HESI Week 1

An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mmHg and HCO 3 is 20 mEq/L. Which disturbance would the nurse identify based on these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis - low pH and low bicarb level are consistent with metabolic acidosis

Which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia? a. assessing the client for fluid overload b. monitoring the client's response, particularly within first 10 min c. assuring that the transfusion flows at a consistent rate during the procedure d. having the client tested for HIV before administering the blood transfusion

b. monitoring the client's response, particularly in first 10 minutes -observe for allergic rxn will permit a quick termination of the infusion

which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L? Select all that apply. anorexia constipation muscle weakness irregular heart rhythm hyperactive bowel tones

c. Muscle weakness d. Irregular heart rhythm e. Hyperactive bowl tones

Which electrolyte abnormality will the nurse expect in a client who is experiencing both tingling of the extremities and tetany? hypokalemia hypocalcemia hyponatremia hypochloremia

hypocalcemia - paresthesias and tetany are signs of hypocalcemia

Which action would the nurse take FIRST when a client reports flank pain halfway through receiving a unit of packed red blood cells? stop transfusion obtain vital signs assess pain further monitor hourly urinary output

stop transfusion

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? - Provide pretzels as a snack daily. - Restrict fluid intake to 1000 mL per day. - Assess neurologic status every 2 hours. - Administer intravenous fluid of one-half (0.45%) normal saline (NS) at 125 mL/hr.

Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr. - because 0.45% NaCl is a hypotonic solution, it is contraindicated. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral or IV fluids (severe case)

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply 1) Seizures 2) Confusion 3) Thirst 4) Erythema 5) Constipation

1) seizures 2) confusion Cellular swelling and cerebral edema are associated with hyponatremia;as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures.Thirst is a symptom of hyper-natremia; it may indicate dehydration.Erythema is not associated with hyponatremia. Diarrhea is associated with hyponatremia

The nurse is caring for a client receiving magnesium sulfate for treatment of preeclampsia. Which findings alert the nurse to signs of magnesium sulfate toxicitiy? select all that apply proteinuria epigastric pain loss of patellar reflexes urine output of 40 mL/h respirations of 10 breaths/min

Respirations of 10 breaths/min Loss of patellar reflexes - hypermangsesemia do the OPPOSITE prefix (depresses CNS and respiratory system; causes urinary retention and decreased deep tendon reflexes)

Which intravenous fluid is a hypertonic solution a. Ringer solution b. 5% dextrose in water c. Lactated Ringer solution d. 5% dextrose in normal saline

d. 5% dextrose in normal saline - pulls fluid from cells, causing them to shrink and the extracellular space to expand

While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? - Panic - Pyrogenic - Anaphylactic - Hemolytic

Anaphylactic - result from hypersensitivity to a product in the blood. signs and symptoms are due to bronchospasm, systemic vasodilation, and compensatory tachycardia. the client may go into threatening shock with prompt treatment

Which findings by the nurse when assessing a client who is receiving IV fluids indicates need for a change in the fluid infusion rate? crackles in lung supple skin turgor urine output of 480 mL over 8 hours heart rate decrease from 126 to 96 bpm

crackles in lungs - indicates client is overloaded with fluids

Which clinical indicator would the nurse expect when an IV line has infiltrated? Select all that apply. heat pallor edema decreased flow rate increased blood pressure

pallor edema decrease flow rate - infiltration is unintentional administration of a non-vescicant in to surrounding tissue

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? 1- Sodium and chloride levels 2- Bicarbonate and sulfate levels 3- Magnesium and protein levels 4- Calcium and phosphate levels

Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting

Which prescription would the nurse question when a client's serum sodium is 123 mEq/L? a. add table salt to each meal b. fluid restriction of 1000ml per day c. assess neurological status Q2 hr d. provide 0.45% sodium chloride intravenously at 125 ml/hr

d. administer iv fluid of one half normal saline at 125 ml/hr - it is a hypotonic solution which means it is contradindicated. It would build upon the issue instead of correcting it.

which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L? - monitor for cardiac dysrhythmias - inquire about changes in bowel patterns - assess for leg muscle twitching or weakness - assess for signs and symptoms of dehydration

monitor for cardiac dysrhythmias - severe bradycardia and slowing of the cardiac conduction system are the most severe complications of HYPERKALEMIA (prefix is SAME except for heart). Other manifestations are signs but not life threatening