MEDSURG QUESTIONS

A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which intravenous solution would increase cellular swelling and cerebral edema?

0.45% normal saline Rationale: Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the intravascular space without potentiating the client's cerebral edema.

The nurse hears the attending health care provider ask an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which IV solution would the nurse expect the intern to prescribe?

0.45% sodium chloride Rationale: Hypotonic solutions have a lower osmolality than do body fluids. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D5W) is isotonic. Solutions of 10% dextrose in water (D10W) and 5% dextrose in 0.9% sodium chloride are hypertonic.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? SELECT ALL THAT APPLY.

1-Ensure adequate oxygenation. 2-Provide assistance to prevent falls. 3-Monitor medication administration of diuretics. 4- Prevent complications during potassium administration. Rationale: The priorities for nursing care of a patient with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least how many minute(s)?

5 minutes Rationale: After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of pressure for a longer period may be needed.

A client is hypovolemic, and plasma expanders are not available. The nurse anticipates that which solution available on the nursing unit will be prescribed by the health care provider?

5% dextrose in 0.45% sodium chloride Rationale: A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options 1 and 2 are isotonic solutions. Option 3 is a hypotonic solution.

Which intravenous solution would be MOST APPROPRIATE for a client who may be experiencing excess fluid volume secondary to heart failure?

5% dextrose in 0.9% normal saline Rationale: The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. The 0.45% normal saline solution is hypotonic, which pulls fluid into the intracellular space. The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions that would worsen the excess fluid volume.

A nurse is calculating a male client's fluid intake for an 8-hour period. The client drank 8 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 10:00 am and at 1:00 pm when taking his medications, and 6 oz of iced tea at lunch. At 8:00 am and again at 2:00 pm, the client received his intravenous antibiotics in 50 mL of normal saline. What is the client's total intake in mL? Fill in the blank.

880mL Rationale: The client consumed a total of 26 oz of fluid (12 oz at breakfast, 8 oz with medications, and 6 oz at lunch). This equals 780 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 8:00 am and 50 mL at 2:00 pm). Therefore, the total intake is 880 mL.

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?

A client with an ileostomy Rationale: 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. A client with heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, are most at risk for fluid volume excess.

Submit The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043 Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem?

Administer prescribed antibiotics. Rationale: The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition MOST LIKELY caused this serum phosphorus level?

Alcoholism Rationale: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn?

Allen's test Rationale: Before radial artery puncture for obtaining a blood sample for ABG analysis, an Allen test should be performed to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Goodell's sign is used during pregnancy and indicates a softening of the cervix at the beginning of the second month of pregnancy. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign is nuchal rigidity on bending the head down toward the chest.

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 signs would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure RATIONALE 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 level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

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/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH with an increased HCO3 Rationale: 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 hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission work-up on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Apply a warm compress. Rationale: The application of a warm compress enhances the absorption of blood in the hematoma. Allen's test is performed before the collection of the specimen to assess collateral blood flow. Heparinized syringes are used for the collection of an arterial blood gas but no heparin is administered to a client. The antidote for heparin is not administered at this time unless prescribed. The laboratory department is not responsible for collecting the ABG specimen. Additionally, there is no useful reason to notify the hospital laboratory supervisor.

The nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Rationale: Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice Rationale: Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz of fluid should be consumed for every pound lost.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

Changes in mental status Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?

Check skin turgor over the client's sternum. Rationale: In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore the next nursing action would be to obtain additional assessment data.

A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances?

Chloride and bicarbonate Rationale: Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect because calcium and potassium are cations. The same is true for option 4.

A nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

Client with an ileostomy Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal (GI) tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid?

Client with an ischemic stroke Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

Daily weight Rationale: Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

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?

Decreased central venous pressure (CVP) Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which signs/symptoms?

Decreased respiratory rate and depth Rationale: A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. A client with metabolic acidosis would display the symptoms noted in option 3. The client with respiratory acidosis and alkalosis would display the symptoms noted in options 1 and 4, respectively.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.

Dehydration Physiological stress Decreased blood volume Rationale: Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, and stress.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

Dehydration Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level?

Depressed ST segment Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

A nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours post-overdose, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 1 and 3 indicate respiratory acidosis and alkalosis, respectively.

A client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. A nurse who is trying to enhance the client's respiratory status should avoid which action?

Encouraging the client to breathe slowly and shallowlyRationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? SELECT ALL THAT APPLY.

Ensure adequate fluid intake. Instruct the client about foods that contain potassium. Encourage the client to obtain assistance to ambulate. Implement safety measures to prevent falls. Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? ARRANGE THE ACTIONS IN THE ORDER THAT THEY SHOULD BE PERFORMED. ALL OPTIONS MUST BE USED.

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. Rationale: The Allen's test is performed before an arterial blood specimen is obtained from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while continuing to compress the radial artery and then assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings.

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH?

Fall Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms, indicating the acid-base disturbance that could occur in the client?

Headache, nausea, vomiting, and diarrhea Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours post-overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

Hypotension Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder?

Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid irregular pulse, and dysrhythmias.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse develops a plan of care to support the client physiologically until the tubular cells secrete a sufficient amount of which substance?

Hydrogen ions Rationale: Hydrogen ions are cations that contribute to a state of acidosis in the body. The renal tubules secrete hydrogen ions and potassium effectively, and in lesser amounts they secrete ammonia and uric acid. Phosphates are anions that tend to neutralize cations. The tubules reabsorb carbon dioxide molecules.

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?

Hyperactive bowel sounds Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. 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 is determined to be in respiratory alkalosis by blood gas analysis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base balance?

Hypokalemia Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

A client becomes hypovolemic as a result of excess blood loss during surgery. The nurse plans care, knowing that which physiological response is needed to restore adequate circulating volume?

Increased production of antidiuretic hormone (ADH) Rationale: The client must produce increased ADH, which will increase reabsorption of water in the renal tubules and increase circulating volume. The production of angiotensin is stimulated, not inhibited, so that vasoconstriction may occur. A decrease in aldosterone will decrease the reabsorption of sodium and water in the kidneys. The client does not require increased erythropoietin to restore circulating volume.

A client has a high potassium level. The nurse plans care, knowing that retention of potassium by the kidneys will be accompanied by which process?

Increased sodium excretion Rationale: With increased potassium retention, the kidneys excrete more sodium. The other options do not reflect the correct relationship between these two electrolytes.

A client who had intracranial surgery is experiencing diabetes insipidus. The nurse plans care, knowing that the client is experiencing which problem?

Insufficient production of antidiuretic hormone (ADH) Rationale: In diabetes insipidus there is insufficient ADH production, which causes the kidneys to excrete large volumes of urine. Water intoxication occurs when there is excess ADH production, resulting in water retention. Options 2 and 3 have nothing to do with diabetes insipidus.

An intravenous (IV) Ringer's lactate solution is prescribed for the postoperative client. The nursing instructor asks the nursing student who is caring for the client about the tonicity of the prescribed IV solution. The nursing student responds correctly by stating that this solution is which type of solution?

Isotonic Rationale: Ringer's lactate solution is an isotonic solution. Isotonic solutions include 5% dextrose in water (D5W), 0.9% saline (NS), and 5% dextrose in 0.225% saline (5% D/¼ NS); 0.45% saline (½ NS) is hypotonic; and 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (5% D/NS), and 5% dextrose in 0.45% saline (5% D/½ NS) are hypertonic solutions.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Lightheadedness and paresthesias Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. Options 1, 2, and 3 are not clinical manifestations of respiratory alkalosis.

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? SELECT ALL THAT APPLY.

Lightheadedness, Tachycardi, Confusion,Nausea Rationale: 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.

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

Loss of deep tendon reflexes Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

The nurse caring for a client with an ileostomy understands that the client is MOST at risk for developing which acid-base disorder?

Metabolic acidosis Rationale: Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy.

A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid-base imbalance?

Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis.

A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse should develop a plan of care because the client is at risk for the development of which type of acid-base imbalance?

Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?

Metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) 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 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 remaining options are incorrect interpretations.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client?

Monitor the client for dysrhythmias. Rationale: The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding INITIALLY will be noted in the client if hyperkalemia is present?

Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result?

Normal results Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45 mm Hg), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Potassium Rationale: The serum potassium level tends to rise with metabolic acidosis. This is becausepotassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte should be monitored closely while the client is treated.

The nurse is administering a dose of triamterene (Dyrenium) to an assigned client. The nurse monitors the client, expecting that the effect of this medication will result in retention of which substance?

Potassium Rationale: Triamterene is a potassium-retaining diuretic. Potassium-retaining diuretics decrease reabsorption of sodium and water and inhibit the excretion of potassium in the renal collecting ducts. The medication has no direct effect on chloride excretion or retention.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L Rationale: The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would MOST LIKELY be noted in this condition?

Potassium level of 3.0 mEq/L Rationale: 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. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is caring for a client with chronic kidney disease. Arterial blood gas (ABG) results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. Which laboratory value should the nurse expect to note?

Potassium level of 5.2 mEq/L Rationale: Interpretation of the ABG indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

Pour into the NG tube through a syringe with the plunger removed. Rationale: After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water, and should not be discarded.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

Processed oat cereals Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.

The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?

Prolonged QT interval Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

The nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance. Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client should try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

A nurse is evaluating a client's serum creatinine level. On noting that the level is high, the nurse plans care, knowing that creatinine is not being adequately secreted by which part of the nephron?

Proximal tubule Rationale: Using the process of filtration, the glomerulus removes creatinine from the body. The kidney actively secretes creatinine from the nephron in the proximal tubule. Options 1, 2, and 4 are not associated with the secretion of creatinine.

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 taking which action? Click on the Question Video button to view a video showing preparation procedures.

Pulling up and releasing the skin on the sternal area Rationale: Click on the Rationale Video button. When preparing to place a client on I&O, the nurse explains the procedure to the client. This will provide the client with information about the purpose and procedure and allow client participation, if feasible, such as contacting the nurse when oral intake is consumed or if the bathroom is used. The nurse also performs a baseline assessment for later comparison and checks for signs of fluid imbalance, including measuring the client's vital signs, weight, and skin turgor. Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor. The actions in options 1, 2, and 3 would not assess turgor.

A client has a prescription for a set of arterial blood gas (ABGs) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Rationale: The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore the remaining options are incorrect.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe?

Respirations that are abnormally deep, regular, and increased in rate Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

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

Respirations that are abnormally deep, regular, and increased in rate Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

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

Respiratory acidosis Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, options 1, 2, and 4 are incorrect.

The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis Rationale: In respiratory acidosis the pH is decreased and the Pco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Pco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is MOST LIKELY to experience what type of acid-base imbalance?

Respiratory acidosis Rationale: Respiratory acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base disturbances can occur in a client with COPD during exacerbation of the disease, but the most likely imbalance is respiratory acidosis. The remaining options are incorrect. COPD is a respiratory condition, not a metabolic one. Respiratory alkalosis is associated with hyperventilation

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Pco2 of 58 mm Hg, Po2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. Normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Pco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question

A nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.34 and the Pco2 is 50 mm Hg. Which acid-base imbalance should the nurse interpret that this client is experiencing?

Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is low and the Pco2 is elevated. This is an expected finding in a client with a neuromuscular disorder such as Guillain-Barré syndrome because the client may retain carbon dioxide as a result of ventilatory failure as paralysis ensues.

The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, a Pco2 of 58 mm Hg, a Po2 of 80 mm Hg, and an Hco3 of 27 mEq/L. The nurse should interpret this to mean that the client has which acid-base disturbance?

Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco2 is elevated. In respiratory alkalosis, an opposite effect occurs; the pH is elevated and the Pco2 is low. In metabolic acidosis, the pH is low and the bicarbonate is low; in metabolic alkalosis, the opposite effect occurs.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3) level is 22 to 27 mEq/L. 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 remaining options are incorrect interpretations.

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3 is 22 mEq/L. The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Pco2 will exhibit opposite effects; in this case, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.

In a client seen in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, Pco2 32 mm Hg, Po2 94 mm Hg, HCO3 level 24 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg, and the normal HCO3 concentration is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore 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.

A nurse reviews a client's arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated Rationale: In respiratory alkalosis, the pH will be higher than normal and the Pco2 will be low. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. The correct option is the only one that reflects these conditions.

The nurse is reviewing the laboratory results of a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 7 mEq/L. On the basis of this laboratory result, the nurse should expect to note which in the client?

Respiratory depression Rationale: Hypermagnesemia may be classified as mild (serum magnesia level of 3 to 5 mEq/L), moderate (6 to 7 mEq/L), severe (10 to 11 mEq/L), and emergency (12 to 15 mEq/L). A client with a mild degree of hypermagnesemia usually is asymptomatic. Neurological depression begins to occur at magnesium levels of 6 to 7 mEq/L and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

Resume full activity level. Rationale: Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

A client suffering from prolonged vomiting has developed metabolic alkalosis. The nurse plans care, knowing that this imbalance will be corrected primarily when the kidneys do which function?

Retain sufficient hydrogen ions. Rationale: Because hydrogen ions contribute to acidosis in the body, the kidneys retain hydrogen ions in alkalosis to restore acid-base balance. Chloride is an anion that will contribute to alkalosis if it is retained because anions combine with cations and neutralize them. Secretion of potassium also will increase the level of anions in the bloodstream. Secretion of water affects fluid balance.

A nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client's safety knowing the risks of this imbalance, by carefully implementing which prescribed precaution?

Seizure precautions Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. Options 1, 3, and 4 are unnecessary in the care of the client experiencing metabolic alkalosis.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?

Sodium chloride Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) should be used rather than water for gastrointestinal irrigations because it is an isotonic solution.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do?

Stop administering the enemas until the health care provider (HCP) is notified. Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? SELECT ALL THAT APPLY.

Strawberries,Raisins,Potatoes,Cantaloupe Rationale: The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

Tall peaked T waves Rationale: A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is MOST at risk for the development of a potassium value at this level?

The client who has sustained a traumatic burn Rationale: A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. 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. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

The client who is taking diuretics Rationale: Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. 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.

Which client is least likely to be at risk for the development of third spacing?

The client with diabetes mellitus Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

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 at risk for fluid volume excess?

The client with kidney disease Rationale: 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. 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 client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route?

The skin Rationale: 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.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. 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. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value?

U waves Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determine the adequacy of which?

Ulnar circulation Rationale: Before radial puncture is performed to obtain an arterial specimen for determination of arterial blood gases, an Allen's test should be performed to determine the adequacy of the ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 2, 3, and 4 are incorrect because these anatomical areas are not associated with adequate circulation to the hand.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.016 to 1.022. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.5 to 8.0 normal), and this value is not used in monitoring hydration status.

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?

pH 7.25, Pco2 50 mm Hg Rationale: 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. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.