Unit 8 - Foundations Ch. 12, 13, 15, 16, 33, 38 & 42 & Patho Ch. 2, 26 (Part 2)

At a first aid station on a marathon route, a patient after the race complains of headache, muscle cramps, weakness, nausea, and confusion. Which statement made by the patient might explain these symptoms? a) "I was really thirsty after the race. I drank several large bottles of water." b) "I perspired quite a bit during the race so I drank sports drinks when I finished." c) "I take steroids regularly and did not stop taking them for the race." d) "I am diabetic and checked my blood sugar after the race. It was normal."

ANS: A Excess intake of hypotonic solutions (e.g., several large bottles of water) will result in hyponatremia, the symptoms described by this patient. Sports drinks contain electrolytes lost through perspiration, so this would not explain the patient's symptoms, indicating hyponatremia. Steroid administration can result in hypokalemia, but the patient's symptoms do not match the symptoms of hypokalemia, so this is not a good explanation. The statement about diabetes does not provide information relevant to the patient's symptoms or to the situation.

The nurse is to administer an intravenous solution to a patient with diffuse edema. This will pull fluid from the interstitial space to the intravascular space. Which prescription would the nurse question for this patient? A prescription for: a) 5% Dextrose in water (D5W) b) 10% Dextrose in water (D10W) c) 5% Dextrose in normal saline (D5 0.9% NaCl) d) 5% Dextrose lactated Ringer's (D5LR)

ANS: A Edema is the presence of excess fluid within the interstitial spaces. Hypertonic fluids, when administered, pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. D10W, D5 0.9% NaCl, and D5 LR are all hypertonic fluids, so the nurse would likely not question a prescription for one of those. D5W, however, is hypotonic in the body, with a tendency to pull fluids out of the intravascular compartment into the interstitial compartment, and thus increase the patient's edema.

An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with which of the following? a) Hypovolemia b) Hypervolemia c) Hypernatremia d) Hyponatremia

ANS: A Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid, weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patient's sodium level is within normal range.

The nurse talks to a patient about the health risks related to smoking and the patient says, "My husband has been nagging me about that, but I really don't smoke all that much and don't see it as much of a problem in my case." Within what transtheoretical stage of change would the nurse classify this patient as operating? a) Precontemplation b) Contemplation c) Preparation d) Action Stage

ANS: A In the precontemplation stage, the patient has no intention to change in the foreseeable future, which describes this patient's response when she says she doesn't see her smoking as much of a problem. In the contemplative stage, patients think seriously about overcoming a problem but haven't committed to the action. This patient does not even see that she has a problem, so is not thinking seriously about changing behavior. In the preparation stage, the individual is reporting an action plan or making other small steps in preparation for taking action within the month. In the action stage, the plan to quit smoking is implemented; this patient is far from that stage.

By which method is water absorbed by the small intestine and the colon? a) Osmosis b) Diffusion c) Filtration d) Active transport

ANS: A Osmosis involves movement of water across a semipermeable membrane, from a more dilute to a more concentrated solution. Absorption of water in the alimentary canal is an example of osmosis. Another example is reabsorption of tissue fluid into the venule ends of the blood capillaries. Diffusion is a passive process by which molecules of a solute move through a cell membrane; this does not fit the described situation. Filtration is movement of water and smaller particles from an area of high pressure (the left ventricle) to one of low pressure (the right ventricle). Active transport occurs when molecules move across cell membranes against a concentration gradient requiring the expenditure of energy. This does not describe the scenario in the question.

The nurse is planning a health promotion class for adolescents. The presentation is too long. Which topic would be least important and therefore appropriate for the nurse to delete? a) Stranger danger b) Motor vehicle safety c) Firearm safety d) Alcohol and drug use

ANS: A Stranger danger is more appropriate for school-age children, so this topic could be safely eliminated. Risks related to motor vehicle accidents are high in the adolescent population and should not be eliminated. Firearm danger is significant for adolescents, so this topic should not be deleted. Alcohol and drug use pose a significant risk for adolescents, so this topic should not be deleted.

A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better he asks the nurse why using the paper bag helped him. What is the nurse's best response? "Breathing into the paper bag allowed you to a) Rebreathe carbon dioxide to correct respiratory alkalosis" b) Reduce carbon dioxide to correct respiratory acidosis" c) Rebreathe carbon dioxide to correct metabolic alkalosis" d) Reduce carbon dioxide to correct metabolic acidosis"

ANS: A When the father used the paper bag, he rebreathed the carbon dioxide he was expelling to maintain adequate carbon dioxide levels and prevent or correct respiratory alkalosis. Rebreathing carbon dioxide would increase carbon dioxide levels and increase pH; it would not correct respiratory acidosis. The man's problem is not a metabolic one; neither of the statements ending in "to correct metabolic alkalosis" is accurate.

Compensation mechanisms in the body for dehydration would include: a. increased antidiuretic hormone (ADH). b. decreased aldosterone. c. slow, strong heart contraction. d. peripheral vasodilation.

ANS: A REF: 21

Which of the following is the primary cation in the extracellular fluid? a. Sodium b. Potassium c. Calcium d. Iron

ANS: A REF: 21

Which of the following causes tetany? a. Increased permeability of nerve membranes due to low serum calcium b. Excess calcium ions in skeletal muscle due to excess parathyroid hormone (PTH) c. Excess calcium ions inside somatic nerves as a result of neoplasms d. Increased stimulation of the nerves in the cerebral cortex

ANS: A REF: 27

When many excess hydrogen ions accumulate in the blood, what happens to serum pH? The pH: a. decreases. b. increases. c. remains constant. d. varies based on metabolism.

ANS: A REF: 28

Which is the correct effect on the body of abnormally slow respirations? a. Increased carbonic acid b. Decreased carbonic acid c. Increased bicarbonate ion d. Decreased bicarbonate ion

ANS: A REF: 31

What is the effect on blood serum when excessive lactic acid accumulates in the body? a. Bicarbonate ion levels decrease b. Bicarbonate ion levels increase c. Carbonic acid levels increase d. pH increases

ANS: A REF: 32

Which serum value indicates decompensated metabolic acidosis? a. pH is below normal range b. pH is above normal range c. Bicarbonate level decreases d. Bicarbonate level increases

ANS: A REF: 32

The nurse working in an ambulatory care program asks questions about the client's locus of control as a part of his assessment because of which of the following? Select all that apply. a) People who feel in charge of their own health are the easiest to motivate toward change. b) People who feel powerless about preventing illness are least likely to engage in health promotion activities. c) People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. d) People who feel in charge of their own health are less motivated by health promotion activities.

ANS: A, B, C Identifying a person's locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change.

The nurse is conducting a risk appraisal related to the patient's lifestyle choices. What questions would be appropriate for the nurse to ask? Select all that apply. a) "What is your job?" b) "What is your marital status?" c) "What are your hobbies?" d) "Are you sexually active?" e) "Have you moved recently?"

ANS: A, B, C, D A person's occupation is a significant component of his lifestyle, so this would be an important question to ask. Marital status plays an important role in lifestyle, so this is an appropriate question to ask. Hobbies should be assessed to determine specific lifestyle risks for this patient. Even married people should be asked about sexual activity, because sexual activity can have a significant impact on health and risk for health problems. A question about a recent move would not be a question asked regarding lifestyle, but might be a question asked when assessing stress levels. Questions about the type of dwelling might also indicate activity levels.

The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Select all that apply. a) Creating a weekly discussion group focused on contemporary news b) Facilitating a relationship between local pastors and residents of subsidized housing c) Coordinating a senior tutorial program for local children at the housing center d) Establishing an on-site healthcare clinic operating 1 day per week

ANS: A, B, C, D The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health.

In a healthy adult, which of the following regulate body fluids? Select all that apply. a) Hormone levels b) Fluid intake c) Oxygen saturation d) Kidney function

ANS: A, B, D A balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body's fluid and electrolyte balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolar-arterial gradient lung disease, and the amount and type of hemoglobin (such as sickle cell anemia).

When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Select all that apply. a) Don sterile gloves and mask (and possibly gown). b) Scrub the insertion site with antibacterial soap for 1 min. c) Verify that informed consent has been obtained. d) Place the patient in low-Fowler's position.

ANS: A, C Maximum barrier sterile technique is used for CVC insertion (sterile gloves, mask, and gown), although some agency policies do not include sterile gown for the nurse. This is an invasive procedure, so informed consent is required. The nurse should confirm that this has been obtained. The scrub is not done with antibacterial soap. The scrub is done with chlorhexidine-alcohol solution or, alternatively, first with 70% alcohol and then with povidone detergent. The patient is placed in Trendelenburg position with a rolled towel between the shoulders for best site access.

Goals for Healthy People 2020 include which of the following? Select all that apply. a) Eliminate health disparities among various groups. b) Decrease the cost of healthcare related to tobacco use. c) Increase the quality and years of healthy life. d) Decrease the number of inpatient days annually.

ANS: A, C The four overarching goals of Healthy People 2020 are to (1) increase the quality and years of healthy life, free of disease, injury, and premature death; (2) eliminate health disparities and improve health for all groups of people; (3) create physical and social environments for people to live a healthy life; and (4) promote quality of life, healthy development, and healthy behaviors at all life stages.

A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Select all that apply. a) Left hand b) Right wrist c) Right antecubital area d) Right saphenous vein

ANS: A, C When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g., left hand) may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site.

Identify the mechanisms involved in acid-base balance. Select all that apply. a) Respiratory mechanisms b) Active transport mechanisms c) Renal mechanisms d) Buffer systems

ANS: A, C, D Acid-base balance is regulated by respiratory mechanisms, renal mechanisms, and buffer systems. Acid-base regulation can be monitored by examining arterial blood gases, especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. The lungs (respiratory mechanisms) control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, "blow off" carbon dioxide and increase the pH. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or excreting bicarbonate, the kidneys affect acid-base balance. Active transport involves the movement of fluids and electrolytes in the body.

According to Pender's Health Promotion Model, which variables must be considered when planning a health promotion program for a client? Select all that apply. a) Individual characteristics and experiences b) Levels of prevention c) Behavioral outcomes d) Behavior-specific cognition and affect

ANS: A, C, D Pender identified three variables that affect health promotion: individual characteristics and experiences, behavior-specific cognition and affect, and behavioral outcomes. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle.

The nurse, working in a substance abuse rehabilitation facility, is talking with a resident who says, "I'm just here to avoid going to jail. I'm not addicted to alcohol. I just enjoy it, but I'm going to quit to avoid getting arrested again." Which of Pender's Health Promotion Model assumptions is this resident demonstrating? Select all that apply. a) Health professionals are part of the person's interpersonal environment. b) The capacity for self-awareness includes assessing one's own competencies. c) The person values positive growth and attempts to balance change and stability. d) The person seeks to actively regulate his own behavior

ANS: A, C, D The resident is aware of the nurse as someone in the environment, so this assumption is demonstrated. The patient evidently values growth because he has agreed to enter a treatment facility to improve his addiction issue. The resident is trying to regulate his behavior while in the treatment facility. The resident demonstrates lack of self-awareness by denying the addiction; this assumption is not being demonstrated.

The nurse is caring for a patient who is normally healthy but is experiencing dehydration secondary to acute diarrhea and vomiting. What assessment findings would indicate a return to fluid homeostasis? Select all that apply. a) Urine output of 35 mL/hour b) Elevated antidiuretic hormone levels c) Reduced renin production d) Reduced aldosterone release e) Formed stools

ANS: A, C, D Urine output within normal limits (e.g., 35 mL/hr) would indicate the patient's fluid status has returned to homeostasis. Renin converts angiotensinogen to angiotensin II to retain sodium and water. Absence of renin would indicate water is no longer being reabsorbed and fluid homeostasis has been reached; therefore, a reduced renin production would indicate "return" to fluid homeostasis. Aldosterone promotes reabsorption of sodium resulting in passive reabsorption of water and will be elevated during periods of dehydration. Production will decline with return to fluid homeostasis. Elevated antidiuretic hormone levels do not indicate fluid homeostasis: Antidiuretic hormone causes the kidneys to retain fluid, which would be seen while the patient was dehydrated but should return to normal levels with homeostasis rather than being elevated. Formed stools will occur when the bowel returns to normal function, but this is not an indicator of fluid homeostasis.

The nurse is caring for a patient with metabolic acidosis secondary to renal failure caused by poor glucose regulation. The patient reports a headache, weakness, and nausea. The nurse assesses an elevated blood sugar, Kussmaul breathing, and peripheral vasodilation. What collaborative interventions will the nurse anticipate to restore pH balance? Select all that apply. a) Insulin to lower blood sugar b) Tylenol for headache c) Mechanical ventilation to correct breathing d) Dialysis to remove toxins e) Bicarbonate administration

ANS: A, D, E Treatment for metabolic acidosis is aimed at correcting the underlying problem, which includes glucose regulation; that would be achieved by administering insulin. Dialysis for kidney failure is aimed at treating an underlying cause of the metabolic acidosis and would be anticipated. Bicarbonate administration can reduce pH and begin the process of resolving the problem. Tylenol will not resolve the patient's headache unless the metabolic acidosis is also resolved. Mechanical ventilation is not indicated, because while metabolic acidosis exists, the breathing pattern helps to compensate; correction of metabolic acidosis will correct the breathing pattern.

Which laboratory result on a client's health record should alert the nurse to a potential problem? a) Na+ = 137 mEq/L b) K+ = 5.2 mEq/L c) Ca2+ = 9.2 mg/dL d) Mg2+ = 1.8 mg/dL

ANS: B A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within normal ranges.

The nurse is teaching a class for diabetics and tells them, "Maintaining your blood glucose within normal limits helps reduce the risk for complications of diabetes." What type of activity does this class represent? a) Health promotion b) Health protection c) Primary prevention d) Tertiary prevention

ANS: B Activities that promote health do also protect health. However, the concepts differ. Health protection is motivated by a desire to avoid illness; health promotion is more about increasing well-being. Health promotion aims at promoting optimal function of a person, whether well or ill, not on preventing specific diseases. In this scenario, the nurse is speaking to a group and is not individualizing the statement to each unique human being. Primary prevention activities are designed to prevent or delay the onset of disease; in this scenario, the clients already have a disease (diabetes). Tertiary prevention focuses on halting the progress of a disease and returning the person to pre-illness. This cannot be done for diabetes, which is a chronic disease.

Which type of health promotion programs seeks to raise the level of knowledge and awareness of individuals and groups about health habits? a) Environmental evaluation and protection b) Information dissemination c) Wellness assessment and appraising health risk d) Lifestyle and behavior changes

ANS: B Disseminating information at the individual, group or community level will help a person recognize a problem and understand options for change.

In order to evaluate a patient's acid-base balance, the primary provider has prescribed diagnostic tests to measure pH, PCO2, and HCO3 - . The nurse realizes that the patient will: a) Have a venous blood sample drawn b) Have an arterial blood sample taken c) Need to provide a fresh voided urine sample d) Need to provide a 24-hour urine sample

ANS: B Evaluation of serum pH, PCO2, and HCO3- requires a sample of arterial blood. It is possible to measure the pH in the urine, but not the other values. Venous blood provides diagnostic information on the various electrolytes (e.g., sodium, potassium), BUN, creatinine, and hematocrit. Venous bicarbonate can be measured, as well.

A patient with pitting edema in the feet and ankles has excess volume in which fluid compartment? a) Intracellular b) Interstitial c) Intravascular d) Transcellular

ANS: B Intracellular fluid is located within the bloodstream and would not be assessed as edema. Interstitial fluid is contained in the spaces within the body cells and will be manifested as edema. Intravascular fluid is the plasma within the blood, allowing blood cells to be transported through the vessels. Excess fluid in the intravascular space may promote edema, but the presence of edema indicates fluid has moved to another space. Transcellular fluid is fluid located in body spaces (e.g., cerebrospinal fluid).

The nurse teaches a class for the community discussing routine screening tests for different types of cancer. What level of health prevention would the nurse classify this activity? a) Primary b) Secondary c) Tertiary d) Maintenance

ANS: B Rationale: The nurse is providing secondary health prevention because the individuals are being taught to screen for existing disease. Primary prevention activities would be taken to prevent the occurrence of cancer; screening tests are not primary health prevention. Tertiary prevention would focus on halting the progress of the cancer. These individuals in the scenario are not receiving cancer treatment, so it is not a tertiary activity. Maintenance is a stage in the transtheoretical model of change, and is not a level of health prevention.

The nurse is caring for a patient with heart failure. The patient has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this patient about fluid and electrolyte balance, which diet is most important for the nurse to explain? a) High calcium b) Low sodium c) Low potassium d) High magnesium

ANS: B Reducing sodium intake helps promote fluid balance and prevent fluid overload because sodium intake increases fluid retention. Before teaching a patient about consuming a high-calcium diet, more information would be needed to determine the patient's calcium intake. Although a high potassium intake may be needed if the patient is taking diuretics that cause potassium loss, more information would be needed to determine this; it is unlikely a low-potassium diet would be of benefit. Magnesium deficiency is rare; low levels may be found in individuals who have a high alcohol intake. It is unlikely this patient needs added magnesium.

A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? a) Invincibility b) Hardiness c) Baseline strength d) Vulnerability

ANS: B Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances.

Which of the following older adult patients needs to increase his daily fluid intake? One who typically drinks (assume three meals per day): a) 200 mL at each meal, plus 1,000 mL throughout the day b) 250 mL at each meal, plus 600 mL throughout the day c) 300 mL at each meal, plus 1,000 mL throughout the day d) 400 mL at each meal, plus 500 mL throughout the day

ANS: B The fluid requirement is 1,500 to 2,000 mL per day. Drinking 250 mL X 3 meals provides a 750 mL intake. Adding 600 mL totals only 1,350 mL per day. Drinking 200 mL per meal provides 600 mL, plus 1,000 mL totals 1,600, which is adequate. Drinking 300 mL per meal X 3 = 900 mL; 900 + 1,000 is a total of 1,900 mL, which is within the acceptable range. Drinking 400 mL per meal X 3 - 1,200 mL, plus 500 mL totals 1,700 mL, within the acceptable range.

The nurse is caring for a patient with gastroenteritis who has been vomiting for 48 hours. A family member of the patient asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH? "He is breathing a) Fast and deep to help reduce carbon dioxide to increase his pH" b) Slow and shallow to try to retain carbon dioxide to decrease his pH" c) Fast and deep to help reduce carbon dioxide to decrease his pH" d) Slow and shallow to try to retain carbon dioxide to increase his pH"

ANS: B The patient's history suggests metabolic alkalosis (due to loss of acid in the stomach resulting from vomiting) so the patient is likely to have decreased respiratory rate and depth as a means of retaining carbon dioxide and decreasing his pH. Because the patient has metabolic alkalosis, his breathing is more likely to be slow and shallow, so both statements beginning with "He is breathing fast and deep" to affect his pH are incorrect. In metabolic alkalosis, the pH is too high; trying to increasing the pH by breathing slow and shallow would not be desirable, even if it were possible.

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patient's urine output should be described as which of the following? a) Low b) Within normal limits c) High d) Inconclusive

ANS: B Urine accounts for the greatest amount of fluid loss. Normal urine output for an average-sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patient's urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine.

The nurse is planning a health promotion class for young adult women. What topic would be most important for the nurse to include for this group? a) Immunizations b) Pap test every 2 or 3 years c) Annual mammograms d) Screening colonoscopies

ANS: B Women should begin having Pap tests by age 21 and have repeat tests every 2 to 3 years; therefore, this would be an appropriate topic to include in a health promotion class. While adult women may require booster tetanus immunizations or other specific immunizations if they travel abroad, this is not a priority concern for most young women. Annual mammograms are not recommended for healthy young adult women unless they have a specific risk factor, such as a history of breast cancer at a young age in their family; therefore, this topic is less important overall. Screening colonoscopies are recommended to begin at age 50, so that is not a topic that needs to be included in this class.

Which of the following would result from a deficit of plasma proteins? a. Increased osmotic pressure b. Decreased osmotic pressure c. Increased hydrostatic pressure d. Decreased hydrostatic pressure

ANS: B REF: 16

One of the factors involved in the increased need for water in infants is: a. proportionally smaller body surface area. b. higher metabolic rate. c. smaller respiratory capacity. d. greater surface area of exposed mucous membranes.

ANS: B REF: 20

Which of the following terms refers to a combination of decreased circulating blood volume combined with excess fluid in a body cavity? a. Dehydration b. Third-spacing c. Hypovolemia d. Water retention

ANS: B REF: 21

Which of the following is a common cause of hyponatremia? a. Loss of the thirst mechanism b. Excessive sweating c. Excessive aldosterone secretion d. Prolonged period of rapid, deep respirations

ANS: B REF: 22-23

Which of the following would likely be related to an elevated hematocrit reading? a. Fluid excess b. Fluid deficit c. Increased sodium level d. Decreased erythrocytes

ANS: B REF: 23-24

A prolonged state of metabolic acidosis often leads to: a. hypokalemia. b. hyperkalemia. c. hyponatremia. d. hypercalcemia.

ANS: B REF: 25

An anxiety attack often causes hyperventilation leading to: a. increased PCO2. b. decreased PCO2. c. respiratory acidosis. d. metabolic acidosis.

ANS: B REF: 32

Compensation for respiratory system depression due to anesthesia and sedation would be: a. decreased reabsorption of bicarbonate ions in the kidneys. b. increased secretion of hydrogen ions into the filtrate. c. increased respiratory rate and depth. d. increased renin secretion.

ANS: B REF: 32

What would a serum pH of 7.33 in a patient with kidney disease indicate? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory alkalosis d. Respiratory acidosis

ANS: B REF: 32

Which condition is likely to cause metabolic acidosis? a. Slow, shallow respirations b. Prolonged diarrhea c. Mild vomiting d. Excessive fluid in the body

ANS: B REF: 32

A patient's blood group is B. The nurse knows the patient can receive blood only from donors with what group of blood? Select all that apply. a) A b) B c) O d) AB

ANS: B, C Persons with blood group B can receive blood only from the blood groups B and O. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. Persons with blood group O may receive blood only from O donors. Blood group AB persons are considered universal recipients, and blood group O persons are considered universal donors.

Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. What are the general characteristics of a hardy person? Select all that apply. a) Contemplation b) Control c) Commitment d) Challenge

ANS: B, C, D Control, commitment, and challenge are associated with a strong resistance to negative feelings that occur under adverse circumstances. Contemplation is the first stage of the Transtheoretical Model of Change, not a characteristic of hardiness.

A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time tomorrow morning. Which of the following are appropriate nursing interventions for the patient? Select all that apply. a) Encourage oral fluid intake as desired. b) Place the patient on strict I&O. c) Weigh the patient before and after dialysis. d) Maintain a total fluid restriction of 1,000 mL as prescribed.

ANS: B, C, D Fluids are restricted in patients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate. Appropriate nursing interventions for this patient include monitoring the intake and output, weighing the patient before and after dialysis, following a strict renal diet, and monitoring laboratory values.

Identify the appropriate interventions for a patient with hypovolemia. Select all that apply. a) Teach deep-breathing techniques. b) Monitor I&O daily. c) Encourage fluid intake. d) Monitor electrolyte balance.

ANS: B, C, D Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep-breathing techniques do not address fluid balance; there is no evidence that the patient has a respiratory disorder.

What teaching points will the nurse develop to address Healthy People 2020 goals? Select all that apply a) How to assess developmental milestones b) How to file for Medicaid c) How to maintaining a safe home and neighborhood d) How to develop and maintain a healthy lifestyle e) How to develop a low-fat, low-calorie diet

ANS: B, C, D Improving access to healthcare is a goal of Healthy People 2020, so teaching patients how to file an application for Medicaid would be an appropriate teaching point. Maintaining a social and physical environment that promotes good health is a Healthy People 2020 goal, so teaching patients how to maintain a safe home environment would be an appropriate teaching point. Teaching patients to develop and maintain a healthy lifestyle would meet the Healthy People 2020 goal of promoting quality of life, healthy development, and healthy behaviors in all stages of the life span. Assessing is not a teaching point, although promoting healthy development is a Healthy People 2020 goal. A low-fat, low-calorie diet is not appropriate for all people, so this would not be a teaching point to be included in meeting Healthy People 2020 goals.

Identify interventions that would be effective when assisting a client in making behavior changes that would reduce his health risk factors. Select all that apply. a) Ask the client to follow a plan you wrote for him. b) Have the client identify two or three goals for change. c) Help the client to understand the benefits of change. d) Allow the client to identify available support and resources within the community.

ANS: B, C, D Nurses have been recognized as leaders in health promotion for a long time. The nurse's role is to motivate clients and facilitate change. You will need to help clients to identify goals that are individualized. To create positive change, the client will need to understand the benefits of change, and most will need support to make the change.

The nurse is caring for a patient with a nursing diagnosis of Activity Intolerance secondary to cardiac disease that causes the patient to produce less energy than is expended with activity. Which theory of health and wellness would support this nursing diagnosis? a) World Health Organization b) Jean Watson c) Betty Neuman d) Myers, Sweeney, and Witmer

ANS: C Betty Neuman's theory defines health as more energy generated than expended, and illness, possibly even death, as more energy expended than generated. The World Health Organization defines health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." That definition does not involve energy expenditure, so is irrelevant to the patient's nursing diagnosis. Jean Watson's definition involves a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness, but does not address energy expenditure. Myers, Sweeney, and Witmer defined wellness as a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated; with no mention of energy balance, this theory is not relevant to the nursing diagnosis.

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor? a) 60 b) 75 c) 125 d) 250

ANS: C Calculate the drip rate by multiplying the number of milliliters to be infused per hour (hourly rate) by the drop factor in drops/mL, divided by 60 minutes. An infusion of 250 mL in 2 hours results in an hourly rate of 125 mL/hr. (125 (mL/hr) X 60 (drops/mL))/ 60 min = 125 drops/min

The school nurse at a local elementary school is performing physical fitness assessments on the third grade children. When assessing students' cardiorespiratory fitness, the most appropriate test is to have the students: a) Step up and down on a 12-inch bench b) Perform the sit-and-reach test c) Run a mile without stopping, if they can d) Perform range-of-motion exercises

ANS: C Field tests for running are good for children and can be used when assessing cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young children. The sit-and-reach test and range-of-motion exercises would be appropriate when assessing flexibility.

The nurse working in an acute care setting provides what level of health prevention most often? a) Primary b) Secondary c) Tertiary d) Assessment

ANS: C Patients who are admitted to the hospital are usually admitted for tertiary prevention, which focuses on stopping the disease from progressing and helping to return the individual to pre-illness health. This is the type of care most often provided. Although the nurse delivers some primary health prevention when, for example, teaching patients about activity and healthy eating, this is not the type of care provided most often. Although the nurse delivers some secondary care, screening patients for disease and educating for detection of complications or problems in the early stages, this is not the level of care provided most often. Assessment is not a "type" of prevention, so does not fit this scenario.

The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect? a) Hypokalemia b) Hypophosphotemia c) Hyperkalemia d) Hypercalcemia

ANS: C Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not trigger ECG changes.

A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? a) Primary prevention b) Secondary prevention c) Tertiary prevention d) Health promotion

ANS: C Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary level interventions. Secondary prevention activities detect illness so that it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing.

A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has "learned what to do." He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? a) "By now, you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own." b) "Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success." c) "You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle." d) "You have entered the 'determination stage' and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time."

ANS: C Prochaska and Diclemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. This patient demonstrates behaviors typical of the action stage. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle.

A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform? a) Elevate the patient's left forearm. b) Schedule daily dressing changes to the new IV site. c) Change the administration set. d) Place the patient in Fowler's position.

ANS: C Reusing an IV set from a previous site increases the risk of contamination. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason to elevate the patient's left forearm, or to place him in Fowler's position.

Which electrolyte is the primary regulator of fluid volume? a) Potassium b) Calcium c) Sodium d) Magnesium

ANS: C Sodium is the major action in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral used in more than 300 biochemical reactions in the body.

Which would be an appropriate topic for the elementary school nurse to include in health promotion activities for students? a) Housing conditions b) Poor sanitation c) Stranger danger d) Preventing STIs

ANS: C Stranger danger is a risk for harm for elementary school students, so this would be an appropriate topic for discussion to promote health. Elementary school students would not be the best audience for the topic of housing conditions. Although elementary school students may be taught about handwashing, sanitation would be too mature a topic for this audience. STIs would be too mature a topic for elementary school students.

The nurse assesses that her patient's intravenous solution has infiltrated into the tissues. What action should she take first? a) Aspirate, then inject 0.5 mL normal saline. b) Restart the IV line in a different vein. c) Stop the infusion immediately. d) Notify the primary care provider.

ANS: C The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. The nurse may need to inform the primary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV.

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination, and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics. What statement made by the patient might be an additional cause of her symptoms? a) "I have been working hard to drink plenty of water to prevent dehydration." b) "I should probably tell you I take steroids regularly because of my asthma." c) "I take calcium supplements to prevent osteoporosis and eat lots of dairy foods." d) "I recently quit drinking alcohol. I quit cold turkey and did it all by myself."

ANS: C The patient is exhibiting symptoms of hypercalcemia. Thiazide diuretics can cause elevated calcium levels in the blood by decreasing the amount of calcium excreted in the urine. Excessive intake of calcium would add to his effect, helping to explain how the symptoms have occurred. Drinking too much water would explain hyponatremia, not hypercalcemia; also, she did not say how much water she drank. Steroids would explain hypokalemia, but not hypercalcemia. Alcohol withdrawal would explain hypophosphatemia, but not hypercalcemia.

The nurse meets with patients who quit smoking, or are planning to quit. Which statement made by a patient would lead the nurse to conclude that that patient is in the maintenance stage of change? a) "I haven't smoked in 2 weeks, but I have to constantly resist the urge to light a cigarette." b) "I don't even think about cigarettes anymore. I really don't miss smoking." c) "Each day I don't smoke, I put money that I would have spent in a jar to pay for a vacation." d) "I am chewing gum and eating carrot sticks to keep myself from lighting a cigarette."

ANS: C The patient who has changed the behavior and is rewarding and reinforcing ongoing success by putting money in a jar to pay for vacation is demonstrating the maintenance stage. A patient who no longer thinks about cigarettes and doesn't miss smoking is in the termination stage; there is little risk of relapse. A patient who has implemented the plan to quit smoking but still requires considerable time and energy to maintain the change is in the action stage (i.e., "I haven't smoked in 2 weeks . . ." and "I am chewing gum and eating carrot sticks . . .").

The nurse is caring for a patient with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and a PCO2 of 20. What intervention is required to correct this pH imbalance? a) Increase fluid infusion. b) Increase oxygen percentage. c) Reduce number of breaths/min. d) Increase number of breaths/min.

ANS: C The patient's PCO2 is too low and his pH is too high; reducing the breaths per minute will help the patient to retain CO2, which will increase the pH. Fluid administration will not reduce pH or increase carbon dioxide retention. Administering oxygen will not reduce pH or increase carbon dioxide retention, and would be indicated only if PaO2 were low. Increasing the number of breaths per minute would further lower PCO2 and increase pH.

A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient? a) Impaired Gas Exchange related to ineffective breathing b) Excess Fluid Volume related to limited fluid output c) Deficient Fluid Volume related to abnormal fluid loss d) Electrolyte Imbalance related to decreased oral intake

ANS: C Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.

Choose the correct proportion of water to body weight to be expected in a healthy male adult's body: a. 30% b. 45% c. 60% d. 70%

ANS: C REF: 15

Insensible fluid loss refers to water lost through: a. perspiration only. b. feces only. c. perspiration and expiration. d. urine and feces.

ANS: C REF: 15

When the osmotic pressure of the blood is elevated above normal, water would shift from the: a. blood into the cells. b. interstitial compartment into the cells. c. interstitial compartment into the blood. d. cells into the interstitial compartment.

ANS: C REF: 16

Choose the correct effect of increased parathyroid hormone. a. Increased movement of calcium ions into the bones b. Increased activation of vitamin D c. Increased absorption of calcium from the digestive tract d. Decreased reabsorption of calcium in the kidneys

ANS: C REF: 26

In which of the following processes is phosphate ion NOT a major component? a. Bone metabolism b. Metabolic processes involving adenosine triphosphate (ATP) c. Blood clotting d. Acid-base balance

ANS: C REF: 28

Which of the following would be considered normal serum pH? a. 4.5-8 b. 7.0 c. 7.4 d. 8

ANS: C REF: 28

What is the slowest but most effective control for acid-base balance? a. Respiratory system b. Buffer systems in the blood c. Kidneys d. Brain

ANS: C REF: 29

The direct effects of acidosis are manifested primarily in the functioning of the: a. Digestive system b. Urinary system c. Nervous system d. Respiratory system

ANS: C REF: 32

Which acid-base imbalance results from impaired expiration due to emphysema? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C REF: 32

A patient has been diagnosed with hypovolemia. Which prescriptions for hydration should the nurse question? Select all that apply. a) 0.9% (normal) saline at 100 mL/hr b) Lactated Ringer's solution at 100 mL/hr c) D50W at 100 mL/hr d) D5W solution at 100 mL/hr

ANS: C, D Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringer's and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. D50W is used to treat diabetic patients who have severe hypoglycemia (low blood sugar).

Which of the following is the principal site for regulation of fluid and electrolyte balance? a) Cardiac system b) Vascular system c) Pulmonary system d) Renal system

ANS: D A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body's fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys—that is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation of acid-base balance.

The nurse conducts an assessment of a 38-year-old patient's fitness using the step test. At the end of the test, which heart rate would indicate the patient is in very poor physical condition? a) 96 beats/min b) 106 beats/min c) 114 beats/min d) 134 beats/min

ANS: D A heart rate of 96 beats/min indicates that the patient is in above average physical condition. A heart rate of 106 beats/min indicates that the patient is in average physical condition. A heart rate of 114 beats/min indicates that the patient is in below average physical condition. A heart rate higher than 130 beats/min indicates the patient is in very poor physical condition.

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? a) Diffusion b) Osmosis c) Filtration d) Active transport

ANS: D Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of ATP, the sodium-potassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes.

A client informs the nurse that he has quit smoking because his father died of lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? a) Healthy living b) Health promotion c) Wellness behaviors d) Health protection

ANS: D Although health promotion and health protection may involve the same activities, their difference lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness behavior and may be considered a step toward healthy living; however, neither of these addresses motivation for action.

When performing a central venous catheter dressing change, which of the following steps is correct? a) Wear sterile gloves while removing and discarding the soiled dressing. b) Apply pressure on the catheter-hub junction when removing the soiled dressing. c) Place a sterile transparent dressing over the site and the catheter-hub junction. d) Have the patient wear a mask or turn his head away from the site.

ANS: D Aseptic technique should be used when approaching the insertion site. Therefore, both nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his head away from the insertion site during the procedure. Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing, but not apply pressure to the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site.

The nurse is working with a client who is obese and reports having a sedentary lifestyle. What is the nurse's first action to promote this client's health? a) Teach the client how to follow a low-calorie diet. b) Assist the client in a plan to increase his activity level. c) Explain the risks associated with the client's weight and lifestyle. d) Help the client identify goals for promoting health.

ANS: D Before instituting any interventions, such as diet teaching, a plan for increasing activity, or discussing risks associated with weight and lifestyle, the nurse must first help the patient identify goals. Most health promotion strategies must be implemented by clients, not by healthcare providers, so the client's goals are essential in planning actions that are likely to be successful. Recall that in the nursing process, interventions are developed on the basis of goals. If the nurse immediately starts teaching about diet and activity, it may be discovered that this patient may not be interested in exercising or increasing activity level.

The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to "shut up and act your age." How should the nurse proceed? a) Request that the mother leave the room immediately. b) Request the help of a coworker to hold the child down. c) Inform the child that "this won't hurt a bit." d) Calmly approach the child and tell him what is going to happen.

ANS: D Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A calm approach can alleviate some of the fear. Explain to the child's mother that the boy's behavior is normal. Informing the child that the blood draw will not hurt is wrong and will make him distrustful of future interventions. The nurse may need the help of a coworker, but she should first try a calm approach.

The nurse is caring for a patient with a low hematocrit. Which condition would accurately explain this finding? a) Elevated blood cell count b) Excess transcellular fluid c) Extracellular fluid deficit d) Intravascular fluid excess

ANS: D Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. This measurement depends on the number of and size of RBCs in the vascular system, as well as the amount of fluid in the blood. An "excess" of fluid in the intravascular space (e.g., overhydration) would explain a low hematocrit because the number of cells would appear low in relation to the fluid volume. Low hematocrit, of course, has other causes (e.g., blood loss, decreased production of RBCs). Conversely, an elevated blood cell count would cause a less than normal fluid amount in relation to blood cells. Because hematocrit is a measure of fluid-to-cell ratio within the vascular system, neither transcellular fluid nor extracellular fluid status would explain a low hematocrit.

The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37C (98.6F). What disorder should the nurse suspect? a) Hypovolemia b) Hypercalcemia c) Hyperkalemia d) Hypervolemia

ANS: D Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended owing to increased intravascular volume.

A patient had gastric surgery 10 days ago and continues to require gastric suction because of a paralytic ileus. The patient reports tingling in the fingers, has hypertonic reflexes, and has a respiratory rate of 8 breaths per minute that are deep in nature. The nurse recognizes that these symptoms are consistent with which diagnosis? a) Respiratory alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Metabolic alkalosis

ANS: D Metabolic acidosis can result from excessive gastric secretion, and the symptoms would match the described patient symptoms. A patient with respiratory alkalosis would present with confusion, difficulty focusing, headache, tingling, palpitations, and tremors; this would not be the anticipated problem based on the scenario in the question. A patient with metabolic acidosis presents with headache, confusion, weakness, peripheral vasodilation, nausea and vomiting, and Kussmaul breathing; this would not be the expected diagnosis based on information presented in the scenario. A patient with respiratory acidosis presents with increased pulse and respiratory rate, headache, dizziness, confusion, and muscle twitching. The scenario described would not result in respiratory acidosis.

Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume? a) Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation. b) Electrolyte balance restored, as evidenced by sodium returning to normal range. c) Patient demonstrates effective coughing and deep-breathing techniques. d) Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours.

ANS: D Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughing and deep breathing are irrelevant.

A patient is receiving an IV infusion of lactated Ringer's solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? a) Infiltration b) Extravasation c) Hematoma d) Phlebitis

ANS: D Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site.

The new mother who just gave birth tells the nurse, "I don't know anything about babies, so I want you to teach me everything you can to help me be a good mother." What nursing diagnosis would be most appropriate for this patient? Readiness for Enhanced: a) Breastfeeding b) Communication c) Family Coping d) Parenting

ANS: D Readiness for Enhanced Parenting is the best nursing diagnosis for this patient, who is seeking information to improve her ability to care for her child (i.e., to nurture growth and development of the child). Although breastfeeding may be part of parenting, this diagnosis is to specific for the information in this scenario. Communication certainly is important to good parenting. However, the patient is asking for more than just information about communication. Coping skills are not what this patient is requesting help with, although parenting may involve these skills.

A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? a) Administer an antihistamine (antiallergenic) medication. b) Flush the blood tubing with D5W immediately. c) Prepare for emergency resuscitation. d) Stop the blood transfusion immediately.

ANS: D The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patient's condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.

Choose the correct proportion of blood (to body weight) in an adult male's body: a. 30% b. 20% c. 10% d. 4%

ANS: D REF: 15

Which of the following would cause edema? a. Decreased capillary hydrostatic pressure b. Increased capillary osmotic pressure c. Decreased capillary permeability d. Increased capillary permeability

ANS: D REF: 16-19

Which of the following is a typical sign of dehydration? a. Rapid, strong pulse b. Low hematocrit c. Increased urine output d. Rough oral mucosa

ANS: D REF: 21

Which of the following is a common effect of both hypokalemia and hyperkalemia? a. Skeletal muscle twitch and cramps b. Oliguria c. Elevated serum pH d. Cardiac arrhythmias

ANS: D REF: 26

Which of the following results from hypocalcemia? 1. Low serum phosphate levels 2. Nausea and constipation 3. Skeletal muscle twitch and spasms 4. Weak cardiac contractions a. 1, 2 b. 1, 4 c. 2, 3 d. 3, 4

ANS: D REF: 27

Which of the following is essential in order to maintain serum pH within normal range? a. Carbonic acid and bicarbonate ion must be present in equal quantities. b. All excess carbonic acid must be excreted by the kidneys. c. The concentration of bicarbonate ion must remain constant. d. The ratio of carbonic acid to bicarbonate ion must be 1:20.

ANS: D REF: 30

In patients with impaired expiration associated with emphysema, effective compensation for the acid-base imbalance would be: a. increased rate and depth of respiration. b. decreased rate and depth of respiration. c. increased urine pH and decreased serum bicarbonate. d. decreased urine pH and increased serum bicarbonate.

ANS: D REF: 32