A priority nursing intervention for a client with hypervolemia involves which of the following?
a) Monitoring respiratory status for signs and symptoms of pulmonary complications.
b) Drawing a blood sample for typing and crossmatching.
c) Encouraging the client to consume sodium-free fluids.
d) Establishing I.V. access with a large-bore catheter.
answer
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question
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
a) Metabolic alkalosis
b) Respiratory alkalosis
c) Respiratory acidosis
d) Metabolic acidosis
answer
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question
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? SELECT ALL THAT APPLY
a) Suction the client's airway.
b) Compare ABG findings with previous results.
c) Maintain intake and output records.
d) Document presenting signs and symptoms.
e) Administer IV bicarbonate.
answer
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question
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching?
a) "A good breakfast for me will include milk and a couple of bananas."
b) "I can use laxatives and enemas but only once a week."
c) "I will be sure to buy frozen vegetables when I grocery shop."
d) "I will take a potassium supplement daily as prescribed."
answer
"I can use laxatives and enemas but only once a week."
The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia.
Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.
question
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?
a) Sodium
b) Magnesium
c) Potassium
d) Calcium
answer
Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.
question
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her:
a) neuromuscular function.
b) electrocardiogram (ECG) results.
c) bowel sounds.
d) respiratory rate.
answer
electrocardiogram (ECG) results.
Explanation:
Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
question
A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output?
a) The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
b) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
c) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
d) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
answer
The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
Explanation:
Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.
question
You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?
a) Hypovolemia
b) Metabolic alkalosis
c) Hypermagnesemia
d) Hypercalcemia
answer
Hypovolemia
Explanation:
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.
question
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?
a) Pitting edema
b) Hypovolemia
c) Anasarca
d) Third-spacing
answer
Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites.
question
Clients diagnosed with hypervolemia should avoid sweet or dry food because
a) it obstructs water elimination.
b) it can cause dehydration.
c) it increases the client's desire to consume fluid.
d) it can lead to weight gain.
answer
it increases the client's desire to consume fluid.
Explanation:
Nursing management for clients with hypervolemia requires collaboration with a dietitian to modify the diet to meet salt/sodium restrictions and to avoid sweet or dry foods. Such foods increase a client's desire to consume fluid. This is not a concern related to sweet or dry food. Hypervolemia refers to a high volume of water in the intravascular fluid compartment. Weight gain is an early sign of hypervolemia that is related to excess fluid volume, not the consumption of sweet or dry foods. Weight regulation is not part of hypervolemia management except to the extent that it is achieved on account of fluid reduction.
question
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?
a) Basic
b) Acidic
c) Alkaline
d) Neutral
answer
Acidic
Explanation:
Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
question
Which of the following is considered an isotonic solution?
a) 0.45% normal saline
b) 0.9% normal saline
c) 3% NaCl
d) Dextran in NS
answer
0.9% normal saline
Explanation:
An isotonic solution is 0.9% normal saline (NaCl). Dextran in NS is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.
question
A 69-year-old male client with congestive heart failure must measure his weight daily and phone it to your office for his medical record. What is the best time of day for this client to weigh himself?
a) After lunch
b) After dinner
c) Same time each day
d) After breakfast
answer
Same time each day
Explanation:
Clients with hypovolemia should be weighed daily at the same time on the same scale and dressed similarly. A loss of 2 lb (1 kg) or more in 24 hours (a 2-lb loss equals 1 L of body fluid) is significant and should be reported.
question
A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
a) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
b) The kidneys regulate the bicarbonate level in the intracellular fluid.
c) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
d) The kidneys react rapidly to compensate for imbalances in the body.
answer
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question
The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?
a) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L
b) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
c) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
d) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
answer
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
Explanation:
Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
question
A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
a) Metabolic acidosis
b) Respiratory acidosis
c) Respiratory alkalosis
d) Metabolic alkalosis
answer
Respiratory acidosis
Explanation:
The pH <7.40, PaCO2 >40, and the HCO3 is normal, therefore it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. Option B is incorrect, the HCO3 = 24, which is within the normal range so it is not metabolic alkalosis. Option C is incorrect, the pH = 7.21, so it is an acidosis not alkalosis. Option D is incorrect, the pH = 7.21 so it is an acidosis, but the HCO3 = 24, which is within the normal range so it is not a metabolic acidosis.
question
A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
a) The kidneys react rapidly to compensate for imbalances in the body.
b) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
c) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
d) The kidneys regulate the bicarbonate level in the intracellular fluid.
answer
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
Explanation:
The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days).
question
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
a) Thalamus
b) Hypothalamus
c) Brainstem
d) Cerebellum
answer
Hypothalamus
Explanation:
Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus.
question
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
a) Respiratory acidosis
b) Metabolic acidosis
c) Respiratory alkalosis
d) Metabolic alkalosis
answer
Respiratory alkalosis
Explanation:
A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
question
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
a) Instruct the client to breathe into a paper bag.
b) Offer the client fluids frequently.
c) Administer an ordered decongestant.
d) Administer ordered supplemental oxygen.
answer
Instruct the client to breathe into a paper bag.
Explanation:
The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
question
Maintaining fluid balance, especially in older adults, can be a challenge. While hypovolemia is to be avoided, there is also an accompanying danger for blood clots and urinary stones. What condition contributes to the possible development of these life-threatening events?
a) Metabolic alkalosis
b) Hemodilution
c) Metabolic acidosis
d) Hemoconcentration
answer
Hemoconcentration
Explanation:
Hemoconcentration, a high ratio of blood components in relation to watery plasma, increases the potential for blood clots and urinary stones and compromises the kidney's ability to excrete nitrogen wastes
question
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
a) Bradycardia
b) Increased urine output
c) Vasodilation
d) Tachycardia
answer
Tachycardia
Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.
question
Which of the following is the most common cause of symptomatic hypomagnesemia?
a) IV drug use
b) Burns
c) Sedentary lifestyle
d) Alcoholism
answer
Alcoholism
Explanation:
Alcoholism is currently the most common cause of symptomatic hypomagnesemia. IV drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.
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