FLUIDS AND ELECTROLYTES; ACID-BASE BALANCE 100 ITEMS
1. What is the nurse's primary concern regarding fuid & electrolytes when caring or an elderly pt who is intermittently conused? A. risk o dehydration B. risk o kidney damage C. risk o stroke . risk o !leeding Answer" 1 #ationale 1" As an adult ages$ the thirst mechanism declines. Adding this in a pt with an altered le%el o consciousness$ there is an increased risk o dehydration & high serum osmolality. #ationale " he risks or kidney damage are not speci(cally related to aging or fuid & electrolyte issues. #ationale )" he risk o stroke is not speci(cally related to aging or fuid & electrolyte issues. #ationale *" he risk o !leeding is not speci(cally related to aging or fuid & electrolyte issues. . he nurse is planning care or a pt with se%ere !urns. Which o the ollowing is this pt at risk or de%eloping? A. intracellular fuid de(cit B. intracellular fuid o%erload C. e+tracellular fuid de(cit . interstitial fuid de(cit Answer" 1 #ationale 1" Because this pt was se%erely !urned$ the fuid within the cells is diminished$ diminished$ leading to an intracellular fuid de(cit. #ationale #ationale " he intracellular fuid is all fuids that e+ist within the cell cytoplasm & nucleus. Because this pt was se%erely !urned$ the fuid within the cells is diminished$ diminished$ leading to an intracellular fuid de(cit. #ationale )" he e+tracellular fuid is all fuids that e+ist outside the cell$ including the interstitial fuid !etween the cells. Because this pt was se%erely !urned$ the fuid within the cells is diminished$ leading to an intracellular intracellular fuid de(cit. #ationale *" he e+tracellular fuid is all fuids that e+ist outside the cell$ including the interstitial fuid !etween the cells. Because this pt was se%erely !urned$ the fuid within the cells is diminished$ leading to an intracellular intracellular fuid de(cit.
). A pt$ e+periencing multisystem multisystem fuid %olume de(cit$ has the symptoms o tachycardia$ pale$ cool skin$ & decreased urine output. he nurse reali,es these (ndings are most likely a direct result o which o the ollowing? A. the !ody's natural compensatory compensatory mechanisms B. pharmacological e-ects o a diuretic C. e-ects o rapidly inused intra%enous fuids . cardiac ailure Answer" 1 #ationale #ationale 1" he internal %asoconstricti%e compensatory reactions within the !ody are responsi!le or the symptoms e+hi!ited. he !ody naturally attempts to conser%e fuid internally speci(cally or the !rain & heart. #ationale " A diuretic would cause urther fuid loss$ & is contraindicated. #ationale )" #apidly inused intra%enous fuids would not cause a decrease in urine output. #ationale *" he maniestations reported are not indicati%e o cardiac ailure in this pt. *. A pregnant pt is admitted with e+cessi%e thirst$ increased urination$ & has a medical diagnosis o dia!etes insipidus. he nurse chooses which o the ollowing nursing diagnoses as most appropriate? A. #isk or m!alanced /luid 0olume B. +cess /luid 0olume C. m!alanced 2utrition . ne-ecti%e issue 3erusion Answer" 1 #ationale 1" he pt with e+cessi%e thirst$ increased urination & a medical diagnosis o dia!etes insipidus is at risk or m!alanced /luid 0olume due to the pt &'s e+cess %olume loss that can increase the serum le%els o sodium. #ationale " +cess /luid 0olume is not an issue or pts with dia!etes insipidus$ especially during the early stages o treatment. #ationale #ationale )" m!alanced 2utrition does not apply. #ationale *" ne-ecti%e issue 3erusion does not apply 4. A pt reco%ering rom surgery has an indwelling urinary catheter. he nurse would contact the pt's primary healthcare pro%ider with which o the ollowing *5hour urine output %olumes? A. 677 m8 B. 947 m8 1
C. 1777 m8 . 177 m8 Answer" 1 #ationale 1" A urine output o less than )7 m8 per hour must !e reported to the primary healthcare pro%ider. his indicates inade:uate renal perusion$ placing the pt at increased risk or acute renal ailure & inade:uate tissue perusion. A minimum o 97 m8 o%er a *5hour period is desired ;)7 m8 multiplied !y * hours e:uals 97 m8 per * hours<. 6. A pt is recei%ing intra%enous fuids postoperati%ely ollowing cardiac surgery. 2ursing assessments should ocus on which postoperati%e complication? A. fuid %olume e+cess B. fuid %olume de(cit C. sei,ure acti%ity . li%er ailure Answer" 1 #ationale 1" Antidiuretic hormone & aldosterone le%els are commonly increased ollowing the stress response !eore$ during$ & immediately ater surgery. his increase leads to sodium & water retention. Adding more fuids intra%enously can cause a fuid %olume e+cess & stress upon the heart & circulatory system. #ationale " Adding more fuids intra%enously can cause a fuid %olume e+cess$ not fuid %olume de(cit$ & stress upon the heart & circulatory system. #ationale )" =ei,ure acti%ity would more commonly !e associated with electrolyte im!alances. #ationale *" 8i%er ailure is not anticipated related to postoperati%e intra%enous fuid administration. 9. A pt is diagnosed with se%ere hyponatremia. he nurse reali,es this pt will mostly likely need which o the ollowing precautions implemented? A. sei,ure B. inection C. neutropenic . high5risk all Answer" 1 #ationale 1" =e%ere hyponatremia can lead to sei,ures. =ei,ure precautions such as a :uiet en%ironment$ raised side rails$ & ha%ing an oral airway at the !edside would !e included. #ationale " nection precautions not speci(cally indicated or a pt with hyponatremia. #ationale )" 2eutropenic precautions not
speci(cally indicated or a pt with hyponatremia. #ationale *" >igh5risk all precautions not speci(cally indicated or a pt with hyponatremia. . A pt is diagnosed with hypokalemia. Ater re%iewing the pt's current medications$ which o the ollowing might ha%e contri!uted to the pt's health pro!lem? A. corticosteroid B. thia,ide diuretic C. narcotic . muscle rela+er Answer" 1 #ationale 1" +cess potassium loss through the kidneys is oten caused !y such meds as corticosteroids$ potassium5wasting diuretics$ amphotericin B$ & large doses o some anti!iotics. #ationale " +cessi%e sodium is lost with the use o thia,ide diuretics. #ationale )" 2arcotics do not typically a-ect electrolyte !alance. #ationale *" @uscle rela+ants do not typically a-ect electrolyte !alance. . A pt prescri!ed spironolactone is demonstrating C changes & complaining o muscle weakness. he nurse reali,es this pt is e+hi!iting signs o which o the ollowing? A. hyperkalemia B. hypokalemia C. hypercalcemia . >ypocalcemia Answer" 1 #ationale 1" >yperkalemia is serum potassium le%el greater than 4.7 m:8. ecreased potassium e+cretion is seen in potassium5sparing diuretics such as spironolactone. Common maniestations o hyperkalemia are muscle weakness & C changes. #ationale " >ypokalemia is seen in non5 potassium diuretics such as urosemide. #ationale )" >ypercalcemia has !een associated with thia,ide diuretics. #ationale *" >ypocalcemia is seen in pts who ha%e recei%ed many units o citrated !lood & is not associated with diuretic use. 17. he nurse is planning care or a pt with fuid %olume o%erload & hyponatremia. Which o the ollowing should !e included in this pt's plan o care? A. #estrict fuids. B. Administer intra%enous fuids. C. 3ro%ide Daye+alate. . Administer intra%enous normal saline with urosemide.
Answer" 1 #ationale 1" he nursing care or a pt with hyponatremia is dependent on the cause. #estriction o fuids to 1$777 m8day is usually implemented to assist sodium increase & to pre%ent the sodium le%el rom dropping urther due to dilution. #ationale " he administration o intra%enous fuids would !e indicated in fuid %olume de(cit & hypernatremia. #ationale )" Daye+alate is used in pts with hyperkalemia. #ationale *" he administration o normal saline with urosemide is used to increase calcium secretion. 11. When caring or a pt diagnosed with hypocalcemia$ which o the ollowing should the nurse additionally assess in the pt? A. other electrolyte distur!ances B. hypertension C. %isual distur!ances . drug to+icity Answer" 1 #ationale 1" he pt diagnosed with hypocalcemia may also ha%e high phosphorus or decreased magnesium le%els. #ationale " he pt with hypocalcemia may e+hi!it hypotension$ & not hypertension. #ationale )" 0isual distur!ances do not occur with hypocalcemia. #ationale *" >ypercalcemia is more commonly caused !y drug to+icities. 1. A pt with a history o stomach ulcers is diagnosed with hypophosphatemia. Which o the ollowing inter%entions should the nurse include in this pt's plan o care? A. #e:uest a dietitian consult or selecting oods high in phosphorous. B. 3ro%ide aluminum hydro+ide antacids as prescri!ed. C. nstruct pt to a%oid poultry$ peanuts$ & seeds. . nstruct to a%oid the intake o sodium phosphate. Answer" 1 #ationale 1" reatment o hypophosphatemia includes treating the underlying cause & promoting a high phosphate diet$ especially milk$ i it is tolerated. Ether oods high in phosphate are dried !eans & peas$ eggs$ (sh$ organ meats$ Bra,il nuts & peanuts$ poultry$ seeds & whole grains. #ationale " 3hosphate5!inding antacids$ such as aluminum hydro+ide$ should !e a%oided. #ationale )" 3oultry$ peanuts$ & seeds are part o a high phosphate diet. #ationale *" @ild hypophosphatemia may !e
corrected !y oral supplements$ such as sodium phosphate. 1). When analy,ing an arterial !lood gas report o a pt with CE3 & respiratory acidosis$ the nurse anticipates that compensation will de%elop through which o the ollowing mechanisms? A. he kidneys retain !icar!onate. B. he kidneys e+crete !icar!onate. C. he lungs will retain car!on dio+ide. . he lungs will e+crete car!on dio+ide. Answer" 1 #ationale 1" he kidneys will compensate or a respiratory disorder !y retaining !icar!onate. #ationale " +creting !icar!onate causes acidosis to de%elop. #ationale )" #etaining car!on dio+ide causes respiratory acidosis. #ationale *" +creting car!on dio+ide causes respiratory alkalosis 1*. he nurse is caring or a pt diagnosed with renal ailure. Which o the ollowing does the nurse recogni,e as compensation or the acid5!ase distur!ance ound in pts with renal ailure? A. he pt !reathes rapidly to eliminate car!on dio+ide. B. he pt will retain !icar!onate in e+cess o normal. C. he p> will decrease rom the present %alue. . he pt's o+ygen saturation le%el will impro%e. Answer" 1 #ationale 1" n meta!olic acidosis compensation is accomplished through increased %entilation or F!lowing o-F C7. his raises the p> !y eliminating the %olatile respiratory acid & compensates or the acidosis. #ationale " Because compensation must !e perormed !y the system other than the a-ected system$ the pt cannot retain !icar!onateG the maniestation o meta!olic acidosis o renal ailure is a lower than normal !icar!onate %alue. #ationale )" @eta!olic acidosis o renal ailure causes a low p>G this is the maniestation o the disease process$ not the compensation. #ationale *" E+ygenation distur!ance is not part o the acid5!ase status o the pt with renal ailure.
)
14. When caring or a group o pts$ the nurse reali,es that which o the ollowing health pro!lems increases the risk or meta!olic alkalosis? A. !ulimia B. dialysis C. %enous stasis ulcer . CE3 Answer" 1 #ationale 1" @eta!olic alkalosis is cause !y %omiting$ diuretic therapy or nasogastric suction$ among others. A pt with !ulimia may engage in %omiting or indiscriminate use o diuretics. #ationale " A pt recei%ing dialysis has kidney ailure$ which causes meta!olic acidosis. #ationale )" A %enous stasis ulcer does not result in an acid5!ase disorder. #ationale *" he pt diagnosed with CE3 typically has hypercapnea & respiratory acidosis. 16. he nurse is caring or a pt who is an+ious & di,,y ollowing a traumatic e+perience. he arterial !lood gas (ndings include" p> 9.*$ 3aE 117$ 3aCE 4$ & >CE) *. he nurse would anticipate which initial inter%ention to correct this pro!lem? A. ncourage the pt to !reathe in & out slowly into a paper !ag. B. mmediately administer o+ygen %ia a mask & monitor o+ygen saturation. C. 3repare to start an intra%enous fuid !olus using isotonic fuids. . Anticipate the administration o intra%enous sodium !icar!onate. Answer" 1 #ationale 1" his pt is e+hi!iting signs o hyper%entilation that is con(rmed with the !lood gas results o respiratory alkalosis. Breathing into a paper !ag will help the pt to retain car!on dio+ide & lower o+ygen le%els to normal$ correcting the cause o the pro!lem. #ationale " he o+ygen le%els are high$ so o+ygen is not indicated$ & would e+acer!ate the pro!lem i gi%en. ntra%enous fuids would not !e the initial inter%ention. #ationale )" 2ot enough inormation is gi%en to determine the need or intra%enous fuids. #ationale *" Bicar!onate would !e contraindicated as the p> is already high. 19. A pt is prescri!ed 7 m: o potassium chloride. he nurse reali,es that the reason the pt is recei%ing this replacement is A. to sustain respiratory unction. B. to help regulate acid5!ase !alance.
C. to keep a %ein open. . to encourage urine output. Answer" #ationale 1" 3otassium does not sustain respiratory unction. #ationale " lectrolytes ha%e many unctions. hey assist in regulating water !alance$ help regulate & maintain acid5!ase !alance$ contri!ute to en,yme reactions$ & are essential or neuromuscular acti%ity. #ationale )" ntra%enous fuids are used to keep %enous access not potassium. #ationale *" Hrinary output is impacted !y fuid intake not potassium. 1. An elderly pt does not complain o thirst. What should the nurse do to assess that this pt is not dehydrated? A. Ask the physician or an order to !egin intra%enous fuid replacement. B. Ask the physician to order a chest +5ray. C. Assess the urine or osmolality. . Ask the physician or an order or a !rain scan. Answer" ) #ationale 1" t is inappropriate to seek an 0 at this stage. #ationale " here is no indication the pt is e+periencing pulmonary complications thus a cheat +5ray is not indicated. #ationale )" he thirst mechanism declines with aging$ which makes older adults more %ulnera!le to dehydration & hyperosmolality. he nurse should check the pt's urine or osmolality as a 1st step in determining hydration status !eore other detailed & in%asi%e testing is done. #ationale *" here is no data to support the need or a !rain scan. 1. An elderly pt who is !eing medicated or pain had an episode o incontinence. he nurse reali,es that this pt is at risk or de%eloping A. dehydration. B. o%er5hydration. C. ecal incontinence. . a stroke. Correct Answer" 1 #ationale 1" /unctional changes o aging also a-ect fuid !alance. Elder adults who ha%e sel5care de(cits$ or who are conused$ depressed$ tu!e5ed$ on !ed rest$ or taking medications ;such as sedati%es$ tran:uili,ers$ diuretics$ & la+ati%es<$ are at greatest risk or fuid %olume im!alance. #ationale " here is inade:uate e%idence to support the risk o o%er5hydration. #ationale )" here is inade:uate e%idence to support the risk o ecal incontinence. *
#ationale *" here is inade:uate e%idence to support the risk o a stroke. 7. he nurse assesses a pt's weight loss as !eing l!s. >ow many liters o fuid did this pt lose? A. 17 B. 14 C. 7 . 4 Correct Answer" A #ationale" ach liter o !ody fuid weighs 1 kg or . l!s. his pt has lost 17 liters o fuid. 1. A postoperati%e pt with a fuid %olume de(cit is prescri!ed progressi%e am!ulation yet is weak rom an inade:uate fuid status. What can the nurse do to help this pt? A. Assist the pt to maintain a standing position or se%eral minutes. B. his pt should !e on !ed rest. C. Assist the pt to mo%e into di-erent positions in stages. . Contact physical therapy to pro%ide a walker. Answer" ) #ationale 1" he pt should a%oid prolonged standing. #ationale " Bed rest can promote skin !reakdown. #ationale )" he pt needs to !e taught how to a%oid orthostatic hypotension which would include assisting & teaching the pt how to mo%e rom one position to another in stages. #ationale *" A physician reerral is needed or physical therapy inter%ention & is not indicated in this situation. . A postoperati%e pt is diagnosed with fuid %olume o%erload. Which o the ollowing should the nurse assess in this pt? A. poor skin turgor B. decreased urine output C. distended neck %eins . concentrated hemoglo!in & hematocrit le%els Answer" ) #ationale 1" 3oor skin turgor is associated with fuid %olume de(cit. #ationale " ecreased urine output is associated with fuid %olume de(cit. #ationale )" Circulatory o%erload causes maniestations such as a ull$ !ounding pulseG distended neck & peripheral %einsG increased central %enous pressureG coughG dyspneaG orthopneaG rales in the lungsG pulmonary edemaG polyuriaG ascitesG
peripheral edema$ or i se%ere$ anasarca$ in which dilution o plasma !y e+cess fuid causes a decreased hematocrit & !lood urea nitrogen ;BH2
demonstrating which o the ollowing? A. hypernatremia B. hyponatremia C. fuid %olume e+cess . >yperkalemia Answer" #ationale 1" >ypernatremia is associated with fuid retention & o%erload. /0 is associated with hypernatremia. #ationale " his elderly pt has watery diarrhea$ which contri!utes to the loss o sodium. he a!dominal & muscle cramps are maniestations o a low serum sodium le%el. #ationale )" his pt is more likely to de%elop clinical maniestations associated with fuid %olume de(cit. #ationale *" >yperkalemia is associated with cardiac dysrhythmias. 6. A pt is admitted with hypernatremia caused !y !eing str&ed on a !oat in the Atlantic Ecean or (%e days without a resh water source. Which o the ollowing is this pt at risk or de%eloping? A. pulmonary edema B. atrial dysrhythmias C. cere!ral !leeding . stress ractures Answer" ) #ationale 1" 3ulmonary edema is not associated with dehydration. #ationale " Atrial dysrhythmias are not a actor or this pt. #ationale )" he !rain e+periences the most serious e-ects o cellular dehydration. As !rain cells contract$ the !rain shrinks$ which puts mechanical traction on cere!ral %essels. hese %essels may tear$ !leed$ & lead to cere!ral %ascular !leeding. #ationale *" here ha%e !een no acti%ities to support the de%elopment or occurrence o stress ractures. 9. he nurse is admitting a pt who was diagnosed with acute renal ailure. Which o the ollowing electrolytes will !e most a-ected with this disorder? A. calcium B. magnesium C. phosphorous . 3otassium Answer" * #ationale 1" his pt will !e less likely to de%elop a calcium im!alance. #ationale " his pt will !e less likely to de%elop a magnesium im!alance. #ationale )" his pt will !e less likely to de%elop a phosphorous im!alance.
#ationale *" Because the kidneys are the principal organs in%ol%ed in the elimination o potassium$ renal ailure . A pt who is taking digo+in ;8ano+in< is admitted with possi!le hypokalemia. Which o the ollowing does the nurse reali,e might occur with this pt? A. igo+in to+icity may occur. B. A higher dose o digo+in ;8ano+in< may !e needed. C. A diuretic may !e needed. . /luid %olume de(cit may occur. Answer" 1 #ationale 1" >ypokalemia increases the risk o digitalis to+icity in pts who recei%e this drug or heart ailure. #ationale " @ore digo+in is not needed. #ationale )" A diuretic may cause urther fuid loss. #ationale *" here is inade:uate inormation to assess or concerns related to fuid %olume de(cits. . A pt is prescri!ed *7 m: potassium as a replacement. he nurse reali,es that this replacement should !e administered A. directly into the %enous access line. B. mi+ed in the prescri!ed intra%enous fuid. C. %ia a rectal suppository. . %ia intramuscular inIection. Answer" #ationale 1" 2e%er administer undiluted potassium directly into a %ein. #ationale " he intra%enous route is the recommended route or diluted potassium. #ationale )" he nurse should administer diluted potassium into the pt's intra%enous line. #ationale *" he nurse should administer diluted potassium into the pt's intra%enous line. )7. An elderly pt with a history o sodium retention arri%es to the clinic with the complaints o Fheart skipping !eatsF & leg tremors. Which o the ollowing should the nurse ask this pt regarding these symptoms? A. F>a%e you stopped taking your digo+in medication?F B. FWhen was the last time you had a !owel mo%ement?F C. FWere you doing any unusual physical acti%ity?F . FAre you using a salt su!stitute?F Answer" * #ationale 1" Although this pt may !e 6
prescri!ed digo+in this is not the primary ocus o this :uestion. #ationale " he pt's !owel ha!its are not o concern at this time. #ationale )" he cardiac & musculoskeletal discomorts !eing reported are not consistent with physical e+ertion. #ationale *" he pt has a history o sodium retention & might think that a salt su!stitute can !e used. Ad%ise pts who are taking a potassium supplement or potassium5sparing diuretic to a%oid salt su!stitutes$ which usually contain potassium. )1. A )45year5old emale pt comes into the clinic postoperati%e parathyroidectomy. Which o the ollowing should the nurse instruct this pt? A. rink one glass o red wine per day. B. A%oid the sun. C. @ilk & milk5!ased products will ensure an ade:uate calcium intake. . #ed meat is the protein source o choice. Answer" ) #ationale 1" his pt should a%oid alcohol. #ationale " his pt can !ene(t rom sun e+posure. #ationale )" his pt is at risk or de%eloping hypocalcemia. his risk can !e a%oided i instructed to ingest milk & milk5!ased products. #ationale *" 3rotein monitoring is not indicated. ). A pt is admitted or treatment o hypercalcemia. he nurse reali,es that this pt's intra%enous fuids will most likely !e which o the ollowing? A. de+trose 4J & water B. de+trose 4J & ? normal saline C. de+trose 4J & ? normal saline . normal saline Answer" * #ationale 1" isotonic saline is not used$ the pt is at risk or hyponatremia in addition to the hypercalcemia. #ationale " his solution is hypotonic. sotonic saline is used !ecause sodium e+cretion is accompanied !y calcium e+cretion through the kidneys. #ationale )" his solution is hypotonic. sotonic saline is used !ecause sodium e+cretion is accompanied !y calcium e+cretion through the kidneys. #ationale *" sotonic saline is used !ecause sodium e+cretion is accompanied !y calcium e+cretion through the kidneys.
)). A 5year5old male pt is admitted with dia!etic ketoacidosis. he nurse reali,es that this pt will ha%e a need or which o the ollowing electrolytes? A. sodium B. potassium C. calcium . @agnesium Answer" * #ationale *" Ene risk actor or hypomagnesaemia is an endocrine disorder$ including dia!etic ketoacidosis. )*. An elderly pt with peripheral neuropathy has !een taking magnesium supplements. he nurse reali,es that which o the ollowing symptoms can indicate hypomagnesaemia? A. hypotension$ warmth$ & sweating B. nausea & %omiting C. hyperrefe+ia . e+cessi%e urination Answer" 1 #ationale 1" le%ations in magnesium le%els are accompanied !y hypotension$ warmth$ & sweating. #ationale " 8ower le%els o magnesium are associated with nausea & %omiting. #ationale )" 8ower le%els o magnesium are associated & hyperrefe+ia. #ationale *" Hrinary changes are not noted. )4. A pt is admitted with !urns o%er 47J o his !ody. he nurse reali,es that this pt is at risk or which o the ollowing electrolyte im!alances? A. hypercalcemia B. hypophosphatemia C. hypernatremia . >ypermagnesemia Correct Answer" #ationale 1" 3ts who e+perience !urns are not at an increased risk or de%eloping increased !lood calcium le%els. #ationale " Causes o hypophosphatemia include stress responses & e+tensi%e !urns. #ationale )" 3ts who e+perience !urns are not at an increased risk or de%eloping increased !lood sodium le%els. #ationale *" 3ts who e+perience !urns are not at an increased risk or de%eloping increased !lood magnesium le%els. )6. A pt is diagnosed with hyperphosphatemia. he nurse reali,es that this pt might also ha%e an im!alance o which o the ollowing electrolytes? A. calcium B. sodium 9
C. potassium . Chloride Answer" 1 #ationale 1" +cessi%e serum phosphate le%els cause ew speci(c symptoms. he e-ects o high serum phosphate le%els on ner%es & muscles are more likely the result o hypocalcemia that de%elops secondary to an ele%ated serum phosphorus le%el. he phosphate in the serum com!ines with ioni,ed calcium$ & the ioni,ed serum calcium le%el alls. )9. he nurse is re%iewing a pt's !lood p> le%el. Which o the systems in the !ody regulate !lood p>? =elect all that apply. A. renal B. cardiac C. !u-ers . #espiratory Answer" 1$) #ationale 1" hree systems work together in the !ody to maintain the p> despite continuous acid production" !u-ers$ the respiratory system$ & the renal system. #ationale " he cardiac system is responsi!le or circulating !lood to the !ody. t does not help maintain the !ody's p>. #ationale )" hree systems work together in the !ody to maintain the p> despite continuous acid production" !u-ers$ the respiratory system$ & the renal system. #ationale *" hree systems work together in the !ody to maintain the p> despite continuous acid production" !u-ers$ the respiratory system$ & the renal system. ). he nurse o!ser%es a pt's respirations & notes that the rate is )7 per minute & the respirations are %ery deep. he meta!olic disorder this pt might !e demonstrating is which o the ollowing? A. hypernatremia B. increasing car!on dio+ide in the !lood C. hypertension . 3ain Answer" #ationale 1" >ypernatremia is associated with prouse sweating & diarrhea. #ationale " Acute increases in either car!on dio+ide or hydrogen ions in the !lood stimulate the respiratory center in the !rain. As a result$ !oth the rate & depth o respiration increase. he increased rate & depth o lung %entilation eliminates car!on dio+ide rom the !ody$ & car!onic acid le%els all$ which !rings the p> to a more normal range.
#ationale )" he respiratory rate in a pt e+hi!iting hypertension is not altered. #ationale *" 3ain may !e maniested in rapid$ shallow respirations. ). he !lood gases o a pt with an acid5!ase disorder show a !lood p> outside o normal limits. he nurse reali,es that this pt is A. ully compensated. B. demonstrating anaero!ic meta!olism. C. partially compensated. . in need o intra%enous fuids Answer" ) #ationale 1" the p> is restored to within normal limits$ the disorder is said to !e ully compensated. #ationale " Anaero!ic meta!olism results when the !ody's cells !ecome hypo+ic. #ationale )" the p> is restored to within normal limits$ the disorder is said to !e ully compensated. When these changes are refected in arterial !lood gas ;AB< %alues !ut the p> remains outside normal limits$ the disorder is said to !e partially compensated. #ationale *" Although the pt may !e in need o intra%enous fuids$ this is not the most correct or de(niti%e answer. *7. A pt's !lood gases show a p> greater o 9.4) & !icar!onate le%el o )6 m:8. he nurse reali,es that the acid5!ase disorder this pt is demonstrating is which o the ollowing? A. respiratory acidosis B. meta!olic acidosis C. respiratory alkalosis . meta!olic alkalosis Answer" * #ationale 1& " #espiratory acidosis & meta!olic acidosis are !oth consistent with p> less than 9.)4. #ationale )" #espiratory alkalosis is associated with a p> greater than 9.*4 & a 3aCE o less than )4 mm>. t is caused !y respiratory related conditions. #ationale *" Arterial !lood gases ;ABs< show a p> greater than 9.*4 & !icar!onate le%el greater than 6 m:8 when the pt is in meta!olic alkalosis. *1. An elderly postoperati%e pt is demonstrating lethargy$ conusion$ & a resp rate o per minute. he nurse sees that the last dose o pain medication administered %ia a pt controlled anesthesia ;3CA< pump was within )7 minutes. Which o the ollowing acid5!ase disorders might this pt !e e+periencing?
A. respiratory acidosis B. meta!olic acidosis C. respiratory alkalosis . meta!olic alkalosis Answer" 1 #ationale 1" Acute respiratory acidosis occurs due to a sudden ailure o %entilation. E%erdoses o narcotic or sedati%e medications can lead to this condition. #ationale " he pt condition !eing descri!ed is respiratory not meta!olic in nature. #ationale )" Acute respiratory acidosis occurs due to a sudden ailure o %entilation. E%erdoses o narcotic or sedati%e medications can lead to this condition. #ationale *" Acute respiratory acidosis occurs due to a sudden ailure o %entilation. E%erdoses o narcotic or sedati%e medications can lead to this condition. he pt condition !eing descri!ed is respiratory not meta!olic in nature. *. he pt has !een placed on a 177 m8 daily fuid restriction. he pt's 0 is inusing at a keep open rate o 17 m8hr. he pt has no additional 0 medications. >ow much fuid should the pt !e allowed rom 7977 until 1477 daily? A. 4*7 ml B. )77 ml C. 677 ml . 47 ml Answer" 4*7 #ationale" /luid allowed is calculated !y (guring the total daily 0 intake ;in this case 17 m8hr K * hours L *7 m8day<$ su!tracting that total rom the daily allowance ;in this case 177m8 5 *7 m8 L 67m8<. he amount calculated is then distri!uted as 47J or the traditional day shit$ 4J5)4J or the traditional e%ening shit$ & the remainder or the traditional night shit. n this case$ 47J o 67 is 4*7 m8. *). he pt is recei%ing intra%enous potassium ;DC8<. Which nursing actions are re:uired? =elect all that apply. A. Administer the dose 0 push o%er ) minutes. B. @onitor the inIection site or redness. C. Add the ordered dose to the 0 hanging. . Hse an inusion controller or the 0. . @onitor fuid intake & output. Answer" $*$4 **. Which pts are at risk or the de%elopment o hypercalcemia? =elect all that apply.
A. the pt with a malignancy B. the pt taking lithium C. the pt who uses sunscreen to e+cess . the pt with hyperparathyroidism . the pt who o%eruses antacids Correct Answer" 1$$*$4 #ationale 1" 3ts with malignancy are at risk or de%elopment o hypercalcemia due to destruction o !one or the production o hormone5like su!stances !y the malignancy. #ationale " 8ithium & o%eruse o antacids can result in hypercalcemia. >ypercalcemia can result rom hyperparathyroidism which causes release o calcium rom the !ones$ increased calcium a!sorption in the intestines & retention o calcium !y the kidneys. #ationale )" he pt who uses sunscreen to e+cess is more likely to ha%e a %itamin de(ciency which would result in hypocalcemia. #ationale *" >ypercalcemia can result rom hyperparathyroidism which causes release o calcium rom the !ones$ increased calcium a!sorption in the intestines & retention o calcium !y the kidneys. #ationale 4" 8ithium & o%eruse o antacids can result in hypercalcemia. *4. he pt who has a serum magnesium le%el o 1.* mgd8 is !eing treated with dietary modi(cation. Which oods should the nurse suggest or this pt? =elect all that apply. A. !ananas B. seaood C. white rice . lean red meat . Chocolate Answer" 1$$4 #ationale" =erum magnesium le%el o 1.* mgd8 suggests mild hypomagnesaemia$ so this pt should !e counseled to eat oods high in magnesium. /oods high in magnesium include green leay %egeta!les$ seaood$ milk$ !ananas$ citrus ruits$ & chocolate. White rice & lean red meat are not included. *6. he pt has a serum phosphate le%el o *.9 mgd8. Which interdisciplinary treatments would the nurse e+pect or this pt? =elect all that apply. A. 0 normal saline B. calcium containing antacids C. 0 potassium phosphate . encouraging milk intake . increasing %itamin intake Answer" 1$ #ationale" =erum phosphate le%el o *.9 mgd8 indicates hyperphosphatemia. 0
normal saline promotes renal e+cretion o phosphate. *9. he pt$ newly diagnosed with dia!etes mellitus$ is admitted to the emergency department with nausea$ %omiting$ & a!dominal pain. AB results re%eal a p> o 9. & a !icar!onate le%el o 7 m:8. Which other assessment (ndings would the nurse anticipate in this pt? =elect all that apply. A. tachycardia B. weakness C. dysrhythmias . Dussmaul's respirations . cold$ clammy skin Answer" $)$* #ationale" /urther assessment (ndings o this condition are weakness$ !radycardia$ dysrhythmias$ general malaise$ decreased le%el o consciousness$ warm fushed skin$ & Dussmaul's respirations. #ationale" hese AB results$ coupled with the pt's recent diagnosis o dia!etes mellitus & history o %omiting would lead the nurse to suspect meta!olic acidosis. /urther assessment (ndings o this condition are weakness$ !radycardia$ dysrhythmias$ general malaise$ decreased le%el o consciousness$ warm fushed skin$ & Dussmaul's respirations. *. A clientMs nursing diagnosis is e(cient /luid 0olume related to e+cessi%e fuid loss. Which action related to the fuid management should !e delegated to a nursing assistant? a. Administer 0 fuids as prescri!ed !y the physician. !. 3ro%ide straws and o-er fuids !etween meals. c. e%elop plan or added fuid intake o%er * hours d. each amily mem!ers to assist client with fuid intake 1. A2=W# B N he nursing assistant can reinorce additional fuild intake once it is part o the care plan. Administering 0 fuids$ de%eloping plans$ and teaching amilies re:uire additional education and skills that are within the scope o practice or the #2. *. he client also has the nursing diagnosis ecreased Cardiac Eutput related to decrease plasma %olume. Which (nding on assessment supports this nursing diagnosis? a. /lattened neck %eins when client is in supine position !. /ull and !ounding pedal and post5ti!ial pulses c. 3itting edema located in eet$ ankles$ and cal%es
d. =hallow respirations with crackles on auscultation . A2=W# A N 2ormally$ neck %eins are distended when the client is in the supine position. he %eins fatten as the client mo%es to a sitting position. he other three responses are characteristic o +cess /luid 0olume. 47. he nursing care plan or the client with dehydration includes inter%entions or oral health. Which inter%entions are within the scope o practice or the 832802 !eing super%ised !y the nurse? ;Choose all that apply.< a. #emind client to a%oid commercial mouthwashes. !. ncourage mouth rinsing with warm saline. c. Assess lips$ tongue$ and mucous mem!ranes d. 3ro%ide mouth care e%ery hours while client is awake e. =eek dietary consult to increase fuids on meal trays. ). A2=W# A$ B$ C$ 5 he 832802Ms scope o practice and educational preparation includes oral care and routine o!ser%ation. =tate practice acts %ary as to whether 832802s are permitted to perorm assessment. he client should !e reminded to a%oid most commercial mouthwashes that contain alcohol$ a drying agent. nitiating a dietary consult is within the pur%iew o the #2 or physician. 41. he physician has written the ollowing orders or the client with +cess /luid %olume. he clientMs morning assessment includes !ounding peripheral pulses$ weight gain o pounds$ pitting ankle edema$ and moist crackles !ilaterally. Which order takes priority at this time? a. Weight client e%ery morning. !. @aintain accurate intake and output. c. #estrict fuid to 1477 m8 per day d. Administer urosemide ;8asi+< *7 mg 0 push *. A2=W# N Bilateral moist crackles indicate fuid5(lled al%eoli$ which intereres with gas e+change. /urosemide is a potent loop diuretic that will help mo!ili,e the fuid in the lungs. he other orders are important !ut not urgent.
4. Oou ha%e !een pulled to the telemetry unit or the day. he monitor inorms you that the client has de%eloped prominent H wa%es. Which la!oratory %alue should you check immediately? a. =odium !. 3otassium c. @agnesium d. Calcium 4. A2=W# B N =uspect hypokalemia and check the clientMs potassium le%el. 17
Common C changes with hypokalemia include = depression$ in%erted wa%es$ and prominent H wa%es. Client with hypokalemia may also de%elop heart !lock. 4). he clientMs potassium le%el is 6.9 m:8. Which inter%ention should you delegate to the student nurse under your super%ision? a. Administer Daye+alate 14 g orally !. Administer spironolactone 4 mg orally c. Assess WC strip or tall wa%es d. Administer potassium 17 m: orally 6. A2=W# A N he clientMs potassium le%el is high ;normal range ).454.7<. Daye+alate remo%es potassium rom the !ody through the gastrointestinal system. =pironolactone is a potassium5sparing diuretic that may cause the clientMs potassium le%el to go e%en higher. he nursing student may not ha%e the skill to assess C strips and this should !e done !y the #2. 4*. A client is admitted to the unit with a diagnosis o syndrome o inappropriate antidiuretic hormone secretion ;=A><. /or which electrolyte a!normality will you !e sure to monitor? a. >ypokalemia !. >yperkalemia c. >yponatremia d. >ypernatremia 9. A2=W# C 5 =A> causes a relati%e sodium de(cit due to e+cessi%e retention o water. 44. he charge nurse assigned in the care or a client with acute renal ailure and hypernatremia to you$ a newly graduated #2. Which actions can you delegate to the nursing assistant? a. 3ro%ide oral care e%ery )5* hours !. @onitor or indications o dehydration c. Administer 7.*4J saline !y 0 line d. Assess daily weights or trends . A2=W# A N 3ro%iding oral care is within the scope o practice or the nursing assistant. @onitoring and assessing clients$ as well as administering 0 fuids$ re:uire the additional education and skill o the #2. 46. he e+perienced 832802 reports that a clientMs !lood pressure and heart rate ha%e decreased and that when the ace is assessed$ one side twitches. What action should you take at this time? a. #eassess the clientMs !lood pressure and heart rate !. #e%iew the clientMs morning calcium le%el c. #e:uest a neurologic consult today d. Check the clientMs papillary reaction to light . A2=W# B N A positi%e Ch%ostekMs sign ;acial twitching o one side o the mouth$ nose$ and cheek in response to tapping the ace Iust !elow and in ront o the ear< is a neurologic maniestation o
hypocalcemia. he 832802 is e+perienced and possesses the skills to take accurate %ital signs. 49.Oou are preparing to discharge a client whose calcium le%el was low !ut is now Iust slightly within the normal range ;517.4 mgd8<. Which statement !y the client indicates the need or additional teaching? a. P will call my doctor i e+perience muscle twitching or sei,ures.Q !. P will make sure to take my %itamin with my calcium each day.Q c. P will take my calcium pill e%ery morning !eore !reakast.Q d. P will a%oid dairy products$ !roccoli$ and spinach when eat.Q 17. A2=W# N Clients with low calcium le%els should !e encouraged to consume dairy products$ seaood$ nuts$ !roccoli$ and spinach. Which are all good sources o dietary calcium. 4.A nursing assistant asks why the client with a chronically low phosphorus le%el needs so much assistance with acti%ities o daily li%ing. What is your !est response? a. Phe clientMs low phosphorus is pro!a!ly due to malnutrition.Q !. Phe client is Iust worn out orm not getting enough rest.Q c. Phe clientMs skeletal muscles are weak !ecause o the low phosphorus.Q d. Phe client will do more or hersel when her phosphorus is normalQ 11. A2=W# C N A musculoskeletal maniestation o low phosphorous is generali,ed muscle weakness that may lead to acute muscle !reakdown ;rha!domyolysis<. %en though the other statements are true$ they do not answer the nursing assistantMs :uestion. 4.Oou are re%iewing a clientMs morning la!oratory results. Which o these results is o most concern? a. =erum potassium 4. m:8 !. =erum sodium 1)* m:8 c. =erum calcium 17.6 mgd8 d. =erum magnesium 7. m:8 4. A2=W# N While all o these la!oratory %alues are outside o the normal range$ the magnesium is most outside o normal. With a magnesium le%el this low$ the client is at risk or C changes and lie5threatening %entricular dysrhythmias. 67. Oou are the charge nurse. Which client is most appropriate to assign to the step5down unit nurse pulled to the intensi%e care unit or the day? a. A 65year5old client on %entilator with acute respiratory ailure and respiratory acidosis !. A 95year5old client with CE3 and normal arterial !lood gases ;ABs< who is %entilator5 11
dependent c. A 465year5old new admission client with dia!etic ketoacidosis ;DA< on a n insulin drip d. A )5year5old client on a %entilator with narcotic o%erdose and respiratory alkalosis 1). A2=W# B N he client with CE3$ although %entilator dependent$ is the most sta!le o this group. Clients with acid5!ase im!alances oten re:uire re:uent la!oratory assessment and changes in therapy to correct their disorders. n addition$ the client with DA is a new admission and will re:uire an in5depth admission assessment. All three o these clients need care rom an e+perienced critical care nurse. 61.A client with respiratory ailure is recei%ing mechanical %entilation and continues to produce AB results indicating respiratory acidosis. Which action should you e+pect to correct this pro!lem? a. ncrease the %entilator rate rom 6 to 17 per minute !. ecrease the %entilator rate rom 17 to 6 per minute c. ncrease the o+ygen concentration or )7J to *7J d. ecrease the o+ygen concentration or *7J to )7J 1*. A2=W# A N the !lood gas component responsi!le or respiratory acidosis is CE ;Car!on dio+ide<. ncreasing the %entilator rate will !low o- more CE and decrease the acidosis. Changes in the o+ygen setting may impro%e o+ygenation !ut will not a-ect respiratory acidosis. 6.Which action should you delegate to the nursing assistant or the client with dia!etic ketoacidosis? ;Choose all that apply.< a. Check (ngerstick glucose e%ery hour. !. #ecord intake and output e%ery hour. c. Check %ital signs e%ery 14 minutes. d. Assess or indicators o fuid im!alance. 14. A2=W# B$ C N he nursing assistantMs training and education include how to take %ital signs and record intake and output. he need to take %ital signs this re:uently indicates that the client may!e unsta!le. he nurse should gi%e the nursing assistant reporting parameters when delegating this action$ should also check the %ital signs or indications in insta!ility. 3erorming (ngerstick glucose checks and assessing clients re:uire additional education and skill that are appropriate to licensed nurses. =ome acilities may train e+perienced nursing assistants to perorm (ngerstick glucose checks and change their role descriptions to designate their new skills$ !ut this is !eyond the normal scope o practice or a nursing assistant. 6).Oou are admitting an elderly client to the medical unit. Which actor indicates that this client has a risk or acid5!ase im!alances?
a. @yocardial inarction 1 year ago !. Eccasional use o antacids c. =hortness o !reath with e+treme e+ertion d. Chronic renal insuRciency 16. A2=W# N #isk actors or acid5 !ase im!alances in the older adult include chronic renal disease and pulmonary disease. Eccasional antacid use will not cause im!alances$ although antacid a!use is a risk actor or meta!olic alkalosis. 6*.A client with lung cancer has recei%ed o+ycodone 17 mg orally or pain. When the student nurse assesses the client$ which (nding should you instruct the student to report immediately? a. #espiratory rate o to 17 per minute !. 3ain le%el decreased rom 617 to 17 c. Client re:uests room door !e closed. d. >eart rate 75177 per minute 19. A2=W# A N A decreased respiratory rate indicates respiratory depression which also puts the client at risk or respiratory acidosis$ All o the other (ndings are important and should !e reported to the #2$ !ut the respiratory rate is urgent. 64.he nursing assistant reports to you that a client seems %ery an+ious and that %ital signs included a respiratory rate o ) per minute. Which acid5!ase im!alance should you suspect? a. #espiratory acidosis !. #espiratory alkalosis c. @eta!olic acidosis d. @eta!olic alkalosis 1. A2=W# B N he client is most likely hyper%entilating and !lowing o- CE. his decrease in CE will lead to an increase in p>$ causing respiratory alkalosis. #espiratory acidosis results rom respiratory depression and retained CE. @eta!olic acidosis and alkalosis result rom pro!lems related to renal acid5!ase control. 66.A client is admitted to the unit or chemotherapy. o pre%ent an acid5!ase pro!lem$ which o the ollowing would you instruct the nursing assistant to report? a. #epeated episodes o nausea and %omiting !. Complaints o pain associated with e+ertion c. /ailure to eat all ood on !reakast tray d. Client hair loss during morning !ath 1. A2=W# A N 3rolonged nausea and %omiting can result in acid de(cit that can lead to meta!olic alkalosis. he other (ndings are important and need to !e assessed !ut are not related to acid5!ase im!alances. 69.A client has a nasogastric tu!e connected to intermittent wall suction. he student 1
nurse asks why the clientMs respiratory rate has increased. What your !est response? a. PtMs common or clients with uncomorta!le procedures such as nasogastric tu!es to ha%e a higher rate to !reathing.Q !. Phe client may ha%e a meta!olic alkalosis due to the 2 suctioning and the increased respiratory rate is a compensatory mechanism.Q c. PWhene%er a client de%elops a respiratory acid5!ase pro!lem$ increasing the respiratory rate helps correct the pro!lem.Q d. Phe client is hyper%entilating !ecause o an+iety and we will ha%e to stay alert or de%elopment o a respiratory acidosis.Q 7. A2=W# B N 2asogastric suctioning can result in a decrease in acid components and meta!olic alkalosis. he clientMs increase in rate and depth o %entilation is an attempt to compensate !y !lowing o- CE. the (rst response may!e true !ut does not address all the components o the :uestion. he third and ourth answers are inaccurate.
a. alkalosis !. alkalosis c. alkalosis d. alkalosis
Hncompensated meta!olic Hncompensated respiratory Compensated respiratory Compensated meta!olic
9). p> 9.6$ pCE *9$ >CE)5 )7" a. Hncompensated meta!olic alkalosis !. Hncompensated respiratory alkalosis c. compensated respiratory alkalosis d. compensated meta!olic alkalosis 9*.A mist tent contains a ne!uli,er that creates a cool$ moist en%ironment or a child with an upper respiratory tract inection. he cool humidity helps the child !reathe !y" A. decreasing respiratory tract edema. B. pre%enting an+iety. C. drying secretions. . increasing fuid intake. 65. 1
6. p> 9.41$ pCE *7$ >CE)5 )1" a. 2ormal !. Hncompensated meta!olic alkalosis c. compensated respiratory acidosis d. Hncompensated respiratory alkalosis 6. p> 9.))$ pCE $ >CE)5 16" a. Hncompensated respiratory alkalosis !. Hncompensated meta!olic acidosis c. Compensated respiratory acidosis d. Hncompensated meta!olic acidosis 97. p> 9.*7$ pCE *7$ >CE)5 *" a. 2ormal !. Hncompensated meta!olic acidosis c. Compensated respiratory acidosis d. Compensated meta!olic acidosis 91. p> 9.1$ pCE 67$ >CE)5 " a. Hncompensated meta!olic acidosis !. Hncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated meta!olic acidosis 9. p> 9.*$ pCE )7$ >CE)5 )"
he mist tent decreases respiratory tract edema$ which causes croup. >owe%er$ the child needs to !e prepared !ecause the con(nement can cause high an+iety. he tent li:ue(es secretions$ rather than drying them$ and it doesn't increase the child's fuid intake. ;=# *744< 94.A !one mineral analysis re%eals that a patient who is postmenopausal has se%ere osteoporosis. Which o the ollowing instructions should the nurse gi%e to the patient's amily to ensure a sae en%ironment or the patient? A. Fisinect the !athroom weekly.F B. FCarpet foor suraces.F C. Fnstall handrails on stairways.F . FDeep the lights dim.F 66. 3
;)< Esteoporosis o the hip increases the risk o hip ractures. ecreased !one mass density puts one at high risk or hip ractures. nstalling handrails on stairways will impro%e mo!ility and pre%ent alls. ;1< isinecting the !athroom does not pre%ent alls and hip ractures in the patient with osteoporosis. ;< Carpeting foor suraces oten makes am!ulation more diRcult. ;*< 3oor lighting increases the risk or alling. Areas should !e well lit. ;=# 4*46< 96.Based on multiple reerrals$ the nurse determines that childhood inIuries are increasing in the community in which she practices. he (rst step the nurse would take in de%eloping an educational program is" 1)
A. assessing or a decrease in reerrals ollowing a pediatric saety class. B. assessing the strengths and needs o the community while identiying !arriers to learning. C. choosing a health promotion or health !elie model as a ramework. . de%eloping and implementing a speci(c plan to decrease childhood inIuries. 68. 2
/ollowing the identi(cation o a learning need$ the (rst step is to assess the strengths and needs o the community while identiying !arriers to learning. ;=# )46< 99.Which o the ollowing acti%ities would the nurse likely choose to implement in response to a nursing diagnosis o Acti%ity ntolerance related to lack o energy conser%ation? A. ncourage the client to perorm all tasks early in the day. B. ncourage the client to alternate periods o rest and acti%ity throughout the day. C. Administer narcotics to promote pain relie and rest. . nstruct the client to not perorm daily hygienic care until acti%ity tolerance impro%es. 69. 2
" he client with rheumatoid arthritis should !e encouraged to alternate periods o acti%ity and rest throughout the day. 1" ncouraging the client to perorm all acti%ities o daily li%ing at once will worsen atigue and stress her a!ility to reco%er. )" 2arcotics are not typically administered to control arthritic pain. *" ncouraging the client to cease all participation in daily acti%ities will decrease acti%ity tolerance and make atigue more pronounced. ;=# )< 9.A client has a diagnosis o !orderline personality disorder. =he has attached hersel to one nurse and reuses to speak with other sta- mem!ers. =he tells the nurse that the other nurses are mean$ withhold her medication$ and mistreat her. he sta- is discussing this pro!lem at their weekly conerence. Which inter%ention would !e most appropriate or the nursing sta- to implement? A. 3ro%ide an unstructured en%ironment or the client. B. #otate the nurses who are assigned to the client. C. gnore the client's !eha%iors. . Bend unit rules to meet the client's needs. 70. 2
#otating sta- mem!ers who work with a client with a !orderline personality
disorder keeps the client rom !ecoming dependent on any one nurse and reduces the use o splitting and her ear o a!andonment. /irm rules and consistency among stamem!ers will help control the client's !eha%ior. gnoring splitting !eha%iors can cause the client to increase the !eha%ior !y trying to get a response rom the sta-. Hnit rules must !e consistently enorced and ollowed !y each nurse to help the client control !eha%ior. ;=# *9< 9.A client's chest tu!e accidentally disconnects rom the drainage tu!e when she turns onto her side. Which o the ollowing actions should the nurse take (rst? A. 2otiy the physician. B. Clamp the chest tu!e. C. #aise the le%el o the drainage system. . #econnect the tu!e. 71. 2
" When a chest tu!e !ecomes disconnected$ the nurse should take immediate steps to pre%ent air rom entering the chest ca%ity which may cause the lung to collapse. hereore$ when a chest tu!e is accidentally disconnected rom the drainage tu!e$ the nurse should either dou!le5clamp the chest tu!e as close to the client as possi!le or place the open end o the tu!e in a container o sterile water or saline solution. hen the physician should !e noti(ed. 1" /irst priority must !e gi%en to clamping the chest tu!e. )" o pre%ent !ackward fow o drainage$ the drainage system should ne%er !e raised a!o%e chest le%el. *" o pre%ent !ackward fow o drainage$ the drainage system should ne%er !e raised a!o%e chest le%el. ;=# )79< 7./or a client with CE3 who has trou!le raising respiratory secretions$ which o the ollowing nursing measures would help reduce the tenacity o secretions? A. nsuring that the client's diet is low in salt. B. nsuring that the client's o+ygen therapy is continuous. C. >elping the client maintain a high fuid intake. . Deeping the client in a semi5sitting position as much as possi!le. 72. 3
)" A fuid intake o to ) 8day$ pro%iding that the client does not ha%e cardio%ascular or renal disease$ helps li:uey !ronchial secretions. 1" A low5 salt diet does not help reduce the %iscosity o mucus. " Continuous o+ygen therapy does not help reduce the %iscosity o mucus. *" @aintaining a semi5sitting position does not help 1*
reduce the %iscosity o mucus. ;=# )749< 1.A client$ now )9 weeks pregnant$ calls the clinic !ecause she's concerned a!out !eing short o !reath and is una!le to sleep unless she places three pillows under her head. Ater listening to her concerns$ the nurse should take which action? A. @ake an appointment !ecause the client needs to !e e%aluated. B. +plain that these are e+pected pro!lems or the latter stages o pregnancy. C. Arrange or the client to !e admitted to the !irth center or deli%ery. . ell the client to go to the hospitalG she may !e e+periencing signs o heart ailure rom a *4J to 47J increase in !lood %olume.
issues can !e remedied inormally. the pro!lem persists$ it may !e necessary to meet Iointly with a manager$ !ut initially the pro!lem should !e addressed !y only those directly in%ol%ed. ;=# )*7< ).he nurse is caring or a client with a history o alls. he (rst priority when caring or a client at risk or alls is" A. placing the call light or easy access. B. keeping the !ed at the lowest position possi!le. C. instructing the client not to get out o !ed without assistance. . keeping the !edpan a%aila!le so that the client doesn't ha%e to get out o !ed. 76. 2
Deeping the !ed at the lowest possi!le position is the (rst priority or clients at risk or alling. Deeping the call light easily accessi!le is important !ut isn't a top priority. nstructing the client not to get out o !ed may not e-ecti%ely pre%ent alls. ;=# )9*<
74. 2
he nurse must distinguish !etween normal physiologic complaints o the latter stages o pregnancy and those that need reerral to the health care pro%ider. n this case$ the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. he client doesn't need to !e seen or admitted or deli%ery. he client's signs aren't indicati%e o heart ailure. ;=# *)4< .A nurse works on a medical5surgical unit where nurses work on 15client pods. ach pod is sta-ed !y two registered nurses. When one o the nurses lea%es the unit$ the remaining nurse cares or all 1 clients. she needs help$ she can call the agency's in5house resource nurse. Ene e%ening when a coworker let the unit$ the remaining nurse$ who was making rounds on the departed nurse's clients$ ound medications let at !edsides and a client with a !lood5draw tourni:uet remaining on his arm. n addressing the pro!lems$ the nurse should" A. inorm the nurse5super%isor right away. B. correct the pro!lems and su!mit a written report. C. speak to the coworker when she returns to the unit. . ask or a meeting with the coworker and a manager. 75. 3
When a nurse disco%ers su!standard practice !y another nurse$ it's always appropriate to address the situation !eore con%eying the inormation to a manager or super%isor. norming the nurse5super%isor (rst doesn't promote goodwill !etween nurses and can a-ect nursing care. t may !e necessary to correct the pro!lem !eore the nurse returns$ !ut a written report may not !e necessary i the
*.Which o the ollowing nursing inter%entions should ha%e the highest priority during the (rst hour ater the admission o a client with cholecystitis who is e+periencing pain$ nausea$ and %omiting? A. Administering pain medication. B. Completing the admission history. C. @aintaining hydration. . eaching a!out planned diagnostic tests. 77. 1
1" Administering pain medication would ha%e the highest priority during the (rst hour ater the client's admission. " Completing the admission history can !e done ater the client's pain is controlled. )" @aintaining hydration is important !ut will !e accomplished o%er time. n the (rst hour ater admission$ the highest priority is pain relie. *" t is not appropriate to try to teach while a client is in pain. eaching a!out planned diagnostic tests can occur ater the client is comorta!le. ;=# )74< 4.
p> L 9.)7 CE L 94 >CE) L A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis
6. or
s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated 14
C. 3artially Compensated 9.
. or
.
7. or
1.
. or
).
p> L 9.)6 CE L ) >CE) L 7 A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Alkalosis . @eta!olic Acidosis
*. or
s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated
4.
p> L 9.* CE L )6 >CE) L )) A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis
6. or
s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated
9.
p> L 9. CE L * >CE) L 6 A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated
s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated p> L 9.* CE L *6 >CE) L A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated p> L 9.) CE L 47 >CE) L 9 A. #espiratory Alkalosis B. @eta!olic Acidosis C. @eta!olic Alkalosis . #espiratory Acidosis s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated p> L 9.47 CE L )4 >CE) L ) A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis
. or
.
p> L 9. CE L 4 >CE) L * A. #espiratory Acidosis B. #espiratory Alkalosis C. @eta!olic Acidosis . @eta!olic Alkalosis
177. or
s this Compensated$ Hncompensated 3artially Compensated? A. Compensated B. Hncompensated C. 3artially Compensated
16
