edema? 2. Peripheral Edema
1. What is a common severe adverse reaction to albumin? 2. Third spacing is indicated by what assessment findings?
1. What are Thiazide or Loop? 2. What is Osmotic diuretic?
1. Which class of diuretic can cause hyponatremia 2. Mannitol is an example of which class of diuretic?
What is Hypertonic solution?
3% solution used for treatment of severe, critical symptomatic hyponatremia. Give slowly and cautiously to avoid intravascular fluid volume overload and pulmonary edema Pulls fluid out of the intracellular compartmen
C. Metabolic alkalosis A client who is experiencing metabolic alkalosis would report manifestations such as confusion, dizziness, circumoral paresthesia, and numbness and tingling of the extremities. Objective findings would include hyperactive reflexes, tetany, and decreased respiratory depth and rate.
A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
B. Conjunctivae
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Dorsal surface of the hand B. Conjunctivae C. Pinnae of the ears D. Dorsal surface of the foot
C. 0.45% sodium chloride
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Dextrose 5% in 0.9% sodium chloride B. Lactated Ringer's C. 0.45% sodium chloride D. Dextrose 10% in water
C. Weak pulse
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Dyspnea B. Increased blood pressure C. Weak pulse D. Decreased heart rate
C. WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. Potassium B. RBC count C. WBC count D. BUN
B. Client has an NG tube to gastric suction Nausea and vomiting The client who has an NG tube to gastric suction is at risk for developing hypokalemia due to the gastrointestinal loss of potassium.
A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? A. Client reports drinking 3.5 to 4 L of water each day B. Client has an NG tube to gastric suction C. Client is currently prescribed spironolactone. D. Client has a history of alcohol abuse disorder
A. Decreased level of consciousness since admission
A patient who has been hospitalized for 3 days has a nasogastric tube to low suction and is receiving normal saline IV at 150 mL/hr. Which assessment finding would be the highest priority for the nurse to report to the health care provider? A. Decreased level of consciousness since admission B. Weight gain of 2 pounds (1 kg) over 3 days C. Serum sodium level of 138 mEq/L D. Oral temperature of 100.1° F
C. Assign the patient to a room near the nurse's station. The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.
A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments? A. Assign the patient to a semiprivate room. B. Place the patient in a room nearest to the water fountain. C. Assign the patient to a room near the nurse's station. D. Place the patient on telemetry to monitor for peaked T waves.
What is blunted response?
Identify the physiologic reason for fluid deficit in the elderly.
What is Hypernatremia?
In Dehydration and DI which electrolyte imbalance is most likely?
C. Monitor for Trousseau's and Chvostek's signs. The Trousseau sign of latent tetany is a way to determine if an individual may have hypocalcemia. Trousseau's sign is considered positive when a carpopedal spasm of the hand and wrist occurs after an individual wears a blood pressure cuff inflated over their systolic blood pressure for 2 to 3 minutes. The increased irritability of the facial nerve, manifested by twitching of the ipsilateral facial muscles on percussion over the branches of the facial nerve, came to be known as Chvostek sign. This clinical finding has become widely accepted in the medical community as a sign of hypocalcemia.
The nurse is caring for a patient who has a calcium level of 6.1 mg/dL. Which nursing action should the nurse include on the care plan? A. Auscultate lung sounds every 4 hours. B. Encourage fluid intake up to 4000 mL daily. C. Monitor for Trousseau's and Chvostek's signs. D. Maintain ambulatory without assistance
a. Elevated C-reactive protein (CRP) 6.5 mg/dL C-reactive protein (CRP) is produced by the liver in response to inflammation, tissue damage, and infection. Blood levels of CRP have been used as a marker for inflammatory and autoimmune disorders. The nurse would expect to see an elevated CRP in a patient with an infected wound. Creatinine is an indicator of kidney function, and bilirubin is an indicator of liver function. Prothrombin time indicates clotting ability of the blood, particularly when the patient is taking warfarin (Coumadin).
The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient's chart? a. Elevated C-reactive protein (CRP) 6.5 mg/dL b. Decreased serum creatinine 0.8 mg/dL c. Elevated serum bilirubin 0.5 mg/dL d. Prothrombin time (PT) 11.5 sec
C. The patient will remain alert and oriented ×3 with no confusion or seizure activity. A patient with low serum magnesium is at risk for neurologic symptoms including confusion, disorientation, and seizures. The highest priority goal for this patient is to avoid neurologic problems that could lead to injury. The other goals are applicable to the patient with low magnesium but are less important.
The nurse is caring for a patient who has a serum magnesium level of 0.8 mEqL. Which is the highest priority goal to include in the patient's plan of care? A. The patient will verbalize the importance of sufficient dietary intake of magnesium. B. The patient's oral mucous membranes will remain free of ulceration and pain. C. The patient will remain alert and oriented ×3 with no confusion or seizure activity. D. The patient will maintain urine output of at least 30 mL/hr.
B. Magnetic resonance imaging (MRI) scan D. Computed tomography (CT) scan CT scan and MRI may be used to determine the presence of an abdominal aortic aneurysm. Endoscopy, needle aspiration, sigmoidoscopy, and thoracentesis will not help make this diagnosis.
The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor's suspicion? (Select all that apply.) A. Flexible sigmoidoscopy B. Magnetic resonance imaging (MRI) scan C. Needle aspiration with biopsy D. Computed tomography (CT) scan E. Thoracentesis F. Fiberoptic endoscopy
a. Hemoglobin A1c 16% Hemoglobin A1c (Hgb A1c), or glycosylated hemoglobin, testing evaluates blood sugar levels over a period of 2 to 3 months This blood test is performed to provide the primary care provider (PCP) with information about long-term blood sugar control. The normal value of Hgb A 1c in patients without diabetes is 4% to 5.9%. The American Diabetes Association (2016) states that diabetes is diagnosed for Hgb A1c levels greater than 6.5%. A higher level indicates that the patient has had poor blood glucose control during the past few weeks, and increases the patient's risk of long-term complications from hyperglycemia. The other tests are not related to long-term diabetes control.
The nurse is caring for a patient who has diabetes. The patient reports compliance with the medical regime. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan? a. Hemoglobin A1c 16% b. Random blood sugar (RBS) 112 mg/dL c. Lactate dehydrogenase (LDH) 55 units/L d. Erythrocyte sedimentation rate (ESR) 14 mm/hr
a. Esophagogastroduodenoscopy (EGD) EGD is performed using a lighted tube that allows for direct visualization of the esophagus, stomach, and upper duodenum. MRI, ultrasound, and PET scanning do not allow physicians to see the esophagus directly.
The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus? a. Esophagogastroduodenoscopy (EGD) b. MRI scan with contrast c. Abdominal ultrasound d. Positron emission tomography (PET) scan
b. Check the patient for a gag reflex. Numbing medication is applied to the back of the throat just before bronchoscopy. This may lead to swallowing difficulty and risk for aspiration until the gag reflex returns. The nurse should keep patient NPO until swallow, gag, and cough reflexes have returned. The nurse does not need to keep the patient NPO after the gag reflex returns so it should be checked in order to allow the patient to have fluids as soon as possible to relieve thirst.
The nurse is caring for a patient who has just undergone bronchoscopy. The patient requests a drink of water. What is the nurse's best action? a. Provide ice chips. b. Check the patient for a gag reflex. c. Provide a small cup of ice water with a straw. d. Keep the patient NPO.
d. Perforation of the bowel resulting in abdominal infection Paracentesis is drainage of fluid from the abdominal cavity. Since the needle is near the intestines, bowel perforation can occur, manifested by abdominal pain and fever as infection (peritonitis) sets in. Possible complications do not include lung collapse, CSF leak, or impaction.
The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor? a. Collapse of the lung with shortness of breath b. Fecal impaction from retained barium in the colon c. Cerebrospinal fluid leak resulting in severe headache d. Perforation of the bowel resulting in abdominal infection
A. Perform regular neurologic checks and institute seizure precautions. A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia.
The nurse is caring for a patient who is admitted with a serum sodium level of 118 mEq/L. Which is the most important intervention for the nurse to perform? A. Perform regular neurologic checks and institute seizure precautions. B. Encourage the patient to eat foods that are high in sodium. C. Assess for signs and symptoms of digoxin (Lanoxin) toxicity. D. Administer hypotonic IV solutions as ordered by the physician.
a. Red blood cell count (RBC) 5.8 million/mm3 c. Hemoglobin (HGB) 14 g/dL Red blood cell count of 5.8 million and hemoglobin value of 14 g/dL are both normal. Hematocrit level of 25% is very low and indicative of ongoing anemia. White blood cell and platelet counts are not checked for anemia.
The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.) a. Red blood cell count (RBC) 5.8 million/mm3 b. Hematocrit (HCT) 25% c. Hemoglobin (HGB) 14 g/dL d. White blood cell count (WBC) 4500/mm3 e. Platelet count (PLT) 255,000/mm3
C. "Weigh yourself every morning before breakfast." Checking the weight every morning before breakfast is a sensitive indicator of the patient's fluid volume status. Weight gain of 2 kg in 3 days generally indicates fluid retention and should be reported to the physician.
The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance? A. "Check to make sure that your urine is a bright yellow color." B. "Count your heart rate every evening before you go to bed." C. "Weigh yourself every morning before breakfast." D. "Drink plain water rather than soda, coffee, or fruit juice."
c. Properly disposing of the needle after the specimen is obtained Proper disposal of needles and sharps after procedures is essential for safe nursing practice to ensure the safety of staff as well as patients. Ensuring that the tourniquet is not left on too long, using the smallest needle possible, and making sure that all of the vials are filled are important steps in venipuncture, but only proper sharps disposal will help ensure the safety of the patient and the nurse.
The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse? a. Ensuring that the tourniquet is not left in place for too long b. Using the smallest possible needle for venipuncture c. Properly disposing of the needle after the specimen is obtained d. Making sure that all of the collection tubes are filled completely
A. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.
The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse? A. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. B. Double-check that the transfusion blood type is an exact match to the patient. C. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F. D. Recheck the patient's blood pressure in 15 minutes after administering pain medication.
a. Anxiety related to potential for cancer diagnosis depending on biopsy results Fear is an emotion commonly experienced by patients waiting for diagnostic tests and biopsy results. Impaired health maintenance related to delayed insurance coverage is not a priority diagnosis for this patient at this time. Powerlessness is about the patient's ability to control an outcome and is not related to the wait for test results. The patient statement of feeling a little nervous about the test results is not indicative of ineffective coping.
The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which Nursing diagnosis is appropriate and important for this patient? a. Anxiety related to potential for cancer diagnosis depending on biopsy results b. Impaired health maintenance related to delayed insurance coverage for procedure c. Powerlessness related to lengthy wait for diagnosis d. Ineffective coping related to patient stated she is a little nervous about the test results
b. Monitor the patient's pulse oximetry and respirations closely. The priority intervention for sedated patients is to monitor pulse oximetry and respirations closely because sedation may suppress the respiratory drive. The nurse should monitor vital signs until the patient is fully awake and observe stools for visible blood. The nurse should also instruct the patient to report any abdominal pain as these assessment findings are alerts for possible perforation of bowel, hypotension, and hemorrhage. Providing a quiet environment is nice for the patient, but dim lighting may impair the nurse's ability to assess the patient. Informing the patient that the procedure has been completed is not a priority. Assessing the patient's bowel sounds and passage of flatus is not as important as careful respiratory monitoring.
The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse? a. Provide a quiet, dark environment so that the patient can rest comfortably. b. Monitor the patient's pulse oximetry and respirations closely. c. Inform the patient that the procedure has been completed. d. Assess the patient's bowel sounds and passage of flatus.
a. Alanine aminotransferase (ALT) b. Alkaline phosphatase (ALP) Alanine aminotransferase (ALT) and alkaline phosphatase (ALP) are indicators of liver function, and increased levels indicate liver damage from a variety of causes. BUN, ANA, ESR, and FDP are not indicators of liver function.
The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient's liver is tolerating the medication without damage to the organ? (Select all that apply.) a. Alanine aminotransferase (ALT) b. Alkaline phosphatase (ALP) c. Blood urea nitrogen (BUN) d. Anti-nuclear antibody (ANA) e. Erythrocyte sedimentation rate (ESR) f. Fibrin degradation products (FDP)
d. "I will drink extra fluids so that the lab will have a large specimen to test." Drinking extra fluids so that the lab will have an extra-large specimen to test is not done as part of 24-hour urine collection, and it may skew the test results. The specimen should be kept chilled on ice or in a refrigerator until it is brought to the lab. If the patient accidentally urinates in the toilet, the test must be started over again. Urine collection is started after the patient's first void of the morning into the toilet.
The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required? a. "I will keep the urine container on ice to keep it chilled until I bring it to the lab." b. "I will start the test over if I forget and urinate into the toilet during the testing time." c. "I will start the test tomorrow after I urinate first thing in the morning." d. "I will drink extra fluids so that the lab will have a large specimen to test."
a. The patient has an implanted insulin pump. Any metal implants are a contraindication for an MRI scan because the scan uses powerful magnets. Insulin pumps often contain metal that can react with the strong magnets in the MRI machine. Breastfeeding is not a contraindication to MRI because there is no radiation exposure. No latex or iodine is used during MRI testing. Profound hearing loss will not be a problem, although MRI scanning is very loud.
The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test? a. The patient has an implanted insulin pump. b. The patient is breastfeeding her newborn infant. c. The patient is severely allergic to iodine and latex. d. The patient has profound hearing loss.
a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. Interventions for the Nursing diagnosis of risk for infection involve monitoring for signs and symptoms of infection, preventing contamination of supplies by maintaining a sterile field during the procedure, and teaching the patient how to care for the site afterward. Providing a caring presence, providing information about liver cancer, and using healing touch may be helpful for the patient but will not minimize the risk of infection.
The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of risk for infection: r/t invasive diagnostic procedure? (Select all that apply.) a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. d. Provide a supportive, caring presence to minimize patient anxiety. e. Provide information about the pathophysiology and treatment options for liver cancer. f. Consider using healing touch and other mind-body-spirit interventions.
a. Label the urine container and lab slips with the patient's name and information. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. The assistant may label the container and lab slips, obtain the urine container from the utility room, and transport the specimen to the lab. These are tasks that do not require nursing judgment. Assessment of the patient is always done by the nurse, as well as explaining the procedure to the patient and ensuring that the correct test is performed.
The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.) a. Label the urine container and lab slips with the patient's name and information. b. Assess the patient's ability to collect the specimen as required. c. Explain the procedure to the patient. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. f. Ensure that the correct test is ordered and collected.
b. The patient's health care provider HIPAA protects the patient by requiring that testing results be shared only with health care professionals who need the information to provide treatment and with individuals designated in writing by the patient. The patient's provider will need the biopsy results to determine the patient's plan of care. The nurse does not give test results to the insurance company. The nurse may share the results with the patient or spouse, but it is not required, unless designated by the patient in writing.
The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results? a. The patient b. The patient's health care provider c. The patient's insurance provider d. The patient's spouse
d. Shrimp and scallops If the patient is undergoing an examination that involves an iodine contrast medium, check for a history of adverse reactions or allergies to iodine-containing food (e.g., shellfish, cabbage, kale, iodized salt). The other allergies are not related.
The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed? a. Gluten and lactose b. Strawberries and blueberries c. Peanuts and cashews d. Shrimp and scallops
a. "I will count the ceiling tiles when the doctor inserts the numbing medicine." The patient will be positioned in the prone or lateral position for the test, so the patient will not be able to count ceiling tiles as a distraction during the numbing step of the test. The patient may take acetaminophen as needed for discomfort afterward. The biopsy site must be kept clean and dry for 24 hours after the biopsy to prevent infection. Holding the nurse's hand will help calm the patient before and during the procedure.
The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed? a. "I will count the ceiling tiles when the doctor inserts the numbing medicine." b. "I will take acetaminophen later today if the site becomes uncomfortable." c. "I will squeeze your hand to help calm my fears about the test." d. "I will keep the biopsy site clean and dry for the next 24 hours."
a. Patient will verbalize understanding of preprocedure preparation to be completed The patient will need to complete colon preparation prior to the sigmoidoscopy testing. The nurse must determine that the patient understands how and when to complete the prep. Having the patient verbalize understanding of the prep procedure is an objective goal so that the nurse can readily determine whether or not it has been met. The other goals are not objective or measurable, so the nurse cannot determine whether or not they have been met.
The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care? a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. b. Patient will feel comfortable about the upcoming test and have trust in the health care providers. c. Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing. d. Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.
B. Gastroenteritis with severe nausea, vomiting, and diarrhea Gastroenteritis with nausea, vomiting, and diarrhea will lead to a metabolic alkalosis resulting from loss of electrolytes and acids through emesis and loose stools. Metabolic alkalosis features the elevated pH of 7.56, elevated HCO3 42 mEq/L, and normal PaCO2 of 32 mm Hg. Widespread tissue ischemia would lead to metabolic acidosis with low pH resulting from release of lactic acid from the tissues. Respiratory failure leads to a respiratory acidosis with a low pH and elevated PaCO2 level. Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO3 level.
The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 35 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results? A. Hyperventilation after a panic attack B. Gastroenteritis with severe nausea, vomiting, and diarrhea C. Widespread tissue ischemia caused by cardiogenic shock D. Respiratory failure caused by pneumonia with pleural effusions
a. Bilirubin level 4 mg/dL An elevated bilirubin level is the result of increased red blood cell destruction. Normal bilirubin levels are 0.3 to 1.0 mg/dL. Increased platelet count, decreased serum acid level, and decreased partial thromboplastin times are not indicative of increased red blood cell destruction.
The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient's chart as a result? a. Bilirubin level 4 mg/dL b. Platelet count 450,000/mm3 c. Serum uric acid level 1.7 mg/dL d. Partial thromboplastin time 45 seconds
D. Risk for injury related to weakened bones that may easily fracture Chronic hypercalcemia can lead to weakened bones as strengthening calcium is removed over time. Pathologic fractures can easily result, so risk for injury is a high priority Nursing diagnosis for this patient. The other Nursing diagnoses apply but are less important than the safety of the patient.
The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient? A. Risk for constipation caused by decreased gastrointestinal motility B. Activity intolerance related to muscle cramping and spasms C. Lack of knowledge related to need for supplemental calcium in diet D. Risk for injury related to weakened bones that may easily fracture
b. Culture and sensitivity (C&S) Culture and sensitivity are performed on specimens to determine which bacteria are causing the infection and which antibiotics will be effective treatment. CBC, renal scan, and radioreceptor assay for HCG will not indicate which antibiotics may be used to treat an infection.
The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection? a. Complete blood count (CBC) b. Culture and sensitivity (C&S) c. Renal scan and angiography d. Radioreceptor assay for HCG
b. Have the patient perform the procedure in front of the nurse. Having the patient successfully perform the procedure in front of the nurse is an excellent way for the nurse to ensure that the patient knows how to do it correctly. Quizzing the patient about the procedure, asking the patient if he/she has questions, and using understandable terminology are fine, but only a return demonstration will assess the patient's ability to perform the procedure successfully and correctly.
The nurse is caring for a patient with diabetes who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly? a. Quiz the patient on the steps of the procedure. b. Have the patient perform the procedure in front of the nurse. c. Ask the patient if he has any questions about the test. d. Use terminology that the patient can easily understand.
B. 3% normal saline A hypertonic 3% saline solution will be used to correct the patient's hyponatremia and fluid overload that have developed due to SIADH. A 0.9% normal saline solution can be used once the serum sodium level has been raised nearer to normal range. A 0.45% or 0.33% normal saline solution is hypotonic and will only worsen the patient's fluid overload and hyponatremia.
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient's fluid imbalance? A. 0.33% normal saline B. 3% normal saline C. 0.45% normal saline D. 0.9% normal saline
D. Ensure that the patient is using the spirometer 10 times every hour. The assessment findings indicate that the patient most likely has atelectasis, so the nurse should ensure that the patient is using the incentive spirometer 10 times every hour to facilitate expansion and reinflation of alveoli. Administering prescribed pain medication is not the priority and may further suppress the patient's respiratory drive. The patient's pulse oximetry is 96% on room air so supplemental oxygen is not needed. A chest x-ray may be ordered if the patient's condition worsens or does not improve with regular spirometer use.
The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored. The patient's pulse oximetry is 96% on room air. This morning's chest x-ray (radiograph) notes patient has bilateral atelectasis in the bases of the lungs. What is the priority action of the nurse? A. Administer 2 L of oxygen via nasal cannula. B. Administer a dose of the prescribed pain medication. C. Obtain an order from the physician for a chest x-ray. D. Ensure that the patient is using the spirometer 10 times every hour.
C. Raise the side rails on the patient's stretcher. Safety of the preoperative patient is a priority after sedation has been administered. Raising the side rails of the stretcher will help prevent the patient from falling. Turning off the lights is nice but is not a priority. Marking the surgical site and signing the consent form must be performed prior to administration of sedation.
The nurse is caring for a preoperative patient who has just received sedation prior to general anesthesia in the OR. What is the priority action of the nurse? A. Turn off the lights and provide a quiet environment. B. Check to make sure that the consent form was signed. C. Raise the side rails on the patient's stretcher. D. Indicate the surgical site with an indelible marker.
a. Needle aspiration with biopsy Needle aspirations are procedures that are used to remove fluid and tissue for testing. A biopsy involves removing a larger collection of cells, as in a tumor or mass, and may be used to detect cancer in the skin, breast, or liver. Paracentesis is drainage of fluid from the abdomen, and thoracentesis is drainage of fluid from the pleural cavity. Fiberoptic endoscopy allows the physician to see inside the upper and/or lower GI tract.
The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this? a. Needle aspiration with biopsy b. Paracentesis c. Thoracentesis d. Fiberoptic endoscopy
d. Albumin 1.4 g/dL Albumin level is an indicator of the patient's protein intake and nutritional status. Normal albumin level is 3.3 to 5 g/dL. It is an essential component of fluid balance, responsible for maintaining colloidal oncotic pressure in the vascular and extravascular spaces. Low levels of albumin may indicate malnutrition.
The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals? a. Serum bilirubin 0.4 mg/dL b. PLT (platelet count) 425,000/mm3 c. Serum cholesterol 175 mg/dL d. Albumin 1.4 g/dL
What are Crystalloids?
These solutions can pass through the semipermeable membrane, contain electrolytes and water
What is FVD? FLUID VOLUME DEFICIT
Thirst, altered LOC, hypotension, tachycardia, weak/thready pulse, flat jugular veins, dry mucous membranes, oliguria, weight loss, sunken fontanelles (infant)
What is Phosphorus?
This electrolyte has an inverse relationship with calcium and is found in dairy, protein sources (i.e. chicken, beef, fish, and nuts), grains, and carbonated beverages.
What is a Potassium?
This electrolyte is found in large amounts in cantaloupes, raisins, bananas, oranges, green leafy vegetables, and lentils
What is free water restriction?
This nursing intervention is used to treat hyponatremia?
What is D5W?
This solution is isotonic only in the container; becomes hypotonic in body after dextrose is metabolized.
What is Chvostek's sign associated with Hypocalcemia?
To test for this electrolyte imbalance, the healthcare provider taps on the patient's facial nerve. A positive response will be a spasm or twitching showing increased neuromuscular irritability
1. What is Albumin? 2. General nursing considerations for hypotonic solution?
1. Plasma expander 2. May worsen existing hypovolemia and hypotension causing cardiovascular collapse. Monitor for signs of fluid volume deficit, such as confusion in older adults and dizziness. Never administer to patients at risk for increased ICP as the potential fluid shift may cause cerebral edema. Avoid in patients with liver disease, trauma or burns
What assessments as a nurse will you take before giving a isotonic solution?
Document baseline data. Before infusion, assess the patient's vital signs, edema status, lung sounds, and heart sounds. Continue monitoring during and after the infusion.
What is Albumin (Colloid IV solution)?
IV solutions given to correct Hypoalbuminemia Malnutrition Circulatory collapse due to third-shift spacing Quicker response and remains in vascular space longer than crystalloids (NS/LR). Requires less amount of fluid compared to crystalloids
A. diarrhea B. diaphoresis (sweating) C. dehydration D. vomiting
Identify the risk factors that contribute to fluid and electrolyte imbalances (select all that apply) A. diarrhea B. diaphoresis (sweating) C. dehydration D. vomiting E. sleeping 8 hours
What is Hyperkalemia?
Kayexalate enemas are used to treat this electrolyte imbalance.
What are precautions for Hypertonic solution?
Monitor for circulatory overload due to ECF expansion. These solutions pull from ICF, so don't administer in conditions causing cellular dehydration (DKA). Avoid in patients with impaired cardiac or renal function. Must be given through Central Access. √ neuro, VS, UOP, Na+
What are Hypertonic solutions?
Provide additional calories Treats severe hyponatremia
What is 0.9% NS?
Shock Hyponatremia Blood transfusions Resuscitation Fluid changes DKA
What is a Hypernatremia?
Symptoms of this electrolyte problem include increased temperature, increased thirst, irritability and agitation, weakness, headache, lethargy, seizures, tachycardia, weak/thready pulse, and edema.
a. Magnetic resonance imaging (MRI) scan d. Computed tomography (CT) scan CT scan and MRI may be used to determine the presence of an abdominal aortic aneurysm. Endoscopy, needle aspiration, sigmoidoscopy, and thoracentesis will not help make this diagnosis.
The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor's suspicion? (Select all that apply.) a. Magnetic resonance imaging (MRI) scan b. Needle aspiration with biopsy c. Fiberoptic endoscopy d. Computed tomography (CT) scan e. Flexible sigmoidoscopy f. Thoracentesis
What is 0.45% sodium chloride (1/2 NS)?
Water replacement & rehydration of cells DKA HHNK Gastric fluid loss from NG or vomiting
What is 0.9% NS (Isotonic)?
Which IV solution is similar to plasma concentration & its purpose is to treat FVD?
D. Oral replacement for potassium Oral replacement is recommended as the fastest way to improve K levels. IV replacement is recommended for patients who can't swallow or have anything by mouth. Kayexalate is given to treat hyperkalemia in some cases.
You are caring for a patient who will need potassium replacement. The current K is 2.9. Which of the following medications would be the best route for administration? A. IV push 20 MEQ Potassium B. IV replacement potassium over 6 hours C. Oral replacement with Kayexalate D. Oral replacement for potassium
1. What is Calcium Gluconate or Calcium Chloride?
1. This is the antidote for Magnesium Toxicity
C. Decrease in level of consciousness Using priority-setting framework a patient with a change in the level of consciousness with hypovolemic requires immediate attention.
A nurse is caring for a patient who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? A. Reporting of thirst B. Dry skin C. Decrease in level of consciousness D. Increased urine output
C. The client who has a nasogastric (NG) tube to suction Rationale: Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. The client who has a tracheostomy tube attached to humidified oxygen B. The client who has an indwelling urinary catheter to gravity drainage C. The client who has a nasogastric (NG) tube to suction D. The client who has a chest tube to water seal
C. Sodium 126 mEq/L Rationale: Therapeutic sodium level is 136 to 145 mEq/L. Low sodium values can be seen with dehydration, use of diuretics, adrenal insufficiency, and water toxicity. Sodium is essential for maintaining acid-base balance and conduction of nerve and muscles tissue. Hyponatremia is a net gain of water or loss of sodium that results in a sodium level less than 136 mEq/L. Manifestations of hyponatremia include headache, confusion, lethargy, muscle weakness, fatigue, decreased deep-tendon reflexes, and seizures.
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Potassium 3.6 mEq/L B. Magnesium 1.9 mEq/L C. Sodium 126 mEq/L D. Chloride 99 mEq/L
What is Lactated ringers? (LR contains some potassium and hyperkalemia can occur)
Contraindicated in patients who cannot metabolize lactate, (i.e. liver disease) or experiencing lactic acidosis. Caution in patients with renal failure
c. Sticky and black Bleeding anywhere along the GI tract results in blood in the stool. Bleeding that occurs in the upper GI tract produces stools that are black and tarry in appearance. Bleeding within the lower GI tract presents with soft stools that have bright red streaks. Watery stool with particles of food is indicative of gastroenteritis. Hard lumps that are difficult to pass indicate constipation, often from medications or lack of fiber in the diet.
The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient's stool to appear? a. Soft and formed with bright red streaks b. Watery with particles of undigested food c. Sticky and black d. Hard lumps that are difficult to pass
