Ch 36, Ch 40, Ch 30, Ch 32
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
What commonly used intravenous solution is hypotonic?
0.45% NaCl
A client is undergoing a knee replacement tomorrow morning and is ordered nothing by mouth (NPO) prior to surgery. The client asks the nurse how long before the procedure can water be taken in. Based on the nurse's knowledge of standard protocols, what is the nurse's best response
2 hours
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?
26 y.o client who is exhibiting a crowing sound
A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound? Select all that apply.
A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation
Which nursing student statement regarding vegetarian diets require further teaching from the nursing instructor?
According to research, vegetarians have a higher incidence of obesity than others.
A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.
Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.
A client with a diagnosis of color cancer has opted for a treatment plan that will included several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
An infant age 4 months
The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location?
Anchoring extension tubing near entry site with tape
The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.
Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.
What should the nurse assess before application of sitz bath therapy? Select all that apply.
Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
Decreased blood volume and intracellular dehydration.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?
Delirium
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?
Desiccation
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another site
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 500 mL. The previous residual was 200 mL. What action should the nurse take?
Hold the enteral nutrition and notify the primary care provider.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory results, which electrolyte imbalance would the nurse most likely find?
Hypokalemia
The student ask the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?
Intracellular
The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?
Iodine
A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client?
Lactated Ringer's
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic?
Lactated Ringer's solution 0.9% NaCl (normal saline)
A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?
Low serum albumin levels
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis
45 y.o client has just resumed eating a normal diet. The nurse checks the blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
Normal
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
Phlebitis
A nurse is assessing a client who is experiencing pulmonary embolus. What would be the nursing intervention for this client?
Place the client in semi-fowler's position
A 50 y.o client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
A nurse has just inserted a NG tube in a client. Which method is most reliable for verifying the correct placement of the tube?
Radiographic confirmation of position
The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?
Reinforced adhesive skin closures will hold my wound together until it heals
The nurse writes a nursing diagnosis of "Fluid Volume:Excess," for a client. What risk factor would the nurse assessing the client
Renal failure
The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency?
Respiratory obstruction
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the seal several times over the wound surface to obtain an adequate specimen
The primary extracellular electrolytes are:
Sodium, chloride, and bicarbonate
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?
Stage 2
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?
Stage 4
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed
A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?
The operating table is a firm surface; we need to be sure your skin looks okay.
A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk?
Total lymphocyte count of 1,500/mm3 (1.50 x 109/L)
Client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Try to ensure that the client's food is attractive and sufficiently warm.
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?
Vitamin D
The student nurse asks,"What is intravascular fluid?" What is the appropriate nursing response?
Watery plasma, or serum, portion of blood
The nurse is assessing clients for BMR (basal metabolic rate). Which client would the nurse would have an increased BMR?
a client who has a fever
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
corticosteroids
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:
fluid and electrolyte levels
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:
low calcium
A nurse is caring for a client who has a BMI of 26.5. Which category should the nurse understand this client would be placed in?
overweight
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?
serosanguineous
A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?
serosanguineous
