NS3205 Exam 2
Which condition or clinical manifestation indicates that the client's treatment for hyperkalemia is effective?
Pulse rate is 76 and regular.
Which acid-base imbalance should the nurse be most alert for when providing care to a client who has several broken ribs?
Respiratory acidosis from inadequate ventilation
An anxious woman is hyperventilating. Blood-gas testing reveals pH 7.58, PaCO2 22 mmHg, HCO3 18 mEq/L. These values indicate:
Respiratory alkalosis, partially compensated
What is the priority nursing diagnosis for a client who has moderate hypokalemia?
Risk for falls related to skeletal muscle weakness
Which of the following nursing diagnoses would be a priority for a client with severe metabolic alkalosis?
Risk for injury related to increased CNS excitement from accompanying hypocalcemia and skeletal muscle weakness
The client states that his brain tumor is benign and does not need to be removed. What is the nurse's best response?
"Because benign tumors continue to get larger, when they are in a place that could damage normal tissue, they need to be removed."
An older client says that she does not perform breast self-examination because there is no history of breast cancer in her family. What is the nurse's best response?
"Breast cancer can be found more frequently in families. However, the risk for general, nonfamilial breast cancer increases with age."
The client says that she has heard that the origin of most cancers is "genetic". What is the nurse's best response?
"Cancers arise in cells that have alterations in the genes."
Based on the higher mortality rates in men from specific types of cancers, which question is most important for the nurse to ask during annual health screenings?
"Do you smoke cigarettes?"
A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective?
"I will avoid excess use of antacids."
What action is most important for the nurse to teach the client who is at continuing risk for mild hypernatremia to take to prevent hypernatremia?
"Read the labels of all packaged foods to determine the sodium content."
What action is most important for the nurse to teach the client who is at continued risk for complications from hypocalcemia?
"Use an electric shaver rather than a straight razor."
Which subjective symptom reported by the client should alert the nurse to the possibility of hypocalcemia?
"Usually I wake up several times a night with painful cramps in my legs or feet."
A client refuses a potassium supplement and prefers dietary intervention. Which foods will best help raise the client's potassium level?
1/2 cup of raisins Glass of skim milk 1 cup of cantaloupe
Which client is at greatest risk for developing hyponatremia?
35-year-old client who is NPO and receiving 1/2 NS as the mainstay of intravenous therapy
A nurse is conducting a cancer risk screening program. Which of the following clients is at greatest risk for skin cancer?
60-year-old mountain biker.
With which client should the nurse be most alert for the development of overhydration?
75-year-old client receiving blood replacement therapy with 3 units of packed red blood cells
A client has an arterial blood gas pH of 7.48. How does the nurse interpret this client's acid-base status?
A deficit in blood hydrogen ion concentration
Which laboratory data and clinical manifestations should cause the nurse to suspect a client may be experiencing acidosis?
A serum potassium level of 6.5 mEq/L and flaccid paralysis
Which intervention for the client with overhydration-induced confusion is most likely to relieve the confusion?
Administering diuretic agents as prescribed
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should the nurse discuss?
Age.
The nurse recognizes which client as at greatest risk for alkalosis?
An adult client with a critical illness receiving total parenteral nutrition
The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment 1 hour ago. What is the nurse's first best action?
Assess the client's rate, rhythm, and dept of respiration.
A 42-year-old female is interested in making dietary changes to reduce the risk of colon cancer. What dietary selections should the nurse suggest?
Bran muffin, skim milk, stir-fried broccoli.
What are the fluid compartment consequences of isotonic dehydration?
ECF compartment volume contracts, ICF volume remains the same
A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned about?
Ca2+ 8.2 mg/dL
A client has been taught the need to restrict sodium. Which food selection indicates appropriate choices?
Chicken leg and 1/2 cup of steamed carrots
A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia?
Client with heart failure using a salt substitute
The client with chronic respiratory acidosis who is receiving oxygen by nasal cannula at 10 L/min now has a respiratory rate of 8. What is the nurse's best action?
Decrease the oxygen flow rate.
The nurse is assessing a 60-year-old male who has hoarseness. The should conduct a focused assessment to determine:
History of tobacco use and alcohol consumption.
EXTRA CREDIT A 42-year-old female highway construction worker is concerned about her cancer risks. She has been married for 18 years, has two children, smokes one pack of cigarettes per day, and occasionally drinks one to two beers. She is 30 lbs overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What behavioral changes should the nurse instruct this client to make to decrease her risk of cancer?
Improve nutrition. Use sunscreen. Stop smoking. Lose weight.
Which assessment findings should the nurse expect in the client with metabolic acidosis?
Increased rate and depth of respiration
Which characteristic of a tumor indicates that it is benign rather than malignant?
It is surrounded by a capsule.
Which intravenous solution should the nurse be prepared to administer to a client who has isotonic dehydration?
Lactated ringers
Mr. Gates has smoked one pack of cigarettes for the last 20 years. He has an increased risk of developing which of the following types of cancers?
Laryngeal Bladder Liver Stomach
A nurse has been asked to create a cancer risk reduction pamphlet for the clients who come to a clinic that serves a large African American population. Therefore, prevention and early detection tips for which cancer types would be most important to include in this pamphlet?
Lung and prostate
A patient has a hernia repair and postoperatively develops a paralytic ileus requiring NG suction. The patient is at greatest risk for developing:
Metabolic alkalosis
The nurse monitors for which acid-base imbalance in the client who has received six units of packed red blood cells in the past 6 hours secondary to blood loss in surgery?
Metabolic alkalosis
The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000-mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns and the nurse notes that the IV site is swollen. What intervention will the nurse perform first?
Stops the IV fluid containing potassium
The nurse correlates the role of suppressor genes in cancer development to which action?
Suppressor genes control the expression of oncogenes, reducing the risk for cancer development.
The nurse determines which client is at greatest risk for acidosis?
The adult client with COPD
The staging of the client's cancer by the TNM classification is T1, N3, M1. What is the correct interpretation of this classification?
The client has a small primary tumor, tumor extension into 3 lymph nodes, and one site of distant metastasis.
Which assessment data obtained by the home care nurse best suggests that a 74-year-old client may be dehydrated?
The client states that he feels lightheaded when he gets out of bed or stands up.
Which client is at greatest risk for developing hypercalcemia?
The client with hyperparathyroidism
A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has increased confusion. What analysis about the client's condition is correct?
The hyponatremia is worse.
Which client is at greatest risk for dehydration?
The older adult client with cognitive impairment
In reviewing a pathology report on a tumor, the nurse interprets which of the following as a "very malignant" or "high-grade" cancer?
Undifferentiated; mitotic index = 50%
Which action represents a type of secondary cancer prevention?
Yearly measurement of prostate-specific antigen levels
The nurse prepares to administer bicarbonate intravenously to the client with which clinical manifestations?
pH 7.28, HCO3- 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea
Which set of arterial blood gas values represents partially compensated metabolic acidosis?
pH 7.32, HCO3- 17 mEq/L, PaCO2 25 mm Hg, PO2 98 mm Hg
The nurse correlates which arterial blood gas values as consistent with fully compensated respiratory acidosis?
pH 7.35, HCO3- 36 mEq/L, PaCO2 65 mm Hg, PO2 78 mm Hg
