Fundamentals Quiz 6
1. A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.)
"I feel a little short of breath." "I feel as though my heart is racing." "The nurse technician told me that my blood pressure was 150 over 90."
A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching?
"Report diarrhea while taking this medication."
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:
0.45% normal saline (NS)
The three steps of oxygenation:
1- Ventilation 2- Perfusion 3- Diffusion
RN cannot delegate
1. Patient education 2. task that needs nursing judgement 3. Nursing assessment
Normal magnesium level
1.3-2.1 mEq/L
Normal sodium level
136-145 mEq/L
Which of the following clients is most at risk for fluid volume deficit? 25-year-old male near-drowning victim 56-year-old woman with salicylate poisoning 45-year-old woman with second-degree burns over 20% of her body 13-year-old boy with an oral temperature of 103.4 F
45-year-old woman with second-degree burns over 20% of her body
Normal calcium level
9-10.5mg/dL
Normal chloride level
98-106 mEq/L
. The nurse recognizes which of the following clients is at the greatest risk for dehydration?
A 79-year-old client who has been diagnosed with advanced Alzheimers disease Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration.
Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?
A milkshake Calcium is necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction.
What is an expected outcome after tracheostomy care is successfully performed?
An inner cannula that is free of secretions
The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning?
Applying intermittent suction for 10 seconds during catheter removal
The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing a face mask. Which action by the student should the nursing instructor question?
Asking the patient to swallow while the catheter is being inserted
Cardiopulmonary circulation process
Blood comes into the right atrium from the body, moves into the right ventricle and is pushed into the pulmonary arteries in the lungs. After picking up oxygen, the blood travels back to the heart through the pulmonary veins into the left atrium, to the left ventricle and out to the body's tissues through the aorta.
A mineral naturally found in various foods, but our main dietary source is sodium chloride, otherwise known as table salt. Chloride carries an electric charge and therefore is classified as an electrolyte, along with sodium and potassium.
Chloride
Which of the following tasks might be delegated to nursing assistive personnel (NAP)?
Chronic wound that needs a nonsterile moist-to-dry dressing change The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic
When observing a patient for symptoms of dehydration, the nurse should observe which assessment?
Decreased capillary filling
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
Evaluate electrolytes Explanation: Assess the client's electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances.
Symptoms: Distended neck veins, increased blood pressure, tachycardia , shortness of breath, crackles in the lungs, edema Treatment: Stop the infusion, raise the head of the bed, measure vital signs and oxygen saturation, adjust the rate after correcting fluid overload, admin diuretics
Fluid overload
The nurse is teaching the patient and family how to perform tracheal suctioning. What does proper technique include?
Having the patient take two to three deep breaths after the procedure
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) a. Hct 55% b. Blood osmolarity 260 mOsm/kg c. Blood sodium 150 mEq/L d. Urine specific gravity 1.035 e. Blood creatinine 0.6 mg/dL
Hct 55% b. Blood osmolarity 260 mOsm/kg Blood sodium 150 mEq/L Urine specific gravity 1.035
The nurse uses nursing diagnoses after completion of the client assessment, because they:
Identify the domain and focus of nursing
Which one of the following is an appropriate etiology for a nursing diagnosis? 1 Myocardial infarction 2 Cardiac catheterization 3 Abnormal blood gas levels 4 Increased airway secretions
Increased airway secretions
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions?
Initiating continuous cardiac monitoring
Although the provider might prescribe other mild cleansing agents, _____________ remain the preferred cleansing agents.
Isotonic solutions
A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
Monitor the color of a client's urinary output
A nurse is preparing to suction a patient via the nasotracheal route. Which conditions should the nurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.)
Motor vehicle accident with acute head injuries History of hemophilia Epiglottitis or croup
Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia?
Nausea and vomiting
The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel?
Obtain preexercise and postexercise vital signs.
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.)
Older adults are more prone to dehydration that younger adults are. Older adults need the same amount of most vitamins and minerals as younger adults do. Many older men and women need calcium supplementation.
A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Postural hypotension
The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are run to assess the level of which component in the patient's blood?
Potassium (K) When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk.
A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
Pull fluid from the cells · Explanation: A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink.
The primary purpose of a nursing diagnosis, according to the nurses, is to:
Recognize the clients response to an illness or situation
The nurse is caring for an unconscious patient who has an oral airway in place, and who has copious amounts of oral secretions. What may the nurse have to do while caring for this patient? (Select all that apply.)
Replace or clean the oral airway. Suction the oral cavity frequently.
An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient?
Risk for injury related to drug interactions
The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the clients assessment?
Serum potassium Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.
The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload?
Tap water · Explanation: A tap-water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop.
A 64-year-old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the clients having an autologous infusion, but there are some drawbacks as well. Which of the following would be considered a drawback to an autologous infusion?
The client may have a decreased hemoglobin and hematocrit level on the day of surgery.
The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue the suctioning if which of the following occurs?
The heart rate decreases from 84 beats per minute to 60 beats per minute.
Pregnancy affects a woman's oxygenation needs primarily because of:
The increased metabolic demands required to support the fetus
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
The nurse is caring for a patient diagnosed with severe dehydration. The nurse notes that the patient's albumin level is 4.0. What might this indicate?
The level may be falsely high. In patients who are dehydrated or who have received infusions of albumin, fresh frozen plasma, or whole blood, serum albumin levels will appear normal.
Cardiopulmonary circulation function
The pulmonary circulation has many essential functions. Its primary function involves the exchange of gases across the alveolar membrane which ultimately supplies oxygenated blood to the rest of the body and eliminates carbon dioxide from the circulation.
The nurse has diagnosed the clients problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:
Total hip replacement Total hip replacement because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the clients response, such as decreased mobility.
The nurse is preparing to suction an infant with a tracheostomy tube. Which action by the nurse follows appropriate procedure?
Using a suction catheter that is half the diameter of the tracheostomy tube
Which of the following processes are involved in respiration? (Select all that apply.) a. Ventilation b. Diffusion c. Oximetry d. Perfusion
Ventilation Diffusion Perfusion Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O2 and CO2 between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries.
The nurse on the unit is determining which activities may be delegated to assistive personnel. Assuming that the nurse assistant is competent, which one of the following activities may be safely delegated by the registered nurse?
Vital signs on a stable client
The nurse performing nasotracheal suctioning should be assessing the patient for which possible unexpected outcomes? (Select all that apply.) a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding
a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding (All answers should be selected)
Complete or partial collapse of a lung or a section (lobe) of a lung.
atelectasis
Pharmacologic intervention for anxiety, pain, agitation
benzodiazepines opioids
Pharmacologic intervention for bronchospasm
bronchodilators
________________ is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation.
cardiac afterload
Pharmacologic intervention for airway inflammation
corticosteroids
Pharmacologic intervention for pulmonary congestion
diuretics nitrates (if heart failure present)
An appropriate technique for the nurse to implement when obtaining an arterial blood gas (ABG) specimen is to:
insert the needle at a 45-degree angle
A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results? pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L
pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L Metabolic acidosis may be found in cases of starvation
The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse's first action should be to:
reduce the infusion rate.
A __________________is inserted directly into the trachea through a small incision made in the patient's neck.
tracheostomy tube
What are the four steps in gas exchange?
ventilation, pulmonary gas exchange, gas transport, and peripheral gas exchange. These processes describe how gas is inhaled, exhaled, exchanged at the alveoli, transported through the blood, and again diffused across cellular membranes in body tissues.
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:
0.45% normal saline (NS) · Explanation: The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid.
Which of the following foods will have the greatest impact on the water balance of the person consuming it?
A pickle Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food
A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.) 1 A respiratory rate of 36 breaths per minute 2 Complaints of numbness in fingers and toes 3 Dizziness when attempting to sit upright 4 Difficulty holding a cup because of tremors 5 An irregular heartbeat on an electrocardiogram (ECG) 6 Warm, flushed skin
A respiratory rate of 36 breaths per minute Complaints of numbness in fingers and toes Dizziness when attempting to sit upright Difficulty holding a cup because of tremors
Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?
A spinach salad Magnesium is essential for enzyme activities, neurochemical activities, and cardiac and skeletal muscle excitability
When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: An elevated hematocrit level Engorged peripheral veins A bounding pulse Rales
An elevated hematocrit level
The patient is being transferred from the emergency department to another institution for treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)?
Assessing the patient's respiratory status before transport
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel?
Assist the client to select food choices from the menu.
What breathing does low potassium cause?
Breathing requires the use of several muscles, particularly the diaphragm. If a person's potassium levels become very low, these muscles may not work properly. A person may have difficulty taking a deep breath or may feel very short of breath.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Decrease in heart rate Explanation: Fluid volume deficit causes tachycardia
Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics?
Decreased bowel sounds Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? Acute pain related to left mastectomy Impaired gas exchange related to altered blood gases Deficient knowledge related to need for cardiac catheterization Need for high protein diet related to alteration in client nutrition
Deficient knowledge related to need for cardiac catheterization
A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced:
Diarrhea A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting
Which symptom is the patient with fluid overload likely to exhibit?
Distended neck veins · Explanation: Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins.
The nurse is caring for a patient receiving parenteral nutrition (PN). In planning the patient's care for the day, which nursing assessment is most essential?
Electrolyte levels Explanation: Since the need for parenteral nutrition (PN) is usually associated with conditions that result in electrolyte instability, maintaining electrolyte balance during therapy is crucial. Monitor the patient's electrolyte levels (potassium, magnesium, and phosphorus) for low serum levels which may indicate a risk for arrhythmias and muscle weakness, Patients at risk may require having electrolyte panels done several times a day.
Body fluid that is not contained in cells. It is found in blood, in lymph, in body cavities lined with serous (moisture-exuding) membrane, in the cavities and channels of the brain and spinal cord, and in muscular and other body tissues.
Extracellular fluid
A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:
Formulates a diagnosis too closely resembling a medical diagnosis A nursing diagnosis should identify the clients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.
A solution that contains more dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood.
Hypertonic solution
_____________ pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.
Hypertonic solutions
Diuretic therapy puts a pt at risk for what?
Hypokalemia is most common adverse reaction
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
Hyponatremia
A solution that contains fewer dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood. Commonly used to give fluids intravenously to hospitalized patients in order to treat or avoid dehydration.
Hypotonic solution
. Which of the following statements best reflects the nurses understanding of team nursing?
I delegate the care of the clients to the appropriate team members and I am responsible for coordinating and directing that care.
Which of the following statements made by a nurse related to the organization of client care requires follow-up by the mentor?
I delegated all the stable vital signs to my nursing assistant and the treatments to the LPN.
Which of the following is an appropriate etiology for a nursing diagnosis? 1 Incisional pain 2 Poor hygienic practices 3 Need to offer bedpan frequently 4 Inadequate prescription of medication
Incisional pain Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a clients response to a health problem, and a condition that a nurse can treat or manage.
A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) a. Increase protein intake to increase muscle mass. b. Decrease fluid intake to prevent urinary incontinence. c. Increase calcium intake to prevent osteoporosis. d. Limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation.
Increase protein intake to increase muscle mass. Increase calcium intake to prevent osteoporosis. Limit sodium intake to prevent edema. Increase fiber intake to prevent constipation.
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?
Infuse hypotonic IV fluids
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?
Infuse hypotonic IV fluids.
The main function is to help with the transport of gases, nutrients, and other molecules. Also important for intracellular communication and cell signaling.
Intracellular fluid
Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as________ fluids.
Isotonic · Explanation: Isotonic fluids have the same osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic the body's fluid loss in the absence of an electrolyte imbalance.
A solution that has the same salt concentration as cells and blood
Isotonic solution
The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the clients:
Lungs clear bilaterally on auscultation
Arterial blood gas levels are obtained for the client. If the clients results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?
Metabolic alkalosis The clients pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis.
The nurse is assessing several patients who have returned from surgery. Which finding most likely indicates a need for suctioning?
Oxygen saturation level of 88%
A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate?
Performing a simple dressing change.
When preparing an infant for an enema, the nurse understands that which solution is the safest?
Physiological normal saline · Explanation: Physiological normal saline is the safest solution. Infants and children can only tolerate this type of solution because of their predisposition to fluid imbalance.
1. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL
Potassium 5.4 mg/dL
A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider? a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L d.) Loose stools
Potassium 5.5 mEq/L
The nurse has completed suctioning a patient's airway. Which action should the nurse take first?
Pull the gloves off over the rolled catheter and discard.
A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by the nurse is appropriate?
Push the catheter in until resistance is felt or the patient coughs.
The client is to receive a Kayexalate enema. The nurse recognizes that this is used to:
Remove excess potassium from the system Kayexalate is a type of medicated enema used to treat clients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent constipation, and Kayexalate is not a diarrheal medication
The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:
Replace the oxygen and allow rest in between suctioning passes
The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include:
Replacement of fluid and electrolytes · Explanation: The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance
An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from:
Respiratory acidosis
An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from:
Respiratory acidosis These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis.
For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with:
Respiratory alkalosis A salicylate overdose may cause respiratory alkalosis because of hyperventilation
The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:
Retention of HCO3 by the kidneys to increase the pH level
The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate?
Transporting the preoperative client from the unit to the holding area
The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor:
Urine output Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved
What is an example of an isotonic solution?
0.9 wt % NaCl solution (regular saline)
Normal phosphate level
3-4.5 mg/dL
Normal potassium level
3.5-5 mEq/L
Normal ionized calcium level
4.5-5.6mg/dL
. If parenteral nutrition (PN) must be discontinued suddenly, hang___________ in water at the same infusion rate to prevent hypoglycemia
5% dextrose Explanation: The 5% dextrose solution will maintain the fluid and electrolyte balance of the patient until the PN therapy may be either restarted or gradually withdrawn.
Which of the following foods will have the greatest impact on the hearts conductivity of the person consuming it?
A banana Explanation: Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food.
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
A client who has nasogastric suctioning
A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?
Abdominal cramping The client has hyponatremia, manifestations include abdominal cramping, weakness, headache, and nausea.
Independent actions that can be taken when a pt has trouble breathing
Adjust bed position breathing exercises encouraging deep breath inspiratory muscle training incentive spirometer
The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse take when the patient develops respiratory distress?
Administer oxygen directly through the suction catheter.
A patient using a nasal cannula has gurgling on inspiration. The nurse notes a productive cough but the inability to clear the secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning?
Apply clean gloves and a mask.
. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel?
Applying restraints Although the nursing assistive personnel can apply the restraints under the nurses direction, they cannot document, evaluate, or take physicians orders.
The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is appropriate?
Applying suction for 15 seconds or less
In reviewing the results of the clients blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is: Magnesium 2.1 mEq/L Potassium 3.5 mEq/L Sodium 140 mEq/L Calcium 3.9 mEq/L
Calcium 3.9 mEq/L A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L
What type of patient should have their weight taken daily?
Cardiac
A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:
Cardiac dysrhythmias Lasix is a nonpotassium-sparing diuretic. Without a potassium supplement the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include?
Check the client's weight each morning.
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?
Crohn's disease
The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question?
Cutting gauze pads to place around the tracheostomy tube Explanation: Do not use scissors to cut gauze pads as they may shed fibers that could be inhaled by the patient.
A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.) 1 Tingling fingers 2 Difficult to arouse 3 Warm, flushed skin 4 Tremors in the hands 5 Reporting a terrible headache 6 Repeatedly asking Where am I?
Difficult to arouse Warm, flushed skin Tremors in the hands Reporting a terrible headache Repeatedly asking Where am I?
Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.) Dry, hot skin Memory lapses Dry, cracked lips Weak, slow pulse Physical weakness Decreased urination
Dry, hot skin Memory lapses Dry, cracked lips Physical weakness Decreased urination
Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?
Dry, sticky tongue
The client is taking medications to promote defecation. Which of the following instructions should be included by the nurse in the teaching plan for this client?
Emollient solutions may increase the amount of water secreted into the bowel.
A client has been admitted to the emergency department with an aspirin overdose. The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate) poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for:
Excess carbon dioxide The body is attempting to correct the acid-base balance, so the respiratory system causes the body to breathe faster in order to try to blow off the excessive carbon dioxide.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
Explanation: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath. Auscultate lung sounds Explanation: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.
A term used to describe the balance of input and output of fluids in the body, to allow metabolic processes to function properly. The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in. Fluid imbalance causes: hypovolemia, normo-volemia with maldistribution of fluid, and hypervolemia, blood loss from due to trauma, dehydration Inadequate fluid intake or excessive fluid loss can lead to dehydration, which in turn can affect cardiac and renal function and electrolyte management. Inadequate urine production can lead to volume overload, renal failure and electrolyte toxicity.
Fluid balance
A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of:
Hypokalemia Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics.
The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?
Hypotonic or isotonic solutions · Explanation: Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss.
Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurses mentor?
I have my nursing assistant take and document all vital signs and intake and outputs. Vitals signs should only be delegated when a patient is in stable condition
The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur?
Impaired gas exchange
What is the principal difference in tracheostomy care between care given in the acute care setting and care given in the home care environment?
In the home care setting, the procedure may be done with clean technique.
Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences.
Inability to speak in complete sentences Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1 Risk for change in body image related to cancer 2 Cardiac output decreased related to motor vehicle accident 3 Ineffective airway clearance related to increased secretions 4 Potential for injury related to improper teaching in the use of crutches
Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology
The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the throat and trachea. Which action by the nurse demonstrates proper technique?
Inserting the suction catheter 6 to 8 inches during inspiration
The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is:
Lactated Ringers · Explanation: Lactated Ringers is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringers are both hypertonic solutions.
A patient with head trauma following a motor vehicle accident is on mechanical ventilation with an endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning?
Limit suctioning to 2 times with each suctioning procedure.
The nurse is reviewing lab results for a patient with hypoxemia. The nurse is aware that which of the following results may worsen the patient's hypoxemia? (Select all that apply.)
Low hemoglobin levels Increased blood pH
Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?
Monitor vital signs every 15 minutes. Explanation: Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure).
A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
Move fluid into the cells · Explanation: Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge.
When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?
Neurological
The nurse is discussing dietary intake with a client who is human immunodeficiency virus (HIV) positive. The nurse informs the client that the diet will include a:
Reduction in fat with smaller, more frequent meals HIV-infected clients typically experience body wasting and severe weight loss. Restorative care for these clients focuses upon maximizing kilocalories and nutrients. Low-fat diets and small, frequent, nutrient-dense meals may be better tolerated.
The nurse in the intensive care unit (ICU) is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.)
Respiratory arrest/Medications/Heart damage/Electrolyte disturbances · Explanation: Causes of dysrhythmia may include electrolyte disturbances (potassium, magnesium, calcium), heart damage, and certain prescribed or recreational medications. Early intervention for a respiratory arrest usually prevents a cardiac arrest.
A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.)
Sodium and water shift that out of the vessels because of increased permeability Plasma that leaves the intravascular space and becomes trapped in blisters Plasma and interstitial fluids that are lost as burn exudate Water vapor that is lost through the skin that is burned Blood leakage via damaged capillaries in the dermis
Which assessment should a nurse expect to see for a patient receiving parenteral nutrition (PN)?
Weight gain of 1 to 2 pounds per week
What should you ask a patient who has rapidly gained weight?
When was the last time you voided?
The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.) a. Violent coughing b. Aspiration of stomach contents c. Increased intracranial pressure d. Bradycardia or tachycardia
a. Violent coughing b. Aspiration of stomach contents c. Increased intracranial pressure d. Bradycardia or tachycardia (all options selected)
__________ is the initial stretching of the cardiac myocytes (muscle cells) prior to contraction.
cardiac preload
The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient's blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n):
forehead sensor.
When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient. Inadequate tissue perfusion is known as .
ischemia
A patient who requires ngtube suctioning is at risk for what?
metabolic alkalosis (due to loss of acid from suction)
Pharmacologic intervention for secretions
mucolytic agents
Signs of hypercalcemia
muscle weakness, bone pain, may be high risk for falls and should call nurse to ambulate
