Which electrolyte controls the function of neuromuscular junctions? A. Calcium D. Magnesium Magnesium controls the function of neuromuscular junctions and is a cofactor for many enzymes The primary health care provider orders the nurse to administer potassium chloride to a Pt with 10 episodes of vomiting in 2 days. Which complication does the nurse anticipate from the potassium chloride? A. Cancer D. Cardiac dysrhythmia Potassium chloride is an intravenous solution that should be carefully administered to a Pt with severe emesis because hyperkalemia may cause fatal cardiac dysrhythmias A Pt. with vomiting and diarrhea reports lightheadedness while standing from a sitting position. The Pts blood pressure is 90/58 mm Hg. Which intervention would best treat this Pt? A. Administering diuretics D. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride A Pt with vomiting and diarrhea may experience lightheadedness due to fluid and electrolyte imbalance. The blood pressure may also be altered while changing positions, resulting in postural hypotension. Administering 1000 mL of NS with 10 mEq of potassium chloride may accelerate the improvement of the Pts condition The skin of a Pt taking intravenous fluids appears blanched, cool to the touch, and edematous. Upon touch, the Pt reports pain. Which complication does this represent? A. Phlebitis B. Extravasation Extravasation and infiltration are manifested by painful and blanched skin that is cool to the touch and edematous A Pt who is undergoing intravenous therapy develops redness, inflammation, and swelling at the catheter site. After further assessment, the nurse finds purulent drainage from the injection site. Which nursing interventions are useful in this situation? Select all that apply. A. Elevating the extremity B. Cleaning the skin with alcohol Redness, inflammation, swelling at the catheter site coupled with purulent indicate an infection. Cleaning the skin with alcohol helps to maintain asepsis. Inserting a new intravenous line in the other extremity helps to reduce the chance of infection Which fluid electrolyte imbalance may develop in a Pt. who consumes spironolactone? A. Hypokalemia B. Hyperkalemia Spironolactone is a potassium-sparing diuretic that may cause hyperkalemia The nurse finds that a patient has sudden weight gain, confusion, and edema in the dependent areas. Upon auscultation, the nurse finds crackles in the lungs. What condition does the nurse suspect? A. Extracellular fluid volume (ECV) excess A. Extracellular fluid volume ECV excess Which laboratory findings can be seen in a patient with clinical dehydration? Select all that apply. A. Blood urea nitrogen (BUN) of 28 mg/dL A. Blood urea nitrogen (BUN) of 28 mg/dL An extracellular fluid volume (ECV) deficit and hypernatremia that occurs at the same time is known as clinical dehydration. A blood urea nitrogen (BUN) level of 28 mg/dL indicates hypernatremia, so this can be a laboratory finding in a patient with clinical dehydration. A urine specific gravity above 1.030 indicates an ECV deficit. A serum sodium level greater than 145 mEq/L indicates hypernatremia. Serum osmolality of 270 mOsm/kg is a laboratory finding of hyponatremia, which is not associated with clinical dehydration. A BUN level of 9 mg/dL (or any level below 10) is a finding of ECV excess, which is not associated with clinical dehydration. Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply. A. Edema B. Thready pulse A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of extracellular fluid volume deficit After assessing a patient, the nurse documents grade 2 phlebitis. What clinical symptom supports the nurse's documentation? A. Pain at the access site with erythema A. Pain at the access site with erythema A patient with grade 2 phlebitis will have pain at the access site with erythema. Erythema at the access site without pain occurs in grade 1 phlebitis. Pain at the access site with erythema, streak formation, and a palpable venous cord occurs in grade 3 phlebitis. Pain at the access site with erythema, streak formation, a palpable venous cord, and purulent drainage occurs in grade 4 phlebitis. A patient on intravenous fluids develops shortness of breath an edema of the extremities. Upon auscultation, the nurse hears crackles in the dependent parts of the lungs. Which nursing intervention is beneficial in this condition? A. Reducing the
flow rate A. Reducing the flow rate A patient with a circulatory overload of intravenous fluids may develop crackles in the dependent parts of the lungs, shortness of breath, and edema of the extremities. Therefore, the nurse should reduce the intravenous flow rate and notify the health care provider. Which conditions are common in a patient with chronic diarrhea? Select all that apply. A. Hyperkalemia B. Hypocalcemia Chronic diarrhea may lead to hypernatremia and result in clinical dehydration. It also leads to hypocalcemia and hypomagnesemia because diarrhea decreases electrolyte absorption. Which factor can be a risk for causing extracellular volume deficit (ECV)? A. Hemorrhage A. Hemorrhage Which assessments should be performed to check the circulatory overload of a patient who is on an intravenous infusion of potassium-containing solution? Select all that apply. A. Muscle strength A. Muscle strength Circulatory overload of solutions containing potassium can lead to muscle weakness and abdominal distention. A nurse is assessing the clinical markers of vascular volume. Which patient may require IV therapy due to extracellular fluid volume deficit? A. A patient with a full pulse rate B. A patient with dark yellow urine A dark yellow color indicates concentrated urine that may be caused by a decrease in the extracellular fluid volume; therefore, this patient may require IV therapy. Which saline solution draws water from cells into the extracellular fluid (ECF) by osmosis? A. 5% sodium chloride A. 5% sodium chloride Saline solution is sodium chloride in water. Sodium chloride 5.0% draws water from the cells into the ECF by osmosis. Sodium chloride 0.9% expands the ECV and does not enter the cells. Sodium chloride 0.45% and 0.225% expand the ECV and rehydrate cells. While caring for a patient who is on IV therapy, the nurse notes crackles on auscultation. What are the appropriate nursing interventions? Select all that apply A. Reducing the IV flow rate A. Reducing the IV flow rate A patient on IV therapy may have circulatory overload if the IV solution is infused too rapidly or in an excessive amount. The nurse must reduce the IV flow rate and notify the primary health care provider for further guidance. The nurse must also raise the head of the patient's bed to make the extracellular volume excess subside. Which physical findings can be seen in a patient with extracellular fluid volume deficit? Select all that apply A. Edema B. Thready pulse A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Which laboratory findings can be seen in a patient with clinical dehydration? Select all that apply. A. Blood urea nitrogen (BUN) of 28 A. Blood urea nitrogen (BUN) of 28 An extracellular fluid volume (ECV) deficit and hypernatremia that occurs at the same time is known as clinical dehydration. A blood urea nitrogen (BUN) level of 28 mg/dL indicates hypernatremia, so this can be a laboratory finding in a patient with clinical dehydration. A urine specific gravity above 1.030 indicates an ECV deficit. A serum sodium level greater than 145 mEq/L indicates hypernatremia. Serum osmolality of 270 mOsm/kg is a laboratory finding of hyponatremia, which is not associated with clinical dehydration. A BUN level of 9 mg/dL (or any level below 10) is a finding of ECV excess, which is not associated with clinical dehydration. To which acid-base imbalance is a patient with diabetes prone? A. Metabolic acidosis A. Metabolic acidosis Metabolic acidosis occurs when there is an increase of metabolic acid or a decrease of a base (bicarbonate). Diabetes causes ketoacidosis; therefore, metabolic acidosis can be suspected in a patient with diabetes. Which electrolyte is necessary for the production of adenosine triphosphate? A. Calcium C. Phosphate Phosphate (PO43-) is necessary for the production of adenosine triphosphate. Calcium (Ca2+) is necessary for muscle contractions. Potassium (K+) is necessary for normal muscle function. Magnesium (Mg2+) influences the function of neuromuscular junctions. How might a serum calcium concentration of 12.2 mg/dL manifest in a patient? Select all that apply A. Fatigue A. Fatigue The normal calcium concentration ranges from 8.4 to 10.5 mg/dL. A concentration above 10.5 mg/dL indicates hypercalcemia. Fatigue and anorexia are symptoms of hypercalcemia. Dysphagia is a symptom of hypomagnesemia. Hypotension is a symptom of hypermagnesemia. Laryngospasm is a symptom of hypocalcemia. A patient reports numbness and a tingling sensation in the fingers and toes. The nurse observes facial muscle contractions in response to a tap on the facial nerve. The patient's electrocardiogram shows a prolonged ST segment. Which electrolyte imbalance does the nurse suspect? A. Sodium B. Calcium Chvostek's sign is associated with the contraction of facial muscles in response to a tap over the facial nerve. It is a test for hypocalcemia, which causes numbness and tingling in the fingers and toes. An electrocardiogram of a patient with hypocalcemia may show prolonged QT due to prolongation of the ST segment.
Which ions are cations? Select all that apply. A. Sodium A. Sodium Positively charged ions are called cations. Negatively charged ions are called anions. Sodium (Na+), calcium (Ca+), and potassium (K+) are cations. Chloride (Cl-) and bicarbonate (HCO3-) ions are anions. What are examples of transcellular fluids? Select all that apply A. synovial fluid A. synovial fluid Synovial, peritoneal, and cerebrospinal fluids are examples of transcellular fluids. These fluids are secreted by epithelial cells. The nurse is providing intravenous therapy to a 78 year old patient. Which nursing action is appropriate in this condition? A. inserting the intravenous line on the back of the hand D. Inserting the intravenous line at a 10 to 15 degree angle A 78-year-old patient may have a loss of supportive tissue and the veins appear to be superficial. Therefore, the nurse should lower the insertion angle for venipuncture to 10 to 15 degrees after penetrating the needle into the skin. Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does and adult lose through feces? Recor your answer using a whole number. __________mL 100 The fluid loss occurs through the skin, lungs, gastrointestinal tract, and kidneys. Even though fluid intake is likely 3 to 6 liters, only 100 mL of fluid is lost through feces. The rest of the fluid is absorbed by the gastrointestinal system. Which patient is most at risk of developing hypokalemia? A. patient with cancer C. patient with diarrhea A patient with diarrhea loses fluids and potassium, which can lead to hypokalemia A patient has been brought to the hospital in an unconscious state. On assessment, the nurse learns that the patient has engaged in binge drinking, and the lab reports reveal a high anion gap level. What can the nurse interpret about the patient's metabolic status? A. the patient has metabolic acidosis A. the patient has metabolic acidosis The patient is at risk of metabolic acidosis due to formation of ketoacids in the blood as a result of excessive alcohol intake. A high anion gap also indicates that the patient has metabolic acidosis. A patient with diabetic ketoacidosis is breathing rapidly and deeply. Intravenous fluids and other treatments have just been started. What should the nurse do about this patient's breathing? A. notify the health care provider that the patient is hyperventilating B. provide frequent oral care to keep the mucous membranes moist Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. Rapid breathing can make oral mucous membranes dry and cracked. A patient has a partial pressure of carbon dioxide (PaCO2) of 30 mm Hg. What does this value indicate about the patient's condition? A. CO2 has accumulated in the blood B. The PaCO2 is lower than normal PaCO2 is the measure of the partial pressure of carbon dioxide in the blood; it measures how well the lungs are excreting carbon dioxide produced during cellular metabolism. Normal values range from 35 to 45 mm Hg. This patient has a value lower than normal. A high PaCO2 indicates accumulation of carbon dioxide in the blood, caused by hypoventilation. The PaCO2 value denotes lung function; the bicarbonate (HCO3-) indicates kidney function. A patient reports abdominal cramps and diarrhea. The patient's serum potassium level is 6.3 mEq/L. What changes would be observed on an electrocardiogram? Select all that apply A. prolonged PR A. prolonged PR The normal level of serum potassium is 3.5 to 5 mEq/L. A potassium level greater than 5 mEq/L indicates hyperkalemia. Prolonged PR, peaked T waves, and a widened QRS complex are found in hyperkalemia. The nurse advises a patient to consume dark green, leafy vegetables and whole grains. What might be the patient's condition? A. muscle weakness D. neuromuscular excitability Dark green leafy vegetables and whole grains are rich in magnesium. The consumption of food containing magnesium is required in patients with hypomagnesemia because this condition increases neuromuscular excitability. Which acute condition will place the patient at a high risk for hyperkalemia? A. cancer B. crush injuries Crush injuries place a patient at risk for hyperkalemia. The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body? A. the liver excretes carbonic acid B. the lungs excrete carbonic acid The lungs are responsible for the excretion of carbonic acid from the body in the form of exhaled carbon dioxide. Thus, the lungs help to maintain the acid-base balance of the body A patient who has not been eating for more than a week presents with abdominal pain. On examination, the patient is confused and disoriented. Which metabolic even is most likely responsible for such presentation? A. metabolic acidosis A. metabolic acidosis Not eating for longer than 3 days leads to a breakdown of fatty acids for energy production, which leads to the development of ketone bodies, resulting in metabolic acidosis. The manifestations include decreased level of consciousness, abdominal pain, cardiac dysrhythmias, and increased rate and depth of respirations. The nurse is teaching a team of student nurses about acid-base balance. Which statements by the nurse are appropriate? Select all that apply A. "the kidneys excrete all acids produced in the patient's body" B. "patients with obstructive lung diseases may have more acid in the blood" Patients with obstructive lung diseases may have more acid in their blood. This can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids occurs in the renal tubules of the kidneys. This is one of the major contributing factors for difficulty in normally excreting metabolic acids. The kidneys excrete all acids except carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences shallow respirations in response to decreased levels of carbon dioxide in the blood to enable the cells to produce more carbon dioxide and make up for the deficit. Which activities can the nurse delegate to nursing assistive personnel (NAP)? Select all that apply A. measuring oral intake and urine output A. measuring oral intake and urine output The nurse is able to delegate measuring oral intake and urine output, reporting an IV container that is low in fluid, and reporting an electronic infusion device alarm.The registered nurse cannot delegate working with intravenous (IV) tubing or changing an IV infusion to nursing assistive personnel (NAP). Which assessment should the nurse perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A. auscultate dependent portions of lungs A. auscultate dependent portions of lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes excess extracellular fluid volume (ECF) with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. The nurse is reviewing the arterial blood gas report of a patient. Which is correct regarding partial pressure of carbon dioxide (PaCO2)? A. PaCO2 is a measure of how well the lungs are excreting CO2 A. PaCO2 is a measure of how well the lungs are excreting CO2 The partial pressure of carbon dioxide (PaCO2) measures how well the lungs are excreting CO2 produced by the cells during metabolism. A higher than normal PaCO2 level indicates the accumulation of carbon dioxide in the blood. A low PaCO2 indicates excessive excretion of carbon dioxide. The arterial pH of a patient is 7.3. How should the nurse record this pH in the patient record? A. alkalosis B. acidosis The normal acceptable range of pH for human beings is between 7.35 and 7.45. A pH less than 7.35 indicates acidosis, which implies that metabolic products acidic in nature are accumulated in the body. A pH greater than 7.45 indicates alkalosis, which implies that the body has lost hydrogen ions and has accumulated bicarbonate. A pH of 7 is considered a neutral pH; however, it is important to distinguish this from a normal pH. A pH value between 7.35 and 7.45 is considered a normal pH. Which patient being cared for by the nurse is at the highest risk of developing respiratory acidosis? A. a patient with hypokalemia D. a patient with chronic obstructive pulmonary disease (COPD) Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mmHg; PaO2, 92mmHg; and HCO3, 8. What do these laboratory values indicate? A. metabolic acidosis A. metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus, metabolic acidosis is the correct interpretation. A patient who was started on IV fluids to correct dehydration develops shortness of breath. On auscultation, the nurse finds crackles in the dependent portion of the lungs and dependent edema. Which interventions are appropriate in correcting the fluid and electrolyte imbalance in the patient? Select all that apply. A. aspirate fluid from lungs B. reduce the IV flow rate The patient's presentation is suggestive of circulatory overload due to intravenous (IV) fluids. The flow rate of the IV solution should be reduced to prevent further worsening of circulatory overload. The primary health care provider should be notified to obtain further instructions. Diuretics should be administered to promote excretion of excess fluid through urine A patient has a pH value of 7.25. Which possible pathological and physiological changes may occur in this patient? Select all that apply A. enzyme dysfunction A. enzyme dysfunction A pH of 7.25 indicates acidosis in the patient. The normal pH value ranges between 7.35 and 7.45. Any deviation from this range will lead to improper functioning of cellular enzymes because enzymes are active only at a certain pH level. A low pH level also interferes with the normal functions of hemoglobin, including oxygen carrying capacity, and may even result in death. A patient with uncontrolled diabetes mellitus has developed diabetic ketoacidosis. Which is the most likely complication that this patient may experience?
A. hypokalemia B. hyperkalemia The most likely complication of diabetic ketoacidosis is hyperkalemia. Acidosis is associated with the shift of potassium from the cells into the extracellular space. The nurse is assessing a group of patients for the risk of fluid and electrolyte imbalance. Which patients are considered to be at an increased risk? Select all that apply. A. older adult patients A. older adult patients Older adults have proportionately less body water and are at increased risk of fluid and electrolyte imbalance. Skin lesions or infection near potential venipuncture sites increase the likelihood of fluid and electrolyte imbalance. Low platelet count increases risk for bleeding and seepage of blood from the puncture site during venipuncture The nurse is caring for a patient with generalized body edema. Which hormones directly influence renal fluid excretion? Select all that apply. A. renin B. aldosterone Aldosterone promotes reabsorption of sodium and water from the kidneys and also facilitates excretion of potassium and hydrogen ions. Antidiuretic hormone is responsible for reabsorption of water from the kidneys. Atrial natriuretic peptide facilitates the urinary excretion of sodium and water. The nurse is learning about fluid, electrolyte, and acid-base balance. Which clinical findings would the nurse evaluate in a patient with hypomagnesemia? Select all that apply. A. lethargy B. insomnia Because hypomagnesemia occurs due to low serum magnesium level, it increases neuromuscular excitability. The patient may experience insomnia. as well as muscle cramps, twitching, and hyperactive deep tendon reflexes. Lethargy is observed in hypermagnesemia, which causes decreased neuromuscular excitability. Hypoactive deep tendon reflexes are also found in hypermagnesemia. Which patient would most likely need teaching regarding dietary sodium restriction? A. an 88 year old scheduled for surgery for a fractured femur B. a 65 yr old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECF) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECF excess worse. The nurse is examining a patient with hypocalcemia. For which clinical findings should the nurse look during the assessment? Select all that apply. A. abdominal distension B. positive Chvostek's sign Hypocalcemia occurs due to low serum calcium level. It increases neuromuscular excitability and can cause a positive Chvostek's sign. Chvostek's sign refers to the contraction of facial muscles when a facial nerve is tapped. Trousseau's sign refers to the carpal spasm in response to hypoxia. This sign is positive in hypocalcemia. In addition, muscle twitching and cramping can be noted. A patient has extracellular volume deficit due to diarrhea. How should the nurse correct the volume deficit in the patient? A. provide caffeinated fluids D. provide fluids that contain sodium The nurse should use fluids such as an electrolyte replacement, which contains sodium to correct extracellular volume deficit. The sodium in the fluids helps to prevent fluid loss through retention Which defining characteristics are consistent with fluid volume deficit? A. a weight loss of 1 lb in 1 week, pale yellow urine C. dry mucous membranes, thready pulse, tachycardia A deficit of fluid volume includes a deficit of extracellular fluid volume (ECF), hypernatremia, and clinical dehydration. ECF deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, When caring for a patient undergoing intravenous therapy, the nurse observes redness and welling around the IV catheter insertion site. A purulent drainage is also present. Which immediate actions should the nurse perform? Select all that apply. A. apply pressure to the dressing over the site C. remove the catheter and preserve for culture The assessment findings show a possibility of infection; therefore, the catheter should be removed and preserved for culture. Antibiotics can be prescribed based on the culture reports. Because there is redness and swelling at the site, a new intravenous line should be started in a different extremity. To avoid the spread of infection, the nurse should clean the site with alcohol and apply a sterile dressing. The nurse understands that various mechanisms in the body help move fluid from one compartment to another. Which transport mechanism is governed by oncotic and hydrostatic pressures? A. osmosis C. filtration A filtration process determines fluid movement in and out of capillaries and is governed by hydrostatic and oncotic pressure within the vascular and interstitial space. Which can cause an excess of extracellular fluid volume? A. vomiting D. chronic heart failure Chronic heart failure results in an excess of extracellular fluid volume, because there is a decrease in urine output due to elevated aldosterone. How much fluid is lost daily through feces in a healthy adult? Record your answer using a whole number. ________mL 100 mL The gastrointestinal system plays a major role in fluid and electrolyte balance in the body. Approximately 3 to 6 L of fluid enters the gastrointestinal system and is absorbed back into the body. Approximately 100 mL of fluid is excreted through feces daily. A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which food items should the nurse include in te patient's diet to help correct hypokalemia? Select all that apply A. instant coffee A. instant coffee Hypokalemia is an abnormally low potassium concentration in the blood. Instant coffee and potatoes contain potassium that can be easily absorbed by the body. A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The nurse is reviewing the patient's laboratory report. Which are likely finding in the laboratory report? A. serum K levels are more than 5 mEq/L C. serum K levels are less than3.5 Chronic diarrhea and vomiting can cause electrolyte imbalances in the body. Diarrhea and vomiting can result in the loss of electrolytes from the body, resulting in decreased potassium levels. The nurse is teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program. About which common causes of hypokalemia would the nurse educate the patients? A. diarrhea A. diarrhea Hypokalemia is a low potassium concentration in the blood that results from the loss of potassium. This can occur in patients with diarrhea or repeated vomiting. Glucocorticoid therapy can also result in potassium loss from the body and cause hypokalemia. The
nurse is caring for a patient who is suffering from diarrhea due to intestinal inflammation. Upon assessment, the nurse notes that the patient has had watery stools with abdominal cramping 10 times since the previous day. Which appropriate actions should the nurse take? A. measure stool output A.
measure stool output Measuring stool output will help to identify the total loss of fluids and to plan further medical management. Easily digested food helps to ease the gastrointestinal tract and provide nutrition. Antidiarrheal medications should be administered as ordered to control watery stools and abdominal cramping. High-fiber food may increase gastrointestinal motility and should be avoided. Fluid intake should be increased to compensate for the fluid loss due to diarrhea. The nurse works in an acute care facility. Which patients should the nurse monitor for development of hypokalemia? Select all that apply. A. patients with adrenal insufficiency C.
patients with diarrhea Hypokalemia is common when potassium output is increased. Diarrhea and vomiting can increase potassium loss through the gastrointestinal tract. Potassium-wasting diuretics may increase potassium loss in urine. A patient has developed circulatory overload. Which therapies should the nurse expect to be prescribed for this patient? Select all that apply A. oxygen A. oxygen Oxygen and morphine are helpful in reducing the dyspnea, cough, crackles, and rales associated with circulatory volume overload. Diuretics are helpful in reducing circulatory volume overload by facilitating salt and water excretion in the kidneys. Which are the best ways to evaluate an evaluated serum potassium level in a patient with renal failure? Select all that apply A. measure urine output B. obtain serial serum potassium levels Hyperkalemia is abnormally high potassium ion content in the blood. Hyperkalemia can be determined by assessing serum potassium levels. A plasma potassium level greater than 5 mEq/L is diagnostic for hyperkalemia. The electrocardiogram (ECG) is the most reliable tool for identifying potassium imbalances. The nurse works at a blood bank. For which diseases should the nurse screen in blood donors? Select all that apply A. human immunodeficiency virus (HIV) A. human immunodeficiency virus (HIV) Human immunodeficiency virus (HIV), syphilis, hepatitis C, and cytomegalovirus are blood-borne infections and may spread from the donor blood to the recipient. Therefore, the donor blood must be screened for these infections to reduce transmission. Gonorrhea is not routinely screened, because it is not transmitted through blood and blood products. The physician orders parenteral nutrition and orders use of hyperosmolar solution. How should the nurse administer the solution to the patient? A. use central IV catheter A. use central IV catheter If the parenteral nutrition fluids to be administered are hyperosmolar, then they must be administered through a central intravenous (IV) catheter. Hyperosmolar solutions tend to cause irritation of tissues and may lead to tissue necrosis if extravasation happens. If the fluids are hypoosmolar, then they must be given through peripheral veins. A patient needs a blood transfusion but is apprehensive due to fear of developing sepsis. Which nursing interventions are helpful in preventing transfusion-related sepsis? A. administer antibiotics D. follow blood-banking standards The infusion of infected blood and blood products may lead to sepsis, which can be prevented by following blood-banking standards. Blood-banking standards include appropriate collection, processing, storage, and transfusion. Antibiotics have no preventive role in transfusion-related sepsis. A patient has had chronic diarrhea for 3 months. He also is experiencing repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find during examination? Select all that apply. A. positive Chvostek's sign D. bilateral muscle weakness In hypokalemia, the patient experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. Signs of digoxin toxicity at normal digoxin levels are also seen. The nurse is caring for an 89 year old patient. The patient is very weak and refuses to eat. IV therapy is planned to restore fluid and electrolyte balance. the nurse performs a venipuncture and initiates the prescribed fluid therapy. After a few hours, the nurse finds that the patient has developed phlebitis. What should the nurse do? Select all that apply. A. assess whether the IV system is intact B. stop infusion and discontinue the IV line Phlebitis is the inflammation of the inner layer of veins. In this case, the nurse should stop the infusion and discontinue the intravenous (IV) line. If continued IV therapy is necessary, the nurse should start a new IV line in the other extremity or at a proximal site. A patient reports nausea, has little interest in eating, and has increased salivation. How would the nurse relieve nausea in the patient? Select all that apply. A. administer antiemetics B. avoid sudden position changes Nausea, little interest in eating, and increased salivation suggest gastric irritation. Sudden changes in the position of the patient should be avoided, because this can worsen the nausea. A comfortable, clean environment that is free from odors, noise, and vibrations helps relieve nausea. Providing oral care every 2 hours promotes oral hygiene. Antiemetics should be administered only if prescribed by the primary health care provider. The nurse is caring for a patient undergoing intravenous therapy. The nurse suspects that the patient is developing phlebitis. Which findings would the nurse expect to observe in this patient? Select all that apply A. red streak along the vein A. red streak along the vein A defined red streak along the vein can be seen in case of phlebitis, due to inflammation of the inner layer of the vein. Tenderness and pain can be observed due to inflammation of the vein. Inflammation of the vein gives rise to warmth along the course of the vein, starting at the access site. Swelling at the catheter-skin entry point is particularly noted in case of local infection at that point during infusion or after removal of catheter. Fresh blood evident at venipuncture site could be a sign of bleeding at the venipuncture site. A patient complains of pain in an extremity that had a running IV line. On examination, the nurse observes redness and warmth along the course of the vein starting at the access site. How should the nurse promote comfort in this patient? Select all that apply A. stop the infusion A. stop the infusion The patient's clinical presentation is suggestive of phlebitis, inflammation of the inner layer of a vein. The infusion should be stopped immediately to prevent worsening of phlebitis, and the intravenous (IV) line should be discontinued. This situation requires application of warm compresses to promote circulation, not cold compresses. The same line should not be reused; however, if there is a continued need for a line, a new line must be set up in another extremity. Alternatively, a new line may be set up in the same extremity proximal to the present line. A patient suffering from gastroenteritis has tachycardia, hypotension, oliguria, and dark-colored urine. The lab reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine. What is the probable electrolyte disturbance in the patient? A. low levels of sodium in the body C. decreased extracellular fluids with normal tonicity Patients with gastroenteritis may have tachycardia, hypotension, oliguria, and dark-colored urine. In addition, increased hematocrit, elevated blood urea nitrogen, and increased specific gravity indicate extracellular volume depletion with isotonicity. The nurse is preparing a patient for blood transfusion. Which drugs should the nurse keep on standby for managing blood transfusion reactions? Select all that apply. A. digoxin D.
antihistamines Reactions may happen during blood transfusions, and the nurse should be prepared for them. Antihistamines and corticosteroids should be kept ready for reducing the intensity of the transfusion reactions. A patient has more than six episodes of diarrhea a day, associated with intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools. Which nursing interventions are appropriate in this situation? Select all that apply. A. measure stool output A. measure stool output Intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools of more than six episodes per day are suggestive of inflammatory diarrhea. Measuring stool output helps to assess the volume loss through stools. Avoiding intake of high-fiber foods helps reduce the inflammation. The intake of easily digestible food allows the bowels to rest. Antiemetics are not helpful in a patient with inflammatory diarrhea, because the patient is not vomiting. Antidiarrheal agents should be administered as prescribed. A patient who had an IV line complains of purulent discharge at the catheter skin entry point. The nurse notices redness, localized warmth, and swelling at the catheter entry point. How should the nurse manage this situation? Select all that apply. A. obtain drainage for culture A. obtain drainage for culture The patient presentation is suggestive of local infection. Therefore, the nurse should obtain a culture of the drainage to test for sensitivity to antibiotics. Cleaning the skin with alcohol helps to limit infection. A sterile dressing should be applied to prevent further contamination. Cold compresses are not useful for local infections. Steroids should not be administered as they aggravate infection. A patient has come to the hospital because of gastroenteritis. Which assessments should the nurse perform on this patient? Select all that apply. A. examine oral mucosa A. examine oral mucosa Patients with gastroenteritis are at risk of dehydration and electrolyte imbalance. The oral mucous membrane should be inspected for degree of moisture content. In gastroenteritis, the urine output is reduced, leading to increased specific gravity proportional to the fluid loss. Blood pressure lowers and pulse rate rises proportional to extracellular volume depletion. On assessment, a patient is found to have extracellular fluid volume depletion associated with dehydration of cells. Which fluids might the nurse choose to correct both extracellular fluid volume depletion and cellular dehydration? Select all that apply. A. 5% dextrose in lactated Ringer's C. 0.45% sodium chloride Sodium chloride solutions of 0.225% and 0.45% are hypotonic in nature and are used to correct both extracellular fluid volume depletion and cellular dehydration. These solutions have an effective osmolality less than body fluids, which helps to move water into cells. Lactated Ringer's (LR) and 0.9% sodium chloride are isotonic and correct only extracellular volume depletion. Solutions of 3% and 5% sodium chloride are hypertonic and they aggravate cellular dehydration. A patient with gastroenteritis experiences light-headedness on sitting upright. On assessment the blood pressure is 90/50 mm Hg in the supine position, pulse rate is 110 beats/minute, and the oral mucous membranes are dry. How should the nurse promote fluid and electrolyte balance in the patient? Select all that apply. A. provide oral fluids A. provide oral fluids The patient is exhibiting signs and symptoms of extracellular fluid depletion due to fluid loss related to gastroenteritis. The management involves providing oral fluids at the preferred temperature to replenish the lost fluids. To prevent hypokalemia, 0.9% NaCl is administered with KCl supplementation. Fluids should not be given beyond the patient's tolerability. Antidiarrheal agents should be given only on receiving prescription from the primary health care provider. A comfortable environment is helpful to patients with nausea due to gastric irritation; however, it may not help to correct the fluid and electrolyte imbalance in the patient. A patient with inflammation develops edema. Arrange the sequence of events that occur during the development of edema in the correct order. - increase in capillary hydrostatic pressure 1. increase in capillary blood flow A patient develops acute intravascular hemolytic transfusion reaction following transfusion with incompatible blood. Which treatment strategies should be included in the patient's management? Select all that apply. A. stop the
transfusion immediately A. stop the transfusion immediately When a patient develops acute intravascular hemolytic transfusion reaction due to a mismatched transfusion, the transfusion should be stopped immediately to prevent further worsening of the condition. The blood bag and transfusion set should be saved for further investigation. The blood pressure (BP) should be maintained to the normal range to ensure perfusion to vital organs. To maintain urinary flow, the nurse may administer diuretics if prescribed. An indwelling urinary catheter may be inserted for hourly monitoring of urine output. The intravenous (IV) line must be kept open by infusing normal saline through new tubing. How can the nurse prevent the development of febrile nonhemolytic reactions in the patient during blood transfusions? Select all that apply. A. by adjusting the transfusion volume B. by pretreating with
antipyretics Blood transfusions may result in febrile nonhemolytic reactions. They can be prevented by pretreatment with antipyretics, especially if the patient has a previous history of febrile nonhemolytic reactions. Leukocytes in the blood are responsible for febrile reactions; therefore, the use of leukocyte-poor blood products (filtered, washed, or frozen) can prevent febrile reactions to blood transfusions. Adjusting the transfusion volume is useful in reducing the circulatory overload and has no role in reducing nonhemolytic reactions. Antihistamines are helpful for allergic reactions but not for febrile reactions. The implementation of blood-banking standards is helpful in reducing the incidence of sepsis. A patient presents with muscle twitching and cramping. On examination, the health care provider diagnoses the patient with calcium deficiency. Which dietary instructions should the nurse give to this patient? Select all that apply. A. supplement with vitamin D A. supplement with vitamin D Hypocalcemia, or low levels of calcium, can manifest as muscle twitching and cramping. The signs and symptoms can be treated by providing adequate calcium in the diet. Vitamin D facilitates the absorption of calcium from the intestines; therefore, vitamin D should be supplemented in the diet. Dairy products, canned fish with bones, broccoli, and oranges are good sources of calcium, and their intake should be promoted. Dark green vegetables are rich in magnesium, not calcium. A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction? A. initiating ordered peripheral IV and administering 1,000 mL 0.9% NaCl with 10 mEq KCl C. offering fluid frequently in large amounts as tolerated Because the patient with vomiting and diarrhea is likely experiencing nausea and lightheadedness, he or she may not be able to tolerate large amounts of fluid; it is more effective to offer this patient small amounts of fluid as tolerated. The other nursing interventions are correct. The nurse should initiate an ordered peripheral IV and administer 1,000 mL 0.9% NaCl with 10 mEq KCl to maintain fluid and electrolyte balance. Providing fluids at the temperature the patient prefers will encourage the patient to consume more than if the temperature is too cold or too warm. Antiemetics will decrease the patient's nausea. The nurse is caring for an 89 year old patient. The patient is very weak and refuses to eat. When preparing to insert the IV line, which site should the nurse select first, considering the patient's age? A. any prominent vein on the hand C. most distal appropriate site on the inner arm Choosing the most distal appropriate site on the inner arm first will allow the use of a proximal site later, if the patient needs venipuncture site change. Veins on the hand and feet should be avoided for venipuncture in older adults because of the increased chances of thrombophlebitis. The patient is experiencing the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). For which electrolyte disturbance should the nurse evaluate the patient? A. hypernatremia B. hyponatremia Patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) have excess antidiuretic hormone (ADH) secretion. Therefore, the patient is most likely to have hyponatremia due to excess retention of water from the kidney, which is disproportionate to salt retention. SIADH is not related to hypernatremia. SIADH is most likely found in diabetes insipidus (deficiency of ADH). Hemoconcentration is seen in conditions associated with extracellular water depletion. In conditions associated with excess ADH, there is a decrease in serum osmolality. After assessing a patient with gastroenteritis, the nurse documents nausea related to gastric irritation. Which symptom supports the nurse's documentation? Select all that apply. A. increased salivation A. increased salivation Increased salivation and little interest in eating in a patient with gastroenteritis are symptoms of nausea related to gastric irritation. Decreased skin turgor indicates impaired skin integrity and deficient fluid volume. A heart rate of 102 bpm and dry oral mucous membranes are symptoms of a deficient fluid volume related to vomiting and diarrhea. |
Arrange the sequence of events that occur during the development of edema in the correct order
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