Midterm Prep U
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia
dehydration
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess
dehydration
The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students is the average daily fluid intake for an adult? 2000 mL 2500 mL 3000 mL 3500 mL
2500 ml
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? Potassium Phosphorus Calcium Magnesium
calcium
When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be triggered. captured. inhibited. nonsynchronous.
captured
The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Red blood cell crenation Red blood cell hydrolysis Cerebral edema Renal failure
cerebral edema
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Hypertension Slow pulse Jaundice
chest pain
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? "I should increase my fluid intake." "I'll enroll in an aerobic exercise program." "I can still drink coffee and tea." "I should eat foods rich in protein."
"I can still drink coffee and tea"
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I'll keep a log of each time my ICD discharges." "I can't wait to get back to my football league." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I need to stay at least 10 inches away from the microwave."
"I'll keep a log of each time my ICD discharges."
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following? "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity? "You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks." "You may resume all normal activity in 1 week; if you are used to playing tennis, you may proceed with this activity." "You should avoid tennis; basketball or football would be a good substitute." "Cancel your tennis tournament and wait until fall, then try hockey; skating is much easier on pacemakers."
"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks."
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? neuromuscular function bowel sounds respiratory rate electrocardiogram (ECG) results
(ECG) results
Which solution is hypotonic? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl
0.45% NaCl
Which is considered an isotonic solution? 0.9% normal saline Dextran in normal saline 0.45% normal saline 3% NaCl
0.9% normal saline
The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be 155 mEq/L (155 mmol/L) 145 mEq/L (145 mmol/L) 135 mEq/L (135 mmol/L) 125 mEq/L (125 mmol/L)
155 mEq/L (155 mmol/L)
A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.50 7.45 7.35 7.30
7.50
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 52-year-old with diarrhea A 72-year-old with a total knee repair
A 52-year-old with diarrhea
The nurse is assigned to care for several clients admitted to a telemetry unit. Which clients should the nurse assess first? A client whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift, requiring amiodarone IV A client who received elective cardioversion 1 hour ago and whose heart rate (HR) is 115 bpm A client diagnosed with new onset of atrial fibrillation, requiring scheduled IV diltiazem A client returned from an electrophysiology procedure 2 hours ago, reporting constipation
A client whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift, requiring amiodarone IV Explanation: The client's implantable cardioverter defibrillator (ICD) that has fired on the previous shift should be seen first. This client is in need of antidysrhythmic medication, which is the priority intervention. The remaining clients should be seen after this client and are in no acute distress.
The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment? A new myocardial infarction client A client with poor kidney perfusion A client with third-degree heart block A client with atrial dysrhythmias
A client with atrial dysrhythmias
The nurse is obtaining a history from a patient diagnosed with hypertrophic cardiomyopathy. What information obtained from the patient is indicative of this form of cardiomyopathy? A history of alcoholism A history of amyloidosis A parent has the same disorder A long-standing history of hypertension
A parent has the same disorder Hypertrophic cardiomyopathy (HCM) is a rare autosomal dominant condition, occurring in men, women, and children (often detected after puberty) with an estimated prevalence rate of 0.05% to 0.2% of the population in the United States (Sander, 2011). Echocardiograms may be performed every year from 12 to 18 years of age and then every 5 years from 18 to 70 years of age in susceptible individuals (i.e., those with a family history of HCM) (Sander, 2011).
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? Red blood cell count Sputum culture Total hemoglobin Arterial blood gas (ABG) analysis
ABG
The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? Administer oxygen. Institute rewarming. Prepare for intubation. Start an IV infusion.
Administer oxygen
You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful? Give bronchodilators. Administer sodium bicarbonate IV. Start potassium IV. Infuse magnesium sulfate.
Administer sodium bicarbonate IV
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a patient with a mechanical valve replacement. The patient's INR is 2.7. Which action should the nurse take? Administer the medication as ordered. Prepare to administer Vitamin K. Hold the medication and notify the HCP. Asses the patient for abnormal bleeding.
Administer the medication as ordered. Explanation: Patients with mechanical valve replacements who take warfarin (Coumadin) usually have individualized target international normalized ratios (INRs) between 2.0 and 3.5. The nurse would give the medication as ordered.
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart? Altered patterns frequently turn into life-threatening arrhythmias. Altered patterns frequently produce neurological deficits. Altered patterns frequently cause a variety of home safety issues. Altered patterns frequently affect the heart's ability to pump blood effectively.
Altered patterns frequently affect the heart's ability to pump blood effectively.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. An elevated hematocrit level A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine
An elevated hematocrit level Electrolyte imbalance
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? Diuretic Anticoagulant Antihypertensive Potassium supplement
Anticoagulant
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? Hematocrit values Hemoglobin levels Pulmonary function Arterial blood gas
Arterial Blood gas
The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle? Atrial depolarization Early ventricular repolarization Ventricular depolarization Ventricular repolarization
Atrial depolarization
A client's electrocardiogram (ECG) tracing reveals a ventricular rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as Atrial flutter Atrial fibrillation Ventricular fibrillation Ventricular tachycardia
Atrial flutter
Which dysrhythmia has an atrial rate between 250 and 400, with saw-toothed P waves? Atrial flutter Atrial fibrillation Ventricular fibrillation Ventricular tachycardia
Atrial flutter
The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what? Atrial rate of 300 to 400 Normal PR interval Regular rhythm P wave resent before each QRS
Atrial rate of 300 to 400
A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid devices with a magnetic field. Use digital cellular telephones. Avoid driving for at least 3 months. Avoid using microwave ovens.
Avoid devices with a magnetic field
A client has had a pacemaker implanted and the nurse will begin client education upon the client becoming alert. Which postimplantation instructions must be provided to the client with a permanent pacemaker? Avoid sources of electrical interference. Keep the arm on the side of the pacemaker higher than the head. Delay activities such as swimming and bowling for at least 3 weeks. Keep moving the arm on the side where the pacemaker is inserted.
Avoid sources of electrical interference. The nurse must instruct the client with a permanent pacemaker to avoid sources of electrical interference, such as MRI devices, large industrial motors, peripheral nerve stimulators, etc.
A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next? Begin cardiopulmonary resuscitation Prepare for endotracheal intubation Provide electrical cardioversion Administer intravenous epinephrine
Begin cardiopulmonary resuscitation
Which is not a likely origination point for cardiac dysrhythmias? bundle of His ventricles atria atrioventricular node
Bundle of his
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? Begin cardiopulmonary resuscitation (CPR) Administer epinephrine Administer atropine 0.5 mg Defibrillate with 360 joules (monophasic defibrillator)
CPR
What is a vasopressor?
Causes constriction of blood pressure, given when BP is low Norepinephrine. Epinephrine. Vasopressin (Vasostrict) Dopamine. Phenylephrine. Dobutamine.
Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium
Chloride
A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis metabolic alkalosis metabolic acidosis r espiratory alkalosis
Chronic respiratory acidosis
A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients? Clients with recurrent life-threatening bradycardias Clients with sinus tachycardia Clients with ventricular bradycardia Clients with recurrent life-threatening tachydysrhythmias
Clients with recurrent life-threatening tachydysrhythmias
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Administer IV bicarbonate. Suction the client's airway.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels
Confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
A patient converts from normal sinus rhythm at 80 beats/min to atrial fibrillation with a ventricular response at 166 beats/min. Blood pressure is 162/74. Respiratory rate is 20/min with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the primary goal of treatment is what? Decrease SA node conduction Control ventricular rate ' Improve oxygenation Maintain anticoagulation
Control ventricular rate Explanation: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice followed by anticoagulation with heparin and then Coumadin.
The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block? A variable heart rate, usually fewer than 60 bpm An irregular rhythm Delayed conduction, producing a prolonged PR interval P waves hidden with the QRS complex
Delayed conduction, producing a prolonged PR interval
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? Decreased cardiac output and decreased systolic and diastolic blood pressure Decreased blood pressure with reflex tachycardia Increased cardiac output and increased systolic and diastolic blood pressure Decreased peripheral vascular resistance
Decreased cardiac output and decreased systolic and diastolic blood pressure
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? Decreased cardiac output and decreased systolic and diastolic blood pressure Decreased blood pressure with reflex tachycardia Increased cardiac output and increased systolic and diastolic blood pressure Decreased peripheral vascular resistance
Decreased cardiac output and decreased systolic and diastolic blood pressure
A middle-aged male with a history of cardiovascular disease has been admitted for cardiogenic shock. In the hours since admission, the client's arterial blood gases indicate acidosis. Which clinical manifestations and diagnostic findings should his care team anticipate before acid-base balance is restored? Select all that apply. Decreased pH Cardiac dysrhythmias Decreased alertness and cognition Hypoventilation Nausea and vomiting
Decreased pH Cardiac dysrhythmias Decreased alertness and cognition Nausea and vomiting
The nurse recognizes which as being true of cardioversion? Amount of voltage used should exceed 400 watts/second. Electrical impulse can be discharged during the T wave. Defibrillator should be set to deliver a shock during the QRS complex. Defibrillator should be set in the non-synchronous mode so the nurse can hit the button at the right time.
Defibrillator should be set to deliver a shock during the QRS complex.
The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication? Variable heart rate, usually fewer than 90 bpm Irregular rhythm Delayed conduction, producing a prolonged PR interval P waves hidden within the QRS complex
Delayed conduction, producing a prolonged PR interval
After teaching a group of students about endocrine disorders, the instructor determines that the teaching was successful when the students identify insulin deficiency, increased levels of counterregulatory hormones, and dehydration as the primary cause of which condition? Diabetic ketoacidosis Ketone bodies Ketonuria Glucosuria
Diabetic Ketoacidosis
A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate the development of left ventricular failure? Dyspnea, orthopnea, pulmonary edema Distended jugular veins, pedal edema, nausea Dyspnea, distended jugular veins, orthopnea Orthopnea, nausea, pedal edema
Dyspnea, orthopnea, pulmonary edema Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea, PND, and pulmonary edema. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right sided heart failure.
The diagnosis of aortic regurgitation (AR) is confirmed by which of the following? Echocardiography Cardiac catheterization Exercise stress testing Myocardial biopsy
Echocardiography Explanation: Diagnosis is confirmed by echocardiography. Cardiac catheterization is not necessary in most patients with AR. Exercise stress testing will assess functional capacity and symptom response. A myocardial biopsy may be performed to analyze myocardial tissue cells in patients with cardiomyopathy.
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis? Cardiac cauterization Computed tomography Echocardiography Chest x-ray
Echocardiography Explanation: Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.
The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the dysrhythmia? Defibrillation Maze procedure Pacemaker implantation Elective cardioversion
Elective cardioversion
A client with an atrial dysrhythmia has come to the clinic for a follow-up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client? Elective electrical cardioversion Chemical cardioversion Mace procedure Elective electrical defibrillation
Elective cardioversion Elective electrical cardioversion is a nonemergency procedure done by a physician to stop rapid, but not necessarily life-threatening, atrial dysrhythmias. Chemical cardioversion is not a procedure; it is drug therapy. A Mace procedure is a distractor for this question. Defibrillation is not an elective procedure.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity
Elevated hematocrit level
Which of the following lab values would be seen in the patient diagnosed with infective endocarditis? Select all that apply. Elevated white blood cell (WBC) count Elevated c-reactive protein Elevated erythrocyte sedimentation rate (ESR) Decreased sedimentation rate Decreased C-reactive protein
Elevated white blood cell (WBC) count Elevated c-reactive protein Elevated erythrocyte sedimentation rate (ESR)
A nurse is caring for a client who has premature ventricular contractions. What sign would the nurse assess in this client? Fluttering/heart skipping Nausea Hypotension Fever
Fluttering/heart skipping
The nurse caring for a client with metabolic alkalosis examines arterial blood gas (ABG) results. Which change from the initial value indicates the client's metabolic alkalosis is improving? pH has increased CO2 has decreased HCO3- has decreased O2 has increased
HCO3 has decreased
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Tetanic contractions Jugular vein distention Weight loss Polyuria
Juglar vein distension
A client is receiving a diuretic as the first-line treatment of mild hypertension. The nurse monitors the client for signs and symptoms of hypokalemia with which agent? Amiloride Spironolactone Triamterene Hydrochlorothiazide
Hydrochlorothiazide
A nurse reviewing a client's echocardiogram report reads the following statements: "The heart muscle is asymmetrically thickened and the overall size and mass are increased, especially along the septum. The ventricular walls are thickened, reducing the size of the ventricular cavities. Several areas of the myocardium show evidence of scaring." The nurse knows these manifestations are indicative of which type of cardiomyopathy? Hypertrophic Dilated Restrictive Arrhythmogenic right ventricular
Hypertrophic Explanation: In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically increases in size and mass, especially along the septum. It often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole. The coronary arteriole walls are also thickened, which decreases the internal diameter of the arterioles. The narrow arterioles restrict the blood supply to the myocardium, causing numerous small areas of ischemia and necrosis. The necrotic areas of the myocardium ultimately fibrose and scar, further impeding ventricular contraction. Because of the structural changes, HCM had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH). Restrictive (or constrictive) cardiomyopathy (RCM) is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? Hypokalemia Alkalosis Hypovolemia Bradycardia
Hypokalemia
When trying to explain the role of potassium and hydrogen related to acid-base, which statement is most accurate? Hypokalemia stimulates H+ secretion. Hyperkalemia will cause the reabsorption of HCO3. Acidosis causes an increase in K+ elimination. Alkalosis tends to increase H+ elimination.
Hypokalemia stimulates H+ secretion.
Which alteration in acid-base balance could be expected as a compensatory response for a client with severe chronic respiratory impairment? Decreased arterial blood pH Increased arterial blood bicarbonate Increased arterial blood oxygen Decreased arterial blood carbon dioxide
Increased arterial blood bicarbonate
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation
Increases arterial PH
Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion? Instruct the client to restrict food and oral intake Administer digitalis and diuretics 24 hours before cardioversion Facilitate CPR until the client is prepared for cardioversion Monitor blood pressure every 4 hours
Instruct the client to restrict food and oral intake
A nurse is providing care for a client who has been diagnosed with metabolic alkalosis after several days of antacid use. Which treatment should the nurse prepare to give? Intravenous or oral administration of free hydrogen ions Intravenous administration of a KCl solution Administration of oxygen and NaHCO3 solution Supplementary oxygen and possible mechanical ventilation
Intravenous administration of a KCl solution KCl administration facilitates the renal retention of hydrogen ions, resulting in lowering of pH. It is not possible to administer free H+ ions, and sodium bicarbonate would exacerbate her condition. Mechanical ventilation is indicated in cases of respiratory acidosis.
A client has an increased serum lactic acid level. The physician understands this is indicative of which disease process? Ischemia Toxicity of lead exposure Free radical injury Apoptosis
Ischemia Ischemia is characterized by impaired oxygen delivery and impaired removal of metabolic end products such as lactic acid. Lead is a particularly toxic metal. Small amounts accumulate to reach toxic levels. The toxicity of lead is related to its multiple biochemical effects. It has the ability to inactivate enzymes, compete with calcium for incorporation into bone, and interfere with nerve transmission and brain development. Many injurious agents exert damaging effects through reactive chemical species known as free radicals. Free radicals are highly reactive chemical species with an unpaired electron in the outer orbit. The actions of free radicals may disrupt and damage cells and tissues. Apoptosis is a selective process that eliminates injured and aged cells. In cells and tissues, free radicals react with proteins, lipids, and carbohydrates, thereby damaging cell membranes, inactivating enzymes, and damaging nucleic acids that make up DNA.
The nurse is caring for a client with a dysrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the dysrhythmia to be which of the following? Peripheral vascular disease Ischemic heart disease Aortic stenosis Atherosclerotic heart disease
Ischemic heart disease The nurse realizes that the most common cause of dysrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque buildup in the vessels may be a component of the disease process but not the best answer.
A client has an increase in her anion gap (AG). What does the nurse determine is the significance of this finding? It indicates the client has metabolic alkalosis. It indicates the client has respiratory alkalosis. It indicates the client has metabolic acidosis. It indicates the client has respiratory acidosis.
It indicates the client has metabolic acidosis.
The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation? It is a scheduled procedure 1 to 10 days in advance. The client is sedated before the procedure. It is used to eliminate ventricular dysrhythmias. It uses less electrical energy than cardioversion.
It is used to eliminate ventricular dysrhythmias.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 5% dextrose and normal saline solution Lactated Ringer's solution Half-normal saline solution 10% dextrose in water
LR
The nurse is reviewing laboratory data for the client with an anion gap of 17. The nurse recognizes which condition is associated with an increased anion gap mEq/L (mmol/L)? Lactic acidosis Hyperkalemia Multiple myeloma Hypermagnesium
Lactic acidosis Normal 8-12 Explanation: The anion gap describes the difference between the serum concentration of the major measured cation (Na) and the sum of the measured anions (Cl and HCO3 ). This difference represents the concentration of unmeasured anions, such as phosphates, sulfates, organic acids, and proteins (Fig. 8-18). Normally, the anion gap ranges between 8 and 12 mEq/L (8 and 12 mmol/L). Lactic acidosis and ketoacidosis results in an increased anion gap as a result of elevated levels of metabolic acids. The other options result in a decreased anion gap.
A patient is 2 days postoperative after having a permanent pacemaker inserted. The nurse observes that the patient is having continuous hiccups as the patient states, "I thought this was normal." What does the nurse understand is occurring with this patient? Fracture of the lead wire Lead wire dislodgement Faulty generator Sensitivity is too low
Lead wire dislodgement
A client who suffered blunt chest trauma in a motor vehicle accident reports chest pain during deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. To relieve this chest pain, which position should the nurse encourage the client to assume? Semi-Fowler's Leaning forward while sitting Supine Prone
Leaning forward while sitting Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, thus helping to relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action, and therefore, do not relieve chest pain associated with pericarditis.
A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the nurse to clarify one of the last treatment options available that the physician mentioned earlier. After checking with the primary nurse, the nursing student would most likely discuss which of the following? Left ventricular assist device Chordoplasty Annuloplasty Open commissurotomy
Left ventricular assist device Explanation: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Because of the limited number of organ donors, many clients die waiting. In some cases, a left ventricular assist device is implanted to support the failing heart until a suitable donor becomes available. The other three choices have to do with failing valves and valve repairs.
For patients diagnosed with aortic stenosis, digoxin would be ordered for which of the following clinical manifestations? Left ventricular dysfunction Angina Edema Dyspnea
Left ventricular dysfunction
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Nausea or vomiting Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
Light-headedness or paresthesia
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Kidney and liver Heart and lungs Lungs and kidney Pancreas and stomach
Lungs and Kidney
Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis? Maintain the client on bed rest Administer a prescribed antipyretic Elevate the client's head Administer supplemental oxygen
Maintain bed rest
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? Keep the client flat for one hour after administration Administer every five minutes during cardiac resuscitation Document heart rate before and after administration Monitor vital signs and cardiac rhythm
Monitor vital signs and cardiac rhythm
A priority nursing intervention for a client with hypervolemia involves which of the following? Establishing I.V. access with a large-bore catheter. Drawing a blood sample for typing and crossmatching. Monitoring respiratory status for signs and symptoms of pulmonary complications. Encouraging the client to consume sodium-free fluids.
Monitoring respiratory status for signs and symptoms
An older adult is reporting increasing fatigue and dark stools. On assessment, the nurse notes pale mucous membranes, low hemoglobin and red cell counts, and upper gastrointestional bleed in the stomach via endoscopy. Questioning reveals excess nonsteroidal anti-inflammatory drug (NSAID) usage to control rheumatoid arthritis pain. Which phenomenon is responsible for the present health problems? NSAIDs increase the gastric production of gastrin, increasing gastric secretions and lowering stomach pH. Drugs such as NSAIDs increase the H+ levels and thus decrease gastric pH, resulting in insult to the stomach lining. NSAIDs, aspirin, and other drugs increase prostaglandin synthesis, resulting in disruption of cellular structures lining the stomach. NSAIDs can disrupt the permeability of the gastric mucosa, causing hydrogen ions to accumulate in the mucosal cells of the lining.
NSAIDs can disrupt the permeability of the gastric mucosa, causing hydrogen ions to accumulate in the mucosal cells of the lining.g
The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as normal sinus rhythm. sinus tachycardia. junctional tachycardia. first-degree atrioventricular block.
NSR
Arterial blood gas analysis would reveal which value related to acute respiratory failure? PaO2 80 mm Hg pH 7.28 PaCO2 32 mm Hg pH 7.35
PH 7.28
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat. Is this normal?" What is the nurse's best response? Premature atrial complex Atrial flutter Sinus tachycardia Ventricular fibrillation
PVC
Undersensing occurs as a pacemaker malfunctions. The nurse understands undersensing occurs as a result of which event? The complex does not follow the pacing spike Pacing spike occurs at the preset level Total absence of the pacing spike Loss of pacing artifact
Pacing spike occurs at the preset level
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat. Is this normal?" What is the nurse's best response? Premature atrial complex Atrial flutter Sinus tachycardia Ventricular fibrillation
Premature atrial complex
When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias? Premature ventricular contraction (PVC) Ventricular bigeminy Ventricular tachycardia Ventricular fibrillation
Premature ventricular contraction (PVC)
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.
Prepare to assist with ventilation
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness
Presence of Trousseau sign Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval
QRS
The nurse analayzes the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which finding indicates the need for follow-up? QT interval that is 0. 46 seconds long PR interval that is 0.18 seconds long QRS complex that is 0.10 seconds long ST segment that is isoelectric in appearance
QT interval that is 0. 46 seconds long
A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next? Question the client about alcohol and illicit drug use. Instruct the client to hold the breath and bear down. Prepare to administer a calcium channel blocker. Place the client on supplemental oxygen.
Question the client about alcohol and illicit drug use.
A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention? Initiate oral rehydration therapy at 100 mL/kg of oral rehydration solution over 4 hours. Request an order from the physician for IV rehydration therapy. Assess vital signs every 15 minutes. Obtain stool specimen for analysis.
Request an order from the physician for IV rehydration therapy.
The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is: Diminished alveolar surface area. Hypercapnia resulting from decreased carbon dioxide elimination. Hypoxemia secondary to impaired oxygen diffusion. Respiratory acidosis.
Respiratory acidosis
Which intervention should the nurse include in the plan of care for a client with valvular heart disease who is experiencing pulmonary congestion? Report a weight gain of 3 pounds in 1 week Rest and sleep in a chair or sit in bed with head elevated Take nitroglycerin if shortness of breath develops Drink at least 2 L of fluid daily and monitor urine output
Rest and sleep in a chair or sit in bed with head elevated Explanation: Clients who experience symptoms of pulmonary congestion are advised to rest and sleep sitting in a chair or bed with the head elevated. In addition, the nurse educates the client to measure weight daily and report gains of 3 pounds in 1 day or 5 pounds in 1 week to the primary provider. The nurse may assist the client with planning activity and rest periods to achieve an acceptable lifestyle.
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1? Right side of sternum, fourth intercostal space Left side of sternum, fourth intercostal space Midway between V2 and V4 Mid-clavicular line, fifth intercostal space
Right side of sternum, fourth intercostal space
After a detailed diagnostic workup, a patient has been diagnosed with atrial septal defect (ASD). The nurse should recognize that this patient may exhibit many of the signs and symptoms that are typically associated with: Unstable angina Right-sided heart failure Myocardial infarction Endocarditis
Right-sided heart failure Explanation: Because of left-to-right shunting of blood in ASDs, patients often experience elevated right heart pressure and pulmonary congestion. This does not mimic the signs and symptoms of acute coronary syndrome or of infectious processes such as endocarditis.
A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? A loud, blowing murmur Hypertension Shortness of breath Tachycardia
SOB
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Serum sodium level of 124 mEq/L
A nurse is caring for a client with acute mitral regurgitation related to an acute myocardial infarction. The nurse knows to monitor the client carefully for symptoms of which initial complication or result? Severe heart failure Kidney failure Cerebral vascular accident (CVA) Infarcted bowel
Severe heart failure Explanation: Acute mitral regurgitation usually manifests as severe congestive heart failure, resulting from blood flowing backward from the left ventricle to the left atria and eventually into the lungs. Kidney failure could become a problem later if cardiac output is too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.
The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe? Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers AV node, SA node, bundle of His, right and left bundle branches, and the Purkinje fibers SA node, AV node, right and left bundle branches, bundle of His, and the Purkinje fibers SA node, AV node, bundle of His, the Purkinje fibers, and the right and left bundle branches
Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first? Stay with the patient, use a calm voice, and ask for assistance via call light. Notify the health care provider immediately. Place the patient in the left lateral recumbent position. Administer morphine by intravenous push slowly.
Stay with the patient, use a calm voice, and ask for assistance via call light The nurse stays with the patient and continues to assess and record signs and symptoms while intervening to decrease patient anxiety. The pulse pressure is narrowing, and the patient is experiencing neck vein distention, indicative of rising central venous pressure. After reaching assistance via the call light from the patient's beside, the nurse notifies the physician immediately and prepares to assist with diagnostic echocardiography and pericardiocentesis. A left lateral recumbent position is used when administering enemas. Morphine would be given to someone who may be experiencing a myocardial infarction, not cardiac tamponade.
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Bradycardia Tachycardia Vasodilation Increased urine output
Tachycardia
The nurse is caring for a client with dysrhythmia. What would be an important procedure to teach a client with dysrhythmia to perform to evaluate his or her response to treatment? Technique for monitoring drug toxicity Technique for palpating and counting the radial pulse Technique for monitoring cardiac response Technique for monitoring blood pressure
Technique for palpating and counting the radial pulse
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make? The client is severely hypoxic. The oxygen level is low but poses no risk for the client. The client's PaO2 level is within normal range. The client requires oxygen therapy with very low oxygen concentrations.
The client is severely hypoxic. Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
A nurse caring for a patient with mitral stenosis understands that the initial cause of disruption to the normal flow of blood through the heart is due to: The increased resistance of a narrowed orifice between the left atrium and the left ventricle. Inadequate left ventricle filling. Atrial hypertrophy. Pulmonary circulation congestion.
The increased resistance of a narrowed orifice between the left atrium and the left ventricle.
A health care provider is caring for an older adult client with a recent diagnosis of renal failure and an acid-base imbalance. The family asks, "What is the underlying cause of the renal failure?" Which phenomenon would most accurately answer the question? The kidneys are integral to the reabsorption of hydrogen ions and maintenance of a low pH. Blood buffer systems and respiratory control can compensate for inadequate renal control of pH. The kidneys have the primary responsibility for eliminating excess hydrogen ions from the body. pH is kept at an optimal level through the renal secretion of bicarbonate ions in blood filtrate.
The kidneys have the primary responsibility for eliminating excess hydrogen ions from the body.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? The lungs are unable to breathe in sufficient oxygen. The lungs are unable to exchange oxygen and carbon dioxide. The lungs have ineffective cilia from years of smoking. The lungs are not able to blow off carbon dioxide.
The lungs are not able to blow off carbon dioxide.
A 70-year-old man who enjoys good health began taking low-dose aspirin several months ago based on recommendations that he read in a magazine article. During the man's most recent visit to his care provider, routine blood work was ordered and the results indicated an unprecedented rise in the man's serum creatinine and blood urea nitrogen (BUN) levels. How should a nurse best interpret these findings? The man may be experiencing a paradoxical effect of aspirin The man may be allergic to aspirin The man may be experiencing liver toxicity from the aspirin The man may be experiencing nephrotoxic effects of aspirin
The man may be experiencing nephrotoxic effects of aspirin
The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated? The registered nurse stating to administer digoxin The registered nurse administering atropine sulfate intravenously The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute The registered nurse stating to administer all medications except those which are cardiotonics
The registered nurse administering atropine sulfate intravenously
A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? Tingling or twitching sensation in the fingers Confusion and depression Dyspnea and laryngospasm Hyperactive bowel sounds.
Tingling or twitching sensation in the fingers
The client has just been diagnosed with a dysrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm? Heart rate between 60 and 150 beats/minute. Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 second. The ventricles depolarize in 0.5 second or less. The sinoatrial (SA) node initiates the impulse.
The sinoatrial (SA) node initiates the impulse.
The nurse participates in the care of a client requiring emergent defibrillation. The nurse determines the steps should be completed in which order? Turn on the defibrillator and place it in "not sync" mode. Charge the defibrillator to the prescribed voltage. Apply the multifunction conductor pads to the client's chest. Call "clear" three times ensuring client and environmental safety. Deliver the prescribed electrical charge.
Turn on the defibrillator and place it in "not sync" mode. Charge the defibrillator to the prescribed voltage. Apply the multifunction conductor pads to the client's chest. Call "clear" three times ensuring client and environmental safety. Deliver the prescribed electrical charge.
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low? U wave T wave P wave QT interval
U wave The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a client's serum potassium level is low. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a client's serum potassium level is high. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.03 Urine pH of 3.0 Absence of protein Absence of glucose
Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.
A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? Ventricular tachycardia Atrial fibrillation Third-degree heart block Ventricular fibrillation
Ventricular fibrillation
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi? Adenosine Amiodarone Warfarin Atropine
Warfarin
A client is brought in by ambulance in a nauseous and confused state and demonstrating carpopedal spasm. Initial arterial blood gases show increased pH and HCO3 and normal PaCO2 levels. Breathing is slow and shallow. As the nurse caring for this client, you know that potassium salt should be a part of the treatment for this client when? Always When hypokalemia is present When there is volume depletion When base bicarbonate accumulates
When hypokalemia is present
The nurse caring for a client with cardiomyopathy plans to have an education session with the client and the client's spouse about ways to improve cardiac output and reduce the workload of the heart. Which of the following instructions would help reduce preload? When resting, sit up with the legs down to pool blood in the legs. Lay flat in bed when resting so the heart does not have to pump against gravity. Adhere to a regular diet without restrictions. Avoid all physical and emotional stress.
When resting, sit up with the legs down to pool blood in the legs. Explanation: Many clients find that sitting up with their legs down is more comfortable than lying in bed. This position is helpful in pooling venous blood in the periphery and reducing preload. Laying flat in bed impairs respiratory efforts due to abdominal contents pushing against the lungs. This client must be on a low sodium cardiac diet to avoid fluid retention. It is impossible to avoid all physical and emotional stress.
Which is the most common cause of symptomatic hypomagnesemia? Intravenous drug use Alcoholism Sedentary lifestyle Burns
alcolism
The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia? Supraventricular tachycardia Atrial flutter Ventricular fibrillation Complete heart block
complete heart block Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.
Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? dyspnea dizziness blurred vision mental confusion
dizziness Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Low heart rate Elevated blood pressure Rapid respiration Subnormal temperature
elevated BP
A client with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The client's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of embolic stroke. myocardial infarction. heart failure. renal failure.
embolic stroke ntervention is implemented to prevent the development of an embolic event/stroke. Clients with a history of previous stroke, transient ischemic attack (TIA), embolic event, mitral stenosis, or prosthetic heart valve and who develop atrial fibrillation are at significant risk of developing an embolic stroke. Antithrombotic therapy is indicated for all clients with atrial fibrillation, especially those at risk of an embolic event, such as a stroke, and it is the only therapy that decreases cardiovascular mortality. These client are often placed on warfarin, in contrast to clients who have no risk factors, and who are often prescribed 81 to 325 mg of aspirin daily.
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? Dehydration Hypokalemia Hypocalcemia Hypomagnesemia
hypocalcemia
The nurse is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client? Fluttering Nausea Hypotension Fever
fluttering
A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the student to clarify one of the last treatment options available that the physician mentioned. After checking with the primary nurse, the student would most likely discuss which of the following? Heart transplantation Xenograft tissue valve Annuloplasty Valvuloplasty
heart transplantation
Which of the following electrolyte imbalances occur with adrenal insufficiency? Hyperkalemia Hypokalemia Hyponatremia Hypernatremia
hyperkalemia
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypocalcemia. hypothyroidism. hypoglycemia. hypokalemia.
hypokalemia
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypokalemia hyperkalemia hypocalcemia hypercalcemia
hypokalemia Explanation: Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.
Which could be a potential cause of respiratory acidosis? Vomiting Hypoventilation Diarrhea Hyperventilation
hypoventilation
Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results? increase in rate and depth of respirations decrease in rate and depth of respirations increase in the rate of respirations and decrease in the depth decrease in the rate of respirations and increase in depth
increase the rate and depth of respirations
Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.
increased breathing effort and weight gain.
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: insert a nasogastric tube (NG) as ordered. administer acetaminophen as ordered. instruct the client to breathe into a paper bag. administer antibiotics as ordered.
instruct the client to breathe into a paper bag.
When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Irregular heart rate Weight loss of 4 lb Mild confusion Blood pressure 96/53 mm Hg
irregular heart rate
A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client? Magnesium Chloride Potassium Phosphorus
magnesium
The client has arterial blood gases (ABG) drawn. The results are a pH of 7.50, PCO2 30 mEq/L (30 mmol/L), and HCO3- 24. The nurse understands that which condition/action could cause these ABG results? Mechanical ventilation Severe potassium deficit Extreme obesity Fasting
mechanical ventilation
A client admitted to the hospital with severe diarrhea has a K+ level of 6.7 mEq/L (6.7 mmol/L), symptoms of paresthesia, restlessness, and dyspnea. What could have caused his condition? Hyperaldosteronism Metabolic acidosis Respiratory alkalosis Diabetes insipidus
metabolic acidosis
The nurse is caring for a client who has excessive diarrhea. Which acid-base disturbance does the nurse anticipate uncovering during evaluation of the arterial blood gas? No change in values from normal An increase in bicarbonate Metabolic acidosis Increased pH value
metabolic acidosis
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
metabolic acidosis
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
metabolic alkalosis
A client tells the nurse that the client has been taking Alka-Seltzer (bicarbonate—antacid) four times a day for the past 2 weeks for an upset stomach. Upon assessment of the client, the nurse notes hyperactive reflexes, tetany, and mental confusion. Arterial blood gases reveal pH 7.55; serum HCO3− 37 mEq/L (37 mmol/L). The nurse suspects the client may be experiencing: Metabolic alkalosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis
metabolic alkalosis
For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis
metabolic alkalosis
For which acid-base imbalance will the nurse monitor for a client taking large doses of loop diuretics? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
metabolic alkalosis
Ms. Crampton is prescribed furosemide for chronic heart failure. The nurse knows that furosemide can cause electrolyte imbalances and what other serious side effect? Metabolic alkalosis Metabolic acidosis Compensated respiratory alkalosis Compensated respiratory acidosis
metabolic alkalosis
Vomiting results in which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
metabolic alkalosis
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: muscle weakness. tremors. diaphoresis. constipation.
muscle weakness
The nurse recognizes that Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they: occur at a rate of more than six per minute occur during the QRS complex have the same shape are paired with a normal beat
occur at a rate of more than six per minute
Which is a correct route of administration for potassium? Subcutaneous Intramuscular Oral IV (intravenous) push
oral
The nurse is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker? Date and time of insertion Location of the generator Model number Pacer rate
pacer rate
A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? Occasional U waves Peaked T waves Flattened P waves Prolonged QT interval
peaked T waves
A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? Occasional U waves Peaked T waves Flattened P waves Prolonged QT interval
peaked t waves
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Tetanic contractions Jugular vein distention Weight loss Polyuria
polyuria
The nurse is reviewing lab results of a client diagnosed with metabolic acidosis. The most important electrolyte for the nurse to assess would be: Potassium (K+) Calcium (Ca2+) Sodium (Na+) Magnesium (Mg2+)
potassium Alterations in potassium levels can affect acid-base balance, and changes in acid-base balance can influence potassium levels. Acidosis tends to increase serum potassium levels by causing potassium to move from the ICF to the ECF.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: an access route to administer medications intravenously. replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis.
replacement of fluids for those lost from vomiting and diarrhea.
A client arrives in the emergency department by ambulance with a family member stating, "He took an overdose of sleeping pills and I found him breathing very shallowly." For which type of acid-base disturbance will the nurse anticipate this client will be treated? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
respiratory acidosis
Which sign is an early indicator of hypoxia in the unconscious client? cyanosis decreased respirations restlessness hypotension
restlessness
A client with a recent history of atrial fibrillation has been prescribed warfarin. What action will the nurse take to confirm safe dosing? assess the client's radial pulse. assess the client's apical pulse. review the client's international normalized ratio (INR). review the client's most recent warfarin blood levels.
review the client's international normalized ratio (INR).
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? Shock Stroke Seizures Hyperglycemia
shock
When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating normal sinus rhythm. sinus bradycardia. sinus dysrhythmia. sinus tachycardia.
sinus dysrhythmia. Explanation: Sinus dysrhythmia occurs when the sinus node creates an impulse at an irregular rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway. Sinus bradycardia occurs when the sinus node regularly creates an impulse at a slower-than-normal rate. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Sodium Potassium Calcium Magnesium
sodium
A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose? supraventricular tachycardia sinus tachycardia heart block atrial flutter
super ventricular tachycardia
A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose? supraventricular tachycardia sinus tachycardia heart block atrial flutter
supraventricular tachycardia
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? third-spacing pitting edema anasarca hypovolemia
third spacing
During electrical cardioversion, the defibrillator is set to synchronize with the electrocardiogram (ECG) so that the electrical impulse discharges during atrial depolarization. ventricular depolarization. ventricular repolarization. the QT interval.
ventricular depolarization
The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? Vital signs Edema Intake and output Weight
weight