Nurs 265 Week 4 EAQ

A 6-month-old infant weighing 15 lb (6.8 kg) is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg electrolyte replacement over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?

28 mL Rationale At 15 lb (6.8 kg) the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The other amounts (32 mL, 38 mL, 42 mL) are too much.

A client's temperature is 100.4° F (38° C) 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature?

Dehydration Rationale A client's temperature may be elevated to 100.4° F (38° C) during the first 24 hours after delivery because of dehydration resulting from the exertion and stress of labor. Mastitis usually develops after breastfeeding is established and the milk supply is present. Puerperal infection usually begins with a fever of 100.4° F (38 °C) or higher on 2 successive days, excluding the first 24 hours after delivery. Urinary tract infection usually becomes evident later in the postpartum period.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is mostimportant for the nurse to assess?

Dehydration Rationale The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. What could be the reason for this condition?

Fluid and electrolyte imbalance Rationale Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in non-pitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother?

Signs of dehydration in infants Rationale It is most important for the mother to learn that immediate treatment is necessary for an infant with vomiting or diarrhea. Because infants have a greater proportion of body fluid to tissue than adults, they cannot maintain fluid balance in the event of a large loss of fluid through vomiting or diarrhea. An infant's diet consists almost totally of milk; teaching the mother about a well-balanced diet is irrelevant at this time. Although cleanliness is important, diarrhea may occur despite cleanliness. Antibiotics are not administered for viral gastroenteritis.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for?

Skin turgor Rationale Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy dry skin? What is the best response by the nurse?

"Use a moisturizer on the skin daily to help reduce itching."Lubricating the skin with a moisturizer effectively relieves dryness and thus the pruritus. Wearing warm clothing will do nothing to lubricate the skin or relieve the pruritus. Warm or cool, not hot, tub baths will decrease itching. Exposing the skin to the air causes further drying and will not relieve pruritus.

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication?

2 Cardiac arrest Rationale Too rapid administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyperkalemia will not lead to acidosis. Psychoticlike reactions do not occur with hyperkalemia. Hyperkalemia usually causes nausea, vomiting, and diarrhea, which may result in dehydration; in this instance, fluid will shift from interstitial spaces to the intravascular compartment. With edema, the fluid shift occurs in the opposite direction.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?

2 Tea The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report?

20 mL urine output for 2 consecutive hours Rationale The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. p. 276

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare?

250 to 350 mL Rationale The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse should prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The patient has a one-time prescription for potassium chloride 20 mEq in 250 mL of normal saline intravenous (IV) to be given immediately. The nurse would seek clarification for this prescription if the patient's more recent potassium level is at what level?

4.5 mEq/L Rationale The normal range for serum potassium is 3.5 to 5 mEq/L. The IV prescription provides a substantial amount of potassium, so the patient's potassium level must be low. A level of 4.5 mEq/L would not warrant this medication. p. 281

A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what?

4200 mL Rationale In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, on what day and at what time, and what material you will cover.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?

Azotemia Rational:The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

A client who has just had a cesarean birth is receiving intravenous fluids and has an indwelling catheter. The client's fluid intake will need to be increased when the nurse identifies what?

Dark amber urine Rationale A dark amber or tea color indicates highly concentrated urine and requires additional hydration of the client. Urinary suppression is not related to fluid status. Tinges of blood in the urine may indicate bladder injury and are not related to the client's fluid status. Cloudy urine indicates urinary infection or hematuria; it is not related to dehydration.Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration?

Failure to secure the catheter adequately Rationale Infiltration is caused by catheter displacement, allowing fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration. Infusion of a chemically irritating medication can lead to phlebitis, not infiltration.

Which hormone aids in regulating intestinal calcium and phosphorous absorption?

Glucocorticoids Rationale Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes?

Hypokalemia Rationale Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released?

Hyponatremia Rationale Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding?

It indicates dilute urine. Rationale Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobin.

Which part of the kidney produces the hormone bradykinin?

Juxtaglomerular cells of the arteriolesThe juxtaglomerular cells of the arterioles produce the hormone bradykinin, which increases blood flow and vascular permeability. The kidney tissues produce prostaglandins that regulate internal blood flow by vasodilation or vasoconstriction. The kidney parenchyma produces erythropoietin that stimulates the bone marrow to make red blood cells. The renin-producing granular cells produce the renin hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. A nurse is providing client

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. What classification of medications should be withheld until consulting with the health care provider?

Loop diuretics Rationale Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range. Antibiotics, bronchodilators, and antihypertensives are not an issue in this case. pp. 282-283

Which parts of the nephron are the sites of action for furosemide? Select all that apply.

Loop of Henle, Distal tubule, & Proximal tubule Rationale Furosemide, known as a 'loop diuretic', inhibits sodium and chloride reabsorption from the ascending loop of Henle and proximal and distal tubules. The glomerulus is a site of glomerular filtration. The Bowman capsule (BC) is a site of the collection of glomerular filtrate.

What is the priority nursing action in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day?

Maintaining potassium levels Rationale Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither drug increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore, the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide.Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia?

Muscle weakness and cardiac dysrhythmias Rationale Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia or hyperkalemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client?

Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

The nurse assesses the present of Trousseau's sign in a patient that had an inadvertent removal of the parathyroids during a thyroidectomy. What electrolyte disturbance should the nurse check the laboratory studies for?

Rationale Trousseau's sign refers to carpal spasms induced by inflating a blood pressure cuff on the arm. Hypocalcemia can be identified by Trousseau's sign. Hypercalcemia, hypermagnesemia, and hyperphosphatemia cannot be identified by Trousseau's sign. p. 284

What is the action of vasopressin?

Reabsorbs water into the capillaries Rationale Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).

Which electrolyte deficiency triggers the secretion of renin?

Sodium--Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

The nurse suspects that a client with inhalation anthrax is in the fulminant stage of the disease. Which symptom supports the nurse's conclusion?

The nurse suspects that a client with inhalation anthrax is in the fulminant stage of the disease. Which symptom supports the nurse's conclusion?

A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

calcium gluconate The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is trying to prevent a seizure.

What is the cup-like structure that collects a client's urine and is located at the end of each papilla?

calyx Rationale The calyx is a cup-like structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.

A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal?

Accelerated bone demineralization Calcium that has left the bones as a response to prolonged inactivity enters the blood and may precipitate in the kidneys, forming calculi. Increased fluid intake is helpful in preventing this condition by preventing urinary stasis. Calcium intake usually is limited to prevent the increased risk for calculi. Calculi may develop despite adequate kidney function; kidney function may be impaired by the presence of calculi and urinary tract infections associated with urinary stasis or repeated catheterizations.

The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client?

Achieve relief of symptoms and maintain kidney function Rationale Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.

The nurse is teaching a client receiving peritoneal dialysis about the reason dialysis solution is warmed before it is instilled into the peritoneal cavity. Which information will the nurse share with the client?

Because it encourages removal of serum urea by preventing constriction of peritoneal blood vessels Encouraging the removal of serum urea by preventing constriction of peritoneal blood vessels promotes vasodilation so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. Heat does not affect the shift of potassium into the cells. The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. Heating dialysis solution does not affect cardiac dysrhythmias.

While taking a patient's blood pressure, a nurse notices that a carpal spasm occurs. What laboratory test should the nurse review after assessing this finding?

CalciumTrousseau's sign (carpal spasm when blood pressure cuff is inflated for a few minutes) is indicative of hypocalcemia Rationale Trousseau's sign (carpal spasm when blood pressure cuff is inflated for a few minutes) is indicative of hypocalcemia. It does not occur with changes in sodium, potassium, or magnesium levels. The nurse should expect the primary health care provider to prescribe a calcium level be drawn. p. 284

The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider?

Crackles in lungs Rationale Crackles in the lungs indicate the client is overloaded with fluids. The nurse should notify the primary healthcare provider to slow or discontinue the IV fluid. Supple skin turgor is a normal finding indicating that the IV fluid is working. A urine output of 240 mL in 8 hours is adequate. Therefore simply having a urine output of 30 mL/hr is not an indication that the IV fluid should be decreased or discontinued; it demonstrates that the kidneys are adequately perfused. An increase in blood pressure is to be expected with administration of fluid. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

A patient has low levels of parathyroid hormone. What other laboratory finding does the nurse expect in the patient?

Decreased calcium levels Rationale Low levels of parathyroid hormone cause hypocalcemia, or decreased calcium levels, because of reduced renal activity, which limits calcium absorption. The nurse would suspect increased potassium levels with hyperkalemia if the patient had adrenal insufficiency. Hypoparathyroidism causes hyperphosphatemia because of impaired renal phosphate excretion. Hypoparathyroidism can result in magnesium deficiency.Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 284

Which medical condition could most probably result in clients developing primary diabetes insipidus (DI)?

Defect in hypothalamus* A defect in the hypothalamus (thirst center) could be the most probable cause of primary DI. Meningitis or a brain tumor could interfere with the synthesis, transport, or release of antidiuretic hormone (ADH) and cause central DI. Lithium therapy affects the renal response to ADH and results in nephrogenic DI, or drug-related DI.

The nurse is caring for a patient with heart failure. What assessment data indicates the patient is at risk for developing fluid volume excess?

Full, bounding pulse Rationale Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full bounding pulse, increased blood pressure, and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit.STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past. p. 276

Which hormonal deficiency causes diabetes insipidus in a client?

Growth hormone Adrenocorticotropic hormoneGrowth hormone deficiency causes decrease in bone density, thereby increasing the risk of fractures. Follicle-stimulating hormone deficiency causes amenorrhea, decreased libido, and infertility in women and impotence in men. Thyroid-stimulating hormone deficiency causes menstrual abnormalities and hirsutism. Adrenocorticotropic hormone deficiency causes hypoglycemia and hyponatremia.

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?

Hyperkalemia and hyponatremia Rationale Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

Which assessment finding in a client signifies a mild form of hypocalcemia?

Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.

The nurse is caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would be identified as an adverse effect related to this therapy?

Phosphorus falling to 2.1 mg/dL Phosphorus falling to 2.1 mg/dL Rationale Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate. Sodium falling, potassium rising, and magnesium rising are not adverse reactions to the treatment.Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. p. 285

A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema?

Rationale Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb (1 kg). Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?

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

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?

Teaching the client to use head movements to scan the left field of vision Rationale The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. The client should be approached from the right side because the left visual field is impaired. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. Although it may help to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?

Turn from side to side Rationale Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed. Drinking a glass of water and deep breathing and coughing do not influence drainage of dialysate from the peritoneal cavity. The position of the catheter should be changed only by the primary healthcare provider.

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client?

Water and electrolytes rationale Fluid and electrolytes are lost through intestinal decompression; on a daily basis about 20% of the total body water is secreted into and almost completely reabsorbed by the gastrointestinal (GI) tract. Because the client is kept nothing by mouth (NPO), there is no stimulus to cause enzymes to be secreted into the GI tract. Intravenous dextrose supplies some carbohydrates as a source of energy; carbohydrates will not be drawn from storage by intestinal decompression. Because the client is being kept NPO, vitamins and minerals are not entering the GI tract and therefore are not lost.

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates?

discontinue the infusion Rationale When an IV infusion infiltrates, it should be removed to prevent edema and pain. Elevation does not change the position of the IV cannula; the infusion must be discontinued. Flushing the tubing will add to the infiltration of fluid. Soaks may be applied, if prescribed, after the IV cannula is removed.

The intravenous (IV) prescription reads "D5.45 normal saline (NS) with 40 mEq KCl/L at 125 mL/hour." The nurse needs to add KCl to the IV because no premixed solutions are available. The unit's medication supply has a stock of KCl 5 mEq/mL in multidose vials. The nurse would need to draw up milliliters to add to the IV solution? Record your answer using a whole number.

8 mL Rationale The end concentration of the KCl is listed on the vial as follows: "5 mEq/mL." Using ratio and proportion, multiply 5 by x and multiply 40 × 1 to yield 5x = 40. Divide 40 by 5 to yield 8 mL. p. 282

What is the most probable cause for Conn's syndrome in an adult client?

Adrenal adenoma Conn's syndrome is primary hyperaldosteronism. Excessive secretion of aldosterone by the adrenal glands due to an adrenal adenoma results in Conn's syndrome. Certain types of hyperaldosteronism that are diagnosed in childhood have genetic causes. High levels of angiotensin II that are stimulated by high levels of plasma rennin are a cause for secondary hyperaldosteronism.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportionalThere is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Deficient fluid volume Rationale The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?

Electrolyte imbalance Rationale When clients do not receive nutrients or fluids by mouth and have loss of electrolytes through the removal of gastric secretions via an NG tube, then electrolyte imbalance is a primary concern. Constipation is usually not a concern in this type of situation. Although dehydration is a possible effect of an NG tube removing gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment Rationale The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client?

Potassium: 2.9 mEq/L Rationale The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is below the normal level. Therefore, it may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL. Thus, the laboratory values of sodium (143 mEq/L), bicarbonate (25 mEq/L), and total calcium (10 mg/dL) lie in the normal range, which does not indicate hyperfunction of the adrenal gland in the client.

The nurse is caring for a patient who is febrile with a body temperature of 103 oF. What clinical manifestation does the nurse anticipate when assessing this patient?

Rationale A patient with an elevated body temperature of 103 oF may have a loss of body fluids leading to decreased blood volume and resulting in postural or orthostatic hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations that occur due to an increase in the body fluid volume. p. 276

A patient has a prescription to receive 0.9% sodium chloride (normal saline) intravenously (IV) at a rate of 100 mL per hour. The current bag of 1000 mL was hung at 1000. When making rounds at 1300, the nurse notes that the IV bag contains 900 mL of normal saline. How would the nurse document this incident report?

Rationale After three hours of infusion time, 300 mL of IV solution should have infused, but the patient has received 100 mL. Therefore the patient has received the wrong rate. The solution, route, and documentation are correct.Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation. p. 308

The nurse is preparing to cleanse the skin around a central venous access device. Which solution would the nurse select as the most effective means of killing harmful bacteria?

Rationale Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol solutions. Therefore chlorhexidine-based solutions should be used to cleanse around the central venous access device. A sterile saline solution does not have any antiseptic properties. p. 296

A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure?

Removing toxins in addition to other metabolic wastes Rationale Peritoneal dialysis uses the peritoneum as a selectively permeable membrane for diffusion of toxins and wastes from the blood into the dialyzing solution. Peritoneal dialysis acts as a substitute for kidney function; it does not reestablish kidney function. The dialysate does not clean the peritoneal membrane; the semipermeable membrane allows toxins and wastes to pass into the dialysate within the abdominal cavity. Fluid in the abdominal cavity does not enter the intracellular compartment.

A pregnant woman reports headaches and shortness of breath to the nurse. The nurse auscultates crackles and a bounding pulse. What is the appropriate nursing action?

Restricting the intake of dietary sodium Rationale A pregnant woman with increased extracellular fluid may develop hypertension and pregnancy-related complications. Restriction of dietary sodium helps to control the fluid accumulation and may help to maintain fluid balance. Application of warm and cold compresses will not relieve the patient's symptoms. Changing the position does not benefit the patient, and providing ice chips may increase the fluid volume and worsen the condition. p. 276

An older adult patient is admitted with pneumonia. Why would it be important for the nurse to closely monitor fluid and electrolyte balance in this patient?

Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults. Rationale Older adults, with less muscle mass and more fat content, have less body water than younger adults. In the older adult, body water content averages 45% to 55% of body weight, leaving them at a higher risk for fluid-related problems than young adults. Renal function, level of consciousness, and severe illnesses are not relevant in this instance. p. 276

The nurse is caring for an older adult patient who has dehydration. The nurse would instruct the unlicensed assistive personnel (UAP) to report which finding?

Urine output of 350 mL in 24 hours Rationale The minimal urine output necessary to maintain kidney function is 30 mLs per hour, or 720 mL per 24 hours. The nurse should be notified of a decrease in urine output so that additional fluid volume-replacement therapy can be instituted. Ambulation is encouraged. The temperature is normal. Frequent use of the urinal would not indicate dehydration. p. 276

The nurse is teaching a caregiver for an older adult patient with dementia about fluid balance maintenance at home. Which statement made by the caregiver indicates that he or she requires further education?

"I should provide fluids only when the patient feels thirsty." Rationale Mental status alterations are a common problem in old age and may lead to decreased ability to express thirst and obtain fluids. Therefore older patients are always encouraged to drink fluids and also to decrease dietary sodium in the diet. Musculoskeletal changes such as stiffness of the hands and fingers may lead to an inability to hold containers. The patient should make a habit of urinating before bed to decrease the chance of nocturia. pp. 276-277

The nurse is preparing to document skin assessment findings for a patient being treated for renal failure. Assessment findings include cool, taut skin over the sternum with a 2-mm indentation when pressing with a thumb over the sternum. How does the nurse document the grade of the edema?

+1 Rationale Cool, taut and hard skin indicates fluid accumulation. An indentation of 2-mm after pressing with the thumb to assess edema indicates a grade of 1+. A 4-mm indentation warrants a grade of 2+, a 6-mm indentation a grade of 3+, and an 8-mm indentation a grade of 4+. p. 277

Which degree of edema will result in a 6-mm deep indentation upon pressure application?

+3 Rationale The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

At 10 AM the nurse hangs a 1000-mL bag of D 5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the healthcare provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic? Quarter hour

1 hour Rationale An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. One quarter, half, and three quarters of an hour are incorrect calculations.

A patient had 5 liters of fluid removed during a paracentesis. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis?

25% albumin solution Rationale After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. p. 293

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare?

500 to 750 mL Rationale In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse is preparing to document output for a patient at the end of the shift. The patient has had 500 mL of urine output, vomited 100 mL of clear liquid, and 25 mL of wound drainage was removed via a wound vacuum device. What does the nurse record as the total output for this shift? Record your answer as a whole number. mL

625 Rationale The calculation of output includes excessive perspiration, urinary output, vomit, diarrhea, and wound drainage. Totaling 500 mL of urine, 100 mL of vomit, and 25 mL of wound drainage results in 625 mL for the shift. p. 277

What is the percentage of total body water in a premature newborn?

85% Rationale The total body water in a premature newborn is 85%. In full-term infants, body water ranges from 70% to 80%. The total body water in a child between the ages of 1 and 12 is approximately 64%.

A nurse finds that a patient has severe diarrhea and may be at risk of fluid volume deficit. What does the nurse anticipate administering to this patient to treat the fluid volume deficit?

Administer lactated Ringer's solution Rationale To correct fluid deficit in the patient the nurse would administer lactated Ringer's solution to replace both water and any needed electrolytes. Isotonic normal saline is used when rapid volume replacement is needed. If the fluid deficit has been identified as due to blood loss, then blood can be transfused. Sodium intake should be restricted in case of fluid excess. p. 276

The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular fluid accumulation?

A patient with renal impairment Rationale Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma, and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and intestinal obstruction result in a loss of body fluid. p. 277

An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia?

A serum electrolyte level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and an x-ray film of long bones have no significance in diagnosing a potassium deficit.

A nurse is administering serum albumin intravenously to a client with ascites. In response to this therapy, what does the nurse expect to decrease?

Abdominal girth Rationale An increased serum albumin level increases the osmotic effect and pulls fluid back into the intravascular compartment. This will increase renal flow and urine output, with a resulting decrease in abdominal girth. Urinary output therapy will increase blood volume and blood flow to the kidney, thereby increasing urinary output. Albumin therapy has no effect on blood ammonia levels. An increased, not decreased, blood ammonia level causes hepatic encephalopathy.

A patient with a tumor of the adrenal glands reports feeling unusually sleepy. After receiving the prescription from the health care provider, which nursing action is most appropriate considering the fact that the patient is at risk of hypernatremia due to primary aldosteronism?

Administer furosemide Rationale A tumor of the adrenal glands may cause hypersecretion of aldosterone, resulting in hypernatremia. Hypernatremia should be treated with a diuretic (to promote excretion of excess sodium) and with sodium-free intravenous fluids such as 5% dextrose in water (to dilute the sodium concentration). Sodium intake should also be restricted. Conivaptan is administered when treating hyponatremia. Potassium supplements are needed in cases of hypokalemia. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience. pp. 279

A client is receiving furosemide to relieve edema. The nurse should monitor the client for which response to the medication?

Hypokalemia Rationale Furosemide is a potent diuretic used to provide rapid diuresis; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. Furosemide inhibits the reabsorption, not retention, of sodium. Furosemide does not affect protein metabolism. With edema, the specific gravity of the fluid more likely will be low.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful?

Broccoli Rationale Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse determine is the probable reason for the increase in phosphate levels in this patient?

Chemotherapy Rationale Phosphate levels greater than 4.4 mg/dL indicate hyperphosphatemia. Chemotherapy drugs increase the patient's phosphate levels. Insulin therapy decreases the phosphate levels to less than 2.4 mg/dL. Patients with total parenteral nutrition have decreased phosphate levels. Phosphate-binding antacids remove phosphates from the body, resulting in hypophosphatemia. p. 285

A patient has been admitted for dehydration. What is a priority nursing intervention?

Daily weights Rationale Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in the patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted. p. 276

Which drug can cause diabetes insipidus?

Demeclocycline Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

Which type of drug-induced hormonal imbalance is likely to be observed in the client undergoing treatment with demeclocycline?

Diabetes insipidus Rationale Drug-induced diabetic insipidus is usually caused by demeclocycline, which can interfere with the response of the kidneys to antidiuretic hormone. Demeclocycline does not cause endocrine disorders, such as acromegaly, diabetes mellitus, and Cushing's syndrome.

Which medical diagnosis would cause the nurse to include nursing interventions appropriate for hyponatremia in the plan of care?

Congestive heart failure Rationale Congestive heart failure increases the patient's risk for developing hyponatremia; therefore this diagnosis would cause the nurse to include interventions specific to hyponatremia in the plan of care. Diabetes insipidus, Cushing syndrome, and uncontrolled diabetes mellitus increase the patient's risk for hypernatremia, not hyponatremia. p. 279

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed?

Coolness Rationale When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder?

Cystic fibrosis Rationale The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Elevate the head of the bed and obtain vital signs Rationale Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Auscultation of breath sounds should be done also. Discontinuing the IV access line is unsafe and may cause unnecessary discomfort if it must be restarted; more information is needed before calling the healthcare provider. No information is available to support changing the IV to an intermittent lock; assessment for allergies should be done on admission. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal Rationale One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

The nurse is preparing to administer sodium polystyrene sulfonate rectally to a patient with an irregular pulse and weakness of the lower extremities. What laboratory finding does the nurse determine is the reason for this treatment?

Hyperkalemia Rationale Irregular pulse and weakness of the lower extremities are generally seen in patients with hyperkalemia. Sodium polystyrene sulfonate binds with potassium in exchange for sodium, thereby reducing hyperkalemia. Hypokalemia can be treated with potassium chloride. Hypocalcemia can be treated with calcium supplements. Hypercalcemia can be treated by administering furosemide. pp. 280-281

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

Fluid movement from the interstitial spaces into the blood vesselsIn dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. p. 276

A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis?

Full pulse Distended neck veins S3 heart sound Rationale Fluid volume excess results in a full, bounding pulse, presence of an S3 heart sound, and jugular venous distention (distended neck veins). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume. p. 277

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

High osmolarity of the feedings Rationale The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?

Hyponatremia and decreased urine output Rationale Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea?

Improvement of fluid balance Rationale Rehydration and correction of electrolyte imbalances are the priorities; diarrhea causes loss of fluid and electrolytes that can be life threatening. Antidiarrheal diets are no longer prescribed for children with diarrhea. Oral rehydration therapy is the treatment of choice. Although maintaining skin integrity in the presence of diarrhea is important, the risk of disrupted skin integrity is not life threatening, nor is it the priority when a young child is dehydrated. There are no data to indicate that the child is overweight or underweight.Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

The nurse is caring for a patient with sickle cell anemia. What common electrolyte imbalance should the nurse carefully assess the patient for that is commonly associated with this disease?

Increased phosphate levels Rationale Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis. p. 285

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider?

No prescription change Rationale The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action should the nurse take next?

Notify the healthcare provider that the potassium level is below normal Rationale The healthcare provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5 mmol/L to 5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because supplemental potassium may be needed. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority?

Observe the client for increasing confusion. Rationale An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

The nurse is performing a physical examination of a client by placing the left hand on the back and supporting the client's right side between the rib cage and the iliac crest. Which physical assessment maneuver is the nurse performing on this client?

Palpation Rationale The physical assessment involves inspection, palpation, percussion, and auscultation. During palpation of the right kidney, the nurse places the left hand behind and supports the client's right side between the ribcage and the iliac crest. During an inspection, the nurse assesses the client for changes in skin, abdomen, weight, face, and extremities. During percussion, the nurse strikes the fist of one hand against the dorsal surface of the other hand, which is placed flat along the post costovertebral angle (CVA) margin. While performing auscultation, the nurse uses the bell of the stethoscope over both CVAs and in the upper abdominal quadrants.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea Rationale A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider?

Potassium 3.0 mEq/L (3.0 mmol/L) Rationale A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm 3is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L).Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.

The emergency room nurse is caring for a patient with a severe fluid volume deficit who presented after several days of diarrhea secondary to C. difficile infection. Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly replace the fluid volume?

Rationale An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and 5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly increase fluid volume.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 276

What other name can the nurse use for vasopressin?

Rationale Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.

A patient is diagnosed with Cushing syndrome. What manifestation does the nurse anticipate while assessing this patient?

Rationale Excess extracellular volume may result from fluid retention during Cushing syndrome. This shift of fluid into the interstitial spaces leads to blockage of air spaces (pulmonary edema) resulting in dyspnea, crackles, and peripheral edema. Dry mouth, weight loss, and restlessness are the common manifestations resulting from extracellular fluid depletion.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 273

Which term is used to describe the fact that extracellular fluid and intracellular fluid have the same osmolality?

Rationale Extracellular fluid and intracellular fluid have the same osmolality; this characteristic is termed isotonic, meaning that there is no net movement of fluids. Hypotonic refers to fluids with a lower osmolality, which results in water moving into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to fluids with a higher osmolality, which results in water moving out of the cells when they are surrounded by a hypertonic solution. Oncotic pressure refers to the pressure of plasma colloids in a solution. p. 273

The nurse is educating a patient regarding skin care management. What statement made by the patient indicates to the nurse that further education is required?

Rationale Good skin care management is essential to prevent fluid loss. The patient should limit the use of soap to prevent the skin from drying. The nurse should advise the patient to either take precautions or to avoid extreme temperatures to avoid dehydration of the skin. Regular skin care by applying moisturizers and changing positions while at rest help to maintain skin hydration and may prevent skin breakdown. p. 277

A patient has been treated for dehydration. What outcome does the nurse determine demonstrates effectiveness of the treatment regimen?

Rationale Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration. Greater intake than output may indicate decreased renal function or impaired ability to excrete urine. p. 276

Which hormone regulates blood levels of calcium?

Rationale Parathyroid hormone (PTH), or parathormone, regulates the blood levels of calcium and phosphorus. Luteinizing hormone (LH) stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. Thyroid stimulating hormone (TSH) stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. Adrenocorticotropic hormone (ACTH) promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

The nurse is completing an assessment of a patient with heart failure who is being treated for accidental overuse of diuretics. For which potential respiratory issue should the nurse monitor the patient?

Rationale Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit. p. 277

A patient is admitted with alcohol abuse. Laboratory data reveals a phosphate level of 1.8 mg/dL. Which assessment finding is consistent with this data?

Rationale Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Seizure activity, diarrhea, and tetany are not associated with this electrolyte imbalance. p. 285

The nurse is caring for a patient with hyponatremia associated with heart failure and liver cirrhosis. What drug does the nurse anticipate administering to treat this patient?

Rationale Tolvaptan is used to treat hyponatremia associated with heart failure and liver cirrhosis. It acts by blocking the activity of antidiuretic hormone. Amiloride is a potassium-sparing diuretic that is not effective in treating hyponatremia. Kayexalate is an ion-exchange resin used to treat hyperkalemia. Pamidronate is used to treat hypercalcemia. pp. 278-279

The nurse is monitoring a patient with hyperkalemia. Which conditions should the nurse conclude may cause this condition?

Renal failure Adrenal insufficiency Rationale Hyperkalemia is a condition in which there is an abnormal increase of potassium in the blood. Renal failure may cause hyperkalemia, because the kidneys cannot remove potassium from the body. Adrenal insufficiency causes aldosterone deficiency, which leads to the retention of potassium ions and also may result in hyperkalemia. Alkalosis is seen in hypocalcemia. Low blood volume and a large urine volume can result in hypokalemia.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 281

A client with a hemoglobin level of 6.2 g/dL (62 mmol/L) is receiving packed red blood cells. Twenty minutes after the infusion starts, the client complains of chest pain, difficulty breathing, and feeling cold. What is the first action the nurse should take?

The client is experiencing an anaphylactic reaction, and the infusion should be stopped to prevent further problems. The healthcare provider should be notified after the transfusion is stopped Rationale The client is experiencing an anaphylactic reaction, and the infusion should be stopped to prevent further problems. The healthcare provider should be notified after the transfusion is stopped. The blood transfusion should be stopped before implementing actions that address the client's anaphylactic reaction. Slowing the infusion will permit more of the incompatible blood to infuse, worsening the response.

While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?

To prevent further edema Rationale A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help to build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help to reduce pain by reducing the transmission and perception of pain impulses.Test-Taking Tip: Elevation of the affected area above heart level prevents the drift of fluids to the site. Find the answer choice that seems the most reasonable.

When assessing the laboratory values of a client with type 2 diabetes, what would the nurse expect the results to reveal?

Urine negative for ketones and positive glucose in the blood Rationale The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.

A patient's insensible water loss is estimated at 900 mL per day. The nurse understands that this fluid is lost via which mechanism?

Vaporized by the lungs and skin Rationale Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1,500 mL is excreted in the urine and 100 mL in the feces. Approximately 8,000 mL of digestive fluids are secreted daily, but most is reabsorbed in the gastrointestinal tract. p. 274

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant?

Weak, rapid pulse Rationale A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

The nurse is caring for a group of patients with a variety of diagnoses. Which conditions would cause the nurse to include interventions in the plan of care to address anticipated hypophosphatemia?

respiratory alkalosis, diabetic ketoacidosis, malabsorption syndrome Renal failure Rationale The nurse would include interventions to address hypophosphatemia when providing care to patients with respiratory alkalosis, diabetic ketoacidosis, and malabsorption syndrome. The nurse should create a care plan for hyperphosphatemia when providing care to patients with renal failure and tumor lysis syndrome. p. 285

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?

take vital signs and notify the primary healthcare provider Rationale Vital signs monitor the cardiopulmonary status; the primary healthcare provider must treat this hyperkalemia[1][2] to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Although obtaining an ECG strip is appropriate, obtaining an antiarrhythmic is premature; vital signs and medical attention is needed first.