Foundations - Questions

The nurse provides care for the client receiving IV therapy. Which assessment findings best indicate the client may be experiencing fluid overload? 1. Decreased blood pressure and pedal edema 2. Crackles in bases of lungs and cough 3. Shortness of breath and tracheal deviation 4. Decreased skin turgor and cool skin

2. Crackles in bases of lungs and cough Pulmonary symptoms of fluid overload are crackles in the lungs, cough, shortness of breath, and frothy sputum. Cardiac signs and symptoms include distended neck veins and increased blood pressure.

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia.

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L 2. 3.8 mEq/L 3. 4 mEq/L 4. 8 mEq/L

1. 3.2 mEq/L The normal serum potassium level in the adult is 3.5-5.0 mEq/L. The correct option is the only value that falls below the therapeutic range.

An adult client has a history of diabetes insipidus. The nurse identifies which imbalance is most likely to develop if this medical problem recurs? 1. Hypernatremia 2. Hyponatremia 3. Hyperkalemia 4. Hypokalemia

1. Hypernatremia Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone, or ADH. Large amounts of water are lost from the body causing a buildup of sodium in the body, leading to hypernatremia. Symptoms include excessive urine output, chronic, severe dehydration, excessive thirst, and weakness. The nurse will record intake and output, monitor urine specific gravity, condition of skin, vital signs, and administer prescribed desmopressin.

A client diagnosed with AIDS has recurrent bouts of diarrhea, nausea, and vomiting. Which is the most important goal for the client? 1. Maintenance of fluid and electrolyte balance 2. Decreased sense of social isolation 3. Improved activity tolerance 4. Expression of grief

1. Maintenance of fluid and electrolyte balance The client is at risk for fluid and electrolyte imbalance. Fluid and electrolyte imbalances could potentially lead to cardiovascular complications, such as ventricular dysrhythmias, and shock due to fluid volume deficit.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the BUN level drops to which value? 1. 3 mg/dL 2. 15 mg/dL 3. 29 mg/dL 4. 35 mg/dL

2. 15 mg/dL The normal BUN level is 10-20 mg/dL.

A client has a diagnosis of renal failure. Which parts of the client's body does the nurse examine to assess for anasarca? 1. Lower extremities 2. All body surfaces 3. Bony prominences 4. Periorbital areas

2. All body surfaces Anasarca is massive generalized edema that develops due to loss of fluid from the intravascular space to interstitial spaces. Edema is evident throughout all body surfaces. Often, if anasarca is evident, the client has severe organ failure.

A client diagnosed with gastroenteritis and dehydration is receiving fluid volume replacement with NS infusing at 100 mL/hour. Four hours after the infusion is started, the nurse assesses the client and notes the blood pressure is 84, 50, the heart rate is 110 bpm and the urine output is 15 mL/hr and dark yellow. Which action does the nurse take initially? 1. Increase the IV fluids to 150 mL/hr 2. Assess the client's IV access 3. Place the client in Trendelenburg position 4. Notify the health care provider

2. Assess the client's IV access The client's vital signs indicate the client is dehydration and not responding to volume resuscitation. The nurse will assess first and ensure the client's IV is infusing as prescribed. The nurse will assess the IV site and determine if the client has received the prescribed amount of fluid in the 4 hour period of time.

The nurse provides care for a client who has a severe decrease in serum albumin levels. Which finding does the nurse expect to observe during assessment of the client? 1. Bounding pedal pulse strength 2. Bilateral pretibial edema 3. Weight loss 4. Increased blood pressure

2. Bilateral pretibial edema Albumin is protein that has strong osmotic effect. It prevents plasma from leaking into interstitial fluid. When Serum albumin levels are low interstitial edema and movement of fluid into "third space" will occur. Hypoalbuminemia is typically seen with kidney disease and cirrhosis.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis Metabolic alkalosis occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid.

The nurse evaluates a client's fluid balance. Which finding most likely requires an intervention? 1. Output is 300mL less than intake 2. Output is 800mL less than intake 3. Intake is 1,800 mL in 24 hours 4. Intake and output are equal

2. Output is 800mL less than intake Intake and output should be within 200 to 300 mL of each other. If a client's output is 800 mL less than intake, it is an indication that the client is retaining fluid and will require an intervention.

The nurse provides care for a client diagnosed with dehydration. Which finding does the nurse anticipate when assessing the client's hemoglobin and hematocrit? 1. The hemoglobin and hematocrit are decreased 2. The hemoglobin and hematocrit are increased 3. The hematocrit is increased and the hemoglobin is decreased 4. The hematocrit is decreased and the hemoglobin is increased

2. The hemoglobin and hematocrit are increased In dehydration, the plasma will have a higher concentration of RBCs to overall fluid volume. The result is an increase in the Hgb and Hct. This hemoconcentration indicates an increase in the perceived number of RBCs, though the actual number remains the same.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would that nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1. Twitching A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety.

An older adult client calls the clinic and speaks with the nurse. The client reports feeling ill for two days and having a poor appetite. The client makes other statements which indicate the client is confused. The client's baseline is alert and oriented. Which is the most likely cause of the client's confusion? 1. Nasal congestion 2. Respiratory insufficiency 3. Decreased fluid intake 4. Normal aging process

3. Decreased fluid intake Older adult clients become easily confused if dehydrated. Confusion is often the first sign of dehydration. Fluid intake may be decreased due to nausea or vomiting when feeling ill.

A client with a 3 day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased Paco2 2. An increased pH and a decreased Paco2 3. A decreased pH and a decreased HCO3- 4. An increased pH and an increased HCO3-

4. An increased pH and an increased HCO3- Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia.

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote 2. Draw a sample for type and crossmatch and transfuse the client 3. Draw a sample for an activated partial thromboplastin time (aPTT) level 4. Draw a sample for prothrombin time (PT) and international normalized ration (INR)

4. Draw a sample for prothrombin time (PT) and international normalized ration (INR) The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client. The aPTT monitors the effects of heparin therapy.

A toddler client has nausea, vomiting, and diarrhea. Which implementation is best for the nurse to use to maintain an adequate fluid intake? 1. Keep the client NPO and give hypotonic solutions intravenously 2. Force fluids and give hypertonic solutions intravenously 3. Provide gelatin and ice pops to increase fluid intake 4. Offer oral rehydration solutions (ORS) to re-hydrate

4. Offer oral rehydration solutions (ORS) to re-hydrate Oral rehydration solutions contains sodium, potassium, chloride, citrate, and glucose. The amount given is determined by the degree of dehydration and the child's weight. If the child is vomiting, give a small amount of oral rehydration solution at frequent intervals.

A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000mm3. The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count 2. Report the abnormally high count 3. Place the client on bleeding precautions 4. Place the normal report in the client's medical record

4. Place the normal report in the client's medical record A normal PLT count ranges from 150k-400k. The nurse should place the report containing the normal laboratory value in the client's medical record.

Which client is at risk for the development of a sodium level at 130 mEq/L? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000 mm3 2. 5800 mm3 3. 8400 mm3 4. 11,500 mm3

1. 2000 mm3 The normal WBC count ranges from 5K-10k. The client who has a decreased in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations

1. A client with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy.

Two days after a subtotal thyroidectomy, a client tells the nurse, "My lips feel all tingly." Which assessment of the client does the nurse make immediately? 1. Check for Chvostek sign 2. Evaluate the client's ability to cough 3. Assess for drainage under the client's neck 4. Monitor the client's pulse rate

1. Check for Chvostek sign The client's report of tingling of the lips indicates the client may be experiencing hypocalcemia. The parathyroid glands are often embedded in the thyroid gland, and can be accidentally removed or damaged during thyroid surgery, resulting in hypocalcemia. Symptoms of hypocalcemia are often described as a tingling sensation or funny feeling in the lips, numbness of the fingers or toes, confusion, tetany, laryngospasm and seizures. A positive Trousseau sign or a positive Chvostek signs can be elicited in a client with hypocalcemia.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8mg/dL. Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1. Malnutrition Causative factors related to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors or hyperphosphatemia.

A client receives fluid replacement because of dehydration. The nurse evaluates the effectiveness of the treatment. Which signs and/or symptoms cause the most alarm? 1. The client has an increase in urinary output and a decrease in urinary osmolarity 2. The client's blood pressure decreases by five mmHg when changing from lying to standing 3. The client has an increasing LOC, including alertness and orientation 4. The client develops dyspnea, crackles, and jugular vein engorgement

4. The client develops dyspnea, crackles, and jugular vein engorgement Dyspnea, crackle, and jugular vein engorgement are signs and symptoms that indicate that the fluid replacement is causing a fluid volume overload. The nurse will stop the infusion and call the health care provider immediately.

The emergency department nurse knows which cause most frequently is associated with tetany? 1. Hypocalcemia 2. Puncture wound from dirty and rusty metal 3. Hypermagnesemia 4. Genetic cardiac defect

1. Hypocalcemia Tetany is a condition characterized by intermittent spasms of voluntary muscle. Hypocalcemia is the most common underlying cause of tetany. Clients with tetany exhibit convulsions, cramps, muscle twitching, sharp flexion of ankle and wrist joints, and possible respiratory stridor. Tetany related to hypocalcemia is treated with IV calcium or calcium gluconate.

A client with full thickness burns over 30% of the body reports weakness and cramping in the lower extremities. The client also has occasional confusion and an irregular heart rate with palpitations. Which condition do these signs and/or symptoms indicate the client is experiencing? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypercalcemia

1. Hypokalemia The client with hypokalemia may exhibit anorexia, vomiting, paralysis, muscle weakness, leg cramps, dysrhythmias, hypotension, shortness of breath, fatigue, lethargy, irritability, and confusion. An EKG may exhibit flattened T waves and appearance of a U wave. Hypokalemia is a potassium level less than 3.5.

The nurse notes that a client's arterial blood as results reveal a pH of 7.50 and a Paco2 of 30 mmHg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1. Nausea 2. Confusion 4. Tachycardia 6. Lightheadedness Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump 2. Monitor urine output during administration 3. Prepare the medication for bolus administration 4. Monitor the IV site for signs of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

1. Obtain an intravenous (IV) infusion pump 2. Monitor urine output during administration 4. Monitor the IV site for signs of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm3 2. Sodium 150 mEq/L 3. Potassium 5.0 mEq/L 4. Segmented neutrophils 40% 5. Serum creatinine, 1 mg/dL 6. White blood cells, 3000 mm3

1. Platelets 35,000 mm3 2. Sodium 150 mEq/L 4. Segmented neutrophils 40% 6. White blood cells, 3000 mm3 The normal values include the following: PLTS 150k-400k; sodium 135-145; potassium 3.5-5.0; segmented neutrophils 62%-68%; serum creatinine male: 0.6-1.2; female: 0.5-1.1; and WBC 5k-10k. The PLT level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the WBC level is low.

The nurse provides care for a client admitted to the hospital for persistent vomiting and abdominal pain. A nasogastric (NG) tube is inserted and connected to suction. An intravenous infusion of 1,000 mL of D5W with 20 mEq of potassium chloride is started to infuse at 100 mL per hour. The nurse understands potassium chloride has been added to the infusion for which reason? 1. Replaces the potassium lost in the gastric fluid 2. Replaces decreased dietary potassium due to NPO status 3. Prevents the loss of sodium in the urine 4. Prevents the loss of potassium in the urine

1. Replaces the potassium lost in the gastric fluid Clients with NG tubes connected to NG suction lose a large amount of fluids and electrolytes. Replacing potassium via an IV will prevent hypokalemia from occurring. Symptoms of hypokalemia include muscle weakness, paresthesias, and dysrhythmias, and it increases sensitivity to digitalis. IV potassium can cause irritation and phlebitis so the nurse will assess the IV site every 2 hours/per agency policy.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics containing base products

1. Respiratory acidosis from inadequate ventilation Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis.

The client's ABG are pH 7.49, Paco2 37 mmHg, Pao2 96 mmHg, SaO2 98%, HCO3 24mEq/L, and potassium 4.2 mEq/L. The nurse understands the blood gases suggest the client is experiencing which condition? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Metabolic alkalosis

1. Respiratory alkalosis pH of greater than 7.45 is considered alkalotic. Paco2 should decrease as the Ph value increases. This occurs because CO2 is exhaled. This creates an alkalosis condition in the body. If the CO2 was retained in the body, it would create an acidosis. Subsequently, the pH value would be less than 7.35 and the Paco2 would increase to greater than 42 mmHg.

The nurse provides care for a client diagnosed with hypokalemia. Which findings does the nurse expect when assessing the client? 1. The ECG has a depressed ST segment and inverted T wave 2. The client exhibits Kussmaul breathing 3. The ECG reflects widening of the QRS complex 4. The client has increased muscle strength

1. The ECG has a depressed ST segment and inverted T wave Hypokalemia alters the repolarization of cardiac cells. ECG changes that can occur with hypokalemia include depression of the ST segment and flattening or inversion of the T wave. The presence of a U wave can occur in more severe hypokalemia. The nurse should anticipate the need for ongoing cardiac monitoring and be able to correctly interpret tracings when caring for clients who are experiencing or are at risk for developing hypokalemia.

The nurse knows which client is most likely to manifest symptoms of fluid volume deficit? 1. The client diagnosed with Addison disease 2. The client diagnosed with cirrhosis of the liver 3. The client diagnosed with epilepsy 4. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)

1. The client diagnosed with Addison disease Addison disease is an adrenal disorder stemming from hyposecretion of corticosteroid hormones from the adrenal gland. Symptoms include fatigue, weakness, dehydration, weight loss, fluid and electrolyte imbalance, and hypotension. Reduced aldosterone secretion results in increased sodium and water excretion, resulting in volume depletion.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1. U waves 3. Inverted T waves 4. Depressed ST segment Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves.

The nurse understands that fatigue, weakness, nausea, and vomiting are signs of which problem? 1. Hyponatremia 2. Hypokalemia 3. Hypernatremia 4. Hyperkalemia

2. Hypokalemia Signs and symptoms of a low potassium level include muscle weakness, paresthesias, fatigue, nausea, vomiting, and dysrhythmias. Hypokalemia can also increase the client's sensitivity to digitalis.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

1. Weight loss and poor skin turgor Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity or the urine, increased hematocrit, and altered LOC.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Paco2 50 mmHg 2. pH 7.35, Paco2 40 mmHg 3. pH 7.50, Paco2 52 mmHg 4. pH 7.52, Paco2 28 mmHg

1. pH 7.25, Paco2 50 mmHg Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. In respiratory acidosis, the pH is decreased and the Paco2 is elevated.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally low 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

2. Respirations that are increased in rate 4. Respirations that are abnormally deep Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs.

A client with atrial fibrillation who is receiving maintenance therapy or warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin The normal PT is 11 to 12.5 seconds. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions notes in the remaining options are incorrect.

A client diagnosed with dehydration due to nausea and vomiting was unable to eat or drink for two days and was receiving IV fluids. The client has begun to resume oral intake. Which nursing action has the highest priority? 1. Assess daily serum electrolyte levels 2. Offer 20 to 30 mL of clear liquid every 30 minutes 3. Discontinue intravenous fluids and remove the IV 4. Weight the client before breakfast

2. Offer 20 to 30 mL of clear liquid every 30 minutes When oral intake resumes, sips of clear liquids or water should be given. If the client is able to tolerate this, the amounts of fluid can be increased and the diet progressed to include gelatin and broth.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 1.8 4. Phosphorus level of 3.0 mg/dL

2. Potassium level of 3.0 mEq/L Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (557 mcmol/L)

2. Requires nasogastric suction Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mmHg, and HCO3- of 20 mEq/L. The nurse analyzes these results as indicating which conditions? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated The values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temperature on the neck behind the ear using an electric device for a client who is diaphoretic

2. Taking an oral temperature for a client with a cough and nasal congestion An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2. "I know that I should follow up after giving medication to make sure it is effective." 3. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." 4. "I know that pain in the older client might manifest as sleep disturbances or depression."

3. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number based scale or a picture based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client in other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered LOC, and decreased hematocrit.

The nurse provides care for a client diagnosed with congestive heart failure who is receiving intravenous fluids. The client states, "I keep coughing and coughing. Maybe I am getting a cold." What action should the nurse take first? 1. Stop the IV fluids 2. Place the client in high Fowler's position 3. Auscultate the client's lungs 4. Provide a humidifier in the client's room

3. Auscultate the client's lungs The first step for the nurse to take is to assess the client. A client with diagnosis of heart failure is at high risk to develop fluid volume overload. Signs of volume overload include coughing, dyspnea, and edema. The nurse will auscultate the client's lungs, review the client's weight and I&O, and assess the client's vital signs.

The nurse identifies which sign or symptoms as an early indication of fluid volume excess? 1. Cyanosis 2. Diarrhea 3. Edema 4. Shock

3. Edema Edema, the collection of fluid in tissues, is often seen as an early sign of fluid volume overload. Other symptoms include increased bounding pulse, elevated blood pressure, dyspnea, and crackles.

The nurse provides care for the client who expresses apprehension about the diagnosis of terminal lung cancer. The nurse notes the client's blood pressure is 140/88, pulse 92 beats per minute, and respirations 36 per minute. The client's blood gas values are pH 7.52, Pao2 95 mmHg, Paco2 39 mmHg, and HCO3 24 mEq/L. Which action does the nurse take first? 1. Administers oxygen at two liters 2. Prepares the client for a tracheostomy 3. Encourages the client to breathe into a paper bag 4. Administers bicarbonate intravenously

3. Encourages the client to breathe into a paper bag The client's vital signs and blood gasses suggest respiratory alkalosis. A respiratory rate of 36 indicates hyperventilation, probably secondary to apprehension and fear. The nurse should implement action that will safely raise the client's Paco2 level. The nurse would encourage the client to take slow, deep breaths and breathe in and out of a paper bag. This action will allow the client to rebreathe CO2.

Two days after a total thyroidectomy, a client reports painful spasms of the hands. The client says, "My muscles tingle and twitch." The nurse identifies the client has developed which electrolyte imbalance? 1. Hypernatremia 2. Hypophosphatemia 3. Hypocalcemia 4. Hyperkalemia

3. Hypocalcemia The accidental removal of or damage to one or more parathyroid glands during thyroidectomy can cause tetany due to calcium loss. It is important to realize the signs of hypocalcemia after a thyroidectomy. These include numbness and tingling sensations in the perioral area or in the fingers and toes; muscle cramps, particularly in the back and lower extremities that may progress to carpopedal spasm (tetany); wheezing that may develop from bronchospasm; dysphagia.

The nurse is reading a primary health care provider's progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

3. Integumentary output Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. COPD

3. Iron deficiency anemia The normal hemoglobin level for an adult female client is 12 to 16 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration.

A client has a NG tube connected to intermittent suction. Which blood test results are of most concern to the nurse? 1. Blood urea nitrogen 16 mg/dL 2. White blood cells 8,500/mm3 3. Potassium 2.9 mEq/L 4. Glucose 90 mg/dL

3. Potassium 2.9 mEq/L Normal serum potassium is 3.5-5.0 mEq/mL. The serum potassium is likely low due to removal of gastric secretions by the nasogastric tube. The client needs potassium replacement in the IV fluids. Indications of hypokalemia include anorexia, nausea, vomiting, muscle weakness, paresthesias, and dysrhythmias. Causes of hypokalemia include vomiting, gastric suction, diarrhea, diuretics, steroids, and inadequate intake.

The 3 year old child is brought to the emergency department with a history of vomiting and diarrhea for the past 3 days. Which finding is the nurse most likely see? 1. Shortness of breath 2. Slow heart rate 3. Sunken eyes 4. Tremors

3. Sunken eyes A 3 year old child who has had vomiting and diarrhea for 3 days will exhibit signs of fluid volume deficit. Indications of a fluid volume deficit include rapid weak pulse, rapid respirations, hypotension, weight loss, emaciation, dry mucous membranes, increased hematocrit, and an increased urine specific gravity.

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes

3. Tall peaked T waves 5. Widened QRS complexes The client with chronic kidney disease is at risk for hyperkalemia. ECG changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves

The nurse provides care for a client diagnosed with diarrhea and dehydration. Which assessment does the nurse expect to see? 1. The client has dark circles around the eyes 2. The client's skin is hot and red 3. The client has voided 100 mL of dark urine in 8 hours 4. The client has a bounding pulse and high blood pressure

3. The client has voided 100 mL of dark urine in 8 hours A decrease in urine output stems from a decreased extracellular fluid volume available to the kidneys. Decreased kidney perfusion and the body's attempt to retain water results in the client voiding small amounts of a more concentrated urine.

The nurse assesses an older adult and prepares to administer a prescribed intravenous potassium supplement. Which assessment finding concerns the nurse? 1. The client has normal ECG results 2. The client reports experiencing dizziness 3. The client reports history of low urine output 4. The client is experiencing muscle cramps

3. The client reports history of low urine output Usually, potassium supplements are contraindicated in clients with impaired kidney function. Knowing the amount of output over time helps determine how well the kidneys are functioning.

The nurse cares for the client with chronic kidney disease. During review of laboratory results, the nurse notes the client's serum magnesium is increased. Which is the priority question for the nurse to ask the client? 1. "Are you drinking many beverages that contain caffeine?" 2. "Do you notice any tremors of your hands and fingers?" 3. "How many dairy products do you consume daily?" 4. "What over the counter medications do you take?"

4. "What over the counter medications do you take?" Magnesium excretion reduced in clients with chronic kidney disease. Antacids and laxatives may contain high levels of magnesium and should be avoided by clients with chronic kidney disease.

Which over the counter medication decreases hyperphosphatemia in clients diagnosed with chronic kidney disease? 1. Aluminum hydroxide/magnesium hydroxide 2. Bismuth subsalicylate 3. Kaolinite and pectin 4. Aluminum hydroxide

4. Aluminum hydroxide Aluminum hydroxide helps bind phosphates and lowers their levels in the blood. Kidney disease is the progressive reduction of functional kidney tissue, resulting in an inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes. Aluminum hydroxide/magnesium hydroxide is used as an antacid. Bismuth subsalicylate and kaolinite and pectin are all used for diarrhea.

The nurse care for a client diagnosed with a fractured right hip. The client's lab values are: Hgb 15 g/dL, Hct 4%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. The nurse is most concerned if which finding is observed? 1. A weight gain of 4 lbs in 1 day 2. An increase in nausea 3. An increase in muscle irritability 4. An episode of ventricular fibrillation

4. An episode of ventricular fibrillation Normal potassium is 3.5-5.9 mEq/L. Severe hyperkalemia may cause ventricular fibrillation, which is life-threatening and must be treated immediately. Think ABCs.

The nurse notices T waves on the ECG of the client diagnosed with acute kidney injury. Based on this finding, the nurse checks the laboratory values for which electrolyte imbalance? 1. Hypocalcemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypokalemia

4. Hypokalemia Hypokalemia is associated with T wave changes and the presence of a U wave. Potassium is involved in cardiac rhythm and nerve transmission.

The nurse provides care for an older adult client diagnosed with dehydration due to vomiting and diarrhea. The nurse needs to evaluate the therapeutic effect of fluid replacement. Which assessment finding best indicates IV fluid replacement is effective for this client? 1. Crackles in the lung bases 2. Blood pressure 90/52 mmHg 3. Urine output 180 mL in 12 hour shift 4. Increased mental alertness

4. Increased mental alertness Brain cells are particularly sensitive to the changes in intracellular and extracellular fluid volume. The client is expected to become more alert when the volume deficit is corrected.

A client is receiving a continuous intravenous infusion of heparin sodium to treat DVT. The client's activated aPTT is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusoin 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is The normal aPTT varies between 30 and 40 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of DVT is to keep the aPTT between 1.5 (45-60) and 2.5 (75-100) times normal. This means that the client's value should not be less than 45 seconds or greater than 100 seconds. Thus, the client's aPTT is within the therapeutic range and the dose should remain unchanged.

The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and respirations are deep and labored with a respiratory rate of 32 breaths per minute. The arterial blood gas values are Paco2 30 mmHg, pH 7.30, and HCO3 20mEq/liter. Which action does the nurse take? 1. Starts an infusion of 5% dextrose and water as per standing orders and contacts the health care provider 2. Places a paper bag over the client's nose and mouth to re-breathe expired air 3. Gives morphine intravenously to relive the client's pain 4. Places the client in Fowler's position and encourages measures to support hyperventilation

4. Places the client in Fowler's position and encourages measures to support hyperventilation Fowler's position will allow full chest expansion and hyperventilation in the respiratory compensatory mechanism for the client's metabolic acidosis.

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4. Preventing and recognizing hyperglycemia The normal reference range for the glycosylated hemoglobin A1C is less than 6.0%. This test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways

The nurse is caring for a client with Crohn's disease who has a calcium level of 8mg/dL (2mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

4. Prolonged QT interval 5. Prolonged ST segment A client with Crohn's disease is at risk for hypocalcemia. EKG changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment.

The nurse cares for the client diagnosed with hypotonic dehydration. Which laboratory study does the nurse monitor in the client? 1. Platelet count 2. Immunoglobulin E level (IgE) 3. Albumin level 4. Sodium level

4. Sodium level In hypotonic dehydration, relatively more sodium than water is lost. Because the serum sodium is low, intravascular water shifts to the extravascular space, exaggerating intravascular volume depletion for a given amount of total body water loss. Diuretic use is a primary cause of hypotonic dehydration. Serum sodium and serum osmolality are carefully monitored.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12 year history of diabetes mellitus

4. The client with kidney disease and a 12 year history of diabetes mellitus The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Atorvastatin

1. Warfarin 2. Glimepiride 3. Amlodipine NSAIDs can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent such as glimepiride; these medication should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided.

The nurse is caring for a postoperative client who is receiving demand dose hydromorphone via a patient controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2 F orally, pulse 52 beats per minute, blood pressure 101/58 mmHg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings 2. Attempt to arouse the client 3. Contact the PHCP immediately 4. Check the medication administration history on the PCA pump

2. Attempt to arouse the client The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused, because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should contact the PHCP and doument the findings after all data collected, after the client is stabilized, and if an abnormality still exists after arousing the client.

The nurse assesses a client and notes that the client is confused, has poor skin turgor, dry mucus membranes, sunken eyeballs, and has only produced a scant amount of amber urine on the previous shift. Which conditions do these signs and/or symptoms suggest the client has? 1. Potassium excess 2. Heart failure 3. Urinary retention 4. Dehydration

4. Dehydration Indications of dehydration include rapid weak pulse, rapid respirations, hypotension, weight loss, emaciation, dry mucous membranes, increased hematocrit, and increased urine specific gravity. Nursing care includes pushing oral fluids, providing isotonic IV fluids, monitoring intake and output hourly, monitoring daily weights, vital signs, assessing skin turgor, and monitoring lab values.

Which explanation best describes the phenomena known as "third spacing"? 1. Fluid moves from the intracellular space to the intravascular space 2. Blood pressure decreases due to a diminished intravascular volume 3. Movement of fluid from the blood vessels into cells 4. Fluid moves from the vasculature to interstitial spaces

4. Fluid moves from the vasculature to interstitial spaces Third spacing occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or "third" space, the nonfunctional area between cells. This can cause potentially serious problems such as edema, reduced cardiac output, and hypotension. Third spacing occurs due to decreased oncotic pressure in the intravascular space. This drop in oncotic pressure means fluid will "leak out" of the intravascular space into the interstitial space.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following pH is 7.12, Paco2 is 90 mmHg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation The acid-base disturbance is respiratory acidosis without compensation. In respiratory acidosis the pH is decreased and the Pco2 is elevated. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mmHg, Paco2 = 32 mmHg, and HCO3- = 28 mEq/L. Which conclusion about the client should the nurse make? 1. The client has acidotic blood 2. The client is probably overreacting 3. The client is fluid volume overloaded 4. The client is probably hyperventilating

4. The client is probably hyperventilating The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating.