EAQ- fluid and electrolytes

the nurse administers regular insulin IV to a patient to manage hyperkalemia. which additional IV medication would the nurse administer with the insulin to prevent complications from this treatment? -glucose -furosemide -pamidronate -calcium gluconate

-glucose

the nurse would assess for which common electrolyte imbalance while providing care for the patient with sickle cell anemia? -increased calcium levels -increased potassium levels -increased phosphate levels -increased magnesium levels

increased phosphate levels

which intervention would the nurse implement first when providing care for a patient being treated with hypernatremia that developed slowly over several days? -initiate seizure precautions -administer prescribed diuretics -monitor the patients weight each day -restrict the patients dietary sodium intake

initiate seizure precautions

which health care provider prescription will the nurse implement when admitting a patient with fluid volume deficit due to severe diarrhea? -restrict the patients dietary sodium intake -insert an iv access and infuse lactated ringers solution -transfuse packed red blood cells as soon as they are available -initiate hypertonic sodium chloride iv fluids

insert an iv access and infuse lactated ringers solution

when extracellular fluid and intracellular fluid have the same osmolality, which term would the nurse use? -isotonic -hypotonic -hypertonic -oncotic pressure

isotonic

the morning laboratory results of a patient admitted with heart failure reveal a serum potassium level of 2.9 mEq/L. which classification of medications would be withheld until consulting with a health care provider? -antibiotics -loop diuretics -bronchodilators -antihypertensives

loop diuretics

which rationale supports the nurses assessment of a patients magnesium level? -the electrolyte may cause extracellular fluid overload -magnesium may affect neuromuscular excitability and contractility -the electrolyte is the most abundant intracellular cation present in the body -the patient is at risk for hypotension when the levels of magnesium decrease

magnesium may affect neuromuscular excitability and contractility

which plan of care change would the nurse implement for the patient who develops cardiac instability secondary to a new onset of hypokalemia? -assess for clinical signs of hypotension -monitor patient for digitalis toxicity -increase dietary intake of potassium -administer sodium polystyrene sulfonate

monitor patient for digitalis toxicity

which patient outcome would the nurse use to evaluate the effectiveness of the treatment regimen for a patients dehydration? -oral intake balances output -oral intake is less than output -oral intake is greater than output -no significant difference in fluid balance

oral intake balances output

which clinical manifestation would the nurse relate to a patients body temperature of 103F (39.4 C)? -muscle spasms -bounding pulse -jugular vein distention -orthostatic hypotension

orthostatic hypotension

to which patient does the nurse apply pulse oximetry ? Patient 1: new onset of heart failure - taut, edematous skin Patient 2: diabetes insipidus- dry skin with tenting Patient 3: prolonged nausea and vomiting - cool, clammy skin Patient 4: heatstroke - moist, warm skin

patient 1

which serum laboratory result would the nurse identify as an adverse effect of administering a patient calcium carbonate for the treatment of osteopenia? -sodium falling to 138 mEq/L -potassium rising to 4.1 mEq/L -magnesium rising to 2.9 mg/dL -phosphorus falling to 2.1 mg/dL

phosphorus falling to 2.1 mg/dL

a patients arterial blood gas results are pH 7.33, PaCO2 50 mm Hg, PaO2 75 mm Hg, HCO3- 24 mEq/L, and SaO2 81%. which interpretation of the ABG data would the nurse correlate to the patients clinical manifestations? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

the nurse reviews several patients serum potassium results. which result supports the need to administer a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours? -3.1 mEq/L -3.9 mEq/L -4.6 mEq/L -5.3 mEq/L

3.1 mEq/L

a patient with diabetes mellitus weighs 60 kg and excreted 3500 mL or urine in the last 24 hours. how much weight has the patient lost in the last 24 hours? _________kg

3.5

which reference interval indicates the normal arterial blood gas values for the partial pressure of carbon dioxide parameter? -25 to 35 mm Hg -35 to 45 mm Hg -45 to 55 mm Hg -55 to 65 mm Hg

35-45 mm Hg

a patient has an IV infusion of D5W at a rate of 125 mL/hr. during the 4 pm assessment, the nurse determined 500 mL were left in the present IV bag. in how many hours would the nurse anticipate handing the next bad of D5W? _____________hrs

4 hrs

the arterial blood gas results for a patient who overdosed on barbiturates are pH 7.32, PaCO@ 52, and HCO3- 23. which interpretation would the nurse use when planning the patients care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

the nurse, providing care for an older adult patient admitted with pneumonia, closely monitors for fluid and electrolyte imbalances. which rational supports the nurses intervention? -an increased risk of impaired renal function exists with older adults -an impaired level of consciousness and a need to be reminded to drink fluids occurs with older adults -older adults are more likely than younger adults to lose extracellular fluid during severe illnesses -small fluid losses are significant in older adults as their body water accounts for about 50% of their body weight

small fluid losses are significant in older adults as their body water accounts for about 50% of their body weight

which statement would the nurse use in response to a patients inquiry about why his or her health care provider prescribed a b-type natriuretic peptide(BNP)? -the BNP is a diagnostic procedure to rule out urine retention -the peptide is a blood test elevated in patients with hyponatremia -the blood test will let us know if there is excess fluid in the heart -the test is an x-ray that helps determine the presence of stomach ulcers

the blood test will let us know if there is excess fluid in the heart

the patient presents with one-time prescription for potassium chloride 20 mEq in 250 mL of normal saline IV, to be given immediately. Upon reviewing a more recent potassium level, which result would trigger the nurse to seek clarification of the patients prescription? -1.7 mEq/L -2.9 mEq/L -3.6 mEq/L -4.5 mEq/L

4.5 mEq/L

a patient had 500 mL of urine output, vomited 100 mL of clear liquid, and 25 mL of drainage was removed from a wound vacuum device. what number would the nurse record as the total output for this patient?_________mL

625 mL

upon review of blood pH values, which would cause the nurse to determine that the patient is acidotic? -7.25 -7.35 -7.45 -7.55

7.25

which reference interval is the normal range for the pH parameter for arterial blood? -7.05 to 7.15 -7.15 to 7.25 -7.25 to 7.35 -7.35 to 7.45

7.35 to 7.45

the clinical manifestations of a patient with encephalitis led the nurse to suspect development of respiratory alkalosis. which laboratory data supports the nurses assessment? -HCO3- 18 mEq/L; PaCO@ 30 mm Hg -HCO3- 22 mEq/L; PaCO@ 35 mm Hg -HCO3- 24 mEq/L; PaCO@ 43 mm Hg -HCO3- 26 mEq/L; PaCO@ 45 mm Hg

HCO3- 18 mEq/L; PaCO2 30 mm Hg

the nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. Which intervention would the nurse implement first? -stop all sources of dietary potassium -administer IV calcium gluconate immediately -locate and administer ion-exchange resins -obtain and administer IV insulin with glucose

administer IV calcium gluconate immediately

the nurse determines that a patients multimumen central access device (CAVD) is missing one of the injection caps, and the patient is exhibiting clinical manifestations of respiratory distress, hypotension, and tachycardia. Which action would the nurse implement first? -administer oxygen via nasal cannula -notify the health care provider -reposition the patient to left side, head down -adjust the IV fluids vis the CAVD

administer oxygen via nasal cannula

which intervention would the nurse implement when providing care for a patient with hypercalcemia? select all that apply -administer furosemide -administer biphosphonates -administer isotonic saline infusions -restrict oral fluid intake to 1000 mL -encourage the patient to breath into a paper bag

-administer furosemide -administer biphosphonates -administer isotonic saline infusions

which statement would the emergency department nurse use to explain the cause of patients respiratory alkalosis to the patient and family? select all that apply -"this acid-base imbalance is not triggered by central nervous system disorders" -"hyperventilation can occur without any physiologic need, such as pain or anxiety" -"this acid-base imbalance can be caused by hyperventilation as a result of increased body temperatures" -"hypoxemia from acute pulmonary disorders, such as pneumonia, is the primary cause of this acid-base imbalance" -"the primary cause of the acid-base imbalance is hypercarbia from an acute pulmonary disorder, such as a pulmonary embolism"

-"hyperventilation can occur without any physiologic need, such as pain or anxiety" -"this acid-base imbalance can be caused by hyperventilation as a result of increased body temperatures" -"hypoxemia from acute pulmonary disorders, such as pneumonia, is the primary cause of this acid-base imbalance"

for which clinical manifestations would the nurse monitor a patient with a total serum calcium level of 11.2 mg/dL? -polyuria -hypotension -nephrolithiasis -chvosteks sign -trousseaus sign

-polyuria -nephrolithiasis

which medication would the nurse associate to the treatment of a patient with hyponatremia secondary to heart failure and liver cirrhosis? -amiloride (midamor) -tolvaptan (samosa) -pamidronate (aredia) -sodium polystyrene sulfonate (kayexalate)

-tolvaptan

the presence of which clinical manifestations would confirm the nurses interpretation of metabolic alkalosis from interpretation of the patients ABG? select all that apply -tremors -vomiting -tachycardia -epigastric pain -numbness of limbs

-tremors -vomiting -tachycardia

shortly after inserting a central venous access device (CVAD) into the subclavian vein, the patient experiences shortness of breath, anxiety, and restlessness. Which intervention would the nurse implement? -administer a sedative -advise the patient to relax -auscultate patient breath sounds -obtain an arterial blood gas analysis

auscultate patient breath sounds

which laboratory finding indicates the nurse would withhold the scheduled dose of potassium phosphate? -calcium 6.4 mg/dL -sodium 133 mEq/L -magnesium 1.8 mEq/L -potassium 5.2 mEq/L

calcium 6.4 mg/dL

which medical diagnosis would cause the nurse to include nursing interventions appropriate for hyponatremia in the plan of care? -diabetes insipidus -cushing syndrome -congestive heart failure -uncontrolled diabetes mellitus

congestive heart failure

which indicator would the nurse use when assessing the fluid balance of a patient being treated with heart failure? -skin turgor -daily weight -intake and output -blood urea nitrogen, sodium, and hematocrit levels

daily weight

to prevent a recurrence of hypocalcemia, the nurse would encourage the patient to increase intake of which foods? -fish -lean meat -diary products -potatoes and starch

dairy products

which instructions would the nurse provide to the patient with heart failure about the importance of obtaining daily weights? -weigh yourself on the same calibrated scale -weigh yourself along with drainage fluid in the catheter bag -measure your weight after your first intake of food every day, consistently -wear clothes when weighing yourself and subtract weight if wearing heavy clothes or showes

-weigh yourself on the same calibrated scale

a patients treatment resulted in blood sugar levels decreasing from 210 mg/dL to 150 mg/dL. which method of fluid movement between intracellular and extracellular fluids support the effectiveness of the patients treatment? -osmosis -diffusion -active transport -facilitated diffusion

facilitated diffusion

after review of the laboratory reports of four patients, the health care provider writes orders to prepare one of the patients for intubation and mechanical ventilation. Which patients reports indicate thinned for this intervention? Patient. A. B. C. D pH. 7.44. 7.36. 7.34. 7.42 PaCO2. 43. 45. 47. 42 -patient a -patient b -patient c -patient d

patient c

after assessing four assigned patients, the nurse suspects the patient receiving diuretic therapy for their chronic kidney disease has developed metabolic alkalosis. Which diagnostics support the nurses assignment? patient. A. B. C. D pH. 7.3. 7.36. 7.4. 7.48 PaCO2. 37. 43. 45. 49 HCO3- 18. 22. 24. 26 -Patient A -Patient B -Patient C -Patient D

patient d

when assessing a patients skin turgor, the nurse pinched a fold of skin over the sternum and release the fold. return of the skin to the original position required 22 seconds. which term would the nurse use to document this finding? -poor -lagged -normal -decreased

poor

a patient with chronic obstructive pulmonary disease has arterial blood gas results of blood pH of 7.29, partial pressure of carbon dioxide of 49 mm Hg, and a bicarbonate ion level of 25 mEq/L. When developing the patients plan of care which condition would the nurse use? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

a patients arterial blood gas results are pH 7.32, PaCO2 56 mm Hg, HCO3- 24 mEq/L. which acid-base imbalance would the nurse use in development of the patients plan of care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

a patients blood gas results are pH 7.31, PaO2 75 mm Hg, PaCO2 50 mm Hg, and HCO3 25 mEq/L. Suspecting hypoxia, which acid-base imbalance would the nurse associate with the patients data? -respiratory acidosis -compensating respiratory acidosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

a patient admitted to the post anesthesia care unit after a patient thyroidectomy has deep-tendon hyperreflexia, a positive Chvostek's sign, and tachypnea. Which acid-base imbalance would the nurse seek affirmation by reviewing the postoperative arterial blood gas report? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory alkalosis

after receiving several respiratory treatments for an exacerbation of asthma, the patients arterial blood gas results are pH 7.40, PaCO2 40 mm Hg, HCO3- 24 mEq/L, PaO2 92 mm Hg, and O2 sat 99%. Which respiratory change would the nurse report to the oncoming shift? -the patients ABGs are within normal limits -a slight metabolic acidosis is evident to buffer the pH -the ABG report indicates mild respiratory acidosis -compensation resulted in a mild respiratory alkalosis

the patients ABGs are within normal limits

which statement describes the function of a buffer? -to excrete weak acids -to secrete hydrogen ions -to convert strong acids to weak acids -to convert ammonia to ammonium ions

to convert strong acids to weak acids

after receiving information about potassium supplementation for the treatment of hypokalemia from the nurse, which statements indicate patient understanding? select all that apply -I will chew my tablets -I will eat a banana everyday -I will include licorice in my diet -I will take my medication with a glass of water -I will tell my dr if I begin to develop constipation

-I will eat a banana everyday -I will take my medication with a glass of water -I will tell my dr if I begin to develop constipation

which factors place the older patient at risk for developing the clinical manifestations of dehydration? select all the apply -decreased taste sensation -disorientation and confusion -inability to hold a cup or glass -decrease in thirst mechanism -fear of stomach bloating and discomfort

-disorientation and confusion -inability to hold a cup or glass -decrease in thirst mechanism

which clinical manifestations would the nurse monitor when assessing a patient with primary hypoparathyroidism? select all the apply -anorexia -easy fatigability -depressed reglexes -circumoral numbness -positive trousseaus sign

-easy fatigability -circumoral numbness -positive trousseaus sign

which clinical manifestations would the nurse observe when assessing cardiovascular changes in a patient suspected of having a medical diagnosis of fluid volume excess? select all that apply -full, bounding pulse -distended neck vein -orthostatic hypotension -increase in the heart rate -presence of an S3 heart sound

-full, bounding pulse -distended neck vein -presence of an S3 heart sound

which disorders would the nurse associate with a patients increased BP, peripheral edema, dyspnea, jugular venous distention, and complaint of a headache? select all that apply -heart failure -hemorrhage -diabetic insipidus -long-term use of corticosteroids -SIADH

-heart failure -long-term use of corticosteroids -SIADH

which foods would the nurse teach to include in the patients diet when diagnosed with hypertension and when the patient has a magnesium level of 1.2 mEq/L? select all that apply -sugar -oranges -bananas -white flour -peanut butter

-oranges -bananas -peanut butter

which clinical manifestations support a patients admitting diagnosis of fluid volume excess related to heart failure? select all that apply -polyuria -dizziness -lung crackles -muscle spasms -peripheral edema -increased respiratory rate

-polyuria -lung crackles -muscle spasms -peripheral edema

which ECG changes would the nurse observe when the patient exhibits polyuria; soft, flabby muscles; an irregular pulse; blood glucose level of 165 mg/dL; and is receiving IV dextrose therapy? select all that apply -loss of P wave -prolonged QRS -Peaked T waves -Presence of U wave -st segment depression

-prolonged QRS -Presence of U wave -st segment depression

for the patient exhibiting clinical manifestations of hypovolemic shock, which fluid replacement therapy would the nurse prepare to administer when responding to the health care providers prescription? -Dextran -0.9% NaCl -0.45% saline -5% dextrose in 0.45% saline

0.9% NaCl

the nurse admits a patient reporting severe diarrhea for several days from a Clostridium Difficile infection. which iv fluid would the nurse associate with the need to rapidly replace the patients fluid volume? -0.9% sodium chloride -0.45% sodium chloride -5% dextrose in 0.9% sodium chloride -5% dextrose in 0.25% sodium chloride

0.9% sodium chloride

which grade of edema would the nurse document when the patients skin is cool, sternal skin is taut, and sternal pressure with a thumb yields a 2 mm indentation? -1+ -2+ -3+ -4+

1+

which serum phosphate level would the nurse associate with the patient experiencing alcohol withdrawal symptoms? -1.4 mg/dL -2.4 mg/dL -3.8 mg/dL -4.8 mg/dL

1.4 mg/dL

upon review of the morning laboratory studies, which patient would have the risk of developing hypomagnesemia? -83 yr old man with lung cancer and hypertension -65 yr old homeless woman with a history of chronic alcoholism -32 yr old pregnant Thomas who has been treated for eclampsia -63 yr old man with benign prostatic hyperplasia (BPH) and a urinary tract infection (UTI)

65 yr old homeless woman with a history of chronic alcoholism

which medication would the nurse administer to counter the signs of toxicity when infusing magnesium sulphate to a patient with preeclampsia? -IV calcium chloride -IV magnesium sulfate -IV potassium chloride -IV 3% sodium chloride

IV calcium chloride

a patient with a chronic obstructive pulmonary disease (COPD) exacerbation has an arterial blood gas (ABG) report of pH 7.34, PaCO2 46, PaO2 87, and oxygen saturation 94%. Which interpretation would the nurse use for the patients plan of care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

Respiratory acidosis

which laboratory results are consistent with a patients diagnosis of milk-alkali syndrome from an excessive intake of antacids? -calcium levels of 7 mg/dL -calcium levels of 15 mg/dL -phosphate levels of 2 mg/dL -phosphate levels of 17 mg/dL

calcium levels of 15 mg/dL

a patient with cancer has a serum phosphate level of 5.4 mg/dL. which reason would the nurse determine is the probable cause for the patients electrolyte imbalance? -chemotherapy -insulin therapy -total parenteral nutrition -phosphate-binding antacids

chemotherapy

which solution would the nurse select as the most effective means of killing harmful bacteria when preparing to cleanse the skin around a central venous access device? -sterile saline solution -isopropyl alcohol solution -povidone-alcohol solutions -chlorhexidine-based solutions

chlorhexdine-based solutions

the patient with primary hypoaldosteronism reports weight gain (20 pounds), diarrhea, headache, nausea, vomiting, and the BP is 140/90. the mechanism of action for which medication may be beneficial for this patient? -amiloride -conivaptan -propranolol -sodium polystyrene sulfonate

conivaptan

when assessing a patient with Cushing syndrome, which clinical manifestation would the nurse observe? -dyspnea -hypoglycemia -weight loss -hypotension

dyspnea

which adverse effect would the nurse monitor when a patients serum potassium level is 2.8 mEq/L? -dysrhythmias -acute renal failure -metabolic alkalosis -malignant hypertension

dysrhythmias

which revision to a plan of care would the nurse integrate for a patient with a new diagnosis of hypercalcemia resulting from treatment of hypocalcemia? -encourage weight-baring exercises -teach the patient to breathe into a bag -administer IV calcium gluconate -administer thiazide diuretic rather than a loop diuretic

encourage weight-baring exercises

which intervention would the nurse add to a patients plan of care when the recent serum potassium level is 5.1 mEq/L? -monitor patient for signs and symptoms of digitalis toxicity -add bananas to the list of approved fruits for this patient -implement continuous monitoring of urine output -ensure availability of IV calcium gluconate at all times

ensure availability of IV calcium gluconate at all times

which fluid and electrolyte imbalance would the nurse associate with the patients laboratory date: Na 132 mEq/L, BUN 5 mg/dL, and HCT 33%? -hyperkalemia -hypernatremia -excess fluid volume -deficient fluid volume

excess fluid volume

which clinical manifestation would indicate a patient with heart failure is at risk for developing fluid volume excess? -full, bounding pulse -flattened neck veins -low blood pressure -easily obliterated pulse

full, bounding pulse

a patient with chronic kidney disease is experiencing sever hyperphosphatemia. The nurse notifies the health care provider in anticipation of which ordered treatment? -hemodialysis -fluid restriction -potassium supplementation -loop diuretic therapy

hemodialysis

which laboratory finding would the nurse determine is the rational for administering sodium polystyrene sulfonate rectally to a patient with an irregular pulse and lower extremity weakness? -hypokalemia -hypocalcemia -hyperkalemia -hypercalcemia

hyperkalemia

when preparing to administering IV albumin 5% to a patient, the nurse understands the solution is used to treat which metabolic alteration? -alkalosis -hypovolemia -hyperkalemia -mixed acid-base disorder

hypovolemia

a patients intravenous fluid is ordered to infuse at 125 mL/hr. at 0800, the nurse notes that 950 mL of fluid has infused from a bag hung at 0400. which action will the nurse take first? -notify the health care provider and complete the incident report -hang a new bag of IV solution to maintain patency of the site -listen to the patients lung sounds and assess respiratory status -discontinue the fluids and saline lock the IV access until the next scheduled bag

listen to the patients lung sounds and assess respiratory status

a patient with chronic obstructive pulmonary disease has arterial blood gas results of pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L and O2 sat of 92%. which interpretation of the data would the nurse report to the primary care provider? -fully compensated respiratory alkalosis -partially compensated respiratory acidosis -normal acid-base balance with hypoxemia -normal acid-base balance with hypercapnia

partially compensated respiratory acidosis

which clinical manifestation would the nurse expect to see when assessing a patient with hypocalcemia? -shortened ST segment -prolonged QT segment -venricular dysrhythmias -increased digitalis effects

prolonged QT segment

a patient, with chronic kidney disease, reports eating many nuts, bananas, peanut butter, and chocolate. the nurses assessment indicates loss of deep tendon reflexes, somnolence, and altered respiratory status. which treatment option would the nurse associate with these clinical findings? -renal dialysis -IV furosemide (Lasix) -IV potassium chloride -IV normal saline at 250 mL per hour

renal dialysis

which patient disorder has a potential complication of developing increased extracellular fluids? -osmotic diuresis -renal impairment -intestinal obstruction -drainage from a rectal fistula

renal impairment

the patient with a nasogastric on intermittent wall suction asks why they are not able to have something to drink. which response would the nurse give? -drinking fluids will cause sodium retension -the suctioned secretions will be falsely elevated -drinking fluids will increase your nausea and vomiting -the additional fluids will increase the loss of critical electrolytes

the additional fluids will increase the loss of critical electrolytes

which syndrome would the nurse suspect when a patient has a potassium level of 6.2 mEq/dL? -cushing syndrome -milk-alkali syndrome -tumor lysis syndrome -malabsorption syndrome

tumor lysis syndrome

which data findings would the nurse instruct the unlicensed assistance personnel (UAP) to report while providing care for an older adult patient with dehydration? -temperature 97.1 F (36.2C) -frequent use of the urinal -urine output of 350 mL in 24 hours -ambulation in the hallway without assistance

urine output of 350 mL in 24 hours

which mechanism would the nurse use to explain a patients insensible water loss of an estimated 900 mL/day? -excreted via urine -excreted in the feces -vaporized by the lungs and skin -secreted into the digestive tract

vaporized by the lungs and skin

for which clinical manifestation would the nurse monitor closely in the patient experiencing respiratory acidosis from chronic obstructive respiratory disease (COPD)? -diarrhea -confusion -abdominal pain -ventricular fibrillation

ventricular fibrillation

when planning the care of a patient with dehydration, which data would the nurse instruct the unlicensed assistive personnel (UAP) to report? -60 mL urine out put in 90 mins -1200 mL urine output in 24 hours -300 mL urine output per 8-hr shift -20 mL urine output for two consecutive hours

-20 mL urine output for two consecutive hours

a patients prescription was 0.9% sodium chloride IV at a rate of 100 mL per hour. the current bag of 1000 mL was hung at 1000. during 1300 rounds, the nurse notes that the IV bag contains 900 mL normal saline. when completing the incident report, which error would the nurse record? -wrong rate -wrong route -wrong solution -wrong documentation

wrong rate

a patient's laboratory reports a sodium concentration of 143 mmol/L and the sum of chloride and bicarbonate ion concentration is 132 mmol/L. Which value would the nurse calculate for this patients anion gap?

11

how much fluid retention would the nurse document a patient experienced when their admission weight was 60 kg, and the weight on day 2 was 62 kg? ___________mL

2000 mL

after removing 5 liters of fluid during a patients paracentesis, which IV solution may be used to pull fluid into the intravascular space? -0.9% sodium chloride -25% albumin solution -lactated ringers solution -5% dextrose in 0.45% saline

25% albumin solution

which serum bicarbonate ion level would indicate a compensatory response in the patient experiencing respiratory acidosis? -24 mEq/L -25 mEq/L -26 mEq/L -27 mEq/L

27 mEq/L

a patient with diabetes mellitus has been fasting since midnight and reports feeling dizzy. the nurse observes the deep, rapid breathing of kussmaul respirations. which condition would the nurse associate with this clinical manifestation? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

a patient with diabetes mellitus presents to the emergency room with a blood sugar of 400 mg/dL. Which type of acid base imbalance would the nurse monitor for the clinical manifestations? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

after review of the morning laboratory reports, the nurse calculated a patients anion gap because an arterial blood gas was not available. which acid-base imbalance would the nurse associate with an increased anion gap? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

the arterial blood gas report of a patient with diabetes mellitus indicates bicarbonate level of 18 mEq/L and pH of 7.32. which acid-base imbalance would the nurse document? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

the patients arterial blood gas values are pH 7.30, PaCO2 35 mm Hg, and HCO3- 16 mEq/L. which interpretation would the nurse use when updating the patients plan of care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

a family member inquires as to the meaning of "third spacing" which the nurse used when assessing their loved one, who has acute pancreatitis. which explanation would the nurse use to explain the process? -"this is just. term that we use to describe generalized edema" -"third spacing refers to how the fluids are distributed in the cells and vessels" -"third spacing describes potential fluid location, such as the cells, blood vessels, and lymph system" -"fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells"

-"fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells"

which condition would the nurse anticipate when waiting for arterial blood gas results on a patient experiencing acute renal failure secondary to severe dehydration? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

a family member takes an older adult patient with dementia to the emergency room; the patient is hound to be hypercarbic. the patients advanced directive indicates use of noninvasive procedures only. which statement would be the nurses best response when the family asks if this issue will resolve itself? -"the kidneys will begin to compensate for increased levels of CO2 within 24 hours" -"the kidneys sense increase levels of CO2 in the blood and conserve HCO3 and secrete increased H+" -"older adults have a harder time compensating because they have decreased respiratory and kidney functions -"the respiratory center senses increased levels of CO2 in the blood and stimulates hyperventilation to compensate

"older adults have a harder time compensating because they have decreased respiratory and kidney function"

an emergency department patient presents with lethargy and confusion, and arterial blood gases reflect metabolic acidosis. the family reports a history of "heart problems" and voices concern about the acidosis affecting the heart. which response would the nurse use to address the family's concern? -"acidosis may affect the patients blood pressure but not the hearts electrical pathways" -"acidosis is often temporary and never life-threatening; this situation is nothing to worry about" -"metabolic acidosis is a symptom of an underlying disorder for which we will evaluate and treat during this admission" -"uncompensated acidosis can cause hypotension and cardia dysrhythmias; we will monitor and work to prevent these complications"

"uncompensated acidosis can cause hypotension and cardia dysrhythmias; we will monitor and work to prevent these complications"

the nurse provided care instruction for an older adult patients dementia and fluid balance maintenance at home. which caregiver statements indicate understanding of the nurses teachings? select all that apply -"I should increase fluid intake and lower dietary sodium" -"I should provide fluids only when the patient voices thirst" -"I should assist the patient when holding utensils and cups" -"I should encourage the patient to pass urine before going to bed" -"I will make sure the patient has a glass of milk near them at all times"

-"I should increase fluid intake and lower dietary sodium" -"I should assist the patient when holding utensils and cups" -"I should encourage the patient to pass urine before going to bed"

which patient statements indicate understanding of nursing instructions regarding skin care management? select all that apply -"avoid extreme temperatures" -"apply moisturizers even at night" -"was my hands and legs frequently with soap" -"change my position regularly while at rest" -"I will not use the foot lift on my recliner"

-"avoid extreme temperatures" -"apply moisturizers even at night" -"change my position regularly while at rest"

which interventions would the nurse perform prior to removing a patients central venous access device? select all that apply -understand the scope of nursing practice -review the health care providers prescription -request a second nurse to assist with the removal -review the health care organizations policy on the procedure -provide pharmacologic intervention prior to removing the CVAD

-understand the scope of nursing practice -review the health care providers prescription -review the health care organizations policy on the procedure

a patient with metabolic acidosis asks how the acid-base imbalance will be corrected. which response would the nurse use? select all that apply -"medications are the primary treatment for acute acid-base imbalances occuring in critically ill patients" -"the renal system compensates slowly, usually reacting to pH changes within 24 hours" -"the respiratory system can compensate quickly to changes in pH and reacts in a matter of minutes" -"the heart is vital in managing the acid-base balance and regulates perfusion to increase or decrease pH" -"the buffer system is the primary manner by which the body changes strong acids into weaker ones to maintain pH balance"

-"the renal system compensates slowly, usually reacting to pH changes within 24 hours" -"the respiratory system can compensate quickly to changes in pH and reacts in a matter of minutes" -"the buffer system is the primary manner by which the body changes strong acids into weaker ones to maintain pH balance"

When evaluating the partial carbon dioxide (PaCO2) parameter within a patients arterial blood gas report, which value indicates the compensatory response to a patient's metabolic alkalosis? -38 mm Hg -40 mm Hg -44 mm Hg -47 mm Hg

-47 mm Hg

which action would the nurse implement immediately when a patient with a central venous access device begins to experience chest pain, dyspnea, hypotension, and tachycardia? select all that apply -administer oxygen -administer anticoagulants -clamp the central venous access catheter -place the patient on the left side with the head down -flush the central venous access device with normal saline using a 10 mL syringe

-administer oxygen -clamp the central venous access catheter -place the patient on the left side with the head down

which nursing intervention would the nurse implement when unable to infuse fluids via the patients central venous access device? select all that apply -assess the catheter for clamping and kinking and alleviate the cause -instruct the patient to remain supine in bed and not to move -force-flush the device with normal saline using a 10 mL syringe -notify radiology of need to perform fluoroscopy to determine the cause and evaluate the site -consult interventional radiology for administration of anticoagulant or thrombolytic agents

-assess the catheter for clamping and kinking and alleviate the cause -notify radiology of need to perform fluoroscopy to determine the cause and evaluate the site -consult interventional radiology for administration of anticoagulant or thrombolytic agents

for the patient with a central venous access, which interventions would the nurse implement to maintain a safe, functioning device? select all that apply -change the catheter dressing regularly -monitor the heart rate and bp -cleanse around the catheter insertion site -measure and record oral intake and output -change the injection caps at regular intervals

-change the catheter dressing regularly -cleanse around the catheter insertion site -change the injection caps at regular intervals

of the four patients receiving care, which patients chart leads the nurse to suspect development of a fluid volume deficit? A: diabetes insipidus- restlessness, decreased skin turgor and capillary refill, urine specific gravity of 1.037 B: heart failure- headache, polyuria, dyspnea, urine specific gravity of 1.003 C: heatstroke- flushed skin, nausea and vomiting, urine specific gravity of 1.025 D: SIADH- generalized weakness, hyporeflexia, urine specific gravity if 1.008 -Patient A -Patient B -Patient C -Patient d

patient A

after assessing four assigned patients, the nurse suspects a patient of developing respiratory alkalosis. which patients arterial blood gas values support the nurses clinical findings? Patient. A. B. C. D pH. 7.45. 7.62. 7.43. 7.37 PaCO2. 38. 30. 35. 39 HCO3- 24. 22. 25. 23 -Patient A -Patient B -Patient C -Patient D

patient B

when a patient is admitted with dehydration, which intervention would the nurse include in a patients plan of care? -preform daily weights -reorient the patient hourly -restrict sodium intake to 2 grams per day -provide continuous oxygen saturation monitoring

perform daily weights

for which patient disorder would the nurse closely monitor clinical manifestations associated with respiratory acidosis? -protracted vomiting -pulmonary embolism -severe pneumonia -recovery from diabetic ketoacidosis

severe pneumonia

which clinical manifestation would the nurse anticipate when providing care for a patient with hyperkalemia? Select all that apply -1+ deep tendon reflex -rapid and shallow respirations -serum blood glucose level of 250 mg/dL -numbness and tingling in the hands and feet -ventricular fibrillation noted on the electrocardiogram

-1+ deep tendon reflex -numbness and tingling in the hands and feet -ventricular fibrillation noted on the electrocardiogram

which statement by a patient indicates understanding of nursing instructions about their peripherally implanted catheters (PICC)?select all that apply -I will need to watch for signs phlebitis for up to 10 days after the PICC is inserted -A PICC line is usually only used for access up to six months, but can be left longer - I can safely take my blood pressure in the arm with the PICC as long as the cuff is blow the insertion site -a PICC has fewer side effects than a central venous catheter, such as lower infection rate and fewer insertion complications -because the dressing seals off the insertion site, I may continue to take showers or go swimming at the health club

-I will need to watch for signs phlebitis for up to 10 days after the PICC is inserted -A PICC line is usually only used for access up to six months, but can be left longer -a PICC has fewer side effects than a central venous catheter, such as lower infection rate and fewer insertion complications

the nurse wold assess for which manifestations when the patient receives a potassium-sparing diuretic? select all that apply -hyperglycemia -anxiety and irritability -a tall, peak T wave on electocardiogram -presence of U wave -abdominal cramping and diarrhea -paresthesias and weakness of lower extremities

-anxiety and irritability -a tall, peak T wave on electocardiogram -abdominal cramping and diarrhea -paresthesias and weakness of lower extremities

which task may a registered nurse on a general medical-surgical unit delegate to a licensed practical nurse, as permitted but the state nurse practice act? -administering a saline infusion to a patient with a diabetic ketoacidosis -assessing a patient with heart failure who has signs of fluid overload -determining if an IV infusion should be given to a patient with an acid-base imbalance -decreasing rate of an existing IV infusion for a patient about to be discharged home

-decreasing rate of an existing IV infusion for a patient about to be discharged home

for a patient with hear failure, which interventions would the nurse include in the plan of care when the patient has 4+edema of the lower extremities and sacral area? select all that apply -elevate edematous lower extremities -protect the patients tissues from extreme heat or cold -apply moisturizing creams or lotions to the skin frequently -rotate the patient from left side lying to right side lying every two hours -frequently assess for edema in areas where soft tissue covers bony areas -encourage the patient to double fluid intake to improve tissue integrity

-elevate edematous lower extremities -protect the patients tissues from extreme heat or cold -apply moisturizing creams or lotions to the skin frequently -frequently assess for edema in areas where soft tissue covers bony areas

which intervention would the nurse implement to relieve the edema associated with a patients soft tissue injury to their ankle? -elevating the extremity -massaging the ankle every one or two hours -applying a warm compress to the ankle -applying warm saline soaks to the extremity

-elevating the extremity

which acid-base mechanisms would the kidney use to buffer a patients acidosis (serum level <7.35)? Select all that apply -eliminating excessive H+ -excreting excess water -eliminating excess CO2 -reabsorbing additional HCO3- -reabsorbing additional sodium ions

-eliminating excess H+ -reabsorbing additional HCO3-

for the patient with recent removal of a pituitary tumor, which clinical manifestation would the nurse report immediately to the health care provider? -excessive thirst -calcium level of 8.6 mg/dL -potassium level of 3.5 mEq/L -urine output of 300 mL in eight hours

-excessive thirst

for which clinical manifestations or disorders would the nurse monitor a patient for the development of respiratory alkalosis? Select all that apply -fever -hypoxia -pulmonary edema -pulmonary emboli -atelectasis

-fever -hypoxia -pulmonary emboli

which fluid shift would the nurse anticipate in the patient with dehydration related to nausea and vomiting? -fluid movement from the blood vessels into the cells -fluid movement from he interstitial spaces into the cells -fluid movement from eh blood vessels into interstitial spaces -fluid movement from the interstitial space into the blood vessels

-fluid movement from the interstitial space into the blood vessels

which assessment data would the nurse associate with the patients serum potassium level of 6.8 mEq/L on admission. select all that apply -insulin therapy initiated in the emergency room -home medications include amiloride po daily -history and treatment of chronic renal disease -electrocardiogram revels flattened t waves -orders incude normal saline with 40 mEq potassium in am

-home medications include amiloride po daily -history and treatment of chronic renal disease

an inadvertent removal of the parathyroid glands occurred during a patients scheduled thyroidectomy. which electrolyte disturbance would the nurse assess for the presence of trousseaus sign and serum electrolytes results? -hypocalcemia -hypercalcemia -hypermagnesemia -hyperphosphatemia

-hypocalcemia

which electrolyte imbalance would prompt the nurse to instruct a patient to consume more diary products in their diet? -hyperkalemia -hypocalcemia -hypercalcemia -hypophosphatemia -hyperphosphatemia

-hypocalcemia -hypophosphatemia

which patient statements about their hypercalcemia indicate understanding of content taught by the nurse? select all that apply -I can use tums as needed for heartburn -I should restrict my fluid intake to less than 200 mL/day -increasing my daily fluid intake to 3000 to 4000 mL is good -renal calculi may occur as a complication of hypercalcemia -weight-baring exercises can help keep my calcium in my bones

-increasing my daily fluid intake to 3000 to 4000 mL is good -renal calculi may occur as a complication of hypercalcemia -weight-baring exercises can help keep my calcium in my bones

which interventions would the nurse implement when unable to flush a central venous access device due to a suspected occlusion? select all that apply -clamp the tubing immediately -obtain cultures of the insertion site -instruct the patient to change positions, raise arm and cough -attempt to force flush 10 mL of normal saline into the device -assess the tubing for clamping or kinking, and alleviate as needed

-instruct the patient to change positions, raise arm and cough -assess the tubing for clamping or kinking, and alleviate as needed

which action would the nurse perform to ensure the patients safety when preparing to administer IV potassium chloride (KCL) to a patient? -administer the KCL via IV push -add the KCL to the handing IV bag -administer the IV KCL in concentrated amounts -invert the IV fluids with KCL several times prior to hanging

-invert the IV fluids with KCL several times prior to hanging

which assessments would the nurse perform to avoid risk factors associated with administration of a hypertonic solution to a patient with dehydration? select all that apply -lung sounds -bowel sounds -bp -serum sodium level -serum potassium level

-lung sounds -bp -serum sodium level

which primary acid-base imbalance would the nurse associate with a patients clinical manifestations of abdominal pain, nausea, and severe diarrhea? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

-metabolic acidosis

a patient, recovering from a surgical procedure, has a nasogastric tube draining copious secretions and reports surgical site pain of 10 on a scale of 0-10. the patients respirations are 32 breaths/minute. which condition would the nurse associate with these clinical manifestations? -hypoxia and respiratory alkalosis -mixed respiratory and metabolic alkalosis -sedative overdose and respiratory acidosis -diabetic keto acidosis and metabolic acidosis

-mixed respiratory and metabolic alkalosis

analysis of which arterial blood gas report led the health care provider to prescribe new orders for the patient with respiratory acidosis? -pH 7.40; PaCO2 44; HCO3- 26 -pH 7.29; PaCO2 47; HCO3- 25 -pH 7.36; PaCO2 41; HCO3- 23 -pH 7.42; PaCO2 42; HCO3- 24

-pH 7.29; PaCO2 47; HCO3- 25

which arterial blood gas data correspond with a patients clinical manifestations of respiratory alkalosis? -pH 7.46, PaCO2 44 mm Hg, PaO2 95 mm Hg, and HCO3- 36 mEq/L -pH 7.27, PaCO2 70 mm Hg, PaO2 80 mm Hg, and HCO3- 26 mEq/L -pH 7.30, PaCO2 35 mm Hg, PaO2 70 mm Hg, and HCO3- 20 mEq/L -pH 7.52, PaCO2 24 mm Hg, PaO2 85 mm Hg, and HCO3- 24 mEq/L

-pH 7.52, PaCO2 24 mm Hg, PaO2 85 mm Hg, and HCO3- 24 mEq/L

which condition would the nurse associate with the patient being monitored for clinical manifestations of hyperkalemia? select all that apply -alkalosis -renal failure -low blood volume -large urine volume -adrenal insufficiency

-renal failure -adrenal insufficiency

for which condition would the nurse include plan of care interventions related to the potential development of hypophosphatemia? select all that apply -renal failure -respiratory alkalosis -diabetic ketoacidosis -tumor lysis syndrome -malabsorption syndrome

-respiratory alkalosis -diabetic ketoacidosis -malabsorption syndrome

a patient with malignant lung cancer experiences weakness, lethargy, depressed reflexes, and bone pain. which changes in the electrocardiogram would lead the nurse to suspect hypercalcemia? select all that apply -shortened QT interval -prolonged QT interval -shortened ST segment -elongation of ST segment -flattened or inverted T wave

-shortened QT interval -shortened ST segment

the nurse receives a health care providers prescription to change a patients IV from D5 1/2 NS with 40 mEq KCL/L to 20 mEq KCL/L. which serum laboratory value on this same patient supports the rationale for this IV prescription change? -sodium 136 mEq/L, potassium 4.5 mEq/L -sodium 145 mEq/L, potassium 4.8 mEq/L -sodium 135 mEq/L, potassium 3.6 mEq/L -sodium 144 mEq/L, potassium 3.7 mEq/L

-sodium 136 mEq/L, potassium 4.5 mEq/L

when evaluating a patient for acid-base imbalances, which questions would the nurse pose? select all that apply -raise questions about the patients vaccinations status -solicit the extent and intensity of a patients exercise routines -raise questions about any special dietary practices -solicit the patients historical and current use of tobacco and smoking -inquire about any deviations from usual bowel and bladder habits

-solicit the extent and intensity of a patients exercise routines -raise questions about any special dietary practices -inquire about any deviations from usual bowel and bladder habits

which clinical manifestations would the nurse evaluate for the presence of dehydration in the older adult patient admitted with nausea and vomiting? select all that apply -hypertension -bradypnea -tachycardia -restlessness -urine output 10 mL/hr

-tachycardia -restlessness -urine output 10 mL/hr

a patient who sustained multiple injuries in a motor vehicle accident received multiple blood transfusions to replace blood lost from a wound hemorrhage. the nurse dings the patient has developed laryngeal stridor, dysphagia, and numbest and tingling around the mouth. which rationale would the nurse associate with these changes? -the patient developed anemia secondary to acute blood loss -the identified clinical changes support development of hypocalcemia -these manifestations indicate fluid overload from multiple transfusions -the newly developed signs and symptoms indicate a hemolytic reaction

-the identified clinical changes support development of hypocalcemia

a patient with diabetes mellitus, malnutrition, and a massive gastrointestinal bleed is NPO, has a NG tube, and received multiple units of packed red blood cells. The morning potassium level is 5.5 mEq/dL. which rationals would the nurse use to explain the mornings potassium level? select all that apply -the potassium level increase may be related to decreased renal perfusion associated with the fluid volume deficit -the patient may be excreting extra sodium and retaining potassium because of malnutrition -the elevated potassium may be due to high blood glucose levels produced when the body experiences physical stress -the transfusion of multiple units of stored hemolyzed blood may increase potassium levels -the patient has been overeating raisins, baked beans, and salt substitute, which could increase the potassium level

-the potassium level increase may be related to decreased renal perfusion associated with the fluid volume deficit -the elevated potassium may be due to high blood glucose levels produced when the body experiences physical stress -the transfusion of multiple units of stored hemolyzed blood may increase potassium levels

the nurse administers a prescribed parenteral nutrition of 10% dextrose with amino acids, electrolytes, vitamins, and trace elements to a patient. which characteristic would the nurse need to understand regarding the prescribed solution? -10% dextrose is a hypertonic solution -the parenteral nutrition is used as a plasma expander -the solution expands the extracellular compartment -administration of this solution is through a central line only

10% dextrose is a hypertonic solution

a patient has a prescription to receive D5W with 20 mEq KCL/L at 100 ml/hr. the nurse would select which solution from he IV supply cart? -1000 mL of 5% dextrose in water with 20 mEq of KCL -100 mL of 5% dextrose in 0.9% sodium chloride with 20 mEq of KCL -200 mL of 5% dextrose lactated ringers solution with 20 mEq of KCL -250 mL of 5% dextrose in 0.45% sodium chloride with 20 mEq of KCL

1000 mL of 5% dextrose in water with 20 mEq of KCL

which prescription would the nurse clarify when prescribed for a patient whose ECG tracing has a short QT interval and a high peaked T wave? -1000 mL of D5W with 20 mEq KCL to run at 125 mL/hr -sodium polystyrene 30 grams by mouth -10 units regular insulin intravenous push a d one-half ampule D50W IVP -2 grams calcium gluconate intravenous administered over two minutes

1000 mL of D5W with 20 mEq KCL to run at 125 mL/hr

the iv prescription reads "1000 mL of D5.45 normal saline with 40 mEq KCL/L at 125 mL/hour." the nurse needs to add KCL to the liter of D5.45 NS solution because no premixed solutions are available. the units medication supply has a stock of KCL 5 mEq/mL in multi dose vials. The nurse would need to draw up _________ mL of KCL to ass to the IV solutions

8 mL

which patient statement indicates understanding of the information presented by the nurse on potassium supplementation for treatment of hypokalemia? -I will eat a banana every day -I can crush my table, so I can swallow them easily -I may include my favorite licorice in my diet -I will take my medication with a full glass of milk

I will eat a banana everyday

a patient has a blood sodium level of 170 mEq/L and is experiencing intense thirst, agitation, and decreased alertness. which intervention would the nurse associate with the patients clinical manifestations? -IV furosemide -IV cation-exchange resin -IV phosphate-binding agent -IV 0.45% sodium chloride saline solution

IV 0.45% sodium chloride saline solution

a patient admitted with gastroenteritis has an arterial blood gas report of pH 7.30, PaO2 80 mm Hg, PaCO2 46 mm Hg, HCO3 14. Which interpretation would the nurse use to affirm nursing interventions? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

a patient reports a headache, nausea, and four episodes of vomiting in the last two hours. the patient is taking deep, rapid breaths, and BP is 90/60 mm Hg. the nurse suspects development of which patient condition? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

in the regulation of water balance, which systems primary effect is anti-inflammatory and increases serum glucose levels? -renal -cardiac -adrenal-cortical -hypothalamic-pituitary

adrenal-cortical

while obtaining a patients BP, a nurse notices the patients arm has carpal spasm. which laboratory test would the nurse review after assessing this finding? -calcium -sodium -potassium -magnesium

calcium

which laboratory findings would the nurse expect when providing care for a patient with low levels of parathyroid hormone? -decreased calcium levels -increased potassium levels -decreased phosphate levels -increased magnesium levels

decreased calcium levels

the nurse prepares to administer a lactated ringers IV solution to a patient requiring a supportive care after several days of vomiting and diarrhea. Clinical manifestations include a urine specific gravity of 1.040 with 15 mL urine output in one hour, BP 84/48 mm Hg upon standing, and a heart rate of 100 beats/min. The nurse would associate the clinical manifestations and the IV solution with treatment of which imbalance? -hyponatremia -hyperkalemia -extracellular fluid volume deficit -extracellular fluid volume excess

extracellular fluid volume deficit

which type of imbalance would the nurse associate with a patient who has second-degree (partial thickness) burns over 30 % of the total body surface area with poor skin turgor, urine output of <50 mL over the past two hours, a rapid and thready pulse, and restlessness? -hyperkalemia -metabolic acidosis -hyperphosphatemia -extracellular fluid volume deficit

extracellular fluid volume deficit

which clinical manifestation would the nurse associate with the patients admitting problem of deficient fluid volume related to nausea and vomiting? -polyuria -decreased pulse -difficulty breathing -general restlessness

general restlessness

a patient reports numbness, tingling around the mouth and extremities, difficulty in swallowing, and a contraction of the patients facial muscles in response to the tap over the facial nerve in front of the ear. the patients ECG shows a prolonged QT interval. Which electrolyte imbalance would the nurse relate to these clinical manifestations? -hypocalcemia -hyperkalemia -hypermagnesemia -hypophosphatemia

hypocalcemia

which health care provider order would the nurse associate with a patients potassium level of 2.9 mEq/L? -implement continuous ECG monitoring -increase the patients PO digoxin to 0.25 mg every day -add 20 mEq of KCL to the existing IV bag and give over 4 hours -infuse 40 mEq of KCL in 100 cc D5W IV piggy back over 30 mins

implement continuous ECG monitoring

which action will the nurse take for a patient with overuse of diuretics based on the BP readings below? lying - 132/84 sitting - 110/78 standing - 92/62 -administer oxygen -apply a pulse oximeter -implement fall precautions -auscultate the lungs for rales

implement fall precautions

a patient with heart failure accidentally overused the prescribed diuretics. for which potential respiratory manifestations would the nurse monitor? -shortness of breath -pulmonary congestion -increased respiratory rate -moist crackles on inspiration

increased respiratory rate

a patient with a diagnosis of heat stroke has a urine output of 4000 mL/day. Which intervention would the nurse implement? -transfuse two units of blood -generously apply skin moisturizer regulary -initiate infusion of lactated ringers solution -provide supplementary water through enteral feedings

initiate infusion of lactated ringers solution

a patient reports an inability to eat for the last 10 days and 'feeling extremely weak and sick." Which acid-base imbalance would the nurse suspect when coordinating the clinical manifestations with the pending arterial blood gas (ABG) report? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic acidosis

a hospitalized patient reports abdominal pain, nausea, and vomiting. suspecting a bowel obstruction, for which primary acid-base imbalance would the nurse plan the patients care, if the obstruction is high in the intentional tract? -respiratory acidosis -metabolic alkalosis -mixed alkalosis -metabolic acidosis

metabolic alkalosis

a patients arterial blood gas report was pH 7.58, PaCO2 38, and HCO3- 30. for which acid base imbalance would the nurse plan the patients care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic alkalosis

for the patient who sought medical treatment after vomiting for three days, which acid-base imbalance would the nurse determine the patient is at risk of developing? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic alkalosis

when admitting a patient with dehydration secondary to nausea and vomiting, which acid-base imbalance would the nurse use to plan the patients care? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic alkalosis

when receiving long-term mineralocorticoid therapy, for which patient condition would the nurse evaluate associated clinical manifestations? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

metabolic alkalosis

a patient who is three days post abdominal surgery continues to have green bilious nasogastric tube output, respiratory rate of 32, and heart rate of 128. abdominal and surgical site pain are poorly controlled. for which acid-base imbalance would the nurse modify nursing interventions? -respiratory acidosis -metabolic alkalosis -mixed alkalosis -mixed acidosis

mixed alkalosis

what process of molecule transport would occur when a patient develops pedal edema and their blood pressure is 160/90 mm Hg? -osmosis -diffusion -active transport -facilitated diffusion

osmosis

which physical assessment findings consistent with a patients total serum calcium level of 6.4 mg/dL? -polyuria -bone pain -paresthesias -diminished deep tendon reflex

parathesias

a patient reports a headache, dizziness, and fatigue and states "I am not able to use this incentive spirometer anymore. just too hard." review of the ECG, x-ray, and laboratory reports indicate vernacular fibrillation, hypotension, and atelectasis. Which acid-base imbalance would the nurse associate with this patients clinical manifestations? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

a patient with a chest wall abnormality is scheduled for a surgical intervention. For which condition would the nurse carefully monitor the patients arterial blood gases? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

after implementing prescribed therapy, the patients arterial blood gas report is pH 7.33, PaCO2 52 mm Hg, PaO2 81 mm Hg, HCO3- 24 mEq/L, and SaO2 84%. which acid-base imbalance would the nurse report when updating the health care provider? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

for which potential complication would the nurse monitor associated clinical manifestations when providing care for a patient with Guillian-Barre Syndrome, an autoimmune disorder? -respiratory acidosis -metabolic alkalosis -respiratory alkalosis -metabolic acidosis

respiratory acidosis

which statement would the intensive care nurse use to address the family concern about the patients respiratory acidosis? -"this disease is treated with mechanical ventilation to ensure oxygenation of tissues" -"this disease is treated with medications such as bicarbonate because the kidneys are injured" -"respiratory acidosis is not something to worry about within the overall treatment regimen" -respiratory acidosis is not a disease but a symptom of a larger disease process we will treat separately"

respiratory acidosis is not a disease but a symptom of a larger disease process we will treat separately

which intervention would the nurse implement when a pregnant patient reports headaches and shortness of breath and the nurse auscultates crackles and a bounding pulse? -apply hot and cold compress -restrict the intake of dietary sodium -ask the patient to sit then stand -provide ice chips to hydrate the patient

restrict the intake of dietary sodium

which rationale would the nurse use to explain events occurring when the respiratory center, located in the medulla, senses an increased concentration of carbon dioxide or H+? -the respiratory center stimulates hyperventilation to get rid of CO2 -the respiratory center stimulates a decreased rate of breathing to retain CO2 -the respiratory center stimulates an increased depth of breathing to retain H+ -the respiratory center stimulates a decreased depth of breathing to get rid of H+

the respiratory center stimulates hyperventilation to get rid of CO2

a patients arterial blood gases, obtained after intubation, are pH of 7.28, Paco2 of 50 mm Hg, a bicarbonate of 25 mm Hg, and a PaO2 level of 95 mm Hg. Which condition would the nurse report to the health acre provider? -uncompensated respiratory acidosis -uncompensated metabolic alkalosis -compensated respiratory alkalosis -compensated metabolic acidosis

uncompensated respiratory acidosis

which assessment finding is consistent with phosphate level of 1.8 mg/dL? -tetany -diarrhea -weakness -muscle cramps

weakness