front 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 | back 1 C. An increase in blood pressure and increased respirations |
front 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 | back 2 B. Requires nasogastric suction |
front 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 | back 3 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. |
front 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. | back 4 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. |
front 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 | back 5 A. Twitching |
front 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 | back 6 D. Prolonged QT interval E. Prolonged ST segement |
front 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 | back 7 C. Tall peaked T waves E. Widened QRS complexes |
front 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 | back 8 A. The client who is taking diuretics |
front 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 | back 9 C. Hyperactive bowel sounds |
front 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 | back 10 A. Malnutrition normal level 3.0-4.5 |
front 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. | back 11 Correct answer: 2, 3, 4, 6 |
front 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. | back 12 Correct answer: 1, 2, 4 |
front 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? | back 13 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. |
front 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? | back 14 Correct answer: 1 |
front 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? | back 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? |
front 16 On review of the clients' medical records, the nurse determines that
which client is at risk for fluid volume excess? | back 16 Correct answer: 4 |
front 17 Which client is at risk for the development of a potassium level of
5.5 mEq/L (5.5 mmol/L)? | back 17 Correct answer: 4 |
front 18 The nurse is caring for a client with heart failure (HF). Which signs
and symptoms could indicate fluid overload? Select all that
apply. | back 18 1. Bounding pulse 4. Presence of dependent edema |
front 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? | back 19 Correct answer: 3 |
front 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? | back 20 urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. |
front 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? | back 21 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. |
front 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? 3. IV fluid intake 4. NG tube intake | back 22 Correct answer: 1 |
front 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? | back 23 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. |
front 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. | back 24 1. Ensure adequate oxygenation. 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. |
front 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? | back 25 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. |
front 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? | back 26 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. |
front 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? | back 27 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. |
front 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. | back 28 1. Dehydration 3. Physiological stress 4. Decreased blood volume |
front 29 Priority Concepts: Clinical Judgment, Fluid and Electrolyte
Balance | back 29 2. Asks the athletes to take a salt tablet before football practice |
front 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? | back 30 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. |
front 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. | back 31 Correct answer: 30 mL |
front 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? | back 32 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. |
front 33 Which clients are most likely to be at risk for the development of
third spacing? Select all that apply. | back 33 1. The client with cirrhosis 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. |
front 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? | back 34 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. |
front 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? | back 35 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. |
front 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? | back 36 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. |
front 37 The nurse is assessing a client with a suspected diagnosis of
hypocalcemia. Which cardiovascular manifestation would the nurse
expect to note? | back 37 Correct answer: 1 |
front 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. | back 38 1. Tetany 4. Hypotension 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. |
front 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? | back 39 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. |
front 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? | back 40 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. |
front 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? | back 41 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. |
front 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? | back 42 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. |
front 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 | back 43 Respiratory alkalosis, compensated |
front 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 | back 44 Metabolic alkalosis |
front 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 | back 45 An increased pH with an increased HCO3 |
front 46 The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? | back 46 Metabolic acidosis |
front 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? | back 47 Respirations that are abnormally deep, regular, and increased in rate |
front 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? | back 48 Respiratory acidosis without compensation |
front 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. | back 49 nausea |
front 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? | back 50 1. pH 7.25, Pco2 50 mm Hg |
front 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? | back 51 2.Potassium level of 3.0 mEq/L |
front 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? | back 52 Respiratory acidosis |
front 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? | back 53 Respiratory acidosis |
front 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? | back 54 Headache, restlessness, and confusion |
front 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? | back 55 Normal results |
front 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)? | back 56 5 minutes |
front 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? | back 57 Respiratory acidosis |
front 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? | back 58 Respiratory alkalosis |
front 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? | back 59 Allen's test |
front 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? | back 60 Lightheadedness and paresthesias |
front 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? | back 61 Apply a warm compress. |
front 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? | back 62 Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. |
front 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? | back 63 Hydrogen ions |
front 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? | back 64 Retain sufficient hydrogen ions. |
front 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? | back 65 Fall |
front 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? | back 66 Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes |
front 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? | back 67 Metabolic acidosis |
front 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? | back 68 Administer prescribed antibiotics. |
front 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? | back 69 2. Potassium level of 5.2 mEq/L |
front 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? | back 70 Metabolic alkalosis |
front 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? | back 71 Respiratory acidosis |
front 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? | back 72 Headache, restlessness, and confusion |
front 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? | back 73 Respiratory acidosis |
front 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? | back 74 Headache, nausea, vomiting, and diarrhea |
front 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? | back 75 Respiratory alkalosis, uncompensated |
front 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. | back 76 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. |
front 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? | back 77 Ulnar circulation |
front 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? | back 78 Respirations that are abnormally deep, regular, and increased in rate |
front 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? | back 79 Respiratory acidosis, uncompensated |
front 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? | back 80 Metabolic acidosis |
front 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? | back 81 Respiratory acidosis |
front 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? | back 82 Hypokalemia |
front 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? | back 83 Encouraging the client to breathe slowly and shallowly |
front 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? | back 84 Provide emotional support and reassurance. |
front 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? | back 85 Potassium |
front 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? | back 86 Seizure precautions |
front 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? | back 87 Drowsiness, headache, and tachypnea |
front 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? | back 88 Decreased respiratory rate and depth |
front 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? | back 89 Discontinue nasogastric suctioning. |