Med-Surg: Fluid & Electrolyte
What is the best food source for calcium? a.) Milk b.) Meat c.) Whole grains d.) Green leafy vegetables
A/R: Milk - milk contains the highest amt. of Calcium.
A nurse's collecting data from a client who is dehydrated due to fluid volume Deficit. Which of the following findings should the nurse expect? A. Moist skin B. Distended neck veins C. Increased urinary output D. Thready pulses
Answer D. A weak thready pulse is an expected manifestation of fluid volume deficit caused by low blood pressure.
A nurse is checking ABG results for a client who has vomited repeatedly during the past 24 hours. Which of the following acid base imbalances should the nurse expect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Answer: D. Metabolic Alkalosis. Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.
After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A. Magnesium level of 2.2 B. Potassium level of 5.6 C. Potassium level of 2.2 D. Phosphorus level of 2.0
Answer - C. Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings.
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client. A. moist skin B. distended neck veins C. increased urinary output D. tachycardia
Answer: D (Tachycardia) Rationale: tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit.
The pt's K+ level is 5.2. When the RN discusses dietary selections, the pt should be instructed to limit intake of what food items? SATA a.) Orange juice b.) Bananas c.) Apples d.) Tomatoes e.) Red meat
A/R: Orange, Bananas, Tomatoes - because these foods are high in K+.
A nurse is reinforcing discharge teaching with a client who has undergone a transurethral resection of the prostate (TURP). Which of the following statements should the nurse include in the teaching? A. increase fluid intake if you're in becomes blood tinged B. take naproxen for discomfort. C. sexual activity is permitted after two weeks. D. urinary dribble and will resolve within 5 days.
Answer : A. Rational. The nurse should reinforce that strenuous activity, straining to the bowel movement and coughing may cause the urine to become blood tinged. If this should occur the client should stop the activity, rest, and increase fluid intake. If urine becomes increasingly blood tinged or does not clear , or if the client has difficulty voiding, then he or she should be instructed to notify the provider.
Nurse collecting data from a client who reports nausea, vomiting and weakness. Client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? SATA A. Decreased turgor B. Concentrated urine C. Bradycardia D. Low grade fever E. Tachypnea
Answer A B D E A. lack of fluid results in dryness of skin and decrease turgor B. urine is concentrated due to lack of fluid in the vascular system. D. low grade fever one of body ways to maintain homeostasis to compensate for lack of fluid E. increased respirations obtain oxygen due to lack of fluid
The nurse offers to take an older neighbor to the grocery store. As they are shopping, the neighbor tells the nurse that, "my doctor told me to watch my salt intake." Which items in the shopping cart would the nurse suggest they put back on the shelf? SATA A. Cheddar cheese B. Ketchup C. Oranges D. Pretzels E. Frozen TV dinner
Answer A, B, D, E: The nurse would assist the neighbor by helping her to read labels. Condiments, many canned foods, frozen foods and prepared items frequently have a high salt content.
Which pt below would have a potassium level of 5.5? A. A 76 year old who reports taking lasix four times a day B. A patient with Addison's disease C. A 55 year old woman who have been vomiting for 3 days consistently D. A patient with liver failure
Answer B. A patient with Addison's disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.
While in the delivery room with his wife, the father begins to develop an anxiety reaction and lightheadedness. Which intervention does the nurse use to prevent respiratory alkalosis? A. Coach panting respirations B. Provide nasal oxygen C. Have him breath into a paper bag D. Have him cough and deep breath
Answer C: Breathing into a paper bag helps the father to "rebreathe" some of the carbon dioxide that he is losing because he is hyperventilating. This will help correct the blood pH. Panting will contribute to respiratory alkalosis.
The patient is on mechanical ventilation. The arterial blood gas results indicate that the patient has respiratory alkalosis. What would the nurse do first? A. Suction the airway for excessive secretions or a mucus plug B. Notify the RN or healthcare provider C. Check the ventilator settings and compare to the orders D. Deliver breaths using a bag valve mask with high flow oxygen
Answer C: Respiratory alkalosis can be related to rapid respiratory rates. The nurse would check the ventilator settings to ensure that they match the orders. If the ventilator settings are incorrect, the nurse would reset them. The RN and provider should be notified about the blood gas results and any action that was taken. Excessive secretions or a mucus plug are more likely to cause respiratory acidosis. Using the bag-valve-mask would be appropriate as a temporary measure if the nurse determines that the ventilator is malfunctioning.
A nurse is reviewing the medical records of a group of clients. The nurse should identify that hemodialysis is appropriate for which of the following clients ? A. A client who has minimal urine output following a drug overdose. B. A client who has acute kidney disease and is responding to diuretics. C. A client who took excessive laxatives and has a potassium level of 2.8mEq/L. D. A client who has been vomiting and has metabolic alkalosis.
Answer. A Rational: the nurse should recognize that hemodialysis therapy is appropriate for clients who have end stage kidney disease, drug overdose, hyperkalemia, fluid overdose or metabolic acidosis.
The nurse is assessing an older adult and observes dry mucous membranes, increased heart rate, decreased blood pressure and poor skin turgor. The patient seems mildly confused and continuously asks for water. What would the nurse do first? A. Assess the patient for additional signs of dehydration B. Offer the patient a glass of water and reassess in several hours C. Count the respirations and assess additional signs of respiratory acidosis D. Call the provider and report the assessment findings.
Answer. A. The patient is showing signs of dehydration. The nurse would assess for other signs/symptoms: flat neck veins, orthostatic hypotension, specific gravity of urine, dark urine, and elevated temperature.
What purpose do the electrolytes serve in the body? (SATA) A. Maintenance of normal body metabolism B. Regulation of water balance in the body C. Regulation of water and electrolyte contents within cells D. Formation of hydrochloric acid in gastric juice E. Transportation of nutrients to cells and waste products from the cells
Answer: A, B, C, D. Electrolytes serve in body metabolism, water and electrolyte balance, and regulation formation of hydrochloric acid. Transportation of nutrients and wastes relies on the fluid component.
A nurse is admitting a client who reports nausea, vomiting and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.) A.Decreased skin turgor B. Concentrated Urine C. Bradycardia D. Low-grade fever E. Tachypnea
Answer: A, B, D, E. Rationale: Decreased skin turgor is due to the lack of fluid within the body and results from dryness of the skin. Concentrated urine is a manifestation of fluid volume deficit. Urine is concentrated due to lack of fluid in the vascular system. This causes a decrease in perfusion of the kidneys resulting in increased urine specific gravity. Low grade fever is one of the body's ways to maintain homeostasis to compensate for the lack of fluid in the body. Tachypnea is the body's way to obtain oxygen due to the lack of fluid volume in the body.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? A. The kidneys retain bicarbonate. B. The kidneys excrete bicarbonate. C. The lungs will retain carbon dioxide. D. The lungs will excrete carbon dioxide.
Answer: A. Rationale A: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale B: Excreting bicarbonate causes acidosis to develop. Rationale C: Retaining carbon dioxide causes respiratory acidosis. Rationale D: Excreting carbon dioxide causes respiratory alkalosis
A nurse is caring for a client who has metabolic alkalosis. As the client compensates for this acid-base imbalance, which of the following mechanisms should the nurse expect the client's body to use? A. Hypoventilation B. Hyperventilation C. Increased renal acid excretion D. Decreased renal acid excretion
Answer: A. Rationale: Hypoventilation is the mechanism that helps clients compensate for metabolic alkalosis. As a result, the client's PaCO2 and HCO3- will increase.
A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching? a) Use pursed-lip breathing during periods of dyspnea b) Limit fluid intake to 1,500 mL per day c) Practice chest breathing each day d) Wear home oxygen to maintain an SaO2 of at least 94%
Answer: A. Rationale: The nurse should instruct the client about using pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange.
A nurse is collecting data from a client who has hyperkalemia. Which of the following disorders is a risk factor for this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart Failure C. Aldosterone excess D. Excessive sweating
Answer: A. Ketoacidosis. Diabetic ketoacidosis, kidney disease, and crash injuries are all risk factors of hyperkalemia
The nurse is planning care for a client with severe burns. Which of the following is this client at risk for developing? a. Intracellular fluid deficit b. intracellular fluid overload c. extracellular fluid deficit d. interstitial fluid deficit
Answer: A. Rationale: Because this client was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
The nurse receives notification from the laboratory that a patient's potassium level is 6 mEq/L. The nurse has paged the provider and is awaiting a call back. What should the nurse do first? A. Attach the patient to a cardiac monitor. B. Encourage foods and fluids that contain potassium. C. Ensure that intravenous calcium gluconate is available. D. Check medications that could affect potassium levels.
Answer: A. High levels of potassium cause cardiac dysrhythmias and cardiac arrest. The nurse would immediately begin to monitor the heart.
The nurse sees that the patient is scheduled to have a potassium supplement. In addition to the last potassium level, what would the nurse assess before administering the potassium? A. Urinary output B. Blood pressure C. Respiratory rate D. Hematocrit level
Answer: A. The nurse must know that the patient is producing urine before administering potassium. If not, the patient will be at risk for hyperkalemia.
A nurse is collecting data from a client who has chronic kidney disease (CKD). Which of the following findings do the nurse expect in early stages? A. Polyuria B.Hypotension C. Increased appetite D. Jaundice skin tone
Answer: A. Polyuria. The inability of the kidneys to concentrate urine is one of the earliestmanifestations of renal impairment. This results in polyuria, dilute urine and nocturia.
A nurse is caring for a client who has a serum sodium level of 133 mEq/L and serum potassium level of 3.4 mEq/L. Which of the following treatments is a risk factor for these laboratory findings? A. Three tap water enemas B. 0.9% NaCl IV C. Dextrose 5% in water with 20 mEq of K+ IV D. Spironolactone therapy
Answer: A. Three tap water enemas Rationale: Three tap water enemas can deplete Na & K. Tap water is hypotonic and can move from the bowel lumen into the ICF, causing water intoxication and electrolyte imbalance
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? A. fluid volume excess B. fluid volume deficit C. seizure activity D. liver failure
Answer: A. fluid volume excess Rationale A: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system. Rationale B: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system. Rationale C: Seizure activity would more commonly be associated with electrolyte imbalances. Rationale D: Liver failure is not anticipated related to postoperative intravenous fluid administration.
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? A. risk of dehydration B. risk of kidney damage C. risk of stroke D. risk of bleeding
Answer: A. risk of dehydration Rationale A: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality. Rationale B: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues. Rationale C: The risk of stroke is not specifically related to aging or fluid & electrolyte issues. Rationale D: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will most likely need which of the following precautions implemented? A. seizure B. infection C. neutropenic D. high-risk fall
Answer: A. seizure Rationale A: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included. Rationale B: Infection precautions not specifically indicated for a pt with hyponatremia. Rationale C: Neutropenic precautions not specifically indicated for a pt with hyponatremia. Rationale D: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
A patient is admitted with burns over 50% of his body. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances? A. Hypercalcemia B. Hypophosphatemia C. Hypernatremia D. Hypermagnesemia
Answer: B Rationale A: Pts who experience burns are not at an increased risk for developing increased blood calcium levels. Rationale B: Causes of hypophosphatemia include stress responses & extensive burns. Rationale C: Pts who experience burns are not at an increased risk for developing increased blood sodium levels. Rationale D: Pts who experience burns are not at an increased risk for developing increased blood magnesium levels.
What's the best way for a nurse to determine a pt fluid balance ? A- access vitals sign B- weigh patient daily C- monitor Iv fluid intake D- check diagnostic test results
Answer: B By weighing the patient daily the nurse can measure how much fluid is being retained or lost. The nurse should weigh the patient every morning before breakfast and have the patient wear the same clothes to ensure an accurate weight is being taken.
A nurse is caring for a client who has a NG tube with low intermittent suctioning. The nurse should monitor the client for which of the following electrolyte imbalances? (SATA) A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypomagnesemia E. Hyperkalemia
Answer: B, D: Hyponatremia, Hypomagnesemia Rationale: Nasogastric losses are isotonic and contain sodium. Thus, nasogastric suction can cause hyponatremia. Nasogastric losses due to suctioning, diarrhea, and fistula drainage can deplete magnesium levels.
Which patient has the Greatest risk for dehydration? A. 30 year old female with vomiting and diarrhea B. 72 year old obese male with fever and anorexia C. 2 year old with an ear infection and vomiting D. 45 year old underweight female with influenza
Answer: B. All of these patients have risk for dehydration, but obese populations, older adults and infants have greater risk because of reduced fluids reserves. The 72-year old obese male has two risk factors. In addition, fever causes insensible fluid loss and anorexia (loss of appetite) may cause the patient to refuse oral foods and fluids.
A nurse is caring for a client who has a post-op ileus and an NG tube that has drained 2500 mL in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor for? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level
Answer: B. Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning
A nurse in a medical surgical unit is caring for a group of clients for which of the following clients should the nurse anticipate a prescription for fluid restriction ? A: A client who has a new diagnosis of adrenal insufficiency. B: A client who has a heart failure. C: A client who is receiving treatment for diabetic ketoacidosis. D: A client who has abdominal ascites.
Answer: B. The nurse should anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart
The nurse is checking the laboratory data of a woman who is at risk for osteoporosis. Which electrolyte value is most relevant to this condition? A. Sodium level of 145 mEq/L B. Calcium level of 3.0 mEq/dL C. Potassium of 3.5 mEq/dL D. Phosphorus level of 3.4 mEq/dL
Answer: B. The patient's calcium level is low, and this increases her risk for bone weakness and other problems associated with osteoporosis. The other values are within normal limits.
What is the best way for the nurse to determine the patient's fluid balance? A. Assess vital signs. B. Weigh the patient's fluid balance. C. Monitor IV fluid intake. D. Check diagnostic tests results.
Answer: B. Weighing the patient daily is the best method to track trends of fluid gain or loss. It is essential that the patient be weighed the same time every day with the same amount of clothing
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acidbase imbalances. a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
Answer: B. Respiratory acidosis is a common complication for COPD. It occurs when patients are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? A. Magnesium 1.8 mg/dL B. Sodium 128 mEq/L C. Potassium 4.0 mEq/L D. Phosphate 3.0 mg/dL
Answer: B. Sodium 128 mEq/L Rationale: Normal sodium levels should always be between 135 to 145.
A nurse is caring for a client whose ABG results are pH 7.30, PaCO2 32 mm HG, and HCO3 19 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis
Answer: C Metabolic acidosis. With metabolic acidosis, the pH is low, the PaCO2 is low or within the expected reference range, and the bicarbonate is low.
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? SATA A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor
Answer: C, D, E. Tachycardia is an expected finding in hypovolemia. Syncope is an expected finding of hypovolemia. Decreased skin turgor is an expected finding in hypovolemia.
A nurse is preparing to assist a provider in withdrawing arterial blood from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. B. Apply ice to the site after obtaining specimens. C. Check the circulation in the client's ulnar artery prior to obtaining the specimen. D. Release the pressure applied to the puncture site 1 minute after the needle is withdrawn.
Answer: C. Rationale: The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
Answer: C. Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.
3. A nurse is observing a client who has acute alcohol intoxication. The nurse should identify that the client is at risk for which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Answer: C. Common causes of metabolic acidosis include alcohol or ethanol intoxication, diabetic ketoacidosis, hypoxia, kidney failure, diarrhea, and pancreatitis.
A nurse is assessing a pt who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A Hyperactive reflexes B. Extreme thirst C. Weak, irregular pulse D. Hyperactive bowel sounds
Answer: C. Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias
A nurse is providing nutrition education to a client who has osteomalacia. The nurse should identify that this condition is caused by a deficiency in which of the following nutrients? a. Fluoride b. Vitamin A c. Vitamin D d. Phosphorus
Answer: C. Osteomalacia is softening of the bones due to defective bone mineralization, resulting from a deficiency of Vit D.
A nurse is caring for a client who has CKD. Which of the following actions should the nurse take to manage fluid overload? A. Weight the client periodically throughout the day. B. Measures the client's output every 8 hours C. Obtain the client's blood pressure at least every 4 hours D. Limit client's oral fluid intake to meal times
Answer: C. The nurse should obtain the client's blood pressure at least every 4 hr. An increase in the blood pressure can indicate fluid overload and hypertension which can lead to further kidney damage. The nurse should monitor the blood pressure of a client who has CKD. The client who is experiencing fluid overload due to CKD will manifest an increase in blood pressure.
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? A. Yogurt B. Corn Flakes C. Hard boiled egg D. Leafy Greens
Answer: C. Hard Boiled Egg Rationale: Hard Boiled eggs contain as little as 5 mg of Magnesium, while yogurt contains 19mg, leafy greens contain 24 mg and corn flakes contain 11 mg of Magnesium.
A nurse is caring for a client who has CKD and has developed Kussmaul respirations. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Answer: C. Metabolic acidosis. Rationale: Acid retention increases with advancing CKD. The client develops Kussmaul respirations (increase in depth and rate) to promote excretion of carbon dioxide through the lungs.
A nurse is collecting data from a client who has hypomagnesemia. Which of the following techniques should the nurse use to check for Chvostek sign? A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope's bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower her chin to her chest
Answer: C. Tap lightly on the client's cheek. Rationale: The nurse taps the client's cheek over the facial nerve just in front of the ear lobe to elicit Chvostek sign. A positive response is facial twitching on the same side of the face. A positive Chvostek's sign indicates hypocalcemia or hypomagnesemia. Hyperactive deeptendon reflexes and muscle tetany are signs of hypomagnesemia.
A client is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase? a. Whole grains and nuts b. Milk products and green, leafy vegetables c. Pork products and canned vegetables d. Orange juice and bananas
Answer: D Rationale: The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.
A nurse is caring for a client who has respiratory acidosis. Which of the following medications should the nurse prepare to administer? A. Antiemetic B. Hypoglycemic C. Antidiarrheal D. Bronchodilator
Answer: D. Rationale: Clients who have respiratory acidosis require interventions that improve oxygenation and ventilation and help maintain airway patency. The nurse should prepare to administer oxygen, a bronchodilator, and possibly a mucolytic and an anti-inflammatory medication.
A nurse is caring for an older adult client in a long-term care facility who is dehydrated. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit the client's intake. B. Observe for indications of peripheral edema C. Encourage the client to promote oxygenation by ambulating D. Monitor for orthostatic hypotension
Answer: D. Rationale: The nurse should monitor for orthostatic hypotension because the client has manifestations of dehydration due to decreased circulatory volume.
A nurse is caring for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse take first? a) Monitor the client's arterial blood gas results b) Reinforce how to perform controlled coughing c) Reinforce how to perform pursed-lip breathing d) Place the client in an upright position.
Answer: D. Rationale: Using the airway. breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow.
The nurse evaluates the results of laboratory tests completed on a client admitted for nonhealing wound. Which of the following values would be a priority for the nurse? a. Blood urea nitrogen 15mg/dL(5.4mmol/L) b. Serum albumin 3.7 g/dL (37g/L) c. Serum potassium 4.5 mEq/L (4.5 mmol/L) d. Serum sodium 153 mEq/L (153 mmol/L)
Answer: D. Rationale: Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L) Increased serum kevel (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces in the vascular system.
Which patient has the greatest risk for developing hypokalemia? a. Has a small bowel obstruction b. Has renal failure c. Consumes excessive alcohol d. Takes prescribed loop diuretic
Answer: D. Patients who take loop diuretics must be cautioned about the signs of low potassium and advised about foods that provide potassium. Patients with small bowel obstruction are more at risk for hyponatremia. Renal failure often results in hyperkalemia. Excessive alcohol consumption is associated with hypocalcemia and hypomagnesemia.
The patient is experiencing hyperkalemia. What treatment does the nurse anticipate? A. Intravenous IV calcium B. Fluid restriction C. Foods high in potassium D. Administration of loop diuretics
Answer: D. Potassium is excreted through the urine; therefore, increasing urine output helps the body rid itself of excess potassium. IV calcium is given to patients with hypocalcemia. Fluid restrictions are used for patients with hyponatremia. Foods high in potassium are given when the patient has hypokalemia
A nurse is caring for a client who had CKD. The nurse should monitor the client for which of the following manifestations of fluid overload? A. Flat Neck Veins B. Weak Pulse C. Increased Hematocrit D. Increased Blood Pressure
Answer: D. The nurse should monitor the blood pressure of a client who has CKD. The client who is experiencing fluid overload due to CKD will manifest an increase in blood pressure.
A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
Answer: D. These laboratory values reflect metabolic alkalosis. The pH and the bicarbonate are greater than the expected reference range, and the PaCO2 is within the expected reference range.
A nurse is caring for a client who has chronic kidney disease (CKD). The client suddenly develops restlessness and dyspnea and the nurse auscultates crackles in the client's lungs. Which of the following actions should the nurse first take? A. Administer IV furosemide. B. Obtain an oxygen saturation level. C. Administer IV morphine sulfate. D. Place the client in a high fowler's position.
Answer: D. Place the client in a high fowler's position. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to place the client experiencing pulmonary edema in a high fowler's position. This action, along with the application of O2, facilities gas exchange and increases the ease of breathing.
A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth
Correct Answer: C. Depressed deep-tendon reflexes A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness. Incorrect Answers: A. Muscle tremors are manifestations of hypocalcemia, not hypercalcemia. B. Positive Chvostek's and Trousseau's signs are manifestations of hypocalcemia, not hypercalcemia. D. Numbness and tingling around the mouth and in the extremities are manifestations of hypocalcemia, not hypercalcemia.
