Acid-base
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing? 1 Kidney failure 2 Mild dehydration 3 Metabolic acidosis 4 Respiratory alkalosis
3 Metabolic acidosis
Arterial Blood gas values and interpretations
pH: 7.35-7.45 PCO2: 35-45 HCO3: 22-26 PO2: 80-100 pH low: acidosis pH high: alkalosis pco2 and ph low: respiratory acidosis pco2 and ph high: respiratory alkalosis hco3 and ph low: metabolic acidosis hco3 and ph high: metabolic alkalosis
When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.) 1 Thirst 2 Confusion 3 Tachycardia 4 Pale coloring 5 Poor tissue turgor
2 Confusion 5 Poor tissue turgor
During the first 48 hours after a thermal injury, the nurse should assess the client for: 1 Hypokalemia and hyponatremia 2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia
2 Hyperkalemia and hyponatremia Massive amounts of potassium are released from the injured cells into the extracellular fluid; large amounts of sodium are lost in edema
What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) 1 Heat 2 Pallor 3 Edema 4 Decreased flow rate 5 Increased blood pressure
2 Pallor 3 Edema 4 Decreased flow rate
A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? (Select all that apply.) 1 Sweating 2 Retinopathy 3 Acetone breath 4 Increased arterial bicarbonate level 5 Decreased arterial carbon dioxide level
3 Acetone breath 5 Decreased arterial carbon dioxide level A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a decreased arterial carbon dioxide level.
A nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of: 1 4.5 2 5.5 3 6.5 4 7.5
4 7.5 Amniotic fluid changes the color of a nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5 or 6.5 would result in a test strip of yellow, olive-yellow or blue green, respectively.
What clinical finding indicates to the nurse that a client may have hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul breathing 4 Abdominal distention
4 Abdominal distention
A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease? 1 Estrogens 2 Androgens 3 Glucocorticoids 4 Mineralocorticoids
4 Mineralocorticoids
A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe? 1 Insulin lispro (Humalog) 2 Insulin glargine (Lantus) 3 NPH insulin (Novolin N) 4 Regular insulin (Novolin R)
4 Regular insulin (Novolin R) Regular insulin is rapid-acting and should be used for diabetic coma . Insulin lispro is too short-acting and must be administered concurrently with longer-acting insulin. Insulin glargine is long-acting insulin, which is not indicated in an emergency. NPH insulin is intermediate-acting insulin; it is not indicated for use in an emergency.