F&E

Which of the following arterial blood gas (ABG) results should the nurse anticipate in the client with profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO 30

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients every:

1 hour

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that the completion time for the bag is:

21:30

A nurse is caring for a client with cirrhosis. The nurse notes that the client is dyspneic and crackles are heard on auscultation of the lungs. What additional signs would the nurse expect to note in this client if a fluid volume excess is present?

An increase in blood pressure

Which clients are at high risk for metabolic acidosis? Select all that apply.

Diabetes clients Renal failure clients Malnourishment clients

A licensed practical nurse (LPN) is assisting in the care of a client who overdosed on aspirin 24 hours ago. The LPN would report to the registered nurse (RN) which of the following findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea

An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client's fluid imbalance?

Flat neck veins

A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that the client who is least likely to develop third spacing of fluids is the one with a diagnosis of:

Hypertension

A nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which of the following diagnoses and is most at risk for fluid volume deficit?

Ileostomy

A nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which of the following diagnoses is the one who has the least amount of risk for developing third-spacing of body fluid?

Ischemic stroke

A nurse is caring for a client whose magnesium level is 4 mg/dL, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present?

Loss of deep tendon reflexes

A 3-year-old child is hospitalized because of persistent vomiting. Which of the following conditions would the nurse expect to occur in this child?

Metabolic alkalosis

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

A nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis

A client enters the emergency room confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.

Monitor intake and output. Monitor the vital signs. Monitor the electrolyte levels. Increase water intake orally. Provide a sodium-reduced diet.

A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves

A nurse is caring for a client with a nasogastric tube who has prescriptions to have the tube irrigated once every 8 hours. The nurse ensures that which of the following solutions is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L?

Normal saline

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a of 7 pounds in the last week. At this time, the initial nursing action would be to:

Obtain orthostatic vital signs.

A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?

Positive Trousseau's sign

A nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a PCO2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which of the following additional laboratory values would the nurse expect to note in this client?

Potassium 5.4 mEq/L

A nurse is caring for a client with renal failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO2 of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and expects to note which of the following?

Potassium level, 5.6 mEq/L

A nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition would cause this serum calcium level?

Prolonged bedrest

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which of the following? (Click on the Question Video button to view a video showing preparation procedures.)

Pulling up and releasing the skin on the sternal area

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe?

Respirations that are abnormally deep, regular, and increased in rate

A client who has fallen from a roof and fractured his ribs has arterial blood gas results of: pH 7.48, PaCO2 32 mm Hg, PaO2 89 mm Hg, and HCO 22 mEq/L. The nurse interprets that the client's blood gases indicate which of the following?

Respiratory alkalosis

A nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which of the following acid-base imbalances?

Respiratory alkalosis

The nurse is told that the blood gas results indicate a pH of 7.50 and a Pco2 of 32 mm Hg. The nurse determines that these results indicate:

Respiratory alkalosis

A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?

Restricting fluid intake

A nurse assists in developing a plan of care for the child with meningitis. What is the priority nursing diagnosis for this child?

Risk for ineffective cerebral tissue perfusion

A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN calculates that the client's insensible fluid loss is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to fluid losses occurring through which of the following areas?

Skin and lungs

A nurse is monitoring a client for hypercalcemia. Which of the following would the nurse note in hypercalcemia?

Slight muscle weakness

A nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:

The

The nurse is reviewing the records of assigned clients. The nurse plans care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which finding did the nurse note?

The skin when pinched immediately fell back to normal when released.

A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic burn

A nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs Allen's test first. The nurse understands that this is being done to determine the adequacy of the:

Ulnar circulation

A nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-sparing diuretic. The nurse would be sure to include which of the following on a list of foods that have low potassium content?

White bread

A nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which of the following additional laboratory values would the nurse expect to note?

A potassium level of 3.2 mEq/L

A nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period?

2520

A nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse would monitor this client for which of the following manifestations of this electrolyte imbalance?

Abdominal cramping

The nurse is caring for a client with renal failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which of the following signs would the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, PCO2 of 34 mm Hg, PO2 of 86 mm Hg, and HCO of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Metabolic acidosis

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?

Metabolic acidosis

A client with diabetes mellitus has a blood glucose on admission of 596 mg/dL. The nurse anticipates that this client would be experiencing which of the following types of acid-base imbalance?

Metabolic acidosis

A nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for signs of:

Metabolic acidosis

A nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis

A nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. The appropriate nursing intervention is to:

Monitor the client for dysrhythmias.

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

A nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse would determine that this is an expected finding if the client had which of the following health problems?

Severe burn injury

A nurse is assisting in monitoring a client who may be started on parenteral (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the albumin level report indicates which critical level?

2.8 g/dL

A nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?

A client with a new burn injury

A nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume in which of the following clients who is at risk for this fluid imbalance?

A client with an ileostomy

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which of the following medications that would be prescribed to treat this acid-base disorder?

Acetazolamide (Diamox)

A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists to implement which measure as the effective means to treat the problem?

Administer prescribed antibiotics.

The nurse reviews the client's serum phosphorus level and notes that the level is 2.0 mg/dL. The nurse understands that which condition caused this serum phosphorus level?

Alcoholism

A nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for injury?

Applying pressure to the site

A nurse is instructing a client on how to decrease the intake of calcium in the . The nurse tells the client that which food item contains the least amount of calcium?

Butter

A nurse is monitoring the fluid balance of a client with human immunodeficiency disease (HIV). Because loss of subcutaneous adipose tissue and muscle atrophy occur in such clients, the nurse understands that which of the following will provide a reliable indicator of fluid balance?

Decreased urine output and hypotension

A nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data is obtained by the nurse?

Decreasing body weight

A nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. On the basis of this laboratory value, the nurse takes which action?

Informs the registered nurse of the laboratory value

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse would do which of the following to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

A nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which of the following acid-base imbalances?

Respiratory acidosis

A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse monitors the client for which acid-base imbalance that most likely occurs in clients with this condition?

Respiratory acidosis

A nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, PCO2 of 52 mm Hg, and HCO of 22 mEq/L. The nurse interprets these results as indicating:

Respiratory acidosis

The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. What data would the nurse expect to note during the data collection? Select all that apply.

Tetany Diarrhea Possible seizure activity A positive Trousseau's sign

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

The client with a colostomy

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at the lowest risk for the development of third-spacing?

The client with diabetes mellitus

A nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?

The client with renal failure

A nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?

The client with renal failure

Which of the following electrocardiogram changes should the nurse note on the cardiac monitor with a client whose potassium (K+) level is 3.2 mEq/L?

U waves

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. A nurse assists with performing Allen's test before drawing the blood to determine the adequacy of the:

Ulnar circulation

A nursing student is assigned to care for a child that has been experiencing vomiting and diarrhea. The health care provider documents a diagnosis of gastroenteritis and isotonic dehydration. The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating that it occurs when:

Water and electrolytes are lost in approximately the same proportion as they exist in the body."

A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

Diabetic mellitus client Malnourished client Renal failure client

A client has the following laboratory values: a pH of 7.55, an HCO level of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do?

Encourage the client to slow down breathing.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid doing which of the following?

Encouraging the client to breathe slowly and shallowly

A nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which of the following signs would be an indication of this diagnosis?

Generalized muscle weakness

The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which of the following on the laboratory result form?

H 7.25, Pco2 50 mm Hg

A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which of the following electrolyte disorders that could accompany the acid-base imbalance?

Hypokalemia

A nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

Hypokalemia

A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in the client with this condition?

Increased specific gravity of the urine

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.

Monitor intake and output. Monitor vital signs. Maintain sodium-reduced diet. Monitor electrolyte levels. Increase water intake orally.

A nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which of the following would be initially noted in the client if hyperkalemia is present?

Muscle weakness

A health care provider (HCP) is discussing the fluid balance of a postoperative client. The HCP states the client's insensible fluid loss is approximately 600 mL daily. The nurse interprets that the HCP is referring to fluid loss that is occurring through the:

Skin and lungs

A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

A nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline. The nurse determines that the treatment measures are effective when the laboratory results reveal a serum sodium level of:

140 mEq/L

A client is scheduled for an arterial blood gas specimen to be drawn, and the nurse assists with performing Allen's test on the client. Arrange the steps for performing Allen's test in order of priority.

Explain the procedure to the client. Apply pressure over the ulnar and radial arteries. Ask the client to open and close the hand repeatedly. Release pressure from the ulnar artery. Assess the color of the extremity distal to the pressure point. Document the findings.

A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?

Decreased respiratory depth and rate and dysrhythmias