Exam #2

Sodium (Na)

135-145 mEq/L

Which phosphate level would the nurse be likely to find in the patient who has alcohol withdrawal symptoms? 1) 1.4 mg/dL 2) 2.4 mg/dL 3) 3.8 mg/dL 4) 4.8 mg/dL

1) 1.4 mg/dL RATIONALE: Alcohol withdrawal can result in hypophosphatemia. Phosphate levels of less than 2.4 mg/dL indicate hypophosphatemia. The nurse would be likely to find the patient's phosphate level at 1.4 mg/dL. Phosphate levels of 2.4, 3.8, and 4.8 mg/dL indicate hyperphosphatemia. The patient with symptoms of alcohol withdrawal does not have hyperphosphatemia.

The emergency room nurse is caring for a patient with a severe fluid volume deficit who presented after several days of diarrhea secondary to C. difficile infection. Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly replace the fluid volume? 1. 0.9% sodium chloride 2. 0.45% sodium chloride 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.25% saline

1. 0.9% sodium chloride RATIONALE: An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and 5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly increase fluid volume.

The nurse is caring for a patient with hypercalcemia. Which nursing interventions are appropriate when caring for a patient for this patient? 1. Administer furosemide. 2. Administer bisphosphonates. 3. Administer isotonic saline infusions. 4. Restrict oral fluid intake to 1000 mL. 5. Encourage patient to breathe into a paper bag.

1. Administer furosemide. 2. Administer bisphosphonates. 3. Administer isotonic saline infusions. RATIONALE: Hypercalcemia is treated by hydrating the patient and promoting urinary excretion of calcium. Therefore the nurse should administer loop diuretics such as furosemide to promote diuresis and should keep the patient hydrated by administering isotonic saline infusions. The nurse can also administer bisphosphonates to inhibit the activity of osteoclasts. The patient should be encouraged to drink at least 3000 to 4000 mL of fluid to promote calcium excretion and prevent kidney stones. The patient is encouraged to breathe into a paper bag if signs of hypocalcemia are evident.

To prevent a recurrence of hypocalcemia, the nurse should encourage the patient to increase intake of which of foods? 1. Fish 2. Lean meat 3. Dairy products 4. Potatoes and starches

3. Dairy products

Potassium (K)

3.5-5.0 mEq/L

Ejection Faction:

50-65%

Calcium (Ca)

8.6-10.2 mg/dL

Moderate Hypothermia

86-93°F

Mild Hypothermia

93.2-96.8°F

Chloride (Cl-)

96-106 mEq/L

Afterdrop:

Cold blood from the extremities comes back to the core and makes the core hypothermic again

Drowing:

Respiratory impairment after submersion in water/other fluid

Gastrointestinal system regulates water balance by:

absorbs our fluids

Normothermia

normal body temperature (97-100°F)

Hypothalamic Pituitary system regulates water balance by:

secreting ADH (anti-diuretic = "no pee")

Herpes Type 2:

sexually transmitted blisters on genitals

Rhabdomyolysis:

skeletal muscle breakdown can lead to myoglobinuria, which can lead to acute kidney injury

Regarding heat-related emergencies, death is related to:

the amount of time the body temperature remains elevated

Thermoregulation:

the process of maintaining the core body temperature at a nearly constant value

Heat stress occurs when:

thermoregulatory mechanisms (sweating, vasodilation) cannot compensate for exposure to ↑ ambient temperatures

Cause of Bacterial vaginosis:

unknown

Does the respiratory rate go up or down as the fever increases?

up

Disseminated Intravascular Coagulation (DIC)

when a person hemorrhages from everywhere: mouth, eyes, nose, gums, etc.

Heat exhaustion signs/symptoms:

1. Fatigue 2. N/V 3. Extreme thirst 4. Anxiety 5. Tachycardia (D/T loss of fluid/electrolytes) 6. Dilated pupils 7. Confusion/Change in LOC 8. Ashen color 9. Profuse diaphoresis (BUT NOT IN HEAT STROKE) (*BIG*) 10. Hypotension 11. Mild to severe temperature elevation (100º F - 105.8 º F) (D/T dehydration)

Viral STIs:

1. HPV (genital warts) 2. Herpes

A nurse reviews the laboratory results of a patient. The arterial blood gas (ABG) values are pH 7.30, PaCO 2 35 mm Hg, and bicarbonate (HCO 3 -) 16 mEq/L. What is the correct interpretation of the values given? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

Magnesium (Mg)

1.5-2.5 mEq/L

The nurse is caring for a patient who is febrile with a body temperature of 103 oF. What clinical manifestation does the nurse anticipate when assessing this patient? 1. Muscle spasm 2. Bounding pulse 3. Jugular vein distention 4. Orthostatic hypotension

4. Orthostatic hypotension RATIONALE: A patient with an elevated body temperature of 103 oF may have a loss of body fluids leading to decreased blood volume and resulting in postural or orthostatic hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations that occur due to an increase in the body fluid volume.

Dysmenorrhea:

pain during or shortly before menstrual cycle

MILD Hypothermia care:

1. Passive external rewarming (move patient to warm, dry place; remove damp clothing; use radiant lights; place warm blankets on patient) 2. Active external rewarming (fluid- or air-filled warming blankets, or warm [98.6° to 104° F] water immersion)

Insensible loss:

600 mL/day

When is Group B Strep a problem?

When pregnant only

Amenorrhea:

absence of menstrual flow

Myoglobinuria:

when myoglobin (D/T Rhabdomyolysis which breaks down muscles and produces myoglobin) goes into the blood, circulates to the kidneys, clogs up the nephron tubules, and injures the kidneys can lead to kidney failure

Which STIs have usually have no signs/symptoms:

1. Chlamydia 2. Gonorrhea 3. Tricnomiosis

A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis? Select all that apply. 1. Full, bounding pulse 2. Distended neck veins 3. Orthostatic hypotension 4. Increase in the heart rate 5. Presence of an S3 heart sound

1. Full, bounding pulse 2. Distended neck veins 5. Presence of an S3 heart sound RATIONALE: Fluid volume excess results in a full, bounding pulse, presence of an S3 heart sound, and jugular venous distention (distended neck veins). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume.

Syphilis signs/symptoms:

1. small lesion in genital area - appears 5-90 days after exposure 2. secondary outbreak - 6-12 months after first outbreak

How does tylenol work?

Causes vasodilation - increases peripheral blood flow to rid of more heat

Renal system regulates water balance by:

Hangs onto/lets go of fluid when needed

What is the temperature difference between heat exhaustion and heat stroke?

Heat exhaustion: 100-105.8º F Heat stroke: > 105.8º F

What is the main visible difference between heat exhaustion and heat stroke?

Heat exhaustion: profuse diaphoresis Heat stroke: can no longer sweat

Which STI can cause blindness in newborns if exposed?

Herpes Type 2

Is a patient with dehydration likely to have a higher or lower temperature?

Higher (HIGH AND DRY)

What may be occurring with a patient who presents with a fever but no signs of an infection, like an elevated WBC count?

Metabolic fever

Where does deep frostbite occur/what does it include?

Muscle, bone, and tendons

Is fever the same as hyperthermia?

NO - in hyperthermia and hypothermia the set point is not changed

Grade C =

No Recommendations For or Against • There may be considerations that support providing the intervention in an individual patient but not for the general population. There is at least moderate certainty that the net benefit is small.

Remittent Fever

a fever that widely fluctuates above normal over a 24-hour period

Is 0.45% NS isotonic, hypotonic, or hypertonic?

hypotonic

Group B Strep:

normal flora found in the vaginal cavity

Antipyretic:

"Anti-fever"

C/F temperature conversion:

( C x 9/5 ) + 32 = F

Formula to calculate F to C:

(9/5 * Cº) + 32 = Fº

Phosphate (PO4)

2.4-4.4 mg/dL

What unexpected therapy may be performed after cardiac arrest?

Therapeutic hypothermia

What is the main method of treatment for fever?

Antipyretics

What is the main method of treatment for hyperthermia?

Cooling mechanism

Does a massage help frostbite?

No, it will damage the cells. Ice crystals form in the cell membranes and a massage would damage them

Candisis treatment:

OTC medication

Is 10% Dextrose isotonic, hypotonic, or hypertonic?

Hypertonic

What is the cause of malignant hyperthermia?

Inherited from family Occurs when a pt receives general anesthesia

I Statement =

Insufficient Evidence to Recommend For or Against • The current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Is 0.9% NS isotonic, hypotonic, or hypertonic?

Isotonic

Is malignant hyperthermia is big concern if it occurs?

Life threat!

Submersion Injury:

Person becomes hypoxic due to submersion in a liquid, usually water

Heat exhaustion

Prolonged exposure to heat over hours/days

Grade D =

Recommends Against • There is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits.

Grade B =

Recommends • There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Grade A =

Strongly Recommends • There is high certainty that the net benefit is substantial.

Premenstrual Syndrome (PMS) treatment:

Treatment of physical symptoms: (*LIKE DYSMENORRHEA*) 1. applying heat to super-pubic area 2. increasing exercise 3. NSAIDs 4. ↓↓↓ red meat intake 5. ↓↓↓ salt intake Treatment of psychological symptoms: 1. treating physical symptoms 2. SSRI's

What is the most widely used antipyretic?

Tylenol (Acetaminophen)

Fever:

an elevation in body temperature due to a change in the set point by the hypothalamus due to exogenous and endogenous factors

Newborn exposure to Herpes Type 2 can cause:

blindness

Secondary Dysmenorrhea treatment:

eliminate the issue causing pain

Vasodilation:

expanding of blood vessels to promote blood flow, which promotes heat loss

Premenstrual Syndrome (PMS):

experiencing one or more physical or psychological symptoms associated with the menstrual cycle

What drug triggers malignant hyperthermia?

general anesthesia

Vaginal Infection STIs:

1. Bacterial vaginosis 2. Candisis (Yeast Infection) 3. Tricnomiosis 4. Group B Strep

Which client body temperatures are indicative of moderate hypothermia? Select all that apply. 1. 80° F (26.7° C) 2. 84° F (28.9° C) 3. 88° F (31.1° C) 4. 92° F (33.3° C) 5. 96° F (35.6° C)

3. 88° F (31.1° C) 4. 92° F (33.3° C)

Upon assessment of laboratory data, the nurse notes a calcium level of 6.4 mg/dL. Which physical assessment finding is consistent with this data? 1. Polyuria 2. Bone pain 3. Paresthesias 4. Diminished deep tendon reflexes

3. Paresthesias RATIONALE: Signs of hypocalcemia include paresthesias, tetany, and muscle weakness. Bone pain, diminished reflexes, and polyuria are signs of hypercalcemia.

What drug counteracts malignant hyperthermia?

Dantrolene (Dantrium)

Which STI is associated with preterm labor?

Bacterial vaginosis

What drug is used to control shivering?

IV chlorpromazine (Thorazine)

Is D5W isotonic, hypotonic, or hypertonic?

isotonic

As hypothermia worsens, everything speeds up or slows down?

Slows down i.e. HR, Respirations

In children, what is the biggest risk for heat stroke? A. Being by a space heater B. Hot bath water C. Inappropriate clothing D. Being in a hot car

D. Being in a hot car RATIONALE: A drastic increase in core temperature can happen in 10-15 minutes

Validity:

For evidence to be valid, it must successfully measure what the study set out to measure. The definition of validity is producing the desired result, effective, sound.

Do antipyretics work with hyperthermia?

No

Would antipyretics work to reverse heat exhaustion/heat stroke?

No - only works when the fever is related to infection

Is a patient with hyperthyroidism (high metabolism) is more likely to run hot or cold?

Run hot

Adrenal Cortical system regulates water balance by:

Secretes aldosterone (SALT) and cortisol (SUGAR)

Cardiac system regulates water balance by:

Secreting BNP - high BNP indicates worsening heart failure. High BNP indicates high levels of sodium

What is the H&H ratio?

1 Hemoglobin : 3 Hematocrit

Which patient statement indicates the need for further education from the nurse regarding potassium supplementation prescribed to treat hypokalemia? 1. "I will chew my tablets." 2. "I will eat a banana every day." 3. "I will avoid licorice in my diet." 4. "I will take my medication with water."

1. "I will chew my tablets." RATIONALE: Potassium supplements should be swallowed whole and not chewed; therefore, this statement indicates the need for the nurse to provide additional education. Eating foods rich in potassium (such as bananas), avoiding licorice, and taking the supplement with water all indicate that no additional education is required.

Care for Heat Exhaustion:

1. *FIRST* Place pt in cool area and remove constrictive clothing 2. Monitor ABG's 3. Oral intake or IV fluids 4. Place moist sheet over pt to decrease core temp.

A patient has a prescription to receive D5W with 20 mEq KCl/L at 100 mL/hour. The nurse should select which solution from the intravenous supply cart? 1. 5% dextrose in water with 20 mEq of KCl 2. 5% dextrose in 0.9% sodium chloride with 20 mEq of KCl 3. 5% dextrose lactated Ringer's solution with 20 mEq of KCl 4. 5% dextrose in 0.45% sodium chloride with 20 mEq of KCl

1. 5% dextrose in water with 20 mEq of KCl RATIONALE: D5W stands for 5% dextrose in water, which is different than normal saline, half normal saline, or lactated Ringer's.

Which physiologic characteristics of newborns affect drug dosage considerations? Select all that apply. 1. A newborn's less regulated body temperature 2. Immature liver and kidneys 3. Thick and less permeable skin 4. Lungs with weaker mucous barriers 5. Bacteria-killing acid in the stomach

1. A newborn's less regulated body temperature 2. Immature liver and kidneys 4. Lungs with weaker mucous barriers RATIONALE: The body temperature of newborns is less regulated and dehydration occurs easily. This characteristic affects the drug dose consideration in newborns. Metabolism and excretion are impaired in pediatric clients due to an immature liver and kidneys. The lungs in pediatric clients have weak mucous barriers; this characteristic also affects the drug dosage considerations in newborns. A newborn's skin is thin and more permeable. The newborn has no acid in the stomach to kill the bacteria; therefore, drug absorption from the gastrointestinal tract is affected, thus impacting drug dosage considerations.

Heat-Related Emergency risk factors:

1. Age 2. Environmental conditions 3. Preexisting illness 4. Prescription drugs 5. Alcohol (causes vasodilation which brings more blood to the surface)(alcohol is also a diuretic) 6. Street drugs

Which STIs do all pregnant women get screened for at first prenatal visit?

1. Chlamydia 2. Gonorrhea 3. Group B Strep

Bacterial STIs:

1. Chlamydia 2. Gonorrhea 3. Syphilis

Frostbite signs/symptoms:

1. Decreased HR 2. Decreased respirations 3. Decreased blood flow 4. Edema

People who are particularly vulnerable to heat stroke:

1. Elderly 2. Diabetes 3. CKD 4. Cardiovascular disease 5. Pulmonary disease

When evaluating a patient arterial blood gases (ABGs) the nurse determines there is an increase in the anion gap. What condition does the nurse interpret this to mean for the patient? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis RATIONALE: The anion gap increases in patients with metabolic acidosis due to increase in the concentration of acid. Metabolic alkalosis, respiratory acidosis, and respiratory alkalosis do not increase the anion gap.

Heat stroke signs/symptoms:

1. NO sweating 2. Vasodilation 3. Increased respiratory rate 4. > 105.8º F 5. Altered mental status 6. Hot, dry, ashen skin 7. *MAJOR* change in LOC

Heat stroke care:

1. Obtain core temperature volume 2. Stabilize ABC's 3. Remove clothing 4. Cover with wet sheet 5. Immerse in cool water bath 6. Apply ice packs to groin and axilla 7. Peritoneal lavage 8. Give 100% oxygen 9. Control shivering (IV chlorpromazine - Thorazine) 10. Monitor for signs of: Rhabdomyolysis, Myoglobinuria, and Disseminated Intravascular Coagulation (DIC)

Who needs to go to the hospital for Heat Exhaustion?

1. Older adult 2. Chronically ill 3. Those who do not improve in 3-4 hours

A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, what nursing action is most important? 1. Preventing shivering 2. Restricting oral fluids 3. Measuring output hourly 4. Taking vital signs hourly

1. Preventing shivering RATIONALE: Shivering increases the metabolic rate, which intensifies the body's need for oxygen and increases body temperature. Restriction of fluids is contraindicated because of the risk for dehydration; fluids should be offered. Although monitoring the child's output will provide information about the level of hydration, it is more important to take action to prevent worsening of the fever. Although monitoring of vital signs is important, it is not the priority.

MILD hypothermia signs/symptoms:

1. Shivering 2. Lethargy 3. Confusion 4. Possible LOC change 5. *Minor* HR changes

Deep frostbite signs/symptoms:

1. Skin is white, hard, and insensitive to touch 2. Molting gradually progresses to gangrene 3. Will have significant edema within 3 hours 4. Will blister within hours/days

A patient's arterial blood gas results indicate the presence of metabolic alkalosis. Which clinical manifestations assessed by the nurse confirm this interpretation? Select all that apply. 1. Tremors 2. Vomiting 3. Tachycardia 4. Epigastric pain 5. Numbness of limbs

1. Tremors 2. Vomiting 3. Tachycardia RATIONALE: Tremors, vomiting, and tachycardia are signs of metabolic alkalosis. Epigastric pain and numbness of limbs are signs of respiratory alkalosis.

SEVERE hypothermia signs/symptoms:

1. Undetectable vital signs 2. Absent reflexes 3. Pupils fixed and dilated 4. Bradycardia, ventricular fibrillation, asystole

Superficial frostbite signs/symptoms:

1. Waxy pale yellow/blue mottled skin 2. Skin feels crunchy and frozen 3. Tingling, numbness, or burning 4. Will blister in hours

Primary Dysmenorrhea treatment:

1. applying heat to super-pubic area 2. increasing exercise 3. NSAIDs 4. ↓↓↓ red meat intake 5. ↓↓↓ salt intake

Endometriosis signs/symptoms:

1. dysmenorrhea 2. pain with intercourse 3. increased risk of infertility

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? 1. 60 mL urine output in 90 minutes 2. 1200 mL urine output in 24 hours 3. 300 mL urine output per 8-hour shift 4. 20 mL urine output for two consecutive hours

4. 20 mL urine output for two consecutive hours RATIONALE: The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

The nurse is evaluating a patient's arterial blood gases. Which value of partial pressure of carbon dioxide (PaCO 2) in arterial blood indicates a compensatory response in metabolic alkalosis? 1. 38 mm Hg 2. 40 mm Hg 3. 44 mm Hg 4. 47 mm Hg

4. 47 mm Hg

The nurse is preparing to cleanse the skin around a central venous access device. Which solution would the nurse select as the most effective means of killing harmful bacteria? 1. Sterile saline solution 2. Isopropyl alcohol solution 3. Povidone-alcohol solution 4. Chlorhexidine-based solution

4. Chlorhexidine-based solution RATIONALE: Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol solutions. Therefore chlorhexidine-based solutions should be used to cleanse around the central venous access device. A sterile saline solution does not have any antiseptic properties.

The intravenous (IV) prescription reads "D5.45 normal saline (NS) with 40 mEq KCl/L at 125 mL/hour." The nurse needs to add KCl to the IV because no premixed solutions are available. The unit's medication supply has a stock of KCl 5 mEq/mL in multidose vials. The nurse would need to draw up _____ milliliters to add to the IV solution? Record your answer using a whole number.

8 RATIONALE: The end concentration of the KCl is listed on the vial as follows: "5 mEq/mL." Using ratio and proportion, multiply 5 by x and multiply 40 × 1 to yield 5x = 40. Divide 40 by 5 to yield 8 mL.

Troponin I range:

<0.04

Fetal exposure to Group B Strep can cause what in the newborn?

Respiratory distress

Heat Cramps:

Severe brief and intense cramps in large muscle groups fatigued by heavy work

Mixed Design Research:

combination of qualitative and quantitative research

SaO2

greater then 95%

Endometriosis:

growth of endometrial tissue outside the uterus

Is D5 1/2 isotonic, hypotonic, or hypertonic?

hypertonic

Severe Hypothermia

less than 86°F

Group B Strep treatment:

give antibiotics during delivery so the pt can deliver vaginally

Hyperthermia

greater than 100°F

Is 3%-5% NS isotonic, hypotonic, or hypertonic?

hypertonic *THIS SOLUTION IS VERY DANGEROUS, NOT OFTEN USED*

Infection stimulates the immune system to make hormones that affect the:

set-point in the hypothalamus

Evaporation:

sweating

Chlamydia signs/symptoms:

usually none

Gonorrhea signs/symptoms:

usually none

When do we treat Group B Strep?

vaginal birth: treat C-Section: possibly treat

Why do very old persons have impaired thermoregulation?

- lowered temperature perception - physiologic slow down - slower metabolism - aging organs - less subcutaneous tissue

The nurse is reviewing the mechanisms of acid-base buffers in the body. The kidneys act as an acid-base buffer by which of these mechanisms? 1. Eliminating excess H + 2. Excreting excess water 3. Eliminating excess CO 2 4. Reabsorbing additional HCO 3 - 5. Reabsorbing additional sodium ions

1. Eliminating excess H + 4. Reabsorbing additional HCO 3 - RATIONALE: As a compensatory mechanism, the pH of the urine can decrease to 4 or increase to 8. To compensate for acidosis, the kidneys can reabsorb additional HCO 3 -and eliminate excess H +. Thus the pH of the blood increases and the pH of the urine decreases. Eliminating excess water or CO 2 or reabsorbing additional sodium ions are not mechanisms of acid-base buffers.

Care for heat cramps:

1. rest 2. replacement of sodium and water 3. elevation 4. gentle massage 5. analgesia (for pain) 6. avoid strenuous activity for 12 hours

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? 1. Frostbite 2. Heatstroke 3. Hypothermia 4. Hyperthermia

2. Heatstroke RATIONALE: Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. What classification of medications should be withheld until consulting with the health care provider? 1. Antibiotics 2. Loop diuretics 3. Bronchodilators 4. Antihypertensives

2. Loop diuretics RATIONALE: Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range. Antibiotics, bronchodilators, and antihypertensives are not an issue in this case.

In the regulation of water balance, which system has a primarily antiinflammatory effect and increases serum glucose levels? 1. Renal 2. Cardiac 3. Adrenal-cortical 4. Hypothalamic-pituitary

3. Adrenal-cortical RATIONALE: The adrenal-cortical system secretes glucocorticoids and mineralocorticoids to regulate water and electrolyte balance. Glucocorticoids have an antiinflammatory effect and increase serum glucose levels. The renal system regulates water balance through urine volume changes and excretion of electrolytes. The cardiac system produces natriuretic peptides that promote the excretion of sodium and water. The hypothalamic-pituitary system releases antidiuretic hormone, which results in increased water reabsorption into the blood and decreased excretion in the urine.

As a nursing priority, the nurse avoids active external rewarming with heating devices because it is contraindicated due to rapid vasodilation. From which condition is the client suffering? 1. The client is suffering from frostnip. 2. The client is suffering from frostbite. 3. The client is suffering from severe hypothermia. 4 .The client is suffering from moderate hypothermia.

3. The client is suffering from severe hypothermia. RATIONALE: The nurse as a nursing priority should avoid active external rewarming for the client with heating devices in case of severe hypothermia. Extreme heating is contraindicated in this kind of client due to rapid vasodilation. Frostnip is a type of superficial cold injury that can be treated with warmth without causing any tissue damage. In case of frostbite, the nurse should not use dry heat or massage the frostbitten area of the client's body. Moderate hypothermia can be cured by both active external and core rewarming methods.

Amount of fluid loss with heat stroke:

4L

A core temperature below ___ º F is life threatening.

Below 89.6º F

Which STI can generally clear up on its own?

HPV (genital warts)

Why do very young children have impaired thermoregulation?

Immature thermoregulation: - smaller surface area - higher body water % - less adipose tissue - immature organs

Is heat exhaustion a medical emergency?

Not necessarily

Will vasodilation keep or get rid of heat? Vasoconstriction?

Vasodilation: get rid of heat Vasoconstriction: keep heat

Malignant Hyperthermia:

a disease that causes a fast rise in body temperature and severe muscle contractions when someone with the disease gets general anesthesia

Is Lactated Ringer's Solution isotonic, hypotonic, or hypertonic?

isotonic

Hypothermia

less than 97°F

Hemoglobin range:

men: 13-17% women: 12-16%

RBC

men: 4.3-5.7 (x 10^6) women: 3.8-5.1 (x 10^6)

Hematocrit range:

men: 40-50% women: 36-48%

Primary Dysmenorrhea:

pain during or shortly before menstrual cycle due to the menstrual cycle itself

How long should someone who is suffering heat cramps avoid strenuous exercise for?

12 hours

Frostbite care:

1. Immerse affected area in circulating water that is 98.6º-104.0º F 2. Warm soaks for facial area 3. NEVER squeeze, massage, or scrub skin 4. Remove clothing and jewelry 5. Elevate to reduce edema after rewarming 6. Tetanus shot *FOR DEEP FROSTBITE* (considered dirty wound) 7. Evaluate for systemic hypothermia

Osmolality range:

280-300 mm/kg

The nurse is assessing the core body temperature of four clients. Which client requires priority critical care? 1. Client with body temperature of 30°C. (86°F) 2. Client with body temperature of 27°C. (80.6°F) 3. Client with body temperature of 32°C. (89.6°F) 4. Client with body temperature of 29°C. (84.2°F)

2. Client with body temperature of 27°C. (80.6°F)

Bicarbonate (HCO3-)

22-26 mEq/L

pH

7.35-7.45

Every effort is made to warm a pt with severe hypothermia to ____ º F before pronounced dead

86º F

If we need to replace multiple electrolytes, which one do we replace first?

Magnesium

What is the most frequent STI?

Chlamydia

What is the difference between dehydration and FVD (fluid volume deficit)?

Dehydration: loss of water FVD: loss of water and electrolytes

How does rewarming of frostbite feel?

Extremely painful. Will feel warm stinging as it thaws.

What information should you obtain from a patient who is due to receive general anesthesia? Why?

Family history to evaluate the risk of malignant hyperthermia

Metabolic fever:

Fever that is not due to infection

What STI can cause respiratory distress in the newborn if exposed as a fetus?

Group B Strep

Why may a cancer patient present with a fever but no signs of infection:

Metabolic fever - in cancer, the metabolic rate of the cells is increased and the person may develop high fever.

What vital sign should you be frequently check in a post-op patient who has received general anesthesia? Why?

Temperature to check for a fever as the result of malignant hyperthermia

What is therapeutic hypothermia, and when/why do we perform?

Therapeutic hypothermia for 24 hours after the return of spontaneous circulation (ROSC) decreases mortality rates and improves neurologic outcomes in many patients

Candisis:

Yeast Infection

Is heat stroke a medical emergency?

Yes

Herpes Type 1:

blisters on mouth (usually associated with fevers)

Secondary Dysmenorrhea:

pain during or shortly before menstrual cycle due to something other than the menstrual cycle itself

Dysmenorrhea signs/symptoms:

pain in super-pubic area

Most body heat is lost as:

radiant heat (head, thorax, lungs)

What does "High and Dry" refer to?

the drier a patient is, the higher their fever will be

Conduction:

touch-to-touch ex: babies lying skin to skin with mom

PaCO2

35-45 mm Hg

Reliability:

Evidence must also be consistently and accurately measured.2 Even clinical experience, as a form of evidence, demonstrates that the same treatment applied to similar patients over time leads to similar outcomes.

MODERATE/SEVERE Hypothermia care:

1. Active internal warming (heated humidified O2, warmed IV fluids, peritoneal lavage with warmed fluids, and extracorporeal circulation with cardiopulmonary bypass, rapid fluid infuser, or hemodialysis) 2. Rewarm core before extremities

When assessing the patient with a multilumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? 1. Administer oxygen 2. Notify the health care provider 3. Reposition the patient to the right side 4. Rapidly administer more intravenous (IV) fluid

1. Administer Oxygen RATIONALE: The cap off the central line could allow entry of air into the circulation. For an air embolus, the priority is to administer oxygen. Next, the catheter is clamped and the patient is positioned on the left side with the head down. Then the health care provider is notified.

Risks of rewarming after hypothermia:

1. Afterdrop 2. Hypotension 3. Dysrhythmias

When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? 1. Change the catheter dressing regularly. 2. Monitor the heart rate and blood pressure. 3. Cleanse around the catheter insertion site. 4. Measure and record oral intake and output. 5. Change the injection caps at regular intervals.

1. Change the catheter dressing regularly. 3. Cleanse around the catheter insertion site. 5. Change the injection caps at regular intervals. RATIONALE: Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed, and the catheter site should be regularly cleansed. These steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices.

What are the mechanisms that cause heat loss?

1. Conduction 2. Convection 3. Vasodilation 4. Evaporation 5. Radiation

A patient's potassium level is 2.9 meq/L. Which health care provider order should the nurse expect? 1. Continuous ECG monitoring 2. Increase digoxin (Lanoxin) to 0.25 mg every day 3. Add 20 meq KCL to the present IV bag hanging and give over four hours 4. 40 meq KCL in 100 cc D5W intravenous piggyback (IVPB) to infuse over 30 minutes

1. Continuous ECG monitoring RATIONALE: Hypokalemia can cause lethal ventricular rhythms. Therefore continuous cardiac monitoring should be expected. Patients with hypokalemia are at risk for digoxin toxicity. The nurse should watch for signs of digoxin toxicity and question an increase in dosage. KCL infusion must be diluted and given at a rate not to exceed 10 meq/hour. 40 meq KCL in 100 cc of fluid is too concentrated and should be given over at least two hours. To prevent bolusing, KCL should never be added to an IV bag that already is hanging.

A patient's ECG tracing has a short QT interval and a high peaked T wave. Which prescription should the nurse question? 1. D5W with 20 meq KCL to run at 125 mL/hr 2. Sodium polystyrene sulfonate 30 grams by mouth 3. 10 units regular insulin IVP and one-half ampule D50W IVP 4. 2 grams calcium gluconate intravenous (IV) administered over two minutes

1. D5W with 20 meq KCL to run at 125 mL/hr RATIONALE: A short QT interval and a high peaked T wave are indicative of hyperkalemia. The prudent nurse should question any prescription that could increase the potassium level in the patient. IV insulin with D50W and calcium gluconate are given to force the potassium back into the cells, temporarily correcting the hyperkalemia. Polystyrene sulfonate binds with potassium in the gastrointestinal (GI) tract and excretes it via feces

While caring for a patient who had a pituitary tumor removed, which finding should be reported immediately to the primary health care provider? 1. Excessive thirst 2. Calcium level of 8.6 mg/dL 3. Potassium level of 3.5 mEq/L 4. Urine output of 300 mL in eight hours

1. Excessive thirst RATIONALE: A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release. The nurse should monitor the urine output closely and notify the primary health care provider of excessive thirst. One would expect large volumes of urine in the absences of ADH production. A urine output of 300 mL in eight hours would not be alarming. The calcium and potassium levels are at the low end of normal. The nurse should continue to monitor these electrolytes.

The nurse is caring for a patient with heart failure. What assessment data indicates the patient is at risk for developing fluid volume excess? 1. Full, bounding pulse 2. Flattened neck veins 3. Low blood pressure 4. Easily obliterated pulse

1. Full, bounding pulse RATIONALE: Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full bounding pulse, increased blood pressure, and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 113° F. Which condition does the nurse suspect in the client? 1. Heat stroke 2. Heat exhaustion 3. Accidental hypothermia 4. Malignant hyperthermia

1. Heat stroke RATIONALE: Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Endometriosis treatment:

1. NSAID's 2. pain medications 3. birth control pills (to help shrink endometrial tissue) 4. surgery to remove endometrial tissue outside of uterus

MODERATE hypothermia signs/symptoms:

1. Rigidity 2. Bradycardia (slow) 3. Bradypnea (slow) 4. BP obtainable only by doppler 5. Metabolic and respiratory acidosis 6. Hypovolemia 7. Shivering decreases

The nurse is caring for a patient admitted with an exacerbation of asthma. After several treatments, the arterial blood gas (ABG) results are pH 7.40, PaCO 2 40 mm Hg, HCO 3 24 mEq/L, PaO 2 92 mm Hg, and O 2 saturation 99%. What does the nurse interpret these findings to indicate? 1. Within normal limits 2. Slight metabolic acidosis 3. Slight respiratory acidosis 4. Slight respiratory alkalosis

1. Within Normal Limits RATIONALE: The normal pH is 7.35 to 7.45. Normal PaCO 2 levels are 35 to 45 mm Hg, and normal HCO 3 levels are 22 to 26 mEq/L. A normal PaO 2 level is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.

A patient's laboratory reports reveal a sodium concentration of 143 mmol/L and the sum of chloride and bicarbonate ion concentration as 132 mmol/L. What is the anion gap of the patient? Record your answer using a whole number.

11.0

The anion gap is calculated by subtracting the concentration of anions from the concentration of cations in the blood. The sum of chloride and bicarbonate ions yields an anion concentration of 132 mmol/L. The cation concentration is the sodium concentration:

143 mmol/L. Simply subtract 132 from 143 to get 11 mmol/L

A nurse is caring for a patient with metabolic acidosis. The patient wants to know how the acid-base imbalance will be corrected. Based on the nurse's knowledge of acid-base imbalance, what is the best response? 1. "Medications are the primary treatment for acute acid-base imbalances." 2. "The renal system compensates slowly, usually reacting to pH changes within 24 hours." 3. "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." 4. "The heart is vital in managing the acid-base balance by regulating perfusion to increase or decrease pH." 5. "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance."

2. "The renal system compensates slowly, usually reacting to pH changes within 24 hours." 3. "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." 5. "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance." RATIONALE: The buffer system is the primary manner in which the body maintains acid-base balance. This system is also the quickest, often working within seconds of sensing an imbalance. The respiratory system can compensate by changing the rate and depth of breathing within minutes of sensing an acid-base derangement. The renal system is slower to react, often working within hours to days. The heart is vital in regulating perfusion, but it does not have a major role in managing acid-base balance. Medications can be used to regulate acid-base imbalances, but the primary treatment is to resolve the underlying cause of the imbalance.

The nurse is caring for a patient in hypovolemic shock. What fluid replacement does the nurse anticipate will have the most positive outcome for this patient? 1. Dextran 2. 0.9% NaCl 3. 0.45% saline 4. 5% dextrose in 0.45% saline

2. 0.9% NaCl RATIONALE: Isotonic saline (0.9% NaCl) may be used when a patient has experienced both fluid and sodium losses or as vascular fluid replacement in hypovolemic shock. The nurse would not administer 0.45% saline, 5% dextrose in 0.45% saline, or dextran, as these are not appropriate for fluid replacement in hypovolemic shock.

A patient had 5 liters of fluid removed during a paracentesis. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis? 1. 0.9% sodium chloride 2. 25% albumin solution 3. Lactated Ringer's solution 4. 5% dextrose in 0.45% saline

2. 25% albumin solution RATIONALE: After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.

A nurse is caring for a patient three days after abdominal surgery who continues to have poorly controlled abdominal pain with green bilious nasogastric output. The patient's respiratory rate is 32 and heart rate is 128. Which acid-base imbalance does the nurse suspect is occurring? 1. Mixed acidosis 2. Mixed alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis

2. Mixed alkalosis RATIONALE: Mixed alkalosis can occur in a patient who is losing CO 2 via hyperventilation (possibly related to pain) while also losing acid by another method, such as prolonged suctioning with a nasogastric tube. Respiratory acidosis occurs when the primary loss of acid is via a respiratory "blow off" of CO 2. Metabolic alkalosis occurs with a systemic loss of acid via a metabolic process such as vomiting or suctioning with a nasogastric tube. Mixed acidosis occurs when acid is retained by both respiratory and metabolic systems, such as in a critically ill patient in shock with hypoperfusion and hypoventilation, and will often cause a more profoundly acidotic pH than either condition could independently create.

While caring for a patient with chronic obstructive pulmonary disease, the nurse finds that the patient's arterial blood gas results show a blood pH of 7.29, partial pressure of carbon dioxide (PaCO 2) of 49 mm Hg, and a bicarbonate ion (HCO 3) level of 25 mEq/L. Which condition does the nurse suspect? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis RATIONALE: The normal ranges of blood pH, partial pressure of carbon dioxide, and bicarbonate ion levels are 7.35 to 7.45, 75 to 100 mm Hg, and 22 to 26 mEq/L, respectively. Patients with chronic obstructive pulmonary disease (COPD) have difficulty breathing, which leads to hypoventilation. This causes a buildup of carbon dioxide in the blood, which increases the concentration of carbonic acid, leading to a decrease in blood pH. Thus the patient is expected to have respiratory acidosis. In respiratory alkalosis, partial pressure of carbon dioxide decreases. Metabolic acidosis is manifested by decreased concentration of bicarbonate in blood. Respiratory alkalosis is manifested by decreased carbonic acid concentration in blood and decreased PaCO 2.

The nurse is caring for a patient with a potassium level of 6.2 mEq/dl. What syndrome does the nurse suspect the patient may have? 1. Cushing syndrome 2. Milk-alkali syndrome 3. Tumor lysis syndrome 4. Malabsorption syndrome

3. Tumor lysis syndrome RATIONALE: Tumor lysis syndrome causes movement of potassium from the intracellular fluid (ICF) to the extracellular fluid (ECF), resulting in hyperkalemia. Cushing syndrome may cause hypernatremia. Milk-alkali syndrome may cause hypercalcemia. Malabsorption syndrome may cause hypophosphatemia.

What is the normal range of blood pH? 1. 7.05 to 7.15 2. 7.15 to 7.25 3. 7.25 to 7.35 4. 7.35 to 7.45

4. 7.35 to 7.45 RATIONALE: The normal range of blood pH is 7.35 to 7.45. A pH less than 7.35 indicates acidosis.

A patient is admitted to the emergency room with second-degree (partial-thickness) burns over 30% of the total body surface area with poor skin turgor, a urine output of less than 50 mL over the past two hours, a rapid and thready pulse, and restlessness. The nurse determines that these symptoms might indicate which type of imbalance? 1. Hyperkalemia 2. Metabolic acidosis 3. Hyperphosphatemia 4. Extracellular fluid volume deficit

4. Extracellular fluid volume deficit RATIONALE: Patients with burns are susceptible to third-space shifts, resulting in extracellular fluid volume deficit. Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased blood pressure, dysrhythmias, nausea, and vomiting.

The nurse is reviewing the laboratory reports of a patient during a follow-up visit and finds that the blood sugar level has decreased to 150 mg/dL from 210 mg/dL. Which movement between intracellular fluid and extracellular fluid can support the effectiveness of treatment? 1. Osmosis 2. Diffusion 3. Active transport 4. Facilitated diffusion

4. Facilitated diffusion RATIONALE: Facilitated diffusion is a process that involves the movement of molecules from higher concentrations to lower concentrations by a protein carrier across the membrane. It is a passive process in which the glucose molecules are transported into the cell by combining with the carrier molecule from extracellular fluid to intracellular fluid. Osmosis allows transport of molecules from lower concentration to higher concentration across the semipermeable membrane. It occurs mainly during urine formation in the kidneys. Diffusion is a simple process of movement of molecules from higher to lower concentration. Active transport is a process similar to diffusion but occurs in the presence of external energy.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? 1. Fluid movement from the blood vessels into the cells 2. Fluid movement from the interstitial spaces into the cells 3. Fluid movement from the blood vessels into interstitial spaces 4. Fluid movement from the interstitial space into the blood vessels

4. Fluid movement from the interstitial space into the blood vessels RATIONALE: In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? 1. Abnormal rapid heart rate 2. Abnormal rapid breathing 3. Increased body temperature 4. Increased expired carbon dioxide

4. Increased expired carbon dioxide RATIONALE: The first sign of malignant hyperthermia is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.

An older adult patient is admitted with pneumonia. Why would it be important for the nurse to closely monitor fluid and electrolyte balance in this patient? 1. Older adults are at an increased risk of impaired renal function. 2. Older adults have an impaired level of consciousness and need to be reminded to drink fluids. 3. Older adults are more likely than younger adults to lose extracellular fluid during severe illnesses. 4. Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults.

4. Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults. RATIONALE: Older adults, with less muscle mass and more fat content, have less body water than younger adults. In the older adult, body water content averages 45% to 55% of body weight, leaving them at a higher risk for fluid-related problems than young adults. Renal function, level of consciousness, and severe illnesses are not relevant in this instance.

Heat stroke can most affect which organ/system? How so?

Can lead to kidney failure. Rabdoliolysis produces myoglobin, circulates to kidneys, clogs up kidney nephrons, kidney failure.

Replicability:

Evidence is built on research findings. Findings can only be verified if they can be repeated. If other researchers are unable to achieve the same results using the same methodology as the original study, the evidence presented by that study is called into question.

A patient sustains a soft tissue injury to the ankle, and a large amount of edema develops. What nursing intervention will relieve edema associated with this injury? 1. Elevating the extremity 2. Massaging the ankle every 1-2 hours 3. Applying a warm compress to the ankle 4. Applying warm saline soaks to the extremity

1. Elevating the extremity RATIONALE: Elevation promotes good venous return, allowing extracellular fluid to flow more readily away from the edematous area. In addition, ice or a cold compress helps ease edema and pain. Warm saline soaks, massage of the extremity, and warm compresses will increase venous circulation and congestion, thereby worsening the edema, as well as the pain.

The nurse is planning care for a patient with a new diagnosis of hypercalcemia resulting from treatment for hypocalcemia. Which change to the plan of care should the nurse anticipate? 1. Encouraging weight-bearing exercises 2. Teaching the patient to breathe into a bag 3. Administering intravenous calcium gluconate 4. Administering a loop rather than a thiazide diuretic

1. Encouraging weight-bearing exercises RATIONALE: A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium gluconate, and administering a loop diuretic are all appropriate for hypocalcemia; therefore these actions should be removed from the plan of care, not added.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? 1. Deficient fluid volume 2. Impaired skin integrity 3. Inadequate nutritional intake 4. Decreased participation in activities

1. Deficient fluid volume RATIONALE: The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? 1. Change the catheter dressing regularly. 2. Monitor the heart rate and blood pressure. 3. Cleanse around the catheter insertion site. 4. Measure and record oral intake and output. 5. Change the injection caps at regular intervals.

1. Change the catheter dressing regularly. 3. Cleanse around the catheter insertion site. 5. Change the injection caps at regular intervals. RATIONALE: Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed, and the catheter site should be regularly cleansed; these steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices.

A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse determine is the probable reason for the increase in phosphate levels in this patient? 1. Chemotherapy 2. Insulin therapy 3. Total parenteral nutrition 4. Phosphate-binding antacids

1. Chemotherapy RATIONALE: Phosphate levels greater than 4.4 mg/dL indicate hyperphosphatemia. Chemotherapy drugs increase the patient's phosphate levels. Insulin therapy decreases the phosphate levels to less than 2.4 mg/dL. Patients with total parenteral nutrition have decreased phosphate levels. Phosphate-binding antacids remove phosphates from the body, resulting in hypophosphatemia.

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate? 1. Core rewarming with warm fluids 2. Ambulation to increase metabolism 3. Frequent oral temperature assessments 4. Gastric tube feedings to increase fluid volume

1. Core rewarming with warm fluids RATIONALE: Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.

The primary health care provider has prescribed parenteral nutrition for a patient. The nurse administers a 10% dextrose solution with amino acids, electrolytes, vitamins, and trace elements. What does the nurse need to know regarding the 10% dextrose solution? 1. It is a hypertonic solution. 2. It is used as a plasma expander. 3. It expands the extracellular compartment. 4. It should be administered only through a central line.

1. It is a hypertonic solution. RATIONALE: A 10% dextrose solution with amino acids, electrolytes, vitamins, and trace elements is used in parenteral nutrition to provide additional calories. It is a hypertonic solution, which provides free water, expanding both the extracellular and intracellular compartments. Solutions with a dextrose concentration of 10% or more should be administered only through a peripheral line. Solutions with a higher dextrose concentration should be administered through a central line. Hypertonic solutions are not used as plasma expanders because they do not stay in the vascular space.

A patient admitted with dehydration is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions? 1. Lung sounds 2. Bowel sounds 3. Blood pressure (BP) 4. Serum sodium level 5. Serum potassium level

1. Lung sounds 3. Blood pressure (BP) 4. Serum sodium level RATIONALE: BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions. Bowel sounds and serum potassium level do not need to be monitored frequently.

A patient reports nausea, four episodes of vomiting, and headache. The nurse finds that the patient is taking deep and rapid breaths and blood pressure as 90/60 mm Hg. Which condition does the nurse suspect in the patient? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis RATIONALE: Deep and rapid respirations are characteristic of Kussmaul's respirations. Normal blood pressure is 120/80 mm Hg. Kussmaul's respirations, low blood pressure, nausea, vomiting, and headache are manifestations of metabolic acidosis. Therefore, the nurse suspects that the patient has metabolic acidosis. Signs of metabolic alkalosis include tetany, nausea, and vomiting. Although headache and hypotension are seen in respiratory acidosis, nausea, vomiting, and rapid respirations are not observed. Respiratory alkalosis is characterized by tetany, anorexia, nausea, and vomiting.

A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action? 1. Radiation 2. Conduction 3. Active transport 4. Fluid vaporization

1. Radiation RATIONALE: Radiation, or the transfer of heat from a warm object to the atmosphere, is prevented by covering the child with a blanket. Reducing body surface area (e.g., flexing all extremities in toward the body) also limits heat loss through radiation. Conduction is the transfer of heat from one molecule to another with contact between the two. Active transport is not related to loss of heat; this is a process that moves ions or molecules across a cell membrane against a concentration gradient. Vaporization is the conversion of liquid or solid into a vapor; it occurs when a person is perspiring.

A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention? 1. Rapidly rewarming the toes by placing the feet in warm water 2. Slowly rewarming the toes by wrapping the feet in a warm cloth 3. Placing the feet in cool water to minimize the temperature difference 4. Wrapping the feet in an ice pack until definitive medical help is available

1. Rapidly rewarming the toes by placing the feet in warm water RATIONALE: Rapid rewarming is accomplished by immersing the body part in well-agitated water at 100° F to 108° F (37.8° C to 42.2° C). Rapid rewarming minimizes tissue damage. The body part should be rewarmed as quickly as possible to minimize tissue damage. Prolonged exposure to the cold will worsen tissue damage.

The nurse is caring for a patient with diabetes mellitus, malnutrition, and massive gastrointestinal (GI) bleeding who is admitted for blood transfusion. In analyzing the morning laboratory results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? 1. The potassium level may be increased if the patient has renal nephropathy. 2. The patient may be excreting extra sodium and retaining potassium because of malnutrition. 3. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. 4. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. 5. The patient has been overeating raisins, baked beans, and salt substitute, which could increase the potassium level.

1. The potassium level may be increased if the patient has renal nephropathy. 3. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. 4. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. RATIONALE: Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. The patient with a massive GI bleed would have a nasogastric (NG) tube and would not be eating.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39ºC. What is this temperature in Fahrenheit? Round your answer to one decimal place.

102.2ºF

A nurse finds that a patient has severe diarrhea and may be at risk of fluid volume deficit. What does the nurse anticipate administering to this patient to treat the fluid volume deficit? 1. Administer isotonic sodium chloride 2. Administer lactated Ringer's solution 3. Transfuse blood and blood products 4. Restrict sodium intake in the patient

2. Administer lactated Ringer's solution RATIONALE: To correct fluid deficit in the patient the nurse would administer lactated Ringer's solution to replace both water and any needed electrolytes. Isotonic normal saline is used when rapid volume replacement is needed. If the fluid deficit has been identified as due to blood loss, then blood can be transfused. Sodium intake should be restricted in case of fluid excess.

The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular fluid accumulation? 1. A patient with osmotic diuresis 2. A patient with renal impairment 3. A patient with an intestinal obstruction 4. A patient with drainage from a rectal fistula

2. A patient with renal impairment RATIONALE: Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma, and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and intestinal obstruction result in a loss of body fluid.

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? 1. Glasgow Coma score of 10 2. Body temperature of 81.2°F 3. Oxygen saturation of 90 percent 4. Presence of carotid pulse with blood pressure of 80 mm Hg

2. Body temperature of 81.2°F RATIONALE: Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90 percent indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mm Hg is acceptable.

A 6-year-old boy is sent to the school nurse on a snowy below-freezing day because he arrived without a coat, wearing shorts, a T-shirt, and sandals. What is the first nursing intervention? 1. Providing warm liquid to drink 2. Checking the child for frostbite 3. Calling Child Protective Services 4. Asking the child who helped him dress

2. Checking the child for frostbite RATIONALE: The child must first be assessed for injuries caused by exposure and treated if necessary. A warm liquid may be offered after the child's physical status is assessed and it is determined that fluids may be ingested. Child Protective Services may be called after further assessment and the determination that neglect may be involved. Questions about the child's family dynamics may be asked after the status of the child is evaluated.

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient with primary hypoparathyroidism? 1. Anorexia 2. Easy fatigability 3. Depressed reflexes 4. Circumoral numbness 5. Positive Trousseau's sign

2. Easy fatigability 4. Circumoral numbness 5. Positive Trousseau's sign RATIONALE: Primary hypoparathyroidism can result in a lack of parathyroid hormone, leading to hypocalcemia. Manifestations of low serum calcium levels include easy fatigability, depression, anxiety, confusion, numbness and tingling in extremities and the region around the mouth, hyperreflexia, muscle cramps, positive Chvostek's and Trousseau's signs, and others. Anorexia and depressed reflexes are manifestations of hypercalcemia.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1. Axilla 2. Fingers 3. Ear lobes 4. Forehead 5. Upper thorax

2. Fingers 3. Ear lobes RATIONALE: Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. 1. Dyspnea 2. Flushed face 3. Precordial pain 4. Increased pulse rate 5. Increased blood pressure

2. Flushed face 4. Increased pulse rate RATIONALE: Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

A patient was admitted with abdominal pain, nausea, and severe diarrhea. Based on this information, the nurse assesses this patient for which primary acid-base imbalance? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Respiratory acidosis

2. Metabolic acidosis RATIONALE: Because gastric secretions are rich in hydrochloric acid, the patient with severe diarrhea will lose significant amounts of bicarbonate and is at increased risk for metabolic acidosis and a fall in pH. Metabolic alkalosis, respiratory alkalosis, and respiratory acidosis will not occur as a result of increased loss of bicarbonate.

The nurse is admitting a patient reporting abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. The patient is assessed for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Metabolic respiration

2. Metabolic alkalosis RATIONALE: Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis. Metabolic acidosis is more likely with diarrhea than vomiting. Respiratory acidosis is associated with the lungs, not the gastrointestinal system. Metabolic respiration is not a real thing.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1. The client's temperature returns to an acceptable value at least once in the past 24 hours 2. The client's fever spikes and falls without a return to normal temperature levels 3. Periods of febrile episodes and periods with acceptable temperature values occur 4. The client has a constant body temperature continuously above 38°C with minimal fluctuation

2. The client's fever spikes and falls without a return to normal temperature levels RATIONALE: In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.

The nursing instructor is discussing peripherally implanted catheters (PICC) with a nursing student. Which nursing student statement would indicate a need for further teaching? 1. "I will need to watch for phlebitis for up to 10 days after the PICC is inserted." 2. "A PICC line is usually only used for access up to six months, but it can be left in longer." 3. "I can safely take blood pressures in the arm with the PICC as long as the cuff is below the insertion site." 4. "A PICC has fewer side effects than a central venous catheter, such as a lower infection rate and fewer insertion complications."

3. "I can safely take blood pressures in the arm with the PICC as long as the cuff is below the insertion site." RATIONALE: Blood pressure should not be taken on an arm with a PICC line because inflation of the cuff can lead to the risk of vein damage or thrombosis. Nurses do need to check for phlebitis for up to 10 days after the PICC is inserted. PICC lines are typically used for access for up to six months, and they can be left longer. PICC lines have fewer side effects than central venous catheters.

The nurse is completing an assessment of a patient with heart failure who is being treated for accidental overuse of diuretics. For which potential respiratory issue should the nurse monitor the patient? 1. Shortness of breath 2. Pulmonary congestion 3. Increased respiratory rate 4. Moist crackles on inspiration

3. Increased respiratory rate RATIONALE: Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit.

The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The results are: pH 7.32; PaCO 2 52; HCO 3- 24. What does the nurse interpret these results to mean? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

What is the function of a buffer? 1. To excrete weak acids 2. To secrete hydrogen ions 3. To convert strong acids to weak acids 4. To convert ammonia to ammonium ions

3. To convert strong acids to weak acids RATIONALE: Buffers convert strong acids to weak acids. Excretion of weak acids, secretion of hydrogen ions into the renal tubule, and conversion of ammonia to ammonium ions takes place in the kidneys.

A patient's insensible water loss is estimated at 900 mL per day. The nurse understands that this fluid is lost via which mechanism? 1. Excreted via urine 2. Excreted in the feces 3. Vaporized by the lungs and skin 4. Secreted into the digestive tract

3. Vaporized by the lungs and skin RATIONALE: Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1,500 mL is excreted in the urine and 100 mL in the feces. Approximately 8,000 mL of digestive fluids are secreted daily, but most is reabsorbed in the gastrointestinal tract.

The nurse is preparing to cleanse the skin around a central venous access device. Which solution would the nurse select as the most effective means of killing harmful bacteria? 1. Sterile saline solution 2. Isopropyl alcohol solution 3. Povidone-alcohol solution 4. Chlorhexidine-based solution

4. Chlorhexidine-based solution RATIONALE: Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol solutions. Therefore chlorhexidine-based solutions should be used to cleanse around the central venous access device. A sterile saline solution does not have any antiseptic properties.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? 1. Fluid movement from the blood vessels into the cells 2. Fluid movement from the interstitial spaces into the cells 3. Fluid movement from the blood vessels into interstitial spaces 4. Fluid movement from the interstitial space into the blood vessels

4. Fluid movement from the interstitial space into the blood vessels RATIONALE: In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

The nurse is caring for a patient with a blood sodium level of 170 mEq/L and is experiencing intense thirst, agitation, and decreased alertness. What does the nurse anticipate administering? 1. Intravenous furosemide 2. Intravenous cation-exchange resin 3. Intravenous phosphate-binding agent 4. Intravenous 0.45% sodium chloride saline solution

4. Intravenous 0.45% sodium chloride saline solution RATIONALE: Hypernatremia is a condition in which water shifts out of the cells into the extracellular fluid, resulting in dehydration. Therefore the patient with hypernatremia would experience intense thirst, agitation, and decreased alertness. To reduce dehydration, fluid should be replaced by administering hypotonic intravenous fluids such as 5% dextrose in water or 0.45% sodium chloride saline solution. Administering intravenous furosemide may help treat hypercalcemia. A cation-exchange resin may be administered to treat hyperkalemia. A phosphate-binding agent may be administered to treat hyperphosphatemia.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? 1. Promote equalization of osmotic pressures 2. Prevent hypoxia associated with diaphoresis 3. Promote integrity of intracerebral neurons 4. Reduce brain metabolism and limit hypoxia

4. Reduce brain metabolism and limit hypoxia RATIONALE: Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

Which patient is suffering from a Remittent Fever? PATIENT A: Day 1: 100° F Day 2: 100.4° F Day 3: 100.8° F Day 4: 100.6° F PATIENT B: Day 1: 102° F Day 2: 98.5° F Day 3: 103° F Day 4: 99° F PATIENT C: Day 1: 103° F Day 2: 101° F Day 3: 104° F Day 4:102° F PATIENT D: Day 1: 102° F Day 2: 98.5° F Day 3: 99.9° F Day 4: 103° F

PATIENT C RATIONALE: body temperature spikes and falls without a return to normal temperature levels. In client C, the temperature for 4 days is febrile with fluctuations, and the temperature does not return to normal. Client A has sustained fever, with a constant body temperature continuously above 38° C (100.4° F) that has little fluctuation. Client B has intermittent fever, in which the fever spikes interspersed with normal temperature levels. Client D has relapsing fever, which has periods of febrile episodes and periods with acceptable temperature values, often for longer than 24 hours.