HurstReview

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 110/70 lying; 100/68 standing 2. Moist mucous membranes 3. Skin turgor recoil below clavicle is 3 seconds 4. Urine specific gravity of 1.033 5. Serum sodium 152 mEq (152 mmol/L)

1. & 2. Correct: These BP readings are within normal limits. Moist mucous membranes is a normal, desired finding.

How should the nurse interpret this arterial blood gas (ABG) report? pH - 7.33 PaO2 - 95% PaCO2 - 28 HCO3 - 18 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1., & 6. Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has not occurred. There is only partial compensation.

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care? 1. Elevate head of bed to a semi-fowlers position. 2. Monitor the color of urine and stools. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily.

1., 2., 3., & 5. Correct: The client needs to have the head of the bed elevated in order to relieve the pressure of ascites off of the diaphragm. The client with ascites is in a fluid volume deficit (FVD) and has the risk for postural hypotension and falls. It is important to monitor for jaundice. When jaundice is present the urine may be dark brown and the stool light gray to tan color. The distended tissue with ascites is fragile and can breakdown. Remember that the problem is the loss of protein into peritoneal cavity. Protein is necessary for tissue repair. This lab level would indicate renal function that can occur due to shock.

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. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 5. Heart rate 88/min 6. CVP 8mmHg

1., 2., 3., 4., & 6. Correct: These are all signs of fluid volume excess seen with heart failure.

Which clinical manifestations would validate to the nurse that a client has developed an electrolyte imbalance due to malabsorption from celiac disease? 1. Numbness 2. Muscle cramps 3. Negative Trousseau 4. Irritable 5. Muscle spasticity 6. Hyperreactivity to sensory stimuli

1., 2., 4., 5., & 6. Correct: Low magnesium is typically due to decreased absorption of magnesium in the gut or increased excretion of magnesium in the urine. Conditions that increase the risk of magnesium deficiency include gastrointestinal (GI) diseases, such as Celiac disease, advanced age, type 2 diabetes, use of loop diuretics, and alcohol dependence. Early signs of low magnesium include nausea, vomiting, weakness, and decreased appetite. As magnesium deficiency worsens, symptoms may include numbness, tingling, muscle cramps, seizures, muscle spasticity, personality changes, dysrhythmias, tremors, hyperactive deep-tendon reflexes, hyperreactivity to sensory stimuli, positive Chvostek and Trousseau signs, tetany, and nystagmus.

Which information should the community health nurse include when explaining to a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV)? 1. Immune globulin contains antibodies 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.

1., 3., 4. & 5. Correct: These are all correct statements about immune globulin for Hepatitis A.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases? 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine

1., 4. & 5. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis.

A client with asthma has been admitted to the emergency room with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? 1. Initiate high flow oxygen. 2. Prepare for endotracheal intubation. 3. Administer 1000mL of lactate ringers (LR). 4. Assess for head and neck injuries.

2. Correct: Intubation must be accomplished quickly while a tube can still be inserted. The burn clients neck and facial area may become edematous due to capillary permeability. This can be done while assuming the client may have a head and neck injury due to the explosion.

The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. Based on the EKG obtained, what action should the nurse take first? 1. Defibrillate at 200 joules x 2 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

2. Correct: The one electrolyte we worry about with arrhythmias is potassium. The first line medication is amiodarone.

A nurse is caring for a client who had an abdominal hernia repair 16 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH - 7.32 PaO2 - 93% PaCO2 - 48 HCO3 - 24 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

2. Correct: The pH is 7.32 (normal 7.35-7.45) which means acidosis. The paCO2 of 48 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis.

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).

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.

Which client would the nurse monitor for the development of hypovolemic shock? 1. Admitted with acute myocardial infarction (MI) 2. Post-operative hip replacement with spinal anesthesia 3. Diagnosed with Addisonian crisis 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with severe vomiting and diarrhea

3., 4. & 5. Correct: These clients are at risk for hypovolemic shock due to the loss of fluid or blood.

A client has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.40, PaCO2: 44, HCO3: 23 2. pH: 7.33, PaCO2: 35, HCO3: 18 3. pH: 7.35, PaCO2: 48, HCO3: 29 4. pH: 7.46, PaCO2: 35, HCO3: 28

4. Correct: The stomach as a lot of acid in it. So, if the client is vomiting a lot, then the client is losing acid. This will make the client alkalotic inside. Is this going to be a lung problem? No. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.46 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 28, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis.

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? 1. Bradypnea 2. Flaccid muscle tone 3. Flushed and warm skin 4. Positive Trousseau's sign 5. Leg cramps 6. Decreased deep tendon reflexes

4., & 5. Correct: A positive Trousseau's sign indicates that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. Hypocalcemia will cause muscle twitching and painful muscle cramps.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaCO2 - 29 HCO3 - 24 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis.

A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene?

Establish airway patency Assess breathing Administer 100% humidified oxygen Soak burned area with cool water. Remove restrictive objects

An adult client has partial and full thickness burns over the anterior trunk and anterior and posterior aspects of both legs. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.

The anterior trunk counts for 18% of the body; entire right leg counts 18%; entire left leg counts 18%. Body surface on this client is 54%.

The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients? The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. The client with facial burns 3 days ago who has been crying since recent visitors left.

The nurse should first see is the client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. This client has a fever and hypotension, indicative of life threatening complications of shock. In this case, septic shock. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L should be seen second. This client is at risk for heart problems (dysrhythmias) with the electrical burn and the elevated potassium level. The third client the nurse should see is the client reporting pain 7/10. The nurse needs to administer pain medication. However, remember that pain never killed anyone. Take care of the other two client first. This are at risk for death. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the most stable.

A nurse assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions are priority? 1. Initiate seizure precautions 2. Monitor potassium level 3. Monitor BUN and creatinine 4. Restrict calicum rich foods 5. Check for airway patency

1. & 5. Correct: The parathyroid glands can accidentally be removed with a thyroidectomy. Low calcium causes rigid and tight muscles.

A client with a diagnosis of heart failure is observed in Fowler's position states, "I can't get my breath". What is the priority intervention for this client? 1. Dangle the client's legs over the side of the bed. 2. Auscultate anterior and posterior lung fields bilaterally. 3. Call respiratory therapy to the room stat to bring an oxygen mask. 4. Administer PRN morphine sulfate 2 mg IVP via existing venous access device.

1. Correct: Since the client is already in a Fowler's position,the correct option would be to "Dangle the client's legs over the side of the bed." The reason is that 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.

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30

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.

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? 1. Blood pressure 96/68; HR 98; RR 20 2. WBC 12,000/mm3 (12 x 10^9)/L 3. CVP- 6 mmHg 4. pH- 7.30; pCO2- 44; pO2 -92; HCO3- 20 5. Urinary output of 20 mL/hr

1., & 3. Correct: The systolic BP should be greater than 90. Normal CVP is 2-6 mmHg.

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. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. 5. Perform the rule of nines

1., 2., 3., & 4. 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.

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? 1. Start oxygen at 4 liters/min 2. Instruct on taking slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic

2., 3., 4. & 5. 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 if necessary.

A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 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

4. Correct: This client's condition indicates pending metabolic alkalosis. Hypokalemia related to potassium loss with a loop diuretic is a cause of metabolic alkalosis.