saunders T1 Flashcards


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1

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and cracked are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

A. Weight loss ad dry skin

B. Flat neck and hand veins and decreased urinary output

C. An increase in blood pressure and increase respirations

D. Weakness and decreased central venous pressure

C. An increase in blood pressure and increased respirations

2

The nurse reviews a client's records and determines that the client is at risk for developing a potassium deficit if which situation is documented?

A. Sustained tissue damage

B. Requires nasogastric suction

C. Has a history of Addison's disease

D. Uric acid level of 9.4 mg/dL

B. Requires nasogastric suction

3

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq. Which patterns should the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply

A. U waves

B. Absent P waves

C. Inverted T waves

D. Depressed ST segment

E. Widened QRS complex

A. U waves

C. Inverted T waves

D. Depressed ST segment

The normal Potassium level is 3.5 - 5.0. A serum potassium level lower than 3.5 indicates hypokalemia. Electrocardiographic changes include shallow, flat, or inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic.

4

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply

A. Obtain an intravenous IV infusion pump

B. Monitor urine output during administration

C. Prepare the medication for bolus administration

D. Ensure that the medication is diluted in the appropriate volume of fluid

E. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

A. Obtain an intravenous IV infusion pump

B. Monitor urine output during administration

D. Ensure that the medication is diluted in the appropriate volume of fluid

E. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

5

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

A. Twitching

B. Hypoactive bowel sounds

C. Negative Trousseau's sign

D. Hypoactive deep tendon reflexes

A. Twitching

6

The nurse is caring for a client with Crohn's disease who has calcium level of 8 mg/dL. Which patterns would the nurse watch for on the electrocardiogram? Select all that apply

A. U waves

B. Widened T wave

C. Prominent U wave

D. Prolonged QT interval

E. Prolonged ST segement

D. Prolonged QT interval

E. Prolonged ST segement

7

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply

A. ST depression

B. Prominent U waves

C. Tall peaked T waves

D. Prolonged ST segment

E. Widened QRS complexes

C. Tall peaked T waves

E. Widened QRS complexes

8

Which client is at risk for the development of a sodium level at 130?

A. The client who is taking diuretics

B. The client with hyperaldosteronism

C. The client with Cushing's syndrome

D. The client who is taking corticosteroids

A. The client who is taking diuretics

9

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

A. Muscle twitches

B. Decreased urinary output

C. Hyperactive bowel sounds

D. Increased specific gravity of the urine

C. Hyperactive bowel sounds

10

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

A. Malnutrition

B. Renal insufficiency

C. Hypoparathyroidism

D. Tumor lysis syndrome

A. Malnutrition

normal level 3.0-4.5

11

4. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
5. Cauliflower
6. Strawberries

Correct answer: 2, 3, 4, 6

Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

12

5. The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.
1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals

Correct answer: 1, 2, 4

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

13

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract

3. Integumentary output

Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

14

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations

Correct answer: 1
Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

15

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
4. Increased respirations and increased blood pressure

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
4. Increased respirations and increased blood pressure

16

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
1. The client taking diuretics and has tenting of the skin
2. The client with an ileostomy from a recent abdominal surgery
3. The client who requires intermittent gastrointestinal suctioning
4. The client with kidney disease and a 12-year history of diabetes mellitus

Correct answer: 4
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

17

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
1. The client with colitis
2. The client with Cushing's syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn

Correct answer: 4
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

18

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.
1. Bounding pulse
2. Difficulty breathing
3. Increased urine output
4. Presence of dependent edema
5. Neck vein distention in the upright position

1. Bounding pulse
2. Difficulty breathing

4. Presence of dependent edema
5. Neck vein distention in the upright position

19

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?
1. Bradycardia
2. Elevated blood pressure
3. Changes in mental status
4. Bilateral crackles in the lungs

Correct answer: 3
Rationale: A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

20

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?
1. An oral temperature of 98.8°F (37.1°C)
2. A urine specific gravity of 1.043
3. A urine output that is pale yellow
4. A blood pressure of 120/80 mm Hg

urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030.

21

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?
1. Increase fluid intake.
2. Resume full activity level.
3. Stay in a cool environment when possible.
4. Monitor voiding for adequacy of urine output.

2. Resume full activity level.

Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

22

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?
1. Daily weight
2. Urinary output

3. IV fluid intake

4. NG tube intake

Correct answer: 1
Rationale: Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

23

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?
1. Tremors
2. Hyperactive reflexes
3. Respiratory depression
4. No specific signs or symptoms because this value is a normal level

3. Respiratory depression

Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

24

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.
1. Ensure adequate oxygenation.
2. Provide assistance to prevent falls.
3. Monitor medication administration of diuretics.
4. Monitor for numbness and tingling around the mouth.
5. Prevent complications during potassium administration.

1. Ensure adequate oxygenation.
2. Provide assistance to prevent falls.

3. Monitor medication administration of diuretics.

5. Prevent complications during potassium administration.

The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

25

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?
1. Confusion
2. Muscle weakness
3. Mental status changes
4. Depressed deep tendon reflexes

2. Muscle weakness

Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

26

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?
1. Urine pH of 6
2. Urine that is pale yellow
3. Urine output of 40 mL/hr
4. Urine specific gravity of 1.032

4. Urine specific gravity of 1.032

Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

27

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?
1. Heparin
2. Platelets
3. Antibiotic
4. Clotting factors

1. Heparin

Rationale: During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

28

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.
1. Dehydration
2. Hypertension
3. Physiological stress
4. Decreased blood volume
5. Decreased plasma osmolarity

1. Dehydration

3. Physiological stress

4. Decreased blood volume

29

Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
32. A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?
1. Weighs athletes before, during, and after football practice
2. Asks the athletes to take a salt tablet before football practice
3. Schedules fluid breaks every 30 minutes throughout practice
4. Tells the athletes to drink 16 oz (475 mL) of fluid per pound lost during practice

2. Asks the athletes to take a salt tablet before football practice

30

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?
1. Pour the aspirate into the NG tube through a syringe with the plunger removed.
2. Dilute with water and inject into the NG tube by putting pressure on the plunger.
3. Discard properly and record as output on the client's intake and output (I&O) record.
4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

1. Pour the aspirate into the NG tube through a syringe with the plunger removed.

After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and should not be discarded.

31

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.
_______ mL

Correct answer: 30 mL
Rationale: The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So, if the client drank 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid this day.

32

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?
1. Tetany
2. Twitches
3. Positive Trousseau sign
4. Loss of deep tendon reflexes

4. Loss of deep tendon reflexes

The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.

33

Which clients are most likely to be at risk for the development of third spacing? Select all that apply.
1. The client with cirrhosis
2. The client with liver failure
3. The client with diabetes mellitus
4. The client with a minor burn injury
5. The client with chronic kidney disease

1. The client with cirrhosis
2. The client with liver failure

5. The client with chronic kidney disease

Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

34

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?
1. Tap water
2. Sterile water
3. Distilled water
4. Sodium chloride

4. Sodium chloride

A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution.

35

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?
1. Dehydration
2. Hypokalemia
3. Fluid overload
4. Hypernatremia

1. Dehydration

When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain.
Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

36

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?
1. Sodium 135 mEq/L (135 mmol/L)
2. Sodium 140 mEq/L (140 mmol/L)
3. Potassium 3.0 mEq/L (3.0 mmol/L)
4. Potassium 5.0 mEq/L (5.0 mmol/L)

3. Potassium 3.0 mEq/L (3.0 mmol/L)

The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

37

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?
1. Hypotension
2. Increased heart rate
3. Bounding peripheral pulses
4. Shortened QT interval on electrocardiography (ECG)

Correct answer: 1
Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

38

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.
1. Tetany
2. Constipation
3. Renal calculi
4. Hypotension
5. Prolonged QT interval
6. Positive Chvostek's sign

1. Tetany

4. Hypotension
5. Prolonged QT interval
6. Positive Chvostek's sign

the normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased, and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

39

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?
1. Client with a major burn
2. Client with an ischemic stroke
3. Client with Laënnec's cirrhosis
4. Client with chronic kidney disease

2. Client with an ischemic stroke

Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

40

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?
1. Client in heart failure
2. Client in acute kidney injury
3. Client with diabetes insipidus
4. Client with controlled hypertension

3. Client with diabetes insipidus

The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

41

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?
1. A client with ulcerative colitis
2. A client with Cushing's syndrome
3. A client admitted 6 hours ago with a 40% burn injury
4. A client who has a history of long-term laxative abuse

3. A client admitted 6 hours ago with a 40% burn injury

Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

42

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?
1. Tap water
2. Sterile water
3. 0.9% sodium chloride
4. 0.45% sodium chloride

3. 0.9% sodium chloride

Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

43

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45 , PacO2 of 30, HCO3 20

The nurse analyzes these results as indicating which condition

1. Metabolic acidosis, compensated

2. Respiratory alkalosis compensated

3. Metabolic alkalosis, uncompensated

4. Respiratory acidosis uncompensated

Respiratory alkalosis, compensated

44

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

Metabolic alkalosis

45

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

1. A decreased Ph and increased PacO2

2. an increased pH and decreased Paco2

3. A decreased Ph and a decreased HCO2

4. An increased pH and an increased HCO2

An increased pH with an increased HCO3

46

The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?

Metabolic acidosis

47

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe?

Respirations that are abnormally deep, regular, and increased in rate

48

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

49

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply.

nausea
confusion
tachycardia
lightheadedness

50

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?
1. pH 7.25, Pco2 50 mm Hg
2. pH 7.35, Pco2 40 mm Hg
3.pH 7.50, Pco2 52 mm Hg
4.pH 7.52, Pco2 28 mm Hg

1. pH 7.25, Pco2 50 mm Hg

51

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
1. Sodium level of 145 mEq/L
2. Potassium level of 3.0 mEq/L
3. Magnesium level of 2.0 mg/dL
4. Phosphorus level of 4.0 mg/dL

2.Potassium level of 3.0 mEq/L

52

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis

53

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Pco2 of 58 mm Hg, Po2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

54

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion

55

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result?

Normal results

56

A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least how many minute(s)?

5 minutes

57

The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis

58

In a client seen in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, Pco2 32 mm Hg, Po2 94 mm Hg, HCO3 level 24 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory alkalosis

59

A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn?

Allen's test

60

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Lightheadedness and paresthesias

61

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission work-up on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Apply a warm compress.

62

A client has a prescription for a set of arterial blood gas (ABGs) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.

63

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse develops a plan of care to support the client physiologically until the tubular cells secrete a sufficient amount of which substance?

Hydrogen ions

64

A client suffering from prolonged vomiting has developed metabolic alkalosis. The nurse plans care, knowing that this imbalance will be corrected primarily when the kidneys do which function?

Retain sufficient hydrogen ions.

65

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH?

Fall

66

The nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes

67

A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse should develop a plan of care because the client is at risk for the development of which type of acid-base imbalance?

Metabolic acidosis

68

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem?

Administer prescribed antibiotics.

69

The nurse is caring for a client with chronic kidney disease. Arterial blood gas (ABG) results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. Which laboratory value should the nurse expect to note?
1. Sodium level of 145 mEq/L
2. Potassium level of 5.2 mEq/L
3. Phosphorus level of 4.0 mg/dL
4. Magnesium level of 2.0 mg/dL

2. Potassium level of 5.2 mEq/L

70

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis

71

The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, a Pco2 of 58 mm Hg, a Po2 of 80 mm Hg, and an Hco3 of 27 mEq/L. The nurse should interpret this to mean that the client has which acid-base disturbance?

Respiratory acidosis

72

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder?

Headache, restlessness, and confusion

73

A nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.34 and the Pco2 is 50 mm Hg. Which acid-base imbalance should the nurse interpret that this client is experiencing?

Respiratory acidosis

74

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms, indicating the acid-base disturbance that could occur in the client?

Headache, nausea, vomiting, and diarrhea

75

A nurse reviews a client's arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

76

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? Arrange the actions in the order that they should be performed. All options must be used.

The Allen's test is performed before an arterial blood specimen is obtained from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while continuing to compress the radial artery and then assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings.

77

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determine the adequacy of which?

Ulnar circulation

78

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which did the nurse observe?

Respirations that are abnormally deep, regular, and increased in rate

79

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3 is 22 mEq/L. The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated

80

A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid-base imbalance?

Metabolic acidosis

81

A nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

82

A client is determined to be in respiratory alkalosis by blood gas analysis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base balance?

Hypokalemia

83

A client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. A nurse who is trying to enhance the client's respiratory status should avoid which action?

Encouraging the client to breathe slowly and shallowly

84

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

85

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Potassium

86

A nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client's safety knowing the risks of this imbalance, by carefully implementing which prescribed precaution?

Seizure precautions

87

A nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea

88

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which signs/symptoms?

Decreased respiratory rate and depth

89

A nurse is providing care to a client with the following arterial blood gas (ABG) results: pH 7.50; Pao2 90 mm Hg; Paco2 40 mm Hg; and bicarbonate 35 mEq/L. When the nurse notifies the health care provider (HCP) about these levels, the nurse should anticipate receiving which prescription for this client from the HCP?

Discontinue nasogastric suctioning.