143 FINAL - Mod 1: FEABS (PRACTICE QUESTIONS)

The nurse reviews a client's electrolyte lab report and notes that the potassium level is low. Which patterns would the nurse watch for on the ECG? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Wide QRS complex

1, 3, 4.

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

1. A client with an ileostomy

The nurse reviews a client's record and determines that the client is at risk for developing hyperkalemia if which situation is documented? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Diabetic ketoacidosis 4. High aldosterone levels

1. Sustained tissue damage

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

1. Twitching

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. Metabolic acidosis

ANS: B Rationale: Extreme anxiety can lead to hyperventilation, the most common cause of acute respiratory alkalosis. During hyperventilation, CO2 is lost through the lungs, creating an alkalotic state and a low PaCO2. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. Metabolic acidosis results from the loss of bicarbonate, not CO2.

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. A. Hypovolemia B. Difficulty breathing C. Cardiovascular overload D. Pulmonary edema E. Hypoglycemia

ANS: B, C, D. Fluid replacement complications can occur, often when large volumes are given rapidly. Therefore, the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock? A. Acute hypertension B. Respiratory distress C. Neurologic compensation D. Cardiac arrest

ANS: B. Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur later if prompt treatment is not provided.

The ICU nurse is caring for a client in neurogenic shock following an overdose of anti anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock? A. Hypertension B. Cool, moist skin C. Bradycardia D. Signs of sympathetic stimulation

ANS: C. In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state? A. Third spacing of fluid B. Dysrhythmias C. Tachycardia D. Gastric hypermotility

ANS: C. Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.

The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance would a positive Chvostek sign indicate? A. Hypermagnesemia B. Hyponatremia C. Hypocalcemia D. Hyperkalemia

ANS: C. The nurse can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be indicated by a positive Chvostek sign.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake.

ANS: C. Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis without compensation B. Metabolic alkalosis with compensatory alkalosis C. Metabolic acidosis without compensation D. Metabolic acidosis with compensatory respiratory alkalosis

ANS: D Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations

ANS: D. If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of client is associated with decreased DTRs, not increased DTRs.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A. Increased urine output B. Decreased heart rate C. Hyperactive bowel sounds D. Cool, clammy skin

ANS: D. In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of: A. increased stroke volume. B. increased cardiac output. C. decreased heart rate. D. decreased venous return.

ANS: D. Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? A. Hypernatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalcemia

ANS: D. The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation is inconsistent with hypophosphatemia.

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

ANS: D. Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure

ANS: D. Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

The nurse is concerned that a patient's arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia

Answer: 1 Explanation: 1. A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia. 2. Acidosis does not contribute to the development of hypokalemia. 3. Acidosis does not contribute to the development of hypercalcemia. 4. Acidosis does not contribute to the development of hypocalcemia.

Which patient would the nurse expect to have the least amount of body fluid? 1. A 75-year-old woman with a body mass index (BMI) in the obese range 2. A 23-year-old female with history of type 1 diabetes 3. A 72-year-old male who had a myocardial infarction at age 50 4. A 16-year-old male who plays football on his high school team

Answer: 1 Explanation: 1. Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water. 2. Since this female is young, she will have more body fluid than older females. Diabetes is not a factor. 3. Since this older adult is male, he tends to have more body fluid than women at that age. 4. This patient is young and male, which tends to increase fluid level. The fact that he plays football is not a factor.

A patient has a serum calcium level of 11 mg/dL (high). The nurse would review this patient's medical record for which conditions? Select all that apply. 1. History of taking thiazide diuretics 2. Diagnosis of hyperparathyroidism 3. Diagnosis of acute pancreatitis 4. Low serum magnesium level 5. Long-term bed rest

Answer: 1, 2, 5 Explanation: 1. Hypercalcemia may result from use of thiazide diuretics. 2. Primary hyperparathyroidism is associated with hypercalcemia. 3. The diagnosis acute pancreatitis is associated with hypocalcemia. 4. A low serum magnesium level often occurs with hypocalcemia. 5. Immobility can cause hypercalcemia.

Laboratory testing reveals a patient's serum osmolality to be 240 mOsm/kg (low). The nurse would assess for which conditions? Select all that apply. 1. Excessive infusion of D5W 2. Dehydration 3. Hyperglycemia 4. Syndrome of inappropriate ADH (SIADH) 5. Acute kidney injury

Answer: 1, 4 Explanation: 1. Excessive D5W IV intake will result in decreased serum osmolality. 2. Dehydration results in increased serum osmolality. 3. Hyperglycemia results in increased serum osmolality. 4. SIADH will result in decreased serum osmolality. 5. Acute kidney injury results in decreased urine osmolality.

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate? 1. Decreasing the amount of oxygen being given 2. Immediate initiation of fluid resuscitation 3. Repeat of the testing in 4 hours 4. Bedside fingerstick level of blood glucose

Answer: 2 Explanation: 1. An increased serum lactate calls for increased oxygenation. 2. A lactate level greater than 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation. 3. There is no need to repeat this test before intervening. 4. Measuring blood glucose is not indicated by this lab result.

A patient is admitted to the emergency department with severe burn injuries. The nurse's priority actions are to prevent development of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive

Answer: 2 Explanation: 1. Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock. 2. Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority. 3. Distributive shock, particularly septic shock, is a potential complication for patients with burn injury, and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care. 4. Depending on other injuries, the patient with burns may develop obstructive shock, but this is not the nurse's highest priority in emergent care.

A nurse is providing care to a patient with progressive shock. Which patient problem is characteristic of this stage and is priority in guiding the selection of interventions for this patient? 1. The patient's airway is often compromised. 2. Perfusion of oxygen and nutrients to tissues is insufficient. 3. The patient experiences maximal physiologic and psychologic stress in this stage. 4. Skin integrity continues to be impaired.

Answer: 2 Explanation: 1. Without additional assessment findings, it is not possible to determine if this patient's airway is compromised. 2. Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority problem for all patients in shock. 3. Undoubtedly this patient is experiencing stress, but this is not the highest priority problem. 4. This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

A patient's temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte? 1. Phosphorous 2. Sodium 3. Potassium 4. Magnesium

Answer: 2 Explanation: 1. It is unlikely that temperature elevation will affect phosphorus levels. 2. With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient's sodium level. 3. It is unlikely that temperature elevation will affect potassium level. 4. It is unlikely that temperature level will affect magnesium level.

A patient's electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypernatremia

Answer: 2 Explanation: 1. Prolongation of the PR interval is not an ECG finding associated with hypokalemia. 2. Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression. 3. Hypocalcemia causes prolongation of the QT interval and a long ST segment. 4. Cardiovascular manifestations of hypernatremia include hypertension and tachycardia.

A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment? 1. Transcellular 2. Intravascular 3. Interstitial 4. Intracellular

Answer: 2 Explanation: 1. Transcellular fluid is cerebrospinal fluid, peritoneal fluid, and synovial fluid. 2. Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid. 3. Interstitial fluid is found between the cells. 4. Intracellular fluid is that fluid found within the cells.

The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present? 1. The fingers hyperflex. 2. The thumb flexes toward the palm. 3. The fingers hyperextend. 4. The thumb hyperextends. 5. The hand makes a fist.

Answer: 2, 3 Explanation: 1. Flexion of the fingers does not indicate positive Trousseau sign. 2. Flexion of the thumb toward the palm indicates a positive Trousseau sign. 3. Hyperextension of the fingers indicates a positive Trousseau sign. 4. Hyperextension of the thumb does not indicate a positive Trousseau sign. 5. Fisting of the hand does not indicate a positive Trousseau sign.

The nurse is assessing the effectiveness of fluid replacement therapy in a patient who has a fluid volume deficit. Which assessment findings would indicate the therapy is effective? Select all that apply. 1. Blood pressure 90/48 mm Hg 2. Weight gain of 2 pounds since yesterday 3. Urine output increase to 40 mL per hour 4. Tenting of skin 5. Serum osmolality of 284 mOm/kg

Answer: 2, 3, 5 Explanation: 1. Low blood pressure indicates that the therapy has not been effective. 2. Increase in weight of 2 pounds in 1 day indicates a change in fluid balance. 3. Increase in urine output indicates improvement of fluid balance status. 4. Tenting of skin indicates poor skin turgor and fluid volume deficit. 5. Normal serum osmolality is 280-300 mOsm/kg. Presence of normal serum osmolality indicates normal fluid volume status.

A patient was admitted to the emergency department for treatment of a severe infection. Which traditional assessment would raise the nurse's concern that this patient may be developing shock? 1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety

Answer: 3 Explanation: 1. Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection. 2. Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system. 3. Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases. 4. Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient's wife says, I thought he didn't have any infection. How should the nurse respond? 1. He probably had an infection that we did not recognize. 2. He developed SIRS after getting multiple organ dysfunction syndrome. 3. Infection isn't necessary to develop SIRS, only a severe inflammation. 4. Your husband's body is working against itself.

Answer: 3 Explanation: 1. SIRS can occur in the absence of infection. 2. Multiple organ dysfunction syndrome follows SIRS. 3. Pancreatitis is a severe inflammatory illness. SIRS can develop without infection. 4. A general statement like this is not an adequate explanation.

A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte? 1. Phosphorous 2. Sodium 3. Magnesium 4. Chloride

Answer: 3 Explanation: 1. The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium. 2. Sodium level will not be affected. 3. Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient's potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance.

A patient is demonstrating tremors and a positive Chvostek's sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance? 1. Low phosphate 2. Low potassium 3. Low magnesium 4. Elevated sodium

Answer: 3 Explanation: 1. A positive Chvostek's sign is associated with hyperphosphatemia. 2. Potassium levels are not associated with a positive Chvostek's sign. 3. The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek's sign are also seen with a low calcium level. 4. Sodium level is not associated with a positive Chvostek's sign.

A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient's plan of care? 1. Test for presence of Chvostek's sign. 2. Monitor for sudden decrease in respiratory rate. 3. Monitor for cardiac dysrhythmias. 4. Monitor for hyperthermia.

Answer: 3 Explanation: 1. Chvostek's sign is positive in hypomagnesemia. 2. A low respiratory rate can be seen with a low magnesium level. 3. Cardiac dysrhythmias have been associated with abnormal magnesium levels. 4. Magnesium does not affect temperature.

The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select? 1. 10% dextrose in water 2. Lactated Ringer's 3. 0.45% normal saline 4. 5% dextrose and 0.45% normal saline

Answer: 3 Explanation: 1. Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia. 2. Lactated Ringer's is an isotonic solution and would not be effective when treating hypernatremia. 3. To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid. 4. Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia.

Which laboratory value would require that the nurse closely monitor a patient's cardiac rhythm? 1. Chloride 94 mEq/L 2. Calcium 2.2 mmol/L 3. Potassium 3.3 mEq/L 4. Phosphate 3 mg/dL

Answer: 3 Explanation: 1. This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances. 2. This normal calcium level would not be implicated in cardiac rhythm disturbances. 3. Both high and low potassium levels can adversely affect cardiac rhythm. 4. This normal phosphate level would not adversely affect cardiac rhythm.

Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? Select all that apply. 1. Flat neck veins 2. Bilateral adventitious lung sounds 3. Flat hand veins when dependent 4. Sunken eyes 5. Tenting of the skin

Answer: 3, 4, 5 Explanation: 1. Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins indicate hypervolemia. 2. Adventitious lung sounds indicate hypervolemia. 3. If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic. 4. Eyes that are sunken in their sockets may indicate hypovolemia. 5. Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults.

A patient has a serum calcium level of 7.9 mg/dL (low). Which nursing interventions would be appropriate for this patient? Select all that apply. 1. Treat tachycardia. 2. Monitor for the development of hypertension. 3. Place on seizure precautions. 4. Strain all urine. 5. Reorient as indicated.

Answer: 3, 5 Explanation: 1. Bradycardia is the expected result of this calcium level. 2. Hypotension is the expected effect of this calcium level. 3. A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures. 4. Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development. 5. This calcium level indicates hypocalcemia. Reduced cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed.

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock? 1. Cold extremities 2. Increase in serum lactate levels 3. Decreased SCVO2 4. Widening of pulse pressure

Answer: 4 Explanation: 1. Cold and mottled extremities are associated with later stages of septic shock. 2. Increased serum lactate levels indicate a later stage of shock. 3. Decreased SCVO2 indicates a later stage of shock. 4. Since the patient's diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1. Urine output 50 mL/hr 2. Hypoactive bowel sounds 3. Temperature 102 F 4. HR 96 5. MAP 65 6. SBP 110

3, 4, 5.

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

3. An increase in blood pressure and increased respirations

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. A. dobutamine B. nitroglycerin C. nitroprusside D. epinephrine E. dopamine

A, D, E. Dobutamine (Dobutrex), dopamine (Intropin), and epinephrine (Adrenalin) are inotropic agents used to improve client's contractility. Nitroprusside (Nipride) and nitroglycerin (Tridil) are vasodilators used to reduce preload and afterload, reducing oxygen demand in the heart.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: A. Blood pressure. B. Breath sounds. C. Heart rate. D. Renal output.

A. By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A. A 52-year-old with diarrhea B. A 72-year-old with a total knee repair C. A 65-year-old with a myocardial infarction D. A 7-year-old with a fracture tibia

A. Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? A. Extracellular fluid volume deficit B. Metabolic alkalosis C. Altered blood urea nitrogen (BUN) value D. Respiratory acidosis

A. Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? A. Lactated Ringer's solution B. Half-normal saline solution C. 5% dextrose and normal saline solution D. 10% dextrose in water

A. Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

A client with COPD is at a greater risk for developing which acid-base imbalance? A. chronic respiratory acidosis B. metabolic acidosis C. respiratory alkalosis D. metabolic alkalosis

A. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess A. Lung sounds B. Skin perfusion C. Mental status D. Bowel sounds

A. The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be A. 7.50 B. 7.30 C. 7.35 D. 7.45

A. The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive blowing off of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: A. Increased PaCO2. B. Increased serum HCO3. C. Decreased serum HCO3. D. Decreased PaCO2.

A. The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

A. This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? A. Circulatory (distributive) B. Obstructive C. Carcinogenic D. Hypovolemic

A. Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

ANS: A Rationale: The pH is below 7.35, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range, so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis, but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines B. Hypotension that responds to bolus fluid resuscitation C. Exaggerated response to vasoactive medications D. Serum lactate greater than 4 mmol/L E. Mean arterial pressure (MAP) of less than 65 mm Hg

ANS: A, D, E. Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. A. Anaphylactic B. Hypovolemic C. Cardiogenic D. Septic E. Neurogenic

ANS: A, D, E. The varied mechanisms leading to the initial vasodilation in distributive shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of distributive shock.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.

ANS: A. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, Wouldn't sterile water be a more appropriate choice than saltwater? Under what circumstances would the nurse administer electrolyte-free water intravenously? A. Never, because it rapidly enters red blood cells, causing them to rupture. B. When the client is severely dehydrated, resulting in neurologic signs and symptoms C. When the client is in excess of calcium and/or magnesium ions D. When a client's fluid volume deficit is due to acute or chronic kidney disease

ANS: A. IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion? A. The client is in the compensatory stage of shock. B. The client is in the progressive stage of shock. C. The client will stabilize and be released by tomorrow. D. The client is in the irreversible stage of shock.

ANS: A. In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Tachycardia C. Cool, clammy skin D. Acute flank pain

ANS: A. To gauge a client's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A. A slow and imperceptible pulse B. A rapid, bounding pulse C. A weak and thready pulse D. A slow but steady pulse

B. A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? A. cardiogenic B. distributive C. organ failure D. hypovolemic

B. Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? A. hydrochlorothiazide B. furosemide C. spironolactone D. metolazone

B. Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? A. Sodium level of 137 mEq/L B. Sodium level of 150 mEq/L C. Potassium level of 3.8 mEq/L D. Potassium level of 6 mEq/L

B. Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A. Serum creatinine level of 0.4 mg/dl B. Serum sodium level of 124 mEq/L C. Serum blood urea nitrogen (BUN) level of 8.6 mg/dl D. Hematocrit of 52%

B. In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? A. pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L B. pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L C. pH: 7.40, PaCO2: 40 mm Hg, HCO3-: 24 mEq /L D. pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L

B. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35-7.40 and the PaCO2 is greater than 40-45 mm Hg and a compensatory increase in the plasma HCO3- occurs. Respiratory acidosis may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.40, PaCO2: 40 mm Hg, and HCO3-: 24 mEq/L indicate a normal result/no imbalance.

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? A. The client with a BMI of 25 who has lost 3 pounds as the result of vomiting B. The client with testicular cancer who is receiving intravenous chemotherapy C. The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) D. The client with pneumonia in the left lower lobe of the lung

B. Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? A. Hemoglobin: 14.2 g/dL (WNL) B. WBC: 42,000/mm3 (high) C. ESR: 19 mm/hour (WNL) D. Potassium: 4.8 mEq/L (WNL)

B. Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk? 1. Loose bowel movement one per day 2. First-degree steam burn on hand and forearm 3. Temperature of 99.6°F 4. Diuretic therapy two doses per day

Answer: 4 Explanation: 1. Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea. 2. Burns also can cause a fluid volume deficit, but it is unlikely that a first-degree burn on the hand and forearm will produce a significant amount of fluid loss. 3. Fever does increase fluid loss, but this is a low-grade temperature so the effect would be minimal. 4. The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? A. Hormone antagonist drugs B. Antimetabolite drugs C. Adrenergic drugs D. Anticholinergic drugs

C. Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? A. Phosphorus B. Potassium C. Calcium D. Iron

C. Calcium deficiency is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? A. Administration of oxygen via venturi mask B. Thoracotomy with chest tube insertion C. Intubation and mechanical ventilation D. Pericardiocentesis

C. Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

With which condition should the nurse expect that a decrease in serum osmolality will occur? A. Influenza B. Hyperglycemia C. Kidney failure D. Uremia

C. Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A. Hyperkalemia B. Hypophosphatemia C. Hypokalemia D. Hypernatremia

C. Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. A. 90 mm Hg B. 80 mm Hg C. 60 mm Hg D. 70 mm Hg

C. Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

C. Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.

Upon assessment of a client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? A. respiratory rate B. bowel sounds C. neuromuscular function D. electrocardiogram (ECG) results

D. Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? A. Kidney and liver B. Pancreas and stomach C. Heart and lungs D. Lungs and kidney

D. The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: A. Vesicular breath sounds B. Positive increase in the fluid balance ratio C. Decreased pulse rate to 110 beats/minute D. Jugular venous distention

D. When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? A. 30 minutes B. Hourly C. 45 minutes D. 15 minutes

D. When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

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

4. The client with kidney disease that developed as a complication of diabetes mellitus

The community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response? A. I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup. B. Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids. C. It is normal to be a little confused following surgery, and it is safe not to urinate at night. D. Confusion and bladder issues are a normal consequence of aging, so I am not too concerned.

ANS: B. In older adult clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in older adults.

A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

ANS: B. Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem? A. Blood is shunted from vital organs to peripheral areas of the body. B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

ANS: B. Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells do not have an adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? A. Hypercalcemia B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

ANS: C Rationale: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

A nurse, who is orienting a newly licensed nurse, is planning care for a nephrology client. The nurse states, A client with kidney disease partially loses the ability to regulate changes in pH. What is the cause of this partial inability? A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B. The kidneys buffer acids through electrolyte changes. C. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH. D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

ANS: C Rationale: The kidneys regulate the bicarbonate level in the extracellular fluid; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH, whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock? A. Elevated systolic blood pressure B. Elevated mean arterial pressure (MAP) C. Shallow, rapid respirations D. Bradycardia

ANS: C. A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? A. Increased hunger B. Decreased thirst C. Decreased urinary output D. Increased capillary perfusion

ANS: C. During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary perfusion decreases as the body shunts blood away from the periphery and to the vital organs.

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A. Closely monitor fluid replacement therapy. B. Inform the client's family immediately that the client will likely not survive. C. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. D. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process.

C. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the client does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the client and helping them to understand the irreversible stage of shock is the best intervention. Informing the client's family too early that the client will not survive would rob the family of hope and interrupt the grieving process. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing end-of-life issues.

A client with excess fluid volume and hyponatremia is in a *comatose* state. What are the nursing considerations concerning fluid replacement? A. Restrict fluids and salt for 24 hours. B. Monitor the serum sodium for changes hourly. C. Correct the sodium deficit rapidly with salt. D. Administer small volumes of a hypertonic solution.

D. In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A. pH, 7.35; PaCO2 40 mm Hg B. pH, 7.5; PaCO2 30 mm Hg C. pH, 7.40; PaCO2 35 mm Hg D. pH, 7.25; PaCO2 50 mm Hg

D. In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? A. hypovolemic shock B. anaphylactic shock C. septic shock D. neurogenic shock

D. Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? A. HCO 21 mEq/L B. O saturation 95% C. PaCO 36 D. pH 7.48

D. Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? A. hyponatremia B. diuretic use C. overhydration D. free water loss

D. Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Monitor the client's heart rhythm. B. Obtain a urine specimen for drug screening. C. Prepare for gastric lavage. D. Prepare to assist with ventilation.

D. Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? A. Administer ordered supplemental oxygen. B. Offer the client fluids frequently. C. Administer an ordered decongestant. D. Instruct the client to breathe into a paper bag.

D. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be A. 145 mEq/L (145 mmol/L) B. 135 mEq/L (135 mmol/L) C. 125 mEq/L (125 mmol/L) D. 155 mEq/L (155 mmol/L)

D. The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.

When a client is in the compensatory stage of shock, which symptom occurs? A. Respiratory acidosis B. Urine output of 45 mL/hr C. Bradycardia D. Tachycardia

D. The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.