Med-Surg Exam 1 - Practice: Fluids/Electrolytes

A patient presented to the unit with an ADH-secreting tumor. Upon diagnostic and physical evaluation, the nurse suspects the patient is experiencing SIADH. Which of the following is a clinical manifestation of SIADH? Select all that apply. a. Hyponatremia b. Hypernatremia c. Increased serum osmolality d. Reduced serum osmolality e. Dry mucous membranes f. Low urine output

a. Hyponatremia d. Reduced serum osmolality f. Low urine output

A nurse has an order to infuse 1000 mL 5% dextrose in lactated Ringers at 80 mL/hour. The nurse time-tapes the bag with a start time of 09:00. After making hourly marks on the time tape, the nurse notes that the completion time for the bag is: 15:30 17:30 19:30 21:30

21:30

A nurse prepares to administer potassium chloride through a central IV line for a client with hypokalemia. The nurse would avoid doing which of the following when preparing and administering this medication? Diluting the medication in an appropriate amount of normal saline Monitoring urine output during administration Monitoring the IV site for redness and inflammation Administering the medication without a controlled IV infusion device

Administering the medication without a controlled IV infusion device

A client with left-sided heart failure is scheduled at 8 a.m. for a daily dose of furosemide (Lasix). The nurse would withhold the dose and report which of the following serum potassium levels to the physician? 3.0 mEq/L 3.9 mEq/L 4.2 mEq/L 5.1 mEq/L

3.0 mEq/L

A nurse notes that a client has a prominent U wave on the ECG monitor. The nurse interprets that this is consistent with which of the following serum potassium levels? 5.4 mEq/L 4.7 mEq/L 3.8 mEq/L 3.0 mEq/L

3.0 mEq/L

The nurse glances at a telephone laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse checks the name at the top of the sheet. The nurse interprets that this is an expected finding because the client identified has which of the following health problems? Ulcerative colitis Long-Term laxative abuse Severe burn injury Cushing's syndrome

Severe burn injury

A physician is discussing the fluid balance of a postoperative client. The physician states the clients insensible fluid loss is approximately 600 mL daily. The nurse interprets that the physician is referring to fluid loss that is occurring thorough the: Wound drain and skin Skin and lungs Nasogastric tube and wound drain Foley catheter and nasogastric tube

Skin and lungs

A nurse prepares to administer sodium polystyrene sulfonate (Kayexalate) to the client. A first-year nursing student asks the nurse how the medication works. The nurse responds that the medication works in the gastrointestinal tract by releasing: Sodium ions exchange for primarily bicarbonate ions Sodium ions exchange for primarily potassium ions Bicarbonate exchange for primarily sodium ions Potassium ions exchange for primarily sodium ions

Sodium ions exchange for primarily potassium ions

A postoperative client without a history of respiratory disease has a pulse oximeter in place. A family member who is visiting the client asks the nurse what the numbers should read on the console. The nurse responds that the pulse oximeter readings should be at least: 85% 90% 95% 100%

95%

Which of the following are signs and symptoms of fluid volume excess (FVE)? A)Low serum osmolarity B)Furrowed tongue C)Jugular vein distension D)Orthostatic hypotension E)Low pulse pressure F)Full and bounding pulse

A)Low serum osmolarity C)Jugular vein distension F)Full and bounding pulse

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A. The client in normal sinus rhythm with a peaked T wave. B. The client diagnosed with atrial fibrillation, HR of 100. C. The client diagnosed with a myocardial infarction who has occasional PVC. D. The client with a first-degree AV block and a rate of 92.

A. The client in normal sinus rhythm with a peaked T wave.

You're a nurse on a med/surg unit and just received report on your 4 patients for the day. Which patient do you see first? A)A 55-year-old male with heart failure and 3+ pitting edema scheduled to receive his Lasix (Furosemide) 30 minutes ago. B)A 36-year-old female who received IV antibiotics an hour ago and is reporting a rash and chest tightness. C)A 75-year-old male post-hip replacement reporting sudden onset 9/10 pain requesting pain medication. D)A 90-year-old patient with COPD and an O2 sat of 89%.

B)A 36-year-old female who received IV antibiotics an hour ago and is reporting a rash and chest tightness. We are concerned about this patient having an anaphylactic reaction to the antibiotics recently infused. The patient could develop anaphylaxis, which could compromise their airway.

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A. Deficient fluid volume related to decreased fluid intake B. Excess fluid volume related to increased water retention C. Deficient fluid volume related to excessive fluid loss D. Risk for injury related to fluid volume loss

B. Excess fluid volume related to increased water retention

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A. Withhold furosemide (Lasix) B. Notify the physician/nurse-practitioner C. Administer the prescribed potassium supplement D. Instruct the client on foods high in potassium

B. Notify the physician/nurse-practitioner

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician/nurse-practitioner

C. Assess for signs of fluid overload

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. B. Anemia. C. Dehydration. D. Renal failure.

C. Dehydration.

A nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which of the following assigned clients is most at risk for fluid volume excess? The client with a draining abdominal wound The client with a nasogastric tube at low suction The client with renal failure The client with an ileostomy

The client with renal failure

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.

D. Place on seizure precautions.

A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse would assess for which of the following signs and symptoms that correlate with this fluid imbalance? Increased blood pressure Decreased pulse Decreased central venous pressure (CVP) Bibasilar crackles

Decreased central venous pressure (CVP)

The nurse is assigned to a group of clients on the clinical nursing unit. The nurse determines that the client who is least likely to develop third spacing of fluids is the one with a diagnosis of: Major burn Renal failure Laennac's cirrhosis Hypertension

Hypertension

A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following assessment findings during the next hour? Serous drainage of the surgical dressing Blood pressure of 100/70 mmHg Urinary output of 20 mL/hour Temperature of 37.6C (99.6F)

Urinary output of 20 mL/hour

The nurse provides patient education related to the management of iron deficiency anemia. Which statement made by the patient signifies understanding of the education provided? a. "I should take my iron pills with a glass of orange juice." b. "I should take my iron pills with breakfast to decrease stomach upset." c. "Iron pills often cause constipation so I should decrease my fluid and fiber intake." d. "I will need to take these pills for only a few days, and then my problem will be fixed."

a. "I should take my iron pills with a glass of orange juice."

The nurse is caring for a 32-year-old with circumferential full-thickness burns to the right arm and trunk. Which nursing intervention has the highest priority in the plan of care? a. Assess radial pulses several times a day. b. Enforce airborne infection control procedures. c. Perform range-of-motion exercises several times per day. d. Remove blisters from the burn area.

a. Assess radial pulses several times a day.

The nurse is explaining the potential signs and symptoms of a transfusion reaction to a patient who is receiving a first blood transfusion for the first time. How will the nurse ensure safe blood product administration? Select all that apply. a. Check ABO compatibility by comparing the blood product label to the patient's medical record. b. Use two patient identifiers, such as the patient's date of birth and name, to verify the blood product. c. Administer the blood product slowly for the first 15 minutes. d. Administer acetaminophen and diphenhydramine, which are standard premedications used in all transfused patients. e. Obtain baseline vital signs before the transfusion is administered.

a. Check ABO compatibility by comparing the blood product label to the patient's medical record. b. Use two patient identifiers, such as the patient's date of birth and name, to verify the blood product. c. Administer the blood product slowly for the first 15 minutes. e. Obtain baseline vital signs before the transfusion is administered.

The nurse is caring for a patient diagnosed with ALL who is receiving initial treatment. The patient has been complaining of a dry cough. The patient also has diminished breath sounds upon auscultation. What should the nurse monitor as priority with regard to potential complications in this patient? a. Hemoglobin b. Absolute neutrophil count (ANC) c. Hematocrit d. Urine

b. Absolute neutrophil count (ANC)

A patient is diagnosed with SIADH. What disturbance should the nurse be aware of related to this diagnosis? a. Excess water loss b. Dilutional hyponatremia c. Serum sodium level of 148 mg/dL d. Decreased urine osmolality

b. Dilutional hyponatremia The basic physiologic disturbances in SIADH are excessive ADH activity, with water retention and dilutional hyponatremia, and inappropriate urinary excretion of sodium in the presence of hyponatremia. Serum sodium levels are decreased. Urine osmolality is increased in SIADH.

When entering a patient's room, the nurse notices blood clots in the IV line. What is the most appropriate nursing intervention at this time? a. Milk the tubing. b. Discontinue the infusion. c. Irrigate the tubing and catheter. d. Aspirate the clot from the tubing.

b. Discontinue the infusion. If blood clots occur in the IV line, the infusion must be discontinued and restarted in another site with a new cannula and administration set. The tubing should not be irrigated or milked. The clot should not be aspirated from the tubing.

A patient with severe burn injuries to the abdomen and legs becomes combative when it is time to change the dressings. What nursing intervention will be most helpful to this patient? a. Allow the patient to determine the time of dressing change. b. Premedicate the patient with pain and anxiety medications before dressing change. c. Tell the patient it is OK to cry during the dressing change. d. Explain the importance of dressing changes.

b. Premedicate the patient with pain and anxiety medications before dressing change.

A patient's 18-year-old son would like to donate blood. The nurse educates him regarding eligibility requirements for blood donation. Which statement demonstrates that he does not understand the education provided? a. "I am so glad that I am old enough to donate." b. "Because I just got a tattoo a week ago, I am unable to donate." c. "Because I live with a friend with HIV, I cannot donate." d. "Because my girlfriend has hepatitis, and we are sexually active, I cannot donate."

c. "Because I live with a friend with HIV, I cannot donate."

A patient who was burned at 10:00 AM reports a pre-burn weight of 154 lb (70 kg). The estimated total body surface area (TBSA) burned is 60%. Using the Parkland/Baxter formula, the nurse verifies that the total amount of intravenous lactated Ringer solution to be infused by 6:00 PM on the day of the burn is which of the following? a. 5,200 mL b. 7,470 mL c. 8,400 mL d. 16,800 mL

c. 8,400 mL

A nurse working on a trauma unit is initiating IV fluids for a patient. For what condition would the nurse administer normal saline? a. Renal impairment b. Pulmonary edema c. Burns d. Heart failure

c. Burns Normal saline (0.9% sodium chloride) is used with blood transfusions and to replace large sodium losses, as in burn injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium retention.

A patient is being treated for sepsis. On the second day of receiving care, the patient experiences epistaxis and persistent bleeding from a venipuncture site. The nurse suspects DIC. Which laboratory result supports the nurse's suspicion? a. Increased fibrinogen, decreased PTT, decreased platelets b. Decreased fibrinogen, increased PTT, increased platelets c. Decreased fibrinogen, increased PTT, decreased platelets d. Increased fibrinogen, increased PTT, increased platelets

c. Decreased fibrinogen, increased PTT, decreased platelets

A nurse is analyzing her patient's ABG values. Which result is inconsistent with the diagnosis of respiratory acidosis? a. pH 7.3 b. PaCO2 50 c. Hyperventilation (PaCO2 25) d. Hypoventilation (PaCO2 60)

c. Hyperventilation (PaCO2 25) Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2. Any condition that causes hypoventilation is associated with an elevated PaCO2. Hyperventilation, causes a decrease in CO2 and is associated with respiratory alkalosis.

What does the nurse expect to see on the ECG reading when serum potassium levels rise to greater than 6 mEq/L? a. Peaked, widened T waves b. ST-segment elevation c. Lengthened QT interval d. ST-segment depression

d. ST-segment depression When potassium levels are greater than 6 mEq/L, the earliest ECG changes are a peaked, narrow T wave, ST-segment depression, and a shortened QT interval. If the serum potassium level continues to increase, the PR interval becomes prolonged and is followed by disappearance of the P waves.

A nurse in the postanesthesia care unit (PACU) receives a client in transfer from the operating room. On admission to the PACU, the client's vital signs are blood pressure (BP) 112/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which of the following actions would the nurse most appropriately take? Recheck the vital signs in 5 minutes Call the surgeon immediately Cover the client with a warm blanket Shake gently to arouse

Recheck the vital signs in 5 minutes

What is a reasonable option for pain management for a 50-year-old man who has just sustained 20% partial-thickness burns to his right leg and abdomen? a. Fentanyl 50 μg intravenously b. Morphine sulfate 10 mg IM into the left deltoid c. Calm, reassuring words to help relax him d. Oxycodone 10 mg PO

a. Fentanyl 50 μg intravenously

A nurse would suspect an inhalation injury with which of the following findings? Select all that apply. a. History of burn occurring in an enclosed space b. Carbonaceous sputum c. Egophony d. Stridor e. Singing of nasal hair

a. History of burn occurring in an enclosed space b. Carbonaceous sputum d. Stridor e. Singing of nasal hair

A nurse receives intershift report and is assigned to a client who has been given desmopressin (DDAVP) for a complication of cranial surgery. The nurse would monitor for which therapeutic effect to the medication during initial shift rounds? Decreased urine output Increased pulse rate Improved Neurological signs Increased blood pressure

Decreased urine output

A nurse is caring for a client with cirrhosis. The client has a nursing diagnosis of fluid volume excess. The nurse would determine that the diagnosis is resolving if which of the following data is obtained by the nurse? Increasing central venous pressure Increasing pulse Decreasing body weight Decreasing urine output

Decreasing body weight

A nurse is caring for a confused elderly client who is beginning total parenteral nutrition (TPN). The client continually tries to get out of bed independently. The nurse writes in the care plan that which of the following should be done to prevent this particular client from injury? Monitor temperature once daily Calculate daily intake and output Monitor blood glucose levels every 12 hours Ensure that all tubing connections are taped

Ensure that all tubing connections are taped

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. An order was written for a new bag at the beginning of the shift, but it has not arrived yet from the pharmacy. The nurse takes which of the following actions first? Hangs a solution of 10% dextrose in water Hangs a solution of 5% dextrose in 0.9% sodium chloride Calls the pharmacy Calls the physician

Hangs a solution of 10% dextrose in water

A nurse has been assigned to the care of a patient that has had D5W running at 125 cc/hr for three days. The nurse is concerned about the potential development of: Hypoglycemia Fluid volume deficit Hyponatremia Hyperkalemia

Hyponatremia

A pateint has an IV of D5W infusing at a KVO rate. On return from Xray, the IV that had 800 cc left to infuse one hour ago, now has 300 cc left to go. You immediately put the IV on a pump and if you were to draw blood work you could expect to see.... Hypernatremia and hyperkalemia Hyponatremia and hyperglycemia Hyperkalemia and hyperglycemia Hypoglycemia and hypokalemia

Hyponatremia and hyperglycemia

The nurse is caring for a client with a nasogastric (NG) tube who has orders to have the tube irrigated once every 8 hours. The nurse ensures that which of the following solutions is placed in the clients room to be used for the irrigation Sterile Water Normal saline Tap water Half-strength normal saline

Normal saline

An adult client has had serum electrolytes drawn as part of preadmission testing before surgery. The nurse would report which abnormal value to the surgeon's office preoperatively? Sodium 142 mEq/L Potassium 5.4 mEq/L Chloride 103 mEq/L Bicarbonate 24 mEq/L

Potassium 5.4 mEq/L