Module 2: Resp, Meds, Acid-Base

1. A patient with cirrhosis is noted to have low serum albumin levels. The patient is to receive 200 mL of albumin in 30 minutes. The drop factor for the IV set is 15 gtt/mL. The nurse correctly adjusts the IV rate to what rate?

ANS: 100 gtt/min (200 mL ´ 15 gtt/mL) ÷ 30 min = 100 gtt/min.

10. A patient is taking a thiazide diuretic and reports anorexia and fatigue. The nurse suspects which electrolyte imbalance in this patient? a. Hypercalcemia b. Hypocalcemia c. Hyperkalemia d. Hypokalemia

ANS: D Thiazide diuretics cause the body to lose potassium. Patients who take thiazide diuretics should be monitored for hypokalemia.

14. A patient is brought to the emergency department and reports having taken "a lot" of acetaminophen extra-strength tablets 16 hours prior. The nurse will expect the provider to order a. acetylcysteine (Mucomyst). b. dornase alfa (Pulmozyme). c. gastric lavage. d. renal enzyme tests.

ANS: A Acetylcysteine is used as an antidote for acetaminophen overdose if given within 12 to 24 hours of ingestion. Dornase alfa is used to treat cystic fibrosis. Gastric lavage is no longer used as treatment. Liver enzyme tests are indicated since acetaminophen is hepatotoxic.

1. The nurse is caring for a patient recently diagnosed with mild emphysema and provides teaching about the disease and medications for treatment. Which statement by the patient indicates understanding of the medication regimen? a. "I should use albuterol when my symptoms worsen." b. "I will need to take oral prednisone on a daily basis." c. "My provider will prescribe prophylactic antibiotics." d. "My symptoms are reversible with proper medications."

ANS: A Albuterol is used to treat bronchospasm during symptom flares. Oral prednisone is given for acute flares but not generally on a daily basis until symptoms are chronic and severe because of the risk of adrenal suppression. Prophylactic antibiotics are not given regularly because of the risk of antibiotic resistance. Symptoms of emphysema are not reversible.

21.A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

ANS: A All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

13. A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3- 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

ANS: A All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

11. A patient with chronic obstructive pulmonary disease (COPD) who has a persistent nonproductive cough asks about a medication that will not cause sedation. The nurse will encourage the patient to discuss which medication with the provider? a. Benzonatate HCl (Tessalon Perles) b. Dextromethorphan hydrobromide (Benylin DM) c. Guaifenesin and codeine d. Promethazine with dextromethorphan

ANS: A Benzonatate will not cause sedation and is safe for patients with COPD. Dextromethorphan is contraindicated in patients with COPD. Codeine and promethazine cause sedation.

1. A patient who has narrow-angle glaucoma asks the nurse to recommend a medication to alleviate cold symptoms such as nasal congestion and runny nose. The nurse will suggest the patient talk to the provider about which medication? a. Azelastine (Astelin) b. Cetirizine (Zyrtec) c. Chlorpheniramine maleate (Chlor-Trimeton) d. Diphenhydramine (Benadryl)

ANS: A Antihistamines have anticholinergic effects, which are contraindicated in patients with narrow-angle glaucoma. Cetirizine and azelastin are second-generation antihistamines, with fewer anticholinergic side effects, but azelastine is a nasal spray and is less likely to have systemic side effects.

20. The nurse is caring for a patient who will receive 10% calcium gluconate to treat a serum potassium level of 5.9 mEq/L. The nurse performs a drug history prior to beginning the infusion. Which drug taken by the patient would cause concern? a. Digitalis b. Hydrochlorothiazide c. Hydrocortisone d. Vitamin D

ANS: A Calcium gluconate is given to treat hyperkalemia in order to decrease irritability of the myocardium. When administered to a patient taking digitalis, it can cause digitalis toxicity. The other drugs may affect potassium levels but are not a cause for concern with calcium gluconate.

15. A patient who is using inhaled cromolyn sodium (Intal) daily calls the clinic to report experiencing cough and a bad taste. The nurse will instruct the patient to perform which action? a. Drink water before and after using the inhaler. b. Schedule an appointment to discuss these effects with the provider. c. Stop taking the medication immediately. d. Use the inhaler only as needed for acute bronchospasms.

ANS: A Cough and a bad taste are the most common side effects associated with cromolyn sodium, and these effects can be decreased by drinking water before and after using the drug. The effects are not serious and do not warrant discussion with the provider. Stopping the medication abruptly can cause a rebound bronchospasm. This medication is not useful in acute bronchospasm.

2. A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation

ANS: A Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

9. A patient who has been taking theophylline at home reports having palpitations and jitteriness. What action will the nurse take? a. Ask the patient if herbal medications are used. b. Notify the provider to report theophylline toxicity. c. Recommend that the patient increase fluid intake. d. Request an order for renal function studies.

ANS: A Ephedra is a stimulant that potentiates theophylline and may increase side effects. Patients should be questioned about use of herbal medications. To determine toxicity, serum drug levels must be drawn; at this point, the patient reports symptoms of theophylline side effects. Increasing fluid intake will not alleviate symptoms. Renal function studies are not indicated.

11.The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

7. The nurse is caring for a newly admitted patient who has severe gastroenteritis. The patient's electrolytes reveal a serum sodium level of 140 mEq/L and a serum potassium level of 3.5 mEq/L. The nurse receives an order for intravenous 5% dextrose and normal saline with 20 mEq/L potassium chloride to infuse at 125 mL per hour. Which action is necessary prior to administering this fluid? a. Evaluate the patient's urine output. b. Contact the provider to order arterial blood gases. c. Request an order for an initial potassium bolus. d. Suggest a diet low in sodium and potassium.

ANS: A If the patient is receiving potassium and the urine output is <25 mL/hr or <600 mL/d, potassium accumulation may occur. Patients with a low urine output should not receive IV potassium. Arterial blood gases are not necessary prior to IV potassium administration. Potassium should never be given as a bolus. Patients should be put on a potassium-enriched diet when foods are tolerated.

12. A patient will begin using an albuterol metered-dose inhaler to treat asthma symptoms. The patient asks the nurse about the difference between using an oral form of albuterol and the inhaled form. The nurse will explain that the inhaled form of albuterol a. has a more immediate onset than the oral form. b. may cause more side effects than the oral preparation. c. requires an increased dose in order to have therapeutic effects. d. will not lead to tolerance with increased doses.

ANS: A Inhaled medications have more immediate effects than oral preparations. As long as they are used correctly, systemic side effects are less common. Less drug is needed for therapeutic effects, since the drug is delivered directly to target tissues. Increased doses will lead to drug tolerance.

11. The nurse is caring for a patient whose serum sodium level is 140 mEq/L and serum potassium level is 5.4 mEq/L. The nurse will contact the patient's provider to discuss an order for a. a low-potassium diet. b. intravenous sodium bicarbonate. c. Kayexalate and sorbitol. d. salt substitutes.

ANS: A Mild hyperkalemia may be treated with dietary restriction of potassium-rich foods. The patient's sodium level is normal, so sodium bicarbonate is not indicated. Kayexalate is used for severe hyperkalemia. Salt substitutes contain potassium and would only compound the hyperkalemia.

13. The nurse is caring for a patient who is receiving oral potassium chloride supplements. The nurse notes that the patient has a heart rate of 120 beats per minute and has had a urine output of 200 mL in the past 12 hours. The patient reports abdominal cramping. Which action will the nurse take? a. Contact the provider to request an order for serum electrolytes. b. Encourage the patient to consume less fluids. c. Report symptoms of hyperchloremia to the provider. d. Request an order to increase the patient's potassium dose.

ANS: A Oliguria, tachycardia, and abdominal cramping are signs of hyperkalemia, so the nurse should request an order for serum electrolytes. This patient should increase fluid intake. The patient is not exhibiting signs of hyperchloremia; the patient is showing signs of hyperkalemia, and an increased potassium dose is not indicated.

5. The nurse is caring for a patient who has a heart rate of 98 beats per minute and a blood pressure of 82/58 mm Hg. The patient is lethargic, is complaining of muscle weakness, and has had gastroenteritis for several days. Based on this patient's vital signs, which sodium value would the nurse expect? a. 126 mEq/L b. 140 mEq/L c. 145 mEq/L d. 158 mEq/L

ANS: A Patients who are hyponatremic will have tachycardia and hypotension along with lethargy and muscle weakness. The normal range for serum sodium is 135 mEq/L to 145 mEq/L; a serum sodium level of 126 mEq/L would be considered hyponatremic.

4. A patient will begin using ipratropium bromide (Atrovent), albuterol (Proventil), and an inhaled glucocorticoid medication (steroid) to treat chronic bronchitis. When teaching this patient about disease and medication management, the nurse will instruct the patient to administer these medications in which order? a. Albuterol, ipratropium bromide, steroid b. Albuterol, steroid, ipratropium bromide c. Ipratropium bromide, albuterol, steroid d. Steroid, ipratropium bromide, albuterol

ANS: A Patients who use a beta agonist should be taught to use it 5 minutes before administering ipratropium bromide, and ipratropium bromide should be given 5 minutes prior to an inhaled glucocorticoid. This helps the bronchioles to dilate so the subsequent medication can be deposited in the bronchioles for improved effect.

19. The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect? a. Fluid volume deficit (FVD) b. Fluid volume excess (FVE) c. Mild extracellular fluid (ECF) deficit d. Renal failure

ANS: A Patients with FVD will exhibit elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin. Patients with FVE will have bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild ECF deficit causes thirst. Renal failure generally leads to FVE.

6. A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3- 16 mEq/L. What action should the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.

ANS: A Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

6.A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

ANS: A Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.

17. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take? a. Decrease the IV fluid rate and notify the provider. b. Increase the IV fluid rate and notify the provider. c. Request an order for a colloidal IV solution. d. Request an order for a hypertonic IV solution.

ANS: A The patient shows signs of fluid volume excess, so the nurse should slow the IV fluid rate and notify the provider. Increasing the rate would compound the problem. Colloidal and hypertonic fluids would pull more fluids into the intravascular space and compound the problem.

8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3- 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the client's nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the client's arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.

15.A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

ANS: A The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse it's safe to visit is demeaning of the spouse's feelings.

15. A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3- = 26 mEq/L O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowler's position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

ANS: A The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client's respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the client's hypoxic drive, nor would it address the client's most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.

4. The nurse is caring for a patient who weighs 75 kg. The patient has intravenous (IV) fluids infusing at a rate of 50 mL/hour and has consumed 100 mL of fluids orally in the past 24 hours. Which action will the nurse take? a. Contact the provider to ask about increasing the IV rate to 90 mL/hour. b. Discuss with the provider the need to increase the IV rate to 150 mL/hour. c. Encourage the patient to drink more water so the IV can be discontinued. d. Instruct the patient to drink 250 mL of water every 8 hours.

ANS: A The recommended daily fluid intake for adults is 30 to 40 mL/kg/day. This patient should have a minimum of 2250 mL/day and is currently receiving 1200 mL IV plus 100 mL orally for a total of 1300 mL. Increasing the IV rate to 90 mL/hour would give the patient 2160 mL. If the patient continues to take oral fluids, the amount of 2250 mL can be met. A rate of 150 mL per hour would give the patient 3600 mL per day, which exceeds the recommended amount. Since this patient is not taking fluids well and is not receiving adequate IV fluids, encouraging an increased fluid intake is not indicated. Even if the patient drank 250 mL of water every 8 hours, the amount would not be sufficient.

8.A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

ANS: A The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

ANS: A This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.

22. A patient is admitted with orthopnea, cough, pulmonary crackles, and peripheral edema. The patient's urine specific gravity is 1.002. The nurse will expect this patient's provider to order which treatment? a. Diuretics b. Colloidal IV fluids c. Hypertonic IV fluids d. Hypotonic IV fluids

ANS: A This patient has signs of fluid volume excess. Diuretics are prescribed to reduce fluid overload.

14. A patient asks the nurse about taking calcium supplements to avoid hypocalcemia. The nurse will suggest that the patient follow which instruction? a. Take a calcium and vitamin D combination supplement. b. Take calcium along with phosphorus to improve absorption. c. Take calcium with antacids to reduce stomach upset. d. Use aspirin instead of acetaminophen when taking calcium.

ANS: A Vitamin D enhances the absorption of calcium in the body. Calcium and phosphorus have an inverse relationship—an increased level of one mineral decreases the level of the other. Antacids can contain magnesium, which can promote calcium loss. Aspirin can alter vitamin D levels and interfere with calcium absorption.

2.A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

ANS: A, B, C Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

2. A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3- 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau's sign

ANS: A, B, C Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseau's sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

3.Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

ANS: B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

4.A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

1. A nurse is planning interventions that regulate acid-base balance to ensure the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs

ANS: A, B, E Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing the effectiveness of many drugs.

4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvostek's sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability

ANS: A, E A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.

1.A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

2. A patient is suspected of having severe hypocalcemia. While waiting for the patient's serum electrolyte results, the nurse will assess for which symptoms? (Select all that apply.) a. Laryngeal spasms b. Fatigue c. Muscle weakness d. Nausea and vomiting e. Numbness of fingers f. Twitching of the mouth

ANS: A, E, F Patients who have hypocalcemia will exhibit laryngeal spasms, numbness of fingers, and twitching of the mouth. The other symptoms are not characteristic of hypocalcemia.

16. The nurse is administering intravenous fluids to a patient who is dehydrated. On the second day of care, the patient's weight is increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has a. equaled urine output. b. exceeded urine output by 1 L. c. exceeded urine output by 2.5 L. d. exceeded urine output by 3 L.

ANS: B A weight gain of 1 kg, or 2.2 to 2.5 lb, is equivalent to 1 L of fluid.

7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3- 22 mEq/L. Which clinical situation should the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

ANS: B Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

6. The nurse is caring for a patient who is hospitalized for an asthma exacerbation. The patient reports taking diphenhydramine at home at night to help with symptoms of allergic rhinitis and cough. The nurse will contact the patient's provider to request an order for which medication? a. Benzonatate (Tessalon Perles) b. Cetirizine (Zyrtec) c. Dextromethorphan hydrobromide (Benylin DM) d. Diphenhydramine (Benadryl)

ANS: B Cetirizine is an antihistamine, which is indicated for this patient's symptoms. Diphenhydramine is also an antihistamine but, because of its anticholinergic side effects, is contraindicated in patients with asthma. Benzonatate and dextromethorphan are anti-tussives and not antihistamines.

9. The nurse is providing teaching for a patient who will use intranasal dexamethasone (Decadron) after discharge home from the hospital. What information is important to include when teaching this patient about this drug? a. "Dexamethasone may be used for year-round symptoms." b. "Dexamethasone should be discontinued after 30 days." c. "Dexamethasone should not be taken with antihistamines." d. "Dexamethasone should not cause systemic steroid side effects."

ANS: B Dexamethasone should not be used longer than 30 days because longer use increases the risk of systemic side effects. Dexamethasone should not be used year-round. It may be used in conjunction with antihistamines. Systemic side effects may occur.

5. The parents of a 3-year-old child tell the nurse that they are planning to give their child diphenhydramine (Benadryl) on a flight to visit the child's grandparents to help the child sleep during the flight. What will the nurse tell the parents about giving this drug? a. Administer 25 mg of diphenhydramine when using to induce sleep. b. Diphenhydramine may have the opposite effect and could cause agitation. c. Give the diphenhydramine about 5 minutes prior to takeoff. d. Loratadine should be used instead of diphenhydramine to minimize side effects.

ANS: B Diphenhydramine can cause excitation in some children. Parents should be advised to expect this possible side effect. The correct dose of diphenhydramine for children at this age is 6.25 mg; 25 mg would be an overdose. Oral diphenhydramine has an onset of 15 to 45 minutes. Loratadine is a second-generation antihistamine and does not cause drowsiness.

2. The nurse is caring for a patient who is receiving diphenhydramine. The nurse notes that the patient has not voided for 12 hours. What action will the nurse take? a. Encourage the patient to drink more fluids. b. Evaluate the bladder to check for distension. c. Request an order for an intravenous fluid bolus. d. Request an order for urinary catheterization.

ANS: B Diphenhydramine has anticholinergic effects, including urinary retention. The nurse should assess for bladder distension to determine if this is the case. Encouraging the patient to drink more fluids or giving intravenous fluids may be necessary if the patient has oliguria secondary to dehydration. Urinary catheterization is not indicated until urinary retention has been identified.

12. A patient who has a nonproductive cough will begin taking guaifenesin to help with secretions. When teaching this patient about the medication, the nurse will provide which instruction? a. "Avoid driving or using heavy machinery." b. "Drink extra water while taking the medication." c. "Monitor urine output closely." d. "Take with an oral antihistamine for better effects."

ANS: B Guaifenesin is an expectorant, and patients taking this medication should be advised to increase fluid intake to at least 8 glasses of water per day. (Remember to assess for contraindications to increasing fluid intake [e.g., heart failure, kidney failure with dialysis, etc.].) Guaifenesin does not cause drowsiness or urinary retention. Antihistamines will dry secretions, making them harder to expectorate.

18. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient's admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct? a. Administer the digoxin and monitor the patient's electrocardiogram closely. b. Hold the digoxin dose and notify the provider of the patient's lab values. c. Request an order for an intravenous bolus of potassium. d. Request an order for oral potassium supplements.

ANS: B Hypokalemia can cause digoxin toxicity, so the nurse should hold the dose and notify the provider. Potassium should never be given as an IV bolus. Oral supplements are not used when hypokalemia is severe.

13.A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

ANS: B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

7.An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

19.A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.

ANS: B Odynophagia is painful swallowing. The nurse should assess the client for this either by asking or by having the client attempt to drink water. It is not related to specific foods and is not assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but it would be a serious situation.

17.A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

ANS: B Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. Hospitalization may or may not be needed but is not the most important action. The client may or may not be able to produce sputum, but sputum cultures for this disease must be obtained via deep suctioning. Blood cultures will be negative.

5.The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

9. After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."

ANS: B Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3- 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

ANS: B The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

14. A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3- 26 mEq/L. Which question should the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?

ANS: B The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance.

5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek's sign

ANS: B The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.

7. The nurse is caring for a patient who is receiving intravenous theophylline. The patient complains of headache and nausea. The nurse will contact the provider to a. change the medication to an oral theophylline. b. obtain an order for a serum theophylline level. c. request an order for an analgesic medication. d. suggest an alternative methylxanthine medication.

ANS: B Theophylline has a narrow therapeutic index and a risk for severe symptoms with toxic levels. When patients report symptoms of theophylline adverse effects, a serum drug level should be obtained. Giving an oral theophylline would only compound the problem if the patient has a toxic drug level. Analgesics may be used, but only after toxicity is ruled out. Adding a different methylxanthine will compound the symptoms and will likely result in drug interaction or unwanted synergism.

14.A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

ANS: B This client has manifestations of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.

12. A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16 mEq/L. Which provider order should the nurse expect to receive? a. Furosemide (Lasix) 40 mg intravenous push b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation d. Indwelling urinary catheter

ANS: B This client's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate should be replaced to help restore this client's acid-base balance. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client's pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this client.

8. The nurse is caring for a patient who will begin taking theophylline at home. During the assessment, the nurse learns that the patient smokes. The nurse reports this to the provider and will expect the provider to a. decrease the dose of theophylline. b. increase the dose of theophylline. c. keep the theophylline dose as ordered. d. discontinue the theophylline.

ANS: B Tobacco smoking increases the metabolism of theophylline, so the dose should be increased. Decreasing the dose will lead to subtherapeutic effects.

3.A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

5. A nurse is planning care for a client who is anxious and irritable. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3- 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been experiencing any vomiting?" e. "Are you experiencing any shortness of breath?"

ANS: B, C This client's symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a client's personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis.

3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis - Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis - Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease

ANS: B, C, E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

1. The nurse is caring for a patient who will receive intravenous calcium gluconate. Which nursing actions are appropriate when giving this solution? (Select all that apply.) a. Administering through a central line b. Assessing for Trousseau's and Chvostek's signs c. Giving as a rapid intravenous bolus d. Mixing in a solution containing sodium bicarbonate e. Monitoring the patient's electrocardiogram (ECG) f. Reporting a serum calcium level >2.5mEq/L

ANS: B, E, F Trousseau's and Chvostek's signs indicate hypocalcemia, and patients receiving calcium should be monitored closely for signs of calcium imbalance. Hypercalcemia can cause ECG changes. A serum calcium level greater than 2.5mEq/L indicates hypercalcemia and therefore should be reported. Calcium does not require infusion through a central line and should not be given as a rapid IV bolus. Calcium should not be added to a solution containing bicarbonate, because rapid precipitation occurs.

1.A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

4. A patient who has seasonal allergies with a runny nose during the daytime reports increasing nighttime symptoms of coughing and sneezing that are interfering with sleep. The provider recommends diphenhydramine (Benadryl) at bedtime. What information will the nurse include when teaching the patient about this medication? a. "Avoid fluids at bedtime to prevent urinary retention." b. "This will help clear your daytime symptoms, too." c. "You should be able to sleep better when you take this medication." d. "You should take this medication on an empty stomach."

ANS: C A side effect of diphenhydramine is drowsiness. Patients whose nighttime symptoms clear should be able to sleep better, especially with drowsiness side effects. Avoiding fluids does not prevent urinary retention. The half-life of diphenhydramine is short, so drug effects will not last through the next day. There is no need to take the medication on an empty stomach.

6. The nurse is teaching a patient who will begin taking oral theophylline (Theo-Dur) when discharged home from the hospital. What information will the nurse include when teaching the patient about this drug? a. An extra dose should be taken when symptoms worsen. b. Anorexia and gastrointestinal upset are unexpected side effects. c. Avoid caffeine while taking this medication. d. Food will decrease the amount of drug absorbed.

ANS: C Caffeine and theophylline are both xanthine derivatives and should not be taken together because of the increased risk of toxicity and severe adverse effects. Theophylline has a narrow therapeutic range and must be dosed carefully; patients should never increase or decrease the dose without consulting their provider. Gastrointestinal symptoms are common side effects. Food slows absorption but does not prevent the full dose from being absorbed.

5. A provider has prescribed ipratropium bromide/albuterol sulfate (Combivent) for a patient who has chronic obstructive pulmonary disease (COPD). The nurse explains that this combination product is prescribed primarily for which reason? a. To be more convenient for patients who require both medications b. To improve compliance in patients who may forget to take both drugs c. To increase forced expiratory volume, an indicator of symptom improvement d. To minimize the side effects that would occur if the drugs are given separately

ANS: C Combivent is more effective and has a longer duration of action than if either agent is used alone, and the two agents combined increase the FEV1. While it is more convenient and may improve compliance, this is not the primary reason for using it. The combination does not alter drug side effects.

11. After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

ANS: C Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

21. The nurse is caring for a patient who is ordered to take nothing by mouth. The patient weighs 65 kg. What volume of intravenous fluid should this patient receive in 24 hours? a. 2225 mL b. 2400 mL c. 2520 mL d. 2640 mL

ANS: C Fluid maintenance needs for the NPO patient are calculated as 4 mL/kg/h for the first 10 kg of weight, 2 mL/kg/h for the second 10 kg of weight, and 1 mL/kg/h for every kg of weight thereafter. This patient's fluid needs are (10 kg ´ 4 mL) + (10 kg ´ 2 mL) + (45 kg ´ 1 mL) = 105 mL/h. The 24-hour total is 105 mL/h ´ 24 h = 2,520 mL.

12.A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

ANS: C INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).

8. The patient who has nasal congestion asks the nurse to recommend a decongestant medication. The nurse performs a medication history and learns that the patient takes a beta blocker to treat hypertension. Which over-the-counter product will the nurse recommend? a. Diphenhydramine (Benadryl) b. Ephedrine HCl (Pretz-D) c. Phenylephrine nasal (NeoSynephrine Nasal) d. Loratadine (Claritin)

ANS: C NeoSynephrine Nasal is a topical decongestant and causes less systemic side effects than ephedrine, which should not be given with beta blockers. Diphenhydramine and loratadine are antihistamines, not decongestants.

1. A patient's serum osmolality is 305 mOsm/kg. Which term describes this patient's body fluid osmolality? a. Iso-osmolar b. Hypo-osmolar c. Hyperosmolar d. Isotonic

ANS: C Normal osmolality is 280 to 300 mOsm/kg. This patient is therefore hyperosmolar.

6. The nurse is caring for a patient who has had severe vomiting. The patient's serum sodium level is 130 mEq/L. The nurse will expect the patient's provider to order which treatment? a. Diuretic therapy b. Intravenous hypertonic 5% saline c. Intravenous normal saline 0.9% d. Oral sodium supplements

ANS: C Patients with hyponatremia may be treated with oral sodium supplements if the patient is able or if the deficit is mild. This patient is vomiting and would not be able to take supplements easily. For a serum level between 125 and 135 mEq/L, normal saline may increase sodium content in vascular fluid. Hypertonic saline is used for severe hyponatremia with a serum sodium <120 mEq/L. Diuretics would further deplete sodium and fluid volume in a patient already likely to be dehydrated from severe vomiting.

10.A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

9. A patient has a serum potassium level of 2.7 mEq/L. The patient's provider has determined that the patient will need 200 mEq of potassium to replace serum losses. How will the nurse caring for this patient expect to administer the potassium? a. As a single-dose 200 mEq oral tablet b. As an intravenous bolus over 15 to 20 minutes c. In an intravenous solution at a rate of 10 mEq/hour d. In an intravenous solution at a rate of 45 mEq/hour

ANS: C Potassium chloride should be given intravenously when hypokalemia is severe, so this patient should receive IV potassium chloride. Potassium should never be given as a bolus and should be administered slowly. The maximum infusion rate for adults with a serum potassium level greater than 2.5 mEq/L is 10 mEq/hour or 200 mEq/24 hours.

12. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy? a. Sodium 125 mEq/L and potassium 2.5 mEq/L b. Sodium 150 mEq/L and potassium 3.6 mEq/L c. Sodium 135 mEq/L and potassium 6.9 mEq/L d. Sodium 148 mEq/L and potassium 5.5 mEq/L

ANS: C Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body's excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation.

13. The nurse is performing a medication history on a patient who reports long-term use of montelukast (Singulair) and an albuterol metered-dose inhaler (Proventil). The nurse will contact the provider to discuss an order for which laboratory tests? a. Cardiac enzymes and serum calcium b. Electrolytes and a complete blood count c. Liver function tests and serum glucose d. Urinalysis and serum magnesium

ANS: C The beta2 agonists can increase serum glucose levels and montelukast can elevate liver enzymes, so these should be monitored in patients taking these medications.

20.A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

ANS: C This "allergy test" is actually a positive tuberculosis test. The client should be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.

2.A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

7. A patient is admitted to the hospital after developing pneumonia. During the admission assessment, the patient reports having used a nasal decongestant spray for the past few weeks but thinks the nasal congestion is getting worse. The nurse will a. request an order for a systemic decongestant medication. b. request an order so the patient can continue to use the decongestant spray. c. tell the patient the congestion will clear up after stopping the spray. d. tell the patient to increase oral fluid intake.

ANS: C Use of nasal decongestants longer than 3 days can cause rebound congestion. This will clear up when the decongestant spray is discontinued for several days or weeks. A systemic decongestant is not indicated. Continuing the spray will increase the congestion. Increasing fluid intake is not recommended.

3. A patient is being treated for shock after a motor vehicle accident. The provider orders 6% dextran 75 to be given intravenously. The nurse should expect which outcome as the result of this infusion? a. Decreased urine output b. Improved blood oxygenation c. Increased interstitial fluid d. Stabilization of heart rate and blood pressure

ANS: D 6% Dextran 75 is a high molecular-weight colloidal solution and is used to treat shock from burns or trauma. Colloids are plasma expanders, and the end result is an improvement in heart rate (decreased) and blood pressure (increased). Plasma expanders will result in an increase in urine output. Blood oxygenation is not affected, and colloids do not increase the amount of interstitial fluid.

18.A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

ANS: D "Valley fever," or coccidioidomycosis, is a fungal infection. Many people do not need treatment and the disease resolves on its own. However, the presence of joint and muscle pain indicates a moderate infection that needs treatment with antifungal medications. IV amphotericin is reserved for pregnant women and those with severe infection. Anti-inflammatory medications may be used to treat muscle aches and pain but are not used long term.

10. A patient asks the nurse about using dextromethorphan for cough. What information will the nurse include when teaching this patient about this drug? a. "It does not cause sedation except at high doses." b. "It may be used to treat cough for up to 2 weeks." c. "It is non-narcotic, and it is OK to consume alcohol while taking this drug." d. "It should not be taken by patients who have chronic obstructive pulmonary disease (COPD)."

ANS: D Dextromethorphan is contraindicated in patients with COPD. It may cause sedation at low doses. If a cough lasts longer than 1 week, patients should be instructed to contact their provider and not to continue to treat with over-the-counter antitussives. Alcohol can cause excess sedation when taken with dextromethorphan.

16.A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

ANS: D Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

3. A patient will be discharged home with albuterol (Proventil) to use for asthma symptoms. What information will the nurse include when teaching this patient about this medication? a. Failure to respond to the medication indicates a need for a higher dose. b. Monitor for hypoglycemia symptoms when using this medication. c. Palpitations are common with this drug even at normal, therapeutic doses. d. Overuse of this medication can result in airway narrowing and bronchospasm.

ANS: D Excessive use of an aerosol drug can occasionally cause severe paradoxical airway resistance, so patients should be cautioned against overuse. Excessive use can also lead to tolerance and loss of drug effectiveness, but patients should not increase the dose because of the risk of bronchospasm and the increased incidence of adverse effects such as tremors and tachycardia. Hyperglycemia can occur. Palpitations are common with increased doses but not at therapeutic doses.

15. The nurse is caring for a newly admitted patient who will receive digoxin to treat a cardiac dysrhythmia. The patient takes hydrochlorothiazide (HydroDIURIL) and reports regular use of over-the-counter laxatives. Before administering the first dose of digoxin, the nurse will review the patient's electrolytes with careful attention to the levels of which electrolytes? a. Calcium and magnesium b. Sodium and calcium c. Potassium and chloride d. Potassium and magnesium

ANS: D Hypomagnesemia, like hypokalemia, enhances the action of digitalis and causes digitalis toxicity. Laxatives and diuretics can deplete both of these electrolytes.

9.A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"

ANS: D Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

2. A patient is admitted after experiencing vomiting and diarrhea for several days. The provider orders intravenous lactated Ringer's solution. The nurse understands that this fluid is given for which purpose? a. To increase interstitial and intracellular hydration b. To maintain plasma volume over time c. To pull water from the interstitial space into the extracellular fluid d. To replace water and electrolytes

ANS: D Lactated Ringer's solution is an isotonic solution and is used to replace water and electrolytes and is often used to replace gastrointestinal losses. Hypotonic fluids increase interstitial and intracellular hydration. Colloidal solutions are used to maintain plasma volume over time. Hypertonic solutions pull water from the interstitial space into the extracellular fluid.

3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

10. The nurse provides teaching for patient who will begin taking montelukast sodium (Singulair). The patient reports sensitivity to aspirin. Which statement by the patient indicates a need for further teaching? a. "I will need to have periodic laboratory tests while taking this medication." b. "I will not take ibuprofen for pain or fever while taking this drug." c. "I will take one tablet daily at bedtime." d. "I will use this as needed for acute symptoms."

ANS: D Montelukast and other leukotriene receptor antagonists are not used to treat acute symptoms. Because they can affect liver enzymes, periodic liver function tests should be performed. Patients taking this drug should not use ibuprofen or aspirin for pain or fever if they have an aspirin sensitivity. Patients will achieve maximum effectiveness if the drug is taken in the evening.

2. The nurse is preparing to administer isoproterenol (Isuprel) to a patient who is experiencing an acute bronchospasm. The nurse understands that, because isoproterenol is a nonselective beta-adrenergic agonist, the patient will experience which effects? a. Alpha- and beta-adrenergic agonist effects b. Anticholinergic effects c. A shorter duration of therapeutic effects d. Cardiac and pulmonary effects

ANS: D Non-selective beta-adrenergic agonists affect both beta1 and beta2 receptors, causing both tachycardia and bronchodilation. Alpha receptors are not affected.

4.A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

3. A patient arrives in the emergency department after developing a rash, runny nose, and sneezing after eating strawberries. What action will the nurse expect to take first? a. Administer diphenhydramine. b. Administer epinephrine. c. Assess for urinary retention. d. Assess heart rate, respiratory rate, and lung sounds.

ANS: D The patient probably has a food allergy, since eating strawberries is the precipitating event. The nurse should assess cardiac and respiratory status to determine whether the patient is developing an anaphylactic reaction. Diphenhydramine will be given for mild allergic symptoms of rash, runny nose, and sneezing, but epinephrine must be given for anaphylaxis. Urinary retention is a side effect of diphenhydramine and will be assessed if diphenhydramine is given.

8. A patient who is being treated for dehydration is receiving 5% dextrose and 0.45% normal saline with 20 mEq/L potassium chloride at a rate of 125 mL/hour. The nurse assuming care for the patient reviews the patient's serum electrolytes and notes a serum sodium level of 140 mEq/L and a serum potassium level of 3.6 mEq/L. The patient had a urine output of 250 mL during the last 12-hour shift. Which action will the nurse take? a. Contact the patient's provider to discuss increasing the potassium chloride to 40 mEq/L. b. Continue the intravenous fluids as ordered and reassess the patient frequently. c. Notify the provider and discuss increasing the rate of fluids to 200 mL/hour. d. Stop the intravenous fluids and notify the provider of the assessment findings.

ANS: D The patient's potassium level is within normal limits, but the urine output is decreased, so the patient should not be receiving IV potassium. The nurse should stop the IV and report the findings to the provider. The patient does not need an increase in potassium. The patient needs more fluids but not with potassium.

4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

ANS: D The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

11. A patient who uses an inhaled glucocorticoid medication reports having a sore tongue. The nurse notes white spots on the patient's tongue and oral mucous membranes. After notifying the provider, the nurse will remind the patient to perform which action? a. Avoid using a spacer with the inhaled glucocorticoid medication. b. Clean the inhaler with hot, soapy water after each use. c. Consume yogurt daily while using this medication. d. Rinse the mouth thoroughly with water after each use.

ANS: D When using inhaled glucocorticoid medications, Candida albicans oropharyngeal infections may be prevented by rinsing the mouth and throat with water after each dose. Patients should also use a spacer to reduce deposits of the drug in the oral cavity. The inhaler should be washed with warm water daily, but not after each use. There is no indication that yogurt is effective.