*Elevate Module 1 Q Review Quiz

The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. As the nurse connects the client to a cardiac monitor, the client becomes unresponsive, without a pulse. The nurse the rhythm. What action should the nurse take first? 1. Defibrillate at 200 joules 2. Administer amiodarone IV 150 mg over 10 minutes 3. Infuse 500 mL NS with 40 mEq KCL (40 mmol/L) at 100 mL/hour 4. Begin 2 person cardiopulmonary resuscitation

ANS: 1. 1. Correct: The client has become unresponsive and does not have a pulse. The monitor is showing Ventricular tachycardia. The first action with pulseless V-tach is defibrillation. 2. Incorrect: Amiodarone is the first action if the client has a pulse with short runs of V-tach. 3. Incorrect: KCL is needed but we need to treat the short run of v-tach first. 4. Incorrect: Start CPR after defibrillating if a pulse is not acquired.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Vital Signs: Blood Pressure 92/54 mmHg, Heart Rate 116 bpm, Respiratory Rate 22 breaths/min, Temperature 103F (39.4C), Oxygen Saturation 91%. Documentation: Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Lung assessment finding 2. Blood pressure reading 3. Elevated temperature 4. Urine description and output

ANS: 1. 1. Correct: Look at the clues: Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. The ET tube is likely down in the right main stem bronchus. This means the left lung is not being oxygenated. 2. Incorrect: The BP is above 90 systolic, so the vital organs are still being perfused. The nurse will definitely keep monitoring, but this is not the priority. 3. Incorrect: The second priority is to treat the infection that is likely the cause of the temperature elevation. But take care of that airway first. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to fix the airway problem.

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? ABGs: pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated

ANS: 1. 1. Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now normal. 2. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid. The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now low. 3. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid. The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now low. 4. Incorrect: The pH is normal but is on the acidic side of normal. The PaCO2 is acid. The HCO3 is alkalotic. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now low.

The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is permanent, so no other injection is required. 3. Common side effects of the injection include soreness and swelling around the injection site. 4. The sooner you get a shot of IG after being exposed to HAV, the greater the likelihood of protection from the virus. 5. Crowded living environments such as dormitories place people at risk for HAV.

ANS: 1., 2. 1., & 2. Correct: Immune globulin contains antibodies that destroy the HAV, preventing infection. IG protection is only temporary, lasting about 3 months. 3. Correct:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 4. Correct:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 5. Correct: This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Cover the pustules to prevent drainage. 2. Implement contact precautions immediately. 3. Instruct the client on the importance of hand hygiene. 4. Inform the client to wear a mask when ambulating in the hall. 5. Instruct visitors to wash hands before entering the client's room.

ANS: 1., 2., 3., 5. 1., 2., 3. & 5. Correct: The pustules should be covered with a dressing, because MRSA is transmitted via contact! It is important that the nurse implement these interventions in order to prevent the spread of infection. The number one way to prevent the spread of infection is handwashing. That includes the client, staff, and visitors. If the client refuses to follow instructions, then isolation precautions are warranted. 4. Incorrect: The client is placed on contact precautions not droplet precautions. The client would not need to wear a mask since the infection is not transmitted via the respiratory system.

The nurse is caring for a client admitted to the unit with heart failure. Upon entering the room, the nurse notes that the client is agitated, gasping for air, and attempting to sit up. The client states "I can't get my breath". What actions should the nurse take? 1. Elevate the head of the bed to sitting position 2. Dangle client's legs over side of the bed 3. Initiate oxygen at 2 liters per nasal cannula 4. Initiate IV of lactated ringers 5. Administer morphine 2 mg IV

ANS: 1., 2., 3., 5. 1., 2., 3., & 5. Correct: What are you worried about? The client has heart failure and is now agitated, gasping for air and trying to sit up. The client is in acute distress, likely from pulmonary edema. The first thing the nurse should do is to sit the client up. This allows for better chest expansion, thereby improving pulmonary capacity. By dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs. Oxygen increases available oxygen for myocardial uptake to combat effects of hypoxia. Morphine decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety. 4. Incorrect: Lactated Ringers is an isotonic solution, which stays in the vascular space. This will make the problem worse.

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? 1. Dysphagia 2. Facial numbness 3. Flushed and warm skin 4. Laryngeal stridor 5. Negative Chvostek's sign

ANS: 1., 2., 4. 1., 2., & 4. Correct: Dyspnea, facial numbness and laryngeal stridor are signs indicating that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. 3. Incorrect: Flushed and warm skin would be seen with hypermagnesemia due to vasodilation. 5. Incorrect: A negative Chvostek's sign is a good thing. It would be positive if the calcium level is low.

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? ABGs: pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%. 1. Administer diazepam 2 mg IV 2. Institute safety precautions 3. Instruct client to take rapid shallow breaths 4. Monitor serum potassium. 5. Start oxygen at 2 liters/min

ANS: 1., 2., 4. 1., 2., & 4. Correct: This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give an anxiolytic. Diazepam is a benzodiazepine or anxiolytic medication that will slow the client's respiratory rate. Safety precautions are needed because this dizziness and faintness can occur with respiratory alkalosis. Hypokalemia may occur as potassium is lost (urine) or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis. 3. Incorrect: The client is already breathing rapidly, which is the problem and blowing off too much carbon dioxide. The client needs to slow down breathing, by taking slow, deep breaths. 5. Incorrect: The client does not have an oxygen problem; they have a CO2 problem. Their O2 is normal.

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based on this information, which nursing action should the nurse initiate? 1. Reposition the client every 2 hours. 2. Request respiratory therapy to perform postural drainage and percussion. 3. Increase oxygen percentage. 4. Initiate incentive spirometry. 5. Assess mental status.

ANS: 1., 4., 5. 1., 4., & 5. Correct: If you had just a colectomy, would you be taking nice deep breaths? No. So what would you be retaining? CO2, which makes your pCO2 go up and your pH go down. These interventions will help improve gas exchange. 2. Incorrect: Requesting postural drainage and percussion form respiratory therapy would not be the best nursing action to address the problem of retaining CO2. 3. Incorrect: How is oxygen going to help this client? It's not until they get rid of what? CO2. And the only way to rid of the CO2 is coughing and deep breathing.

The nurse is caring for a client in the emergency department with agitation, diarrhea, and peripheral edema. Family reports client has a history of chronic renal damage and has been taking a lot of antacids for indigestion. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.34, PaCO2: 48, HCO3: 29 2. pH: 7.50, PaCO2: 35, HCO3: 32 3. pH: 7.32, PaCO2: 36, HCO3: 20 4. pH: 7.42, PaCO2: 40, HCO3: 24

ANS: 2. 2. Correct: Metabolic alkalosis may not show any symptoms. People with this type of alkalosis more often complain of the underlying conditions that are causing it. These can include vomiting, diarrhea, swelling in the lower legs, and fatigue. Severe cases of metabolic alkalosis can cause agitation, disorientation, seizures, and coma. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.50 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2 is 35, which is on the low end of normal (34-45). The HCO3 is 32, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis. 1. Incorrect: This is partially compensated respiratory acidosis. pH: 7.34 (acid), PaCO2: 48 (acid), HCO3: 29 (alkaline) 3. Incorrect: This is metabolic acidosis. pH: 7.32 (acid), PaCO2: 36 (normal), HCO3: 20 (acid) 4. Incorrect: These are normal ABGs. pH: 7.42 (normal), PaCO2: 40 (normal), HCO3: 24 (normal)

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.35, PaCO2 - 45, HCO3 - 22 2. pH - 7.45, PaCO2 - 32, HCO3 - 20 3. pH - 7.46, PaCO2 - 34, HCO3 - 26 4. pH - 7.48, PaCO2 - 44, HCO3 - 28

ANS: 2. 2. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). Both the PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are abnormal at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred. 1. Incorrect: These are normal ABGs. 3. Incorrect: This set of ABGs indicates uncompensated respiratory alkalosis. Compensation has not occurred as the pH is still abnormal and the bicarb is still normal. 4. Incorrect: This set of ABGs indicates uncompensated metabolic alkalosis. The pH is abnormally high (alkalosis). The PaCO2 is normal and the HCO3 are abnormally high (alkalosis). The pH and the HCO3 are both are alkalotic. So we have uncompensated metabolic alkalosis.

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? 1. Determine body surface area injured using the Lund and Browder Method. 2. Draw blood for cardiac enzymes. 3. Infuse Lactated Ringers to maintain hourly urine output between 75-100 mL/hr. 4. Obtain 12 lead electrocardiogram (EKG). 5. Remove nonadherent clothing.

ANS: 2., 3., 4., 5. 2., 3., 4 & 5. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. So the heart can be damaged. We need to assess damage by drawing blood for cardiac enzymes, and by obtaining a 12 lead EKG. Large-bore IV access and large-volume fluid resuscitation is important in patients with anything more than a very minor low-voltage injury. Fluids should be titrated to produce adequate urine output (75 to 100 mL/hr in adults or 1 mg/kg/hr in children). Remove nonadherent clothing so that proper inspection and care can be provided. 1. Incorrect: The Lund and Browder method would not be used for an electrical injury. Visual examination is not predictive of burn size and severity with an electrical burn injury.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.33, PaCO2 = 49, HCO3 = 26, O2 = 92%. What medication could have contributed to these blood gases? 1. Furosemide 2. Chloral hydrate 3. Heroin 4. Methadone 5. Methylphenidate 6. Tramadol

ANS: 2., 3., 4., 6. 2., 3., 4., & 6. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis. 1. Incorrect: No. Diuretics do not affect breathing patterns. 5. Incorrect: No. Ritalin (methylphenidate) is a central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control. It does not generally cause a problem with the respiratory system.

A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? 1. Almond odor to breath 2. Blurred Vision 3. Dull headache 4. Excess salivation 5. Respirations 10

ANS: 2., 3., 5. 2.,3. & 5. Correct: Not enough oxygen is getting to the vital organs, such as the brain and heart, so blurred vision, a dull headache and respiratory depression can occur. 1. Incorrect: An almond odor to the breath is a manifestation of cyanide poisoning. 4. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis.

What should the nurse assess when examining a client who has had a fasciotomy of the arm? 1. Airway 2. Capillary refill 3. Color 4. Level of consciousness 5. Proximal pulses 6. Sensation

ANS: 2., 3., 6. 2., 3., & 6. Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored. 1. Incorrect: We are looking at the arm. The airway is important but we are doing a focused assessment of the arm. 4. Incorrect: Level of consciousness will need to be monitored, but the question specifically asks about the arm. 5. Incorrect: We want to know if circulation below the fasciotomy is impaired or not. So check distal pulses.

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that further treatment is required? 1. CVP 5 mmHg 2. Persistent cough 3. 4.4 kg weight loss in 24 hours 4. Ventricular gallop 5. Urinary output 160 mL/8 hrs 6. S2 heart sound

ANS: 2., 4., 5. 2., 4., & 5. Correct: These are all signs of fluid volume excess seen with heart failure. So further treatment is necessary. 1. Incorrect: This is a normal CVP value, which would indicate the client is improving. 3. Incorrect: A weight loss of 4.4 kg in 24 hours is a good thing. Excess fluid is being removed from the body. 6. Incorrect: S1 and S2 are normal heart sounds.

An intravenous infusion of 0.9% normal saline is prescribed at a rate of 1000 mL in 12 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number. Provide your answer using numbers and decimal points only.

ANS: 21 The formula used to calculate drop rates is the total number of milliliters divided by the total number of minutes multiplied by the drop factor. In this circumstance, the minutes portion must be figured first, that is, 12 hours equals 720 minutes. Then, dividing 1000 by 720 equals 1.38888889. This is multiplied by the drop factor, which is 15. Multiplying 15 by 1.38888889 equals 20.83, which rounds to 21.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary catheter. 4. Weigh the client.

ANS: 3. 3. Correct: The LPN can insert a urinary catheter. 1. Incorrect: This is a new client admit. The RN should perform the physical assessment. 2. Incorrect: The RN should start an initial IV with a potassium supplement. 4. Incorrect: This can best be accomplished by the unlicensed assistive personnel (UAP), it can be done by LPN but not best use of resources.

The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).

ANS: 3., 5. 3. & 5. Correct: Although all the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrhythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dl (normal 9.0-10.5 mg/dl), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrhythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated. 1. Incorrect: While this client's PCO2 of 50 is elevated (normal is 35-45 mm Hg), this is neither unexpected or unusual for an individual with COPD. This client will frequently experience elevated levels of PCO2; therefore, the nurse should just continue monitoring for any changes in respiratory status. 2. Incorrect: This diabetic client has a fasting blood sugar of 145, which is elevated above normal levels of 70-110. However, it is not uncommon for diabetics to occasionally have elevated glucose levels, even early in the morning. The nurse can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary healthcare provider. 4. Incorrect: It is expected that clients diagnosed with sepsis will have extremely elevated white blood cell counts. Despite the fact that this lab result is outside of normal values (4,500 - 10,000 mm3), this level is not concerning enough to immediately contact the primary healthcare provider.

What clinical manifestation does the nurse expect to see in a client suspected of having hypercalcemia? 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes

ANS: 3., 5. 3., & 5. Correct: Hypercalcemia is a condition in which the calcium level in blood is above normal. Too much calcium in blood can weaken bones, create kidney stones, and interfere with heart and brain function. Hypercalcemia is usually a result of overactive parathyroid glands. Other causes include cancer, some medications, and taking too much of calcium and vitamin D supplements. Signs and symptoms of hypercalcemia range from nonexistent to severe. Lethargy and decreased deep tendon reflexes are two manifestations of hypercalcemia. 1. Incorrect: Bradycardia rather than tachycardia is seen with hypercalcemia. Remember - muscles are sedated. 2. Incorrect: A Negative Chvostek will be seen with hypercalcemia. It will be positive in hypocalcemia. 4. Incorrect: Hypercalcemia will result in a decreased, rather than increased respiratory rate.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? ABGs: pH - 7.48 PaO2 - 96% PaCO2 - 48 HCO3 - 34 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

ANS: 3., 6. 3., & 6. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.48 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 48 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 34 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis. 1. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 2. Incorrect: The PaCO2 would be low rather than high if the problem was respiratory alkalosis. 4. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 5. Incorrect: If the ABGs indicated that compensation had not begun (uncompensated) then the CO2 would be normal. Since it is high, the lungs are attempting to compensate for the metabolic alkalosis retaining more acid (Decrease breathing to hold on to acid). 7. Incorrect: Full compensation does not occur until the pH is normal. The pH is still abnormal here.

An agitated client arrives in the emergency department reporting fatigue, diarrhea, and swelling in the legs. Current health history includes cirrhosis. Current medications include spironolactone 25 mg by mouth every morning. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

ANS: 4. 4. Correct: This client's condition indicates metabolic alkalosis. Reduced volume of blood in the arteries can come from both a weakened heart and from cirrhosis of the liver. A reduced blood flow impairs the body's ability to remove the alkaline bicarbonate ions. 1. Incorrect: This client has no respiratory symptoms. This is not respiratory acidosis. 2. Incorrect: This client has no respiratory symptoms. This is not respiratory alkalosis. 3. Incorrect: This client's condition is related to cirrhosis of the liver.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? ABGs: pH - 7.46 PaCO2 - 32 HCO3 - 22 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

ANS: 4., 5. 4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.46 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 32 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis. 1. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 2. Incorrect: The blood gases confirm respiratory alkalosis. The PaCO2 of 32 (normal 35-45) is low which indicates alkalosis. For this client to be in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 6. Incorrect: Compensation has not begun because the bicarb is normal. To compensate the bicarb would need to decrease to bring the pH down to normal. 7. Incorrect: Fully compensated would occur if the pH is normal with abnormal CO2 and bicarb.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that treatment has been successful? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

ANS: 4., 5. 4., & 5. Correct: With fluid volume deficit, the specific gravity can be expected to be abnormally high. This urine specific gravity is normal. This is a normal sodium level. 1. Incorrect: The systolic BP has dropped more than 20 mm Hg from lying to standing. This is considered orthostatic hypotension and indicates that the client is still in a fluid volume deficit. 2. Incorrect: A bounding pulse is an indication of fluid volume excess. We have given the client too much fluid. 3. Incorrect: This weight gain for one day is way too much. This indicates that we have put the client into fluid volume excess, which is a problem.

A client weighing 132.3 pounds (60 kg) is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using numbers and decimal points only.

ANS: 9600 4 mL x 60 kg= 240 240 mL x 40 tbsa= 9,600 mL in the first 24 hours