Med Surg Adaptive Quizzing and Rationale|2022

Med Surg Adaptive Quizzing and Rationale The nurse is planning care for a patient with a new diagnosis of hypercalcemia resulting from treatment for hypocalcemia. Which change to the plan of care should the nurse anticipate? - weight bearing exercises A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium gluconate, and administering a thiazide diuretic are all appropriate for hypocalcemia; therefore these actions should be removed from the plan of care, not added The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular fluid accumulation? 1.A patient with drainage from a rectal fistula 2.A patient with osmotic diuresis 3.A patient with renal impairment 4.A patient with an intestinal obstruction 3 Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma, and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and intestinal obstruction result in a loss of body fluid. A patient asks why the primary health care provider prescribed a b-type natriuretic peptide (BNP). Which response by the nurse is accurate? 1.It is a diagnostic procedure to rule out urine retention. 2.It is a blood test that is elevated in patients with hyponatremia. 3.It is a blood test that shows if there is excess fluid in the heart. 4.It is an x-ray that helps determine the presence of stomach ulcers. 3 BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure increases because of increased venous return and hypernatremia. The test gives no information to rule out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine hyponatremia. The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The results are: pH 7.32; PaCO 2 52; HCO 3- 24. What does the nurse interpret these results to mean? respiratory acidosis Normal pH is 7.35 to 7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO 2 is 35 to 45 mm Hg. Because the HCO 3- is normal and the PaCO 2 is elevated, the source of the acidosis is respiratory. The patient is in respiratory acidosis. The nursing instructor is discussing peripherally implanted catheters (PICC) with a nursing student. Which nursing student statement would indicate a need for further teaching? Blood pressure should not be taken on an arm with a PICC line because inflation of the cuff can lead to the risk of vein damage or thrombosis. Nurses do need to check for phlebitis for up to 10 days after the PICC is inserted. PICC lines are typically used for access for up to six months, and they can be left longer. PICC lines have fewer side effects than central venous catheters. The nurse is caring for a patient with acute kidney failure due to severe dehydration. When evaluation of the arterial blood gases is done, what condition does the nurse likely interpret the findings to indicate? metabolic acidosis Renal failure will make the blood more acidic because of the inability of the kidneys to excrete acid. Therefore the nurse suspects that the patient would develop metabolic acidosis. Metabolic alkalosis is caused by excess bicarbonate intake and a potassium deficit. Respiratory acidosis is caused by hypoventilation. Respiratory alkalosis is caused by hyperventilation. A patient has been admitted for dehydration. What is a priority nursing intervention? a) Perform daily weights. b) Reorient the patient hourly. c) Restrict sodium intake to 2 grams per day. d) Provide continuous oxygen saturation monitoring A Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in the patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted. When assessing a patient admitted with nausea and vomiting, which finding supports a determination of deficient fluid volume? General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma. Polyuria, decreased pulse, and difficulty breathing do not support a determination of deficient fluid volume. A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse determine is the probable reason for the increase in phosphate levels in this patient? Chemotherapy Insulin therapy Total parenteral nutrition Phosphate-binding antacids chemotherapy Phosphate levels greater than 4.4 mg/dL indicate hyperphosphatemia. Chemotherapy drugs increase the patient's phosphate levels. Insulin therapy decreases the phosphate levels to less than 2.4 mg/dL. Patients with total parenteral nutrition have decreased phosphate levels. Phosphate-binding antacids remove phosphates from the body, resulting in hypophosphatemia. The nurse is preparing to remove a patient's central venous access device (CVAD). What actions are important for the nurse to perform prior to removal? Select all that apply. 1) Understand the scope of nursing practice 2) Review the health care provider's prescription 3) Request a second nurse to assist with the removal 4) Review the health care organization's policy on the procedure 5) Provide pharmacologic intervention prior to removing the CVAD 1,2,4 Not all health care agencies allow a nurse to perform this procedure. Prior to removing a patient's CVAD, the nurse should know the health care organization's policy, confirm that the removal is in the scope of a registered nurse's practice to perform, and review the health care provider's prescription. It is not necessary to have another nurse assist with the removal of a CVAD or to routinely medicate the patient. For which clinical manifestations would the nurse monitor a patient with a serum calcium level of 11.2 mg/dL? Select all that apply. Polyuria Hypotension Nephrolithiasis Chvostek's sign Trousseau's sign polyuria, nephrolithiasis Plasma concentration of calcium greater than 10.2 mg/dL indicates hypercalcemia, which results in increased concentration of calcium in the urine. This impairs sodium and water reabsorption and causes polyuria. Hypercalcemia can cause kidney stones, or nephrolithiasis, because an increased concentration of calcium in the urine deposits crystals in the kidney, which combine to form kidney stones. Hypotension, Chvostek's sign, and Trousseau's sign are clinical manifestations of hypocalcemia. The nurse is caring for a group of patients with a variety of diagnoses. Which conditions would cause the nurse to include interventions in the plan of care to address anticipated hypophosphatemia? Select all that apply. 1) Renal failure 2) Respiratory alkalosis 3) Diabetic ketoacidosis 4) Tumor lysis syndrome 5) Malabsorption syndrome 2,3,5 The nurse would include interventions to address hypophosphatemia when providing care to patients with respiratory alkalosis, diabetic ketoacidosis, and malabsorption syndrome. The nurse should create a care plan for hyperphosphatemia when providing care to patients with renal failure and tumor lysis syndrome. The nurse is caring for a patient with a blood sodium level of 170 mEq/L and is experiencing intense thirst, agitation, and decreased alertness. What does the nurse anticipate administering? Intravenous 0.45% sodium chloride saline solution Hypernatremia is a condition in which water shifts out of the cells into the extracellular fluid, resulting in dehydration. Therefore the patient with hypernatremia would experience intense thirst, agitation, and decreased alertness. To reduce dehydration, fluid should be replaced by administering hypotonic intravenous fluids such as 5% dextrose in water or 0.45% sodium chloride saline solution. Administering intravenous furosemide may help treat hypercalcemia. A cation-exchange resin may be administered to treat hyperkalemia. A phosphate-binding agent may be administered to treat hyperphosphatemia. The nurse is documenting a patient's skin turgor assessment. After pinching a fold of skin over the sternum, it takes approximately 22 seconds for the pinched skin to return to normal after being released. How would the nurse most accurately document this finding? poor Poor skin turgor is characterized by skin that takes 20 to 30 seconds to return to normal after being pinched. "Lagged" is not a term used to describe skin turgor. With normal skin turgor, the skin resumes shape within seconds of being released. "Decreased" skin turgor is too vague a description of the finding. The nurse is caring for an older patient who is receiving intravenous (IV) fluids postoperatively. During the 0800 assessment of this patient, the nurse notes that the IV solution, which was prescribed to infuse at 125 mL/hr, has infused 950 mL since it was hung at 0400. What is the priority nursing intervention? Listen to the patient's lung sounds and assess respiratory status. After four hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and the nurse should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further prescriptions. A nurse is caring for a patient with metabolic acidosis. The patient wants to know how the acid-base imbalance will be corrected. Based on the nurse's knowledge of acid-base imbalance, what is the best response? Select all that apply. "Medications are the primary treatment for acute acid-base imbalances." "The renal system compensates slowly, usually reacting to pH changes within 24 hours." "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." "The heart is vital in managing the acid-base balance by regulating perfusion to increase or decrease pH." "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance." "The renal system compensates slowly, usually reacting to pH changes within 24 hours." "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance." The buffer system is the primary manner in which the body maintains acid-base balance. This system is also the quickest, often working within seconds of sensing an imbalance. The respiratory system can compensate by changing the rate and depth of breathing within minutes of sensing an acid-base derangement; the renal system is slower to react, often working within hours to days. The heart is vital in regulating perfusion, but it does not have a major role in managing acid-base balance. Medications can be used to regulate acid-base imbalances, but the primary treatment is to resolve the underlying cause of the imbalance. A diabetic patient fasting before surgery reports feeling dizzy with deep, rapid breathing. A nurse observes that the patient has developed Kussmaul respirations. What condition is the patient most likely experiencing? metabolic acidoses The patient has been fasting and complains of dizziness. The patient has likely developed diabetic ketoacidosis, a type of metabolic acidosis. Kussmaul respiration is deep, rapid breathing that develops in response to metabolic acidosis. This type of breathing is a compensatory mechanism to excrete excess carbon dioxide from the lungs. Metabolic alkalosis occurs when there is a loss of acid or a gain in bicarbonate. It is not associated with Kussmaul respiration. Respiratory acidosis results when the person hypoventilates and carbonic acid accumulates in the blood. Respiratory alkalosis occurs when the person hyperventilates. The nurse is caring for a patient in hypovolemic shock. What fluid replacement does the nurse anticipate will have the most positive outcome for this patient? 0.9% NaCl Isotonic saline (0.9% NaCl) may be used when a patient has experienced both fluid and sodium losses or as vascular fluid replacement in hypovolemic shock. The nurse would not administer 0.45% saline, 5% dextrose in 0.45% saline, or dextran, as these are not appropriate for fluid replacement in hypovolemic shock. The nurse is performing an assessment on a client that is experiencing hyperreflexia. What condition should the nurse review the arterial blood gas results for? respiratory alkalosis Respiratory alkalosis is manifested by hyperreflexia. Metabolic acidosis is manifested by abdominal pain and Kussmaul respirations. Tachycardia, anorexia, and muscle cramps are the manifestations of metabolic alkalosis. Headache, seizures, and hypotension are the manifestations of respiratory acidosis. The arterial blood gas (ABG) analysis of a patient with diabetes mellitus shows a bicarbonate level of 15 mEq/L and pH of 7.15. Which acid-base imbalance would the nurse document these findings as? metabolic acidosis Metabolic acidosis is characterized by increased levels of acid and or decreased levels of base in the blood. As a result, the pH of the blood decreases. The normal pH range of blood is 7.35 to 7.45, and the normal value of bicarbonate is 23 to 30 mEq/L. The patient's numbers indicate metabolic acidosis. Metabolic alkalosis is manifested by an increased pH. A decreased pH and elevated PaCO 2 indicate respiratory acidosis. Respiratory alkalosis is manifested by increased plasma pH and decreased PaCO 2. The nurse is completing an assessment of a patient with heart failure who is being treated for accidental overuse of diuretics. For which potential respiratory issue should the nurse monitor the patient? increased respiratory rate Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit. A patient has a prescription to receive D5W with 20 mEq KCl/L at 100 mL/hour. The nurse should select which solution from the intravenous supply cart? 5% dextrose in water with 20 mEq of KCl D5W stands for 5% dextrose in water, which is different than normal saline, half normal saline, or lactated Ringer's. A patient has low levels of parathyroid hormone. What other laboratory finding does the nurse expect in the patient? decreased calcium levels Rationale Low levels of parathyroid hormone cause hypocalcemia, or decreased calcium levels, because of reduced renal activity, which limits calcium absorption. The nurse would suspect increased potassium levels with hyperkalemia if the patient had adrenal insufficiency. Hypoparathyroidism causes hyperphosphatemia because of impaired renal phosphate excretion. Hypoparathyroidism can result in magnesium deficiency. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiplechoice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. The nurse is caring for a patient that has a nasogastric tube (NGT) on intermittent suction. The patient asks why they cannot have something to drink. What is the best response by the nurse? "It will increase the loss of electrolytes." Allowing a patient with an NGT to drink water increases the loss of electrolytes. It will not cause sodium retention, but sodium depletion. The free water will pull electrolytes into the stomach and the NGT will suck the fluids and electrolytes out of the stomach. Depending on the patient's condition and amount of water being ingested, it may increase nausea and vomiting. However, this would most likely happen if the suction was not working properly; it is not the primary reason for withholding oral fluids. Oral intake of water would not disrupt the intermittent suction. To prevent a recurrence of hypocalcemia, the nurse should encourage the patient to increase intake of which of foods? Fish Lean meat Dairy products Potatoes and starches dairy products While documenting the arterial blood gas values of a group of patients, the nurse suspects a patient to have respiratory alkalosis. Which patient's findings support the nurse's suspicion? patient B Respiratory alkalosis is characterized by an increased pH and decreased carbon dioxide concentration (PaCO 2) in blood. The normal values of blood pH, partial pressure of carbon dioxide (PaCO 2), and bicarbonate ion (HCO 3 -) are between 7.35 and 7.45, 35 and 45 mm Hg, and 22 and 26 mEq/L, respectively. The increased pH and decreased PaCO 2 in patient B are indicators of respiratory alkalosis. Image: While documenting the arterial blood gas values of a group of patients, the nurse suspects a patient to have respiratory alkalosis. Which patient's findings support the nurse's suspicion? The patient has a prescription for lactated Ringers intravenously (IV) at a rate of 200 mL/hour. An IV pump is not available. The IV tubing has a drop factor of 10 drops/mL. The nurse will administer the lactated Ringers solution at how many drops per minute? 33gtt/ml Use the following formula to calculate the rate of IV solutions: Volume multiplied by drop factor divided by time (in minutes). Multiply 200 by 10 to yield 2000 and divide this by 60 to yield 33.3 or 33 gtt/minute (because the nurse cannot count a fraction of a drop). The nurse is providing care to a patient whose serum potassium level is 5.1 mEq/L. Which change should the nurse make to the plan of care to address this finding? ensuring IV calcium gluconate A patient with hyperkalemia, as indicated by the serum potassium level, is at risk for dysrhythmia. Therefore the nurse should ensure that intravenous calcium gluconate is available at all times. Monitoring for digitalis toxicity, adding bananas to the list of approved fruits, and implementing continuous monitoring of urine output are interventions the nurse should add to the plan of care for a patient who develops hypokalemia, not hyperkalemia. A patient had 5 liters of fluid removed during a paracentesis. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis? 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action. In the regulation of water balance, which system has a primarily antiinflammatory effect and increases serum glucose levels? adrenal corticol Water regulation: Hypothalamic-Pituitary Regulation: Water ingestion will equal water loss in the individual who has free access to water, a normal thirst and ADH mechanism, and normally functioning kidneys. An intact thirst mechanism is critical because it is the primary protection against the development of hyperosmolality. Osmoreceptors in the hypothalamus sense a body fluid deficit or increase in plasma osmolality, which in turn stimulates thirst and ADH release. The distal tubules and collecting ducts in the kidneys respond to ADH by becoming more permeable to water. The result is increased water reabsorption from the tubular filtrate into the blood and decreased excretion in the urine. Together these factors result in increased free water in the body and decreased plasma osmolality. Other factors that stimulate ADH release include stress, nausea, nicotine, and morphine. A decreased plasma osmolality or water excess suppresses secretion of ADH, resulting in urinary excretion of water. It is common for the postoperative patient to have a lower plasma osmolality, possibly because of the stress of surgery and opioid analgesia. Social and psychologic factors not related to fluid balance also affect the desire to consume fluids. A dry mouth will cause the patient to drink, even when there is no measurable body water deficit. Renal Regulation: The kidneys regulate water balance by adjusting urine volume and the urinary excretion of most electrolytes to maintain a balance between overall intake and output. The kidneys regulate water balance by adjusting urine volume and the urinary excretion of most electrolytes to maintain a balance between overall intake and output. The kidneys regulate water balance by adjusting urine volume and the urinary excretion of most electrolytes to maintain a balance between overall intake and output. Adrenal Cortical: Glucocorticoids and mineralocorticoids secreted by the adrenal cortex help regulate both water and electrolytes. The glucocorticoids (e.g., cortisol) primarily have an antiinflammatory effect and increase serum glucose levels, whereas the mineralocorticoids (e.g., aldosterone) enhance sodium retention and potassium excretion (Fig. 17-9). When sodium is reabsorbed, water follows because of osmotic changes. Aldosterone is a mineralocorticoid with potent sodium-retaining and potassium-excreting capabilities. Decreased renal perfusion or decreased sodium delivery to the distal portion of the renal tubule activates the renin-angiotensin-aldosterone system (RAAS), which results in aldosterone secretion (see Fig. 45-4). In addition to the RAAS, increased plasma potassium, decreased plasma sodium, and adrenocorticotropic hormone (ACTH) from the anterior pituitary act directly on the adrenal cortex to stimulate the secretion of aldosterone. Cardiac: Natriuretic peptides, including atrial natriuretic peptide (ANP) and b-type natriuretic peptide (BNP), are hormones produced by cardiomyocytes. They are natural antagonists to the RAAS. They are produced in response to increased atrial pressure (increased volume, such as occurs in heart failure) and high serum sodium levels. They suppress secretion of aldosterone, renin, and ADH, and the action of angiotensin II. In the renal tubules these peptides promote excretion of sodium and water, resulting in a decrease in blood volume and blood pressure. Gastrointestinal: Daily water intake and output are normally between 2000 and 3000 mL Regulation of electrolytes: Osmosis: Movement of water Low solute to high Passive no energy required Facilitated Diffusion: Selective Might need hitch a ride Example insulin to carry glucose into cell Diffusion: Movement of solute (particles) High solute to low Passive no energy required Active transport: Solutes move lower to higher concentration, (swimming against the current) Requires energy= adenosine triphosphate (ATP) During active transport energy from ATP moves solutes from lower to higher concentration areas Example: sodium/potassium pump, calcium, acids, and sugars The nurse is preparing to administer a dose of potassium phosphate. What laboratory finding would indicate that the nurse should withhold the medication? Calcium 6.4 mg/dL Phosphorus and calcium have inverse or reciprocal relationships, meaning that when calcium levels are high, phosphorus levels tend to be low. Therefore administration of phosphorus will reduce a patient's already abnormally low calcium level, which can result in life-threatening complications. Potassium phosphate will not have any effect on sodium, magnesium, or potassium levels. The nurse is caring for a patient admitted with an exacerbation of asthma. After several treatments, the arterial blood gas (ABG) results are pH 7.40, PaCO 2 40 mm Hg, HCO 3 24 mEq/L, PaO 2 92 mm Hg, and O 2 saturation 99%. What does the nurse interpret these findings to indicate? WNL The normal pH is 7.35 to 7.45. Normal PaCO 2 levels are 35 to 45 mm Hg, and normal HCO 3 levels are 22 to 26 mEq/L. A normal PaO 2 level is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits. The nurse admits a patient that states they have been unable to eat for 10 days and feel extremely weak and sick. When reviewing the arterial blood gas results, what condition does the nurse expect to find? metabolic acidosis Starvation leads to production of lactic acid from the cells, resulting in metabolic acidosis. Metabolic alkalosis is caused by severe vomiting, gastric suction, and diuretic therapy. Factors such as chest wall abnormality and chronic obstructive pulmonary disease may cause respiratory acidosis. Septicemia, hypoxia, and anxiety cause respiratory alkalosis. The nurse suspects which possible conditions in a patient whose serum potassium level is 6.8 mEq/L on admission? Select all that apply. The patient is on insulin therapy. The patient is taking amiloride daily. The patient suffers from renal disease. The patient's electrocardiogram reveals flattened T waves. The patient's orders will include intravenous fluids with added potassium. The patient is taking amiloride daily. The patient suffers from renal disease. Potassium levels greater than 5.0 mEq/mL indicated hyperkalemia. Potassium-sparing diuretics, such as amiloride, increase the potassium levels. The kidneys excrete potassium, so renal disease can also lead to increased potassium levels. Insulin moves potassium into the cell and decreases serum potassium values. Hyperkalemia is manifested on an electrocardiogram as tall, peaked T waves, not flattened T waves. Potassium should not be added to IV fluids if the patient is already suffering from hyperkalemia. The nurse is preparing to administer sodium polystyrene sulfonate rectally to a patient with an irregular pulse and weakness of the lower extremities. What laboratory finding does the nurse determine is the reason for this treatment? hyperkalemia Irregular pulse and weakness of the lower extremities are generally seen in patients with hyperkalemia. Sodium polystyrene sulfonate binds with potassium in exchange for sodium, thereby reducing hyperkalemia. Hypokalemia can be treated with potassium chloride. Hypocalcemia can be treated with calcium supplements. Hypercalcemia can be treated by administering furosemide. An older adult patient with dementia arrives in the emergency department with a family member; the patient is found to be hypercarbic. The patient has an advanced directive and does not want any invasive procedure. The family member asks if this issue will resolve by itself. Which is the nurse's most appropriate response? c) "Older adults have a harder time compensating because they have decreased respiratory and kidney functions." Hypercarbia is an increased level of CO 2 in the blood, which is a hallmark of respiratory acidosis. Older adults have difficulty compensating for acid-base imbalances because of decreased functional capacity in the respiratory and renal systems. Hyperventilation is a normal physiologic response to hypercarbia; hyperventilation may not be possible with decreased functional respiratory reserves. Normal kidneys can sense hypercarbia and begin to reabsorb buffer to normalize pH; however, older adults may lack the functional capacity or have some degree of kidney disease. Normal renal compensation is slow and will often begin in 24 hours, if kidney function is normal. The nurse is caring for a patient scheduled for surgery with a chest wall abnormality. Which condition should the nurse carefully monitor the client's arterial blood gases for? respiratory acidosis A chest wall abnormality may cause difficulty in breathing, leading to hypoventilation. Hypoventilation may result in respiratory acidosis. Metabolic acidosis is caused by factors that increase the concentration of acid other than carbonic acid. Metabolic alkalosis occurs as a result of factors contributing to the loss of bicarbonate or gain of acids. Respiratory alkalosis is caused by conditions which result in hyperventilation. The emergency room nurse is caring for a patient with a severe fluid volume deficit who presented after several days of diarrhea secondary to C. difficile infection. Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly replace the fluid volume? 0.9% sodium chloride An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and 5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly increase fluid volume. A patient reports weight gain, diarrhea, headache, nausea, and vomiting. The patient's blood pressure is 140/90 mm Hg. The patient's previous health records reveal primary hypoaldosteronism. Which medication may be beneficial for the patient? Conivaptan Hyperaldosteronism can be manifested by weight gain, diarrhea, headache, nausea, vomiting, and elevated blood pressure. There is also a dilutional hyponatremia. Conivaptan blocks the activity of antidiuretic hormone and results in increased urine output without loss of electrolytes, thereby improving the patient's hyponatremia. Amiloride, propranolol, and sodium polystyrene sulfate treat hypokalemia, but not hyponatremia. The family of a patient being treated for acute pancreatitis hears the nurse referring to "third spacing" during the assessment and asks the nurse what that means. Which explanation provides the best description for the family? "The fluid normally in the cells becomes trapped in between the cells and has difficulty moving back into the cells." Third spacing refers to the collection of excess fluid in the nonfunctional areas between the cells. The fluid becomes trapped and has difficulty moving back into the cells. First spacing describes the normal distribution of fluids in the intracellular fluid and extracellular fluid compartments. Second spacing refers to edema. "Extracellular" and "intracellular" are terms that describe places where fluids can be found in the cells, blood vessels, and lymph system. The nurse is caring for a patient who is febrile with a body temperature of 103o F. What clinical manifestation does the nurse anticipate when assessing this patient? orthostatic hypotension A patient with an elevated body temperature of 103 oF may have a loss of body fluids leading to decreased blood volume and resulting in postural or orthostatic hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations that occur due to an increase in the body fluid volume. A patient reports nausea, four episodes of vomiting, and headache. The nurse finds that the patient is taking deep and rapid breaths and blood pressure as 90/60 mm Hg. Which condition does the nurse suspect in the patient? metabolic acidosis Deep and rapid respirations are characteristic of Kussmaul's respirations. Normal blood pressure is 120/80 mm Hg. Kussmaul's respirations, low blood pressure, nausea, vomiting, and headache are manifestations of metabolic acidosis. Therefore, the nurse suspects that the patient has metabolic acidosis. Signs of metabolic alkalosis include tetany, nausea, and vomiting. Although headache and hypotension are seen in respiratory acidosis, nausea, vomiting, and rapid respirations are not observed. Respiratory alkalosis is characterized by tetany, anorexia, nausea, and vomiting. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. Which phosphate level would the nurse be likely to find in the patient who has alcohol withdrawal symptoms? 1.4 mg/dL Alcohol withdrawal can result in hypophosphatemia. Phosphate levels of less than 2.4 mg/dL indicate hypophosphatemia. The nurse would be likely to find the patient's phosphate level at 1.4 mg/dL. Phosphate levels of 2.4, 3.8, and 4.8 mg/dL indicate hyperphosphatemia. The patient with symptoms of alcohol withdrawal does not have hyperphosphatemia. A nurse reviews a patient's blood gas results: pH 7.15, PaO 2 40 mm Hg, PaCO 2 70 mm Hg, and HCO 3 25 mEq/L. The nurse suspects hypoxia and what other condition? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Compensating respiratory acidosis respiratory acidosis This patient is not breathing effectively and therefore has a buildup of carbon dioxide in the form of carbonic acid. This places the patient in an acidotic state because the pH is less than 7.35. Metabolic and respiratory alkalosis are therefore eliminated as possibilities. Because the PaCO 2 is high at 70 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO 3 -is normal at 25 mEq/L (normal range is 22 to 28 mEq/L), the patient is in respiratory acidosis. The patient is not compensated, because the HCO 3 -is still within normal range. If the HCO 3 -were increased, this would be an indication of compensation. The nurse caring for a patient with a central venous access device is unable to infuse fluids into the catheter. Which nursing interventions are appropriate for the patient's treatment plan to address the issue of the catheter occlusion? Select all that apply. 1 Instruct the patient to remain supine in bed and not to move. 2 Assess the catheter for clamping and kinking, and alleviate the cause. 3 Force-flush the device with normal saline using a 10-mL syringe. 4 Perform fluoroscopy to determine the cause and evaluate the site. 5 Administer anticoagulant or thrombolytic agents. 2,4,5 Occlusion is a common problem with central venous catheters. If occlusion is suspected, the nurse should instruct the patient to change position, raise the arm, and cough, which helps move any blockage. The nurse must assess the catheter for clamping and kinking and undo it if found. The nurse should inform the health care provider about the catheter occlusion so that fluoroscopy can be performed if needed to determine the cause and site of occlusion. In addition, anticoagulants or antithrombolytic agents can be administered. Having the patient lie supine and motionless is not appropriate when assessing possible occlusion. Flushing is a very important step in maintaining the patency of the catheter. Flushing should be done with normal saline in a 10-mL syringe to avoid pressure on the catheter. Force should not be applied if resistance is felt. A nurse is caring for a patient three days after abdominal surgery who continues to have poorly controlled abdominal pain with green bilious nasogastric output. The patient's respiratory rate is 32 and heart rate is 128. Which acid-base imbalance does the nurse suspect is occurring? mixed alkalosis Mixed alkalosis can occur in a patient who is losing CO 2 via hyperventilation (possibly related to pain) while also losing acid by another method, such as prolonged suctioning with a nasogastric tube. Respiratory acidosis occurs when the primary loss of acid is via a respiratory "blow off" of CO 2. Metabolic alkalosis occurs with a systemic loss of acid via a metabolic process such as vomiting or suctioning with a nasogastric tube. Mixed acidosis occurs when acid is retained by both respiratory and metabolic systems, such as in a critically ill patient in shock with hypoperfusion and hypoventilation, and will often cause a more profoundly acidotic pH than either condition could independently create. The nurse is unable to flush a central venous access device and suspects occlusion. Which of these would be appropriate interventions to undertake? Select all that apply. Clamp the tubing immediately. Obtain cultures of the insertion site. Instruct the patient to change positions, raise arm, and cough. Attempt to force flush 10 mL of normal saline into the device. Assess the tubing for clamping or kinking, and alleviate as needed. Instruct the patient to change positions, raise arm, and cough. Assess the tubing for clamping or kinking, and alleviate as needed. Catheter occlusion interventions include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking; flushing with normal saline using a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site; and instilling anticoagulant or thrombolytic agents. Clamping the tubing and culturing the site would not assist in flushing the line or resolve the occlusion. The nurse should not force flush the line. What happens when the respiratory center in the medulla senses an increased concentration of carbon dioxide (CO2) or H+? The respiratory center stimulates hyperventilation to get rid of CO2. Increased CO 2 or H + signals acidosis, which triggers the respiratory center to hyperventilate and get rid of CO 2 to balance the pH. CO 2 retention occurs to correct alkalosis. A decreased depth of breathing occurs in respiratory dysfunction. An increased depth of breathing occurs in hyperventilation; in this case, the body will expel CO 2 to decrease H +. The nurse is reviewing magnesium levels for a patient. What does the nurse recognize is the importance of assessing this level for a patient? Can affect neuromuscular excitability and contractility. Alterations in serum magnesium levels profoundly affect neuromuscular excitability and contractility because magnesium directly acts on the myoneural junction. A decrease in blood magnesium levels increases the blood pressure. Magnesium is the second most abundant intracellular cation. The majority of the body's magnesium is present in the bones. Causing extracellular fluid overload, being the most abundant intracellular cation, and the patient being at risk for hypotension are not relevant to this situation. Upon assessment of laboratory data, the nurse notes a calcium level of 6.4 mg/dL. Which physical assessment finding is consistent with this data? Paresthesias Signs of hypocalcemia include paresthesias, tetany, and muscle weakness. Bone pain, diminished reflexes, and polyuria are signs of hypercalcemia. While caring for a patient with encephalitis, the nurse suspects that the patient has developed respiratory alkalosis. Which finding in the patient supports the nurse's suspicion? Bicarbonate ion concentration, 18 mEq/L, partial pressure of carbon dioxide, 30 mm Hg The normal range of bicarbonate (HCO3-) ion concentration in blood is 22 to 26 mEq/L, and the normal range of partial pressure of carbon dioxide (PaCO 2) is 35 to 45 mm Hg. When the respiratory center is stimulated, patients with encephalitis will hyperventilate. This condition causes a decrease in partial pressure of carbon dioxide, resulting in decreased carbonic acid concentration. Because the laboratory reports show a decreased partial pressure of carbon dioxide and bicarbonate ion concentration, the nurse suspects respiratory alkalosis. When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? Select all that apply. Change the catheter dressing regularly. Monitor the heart rate and blood pressure. Cleanse around the catheter insertion site. Measure and record oral intake and output. Change the injection caps at regular intervals. Change the catheter dressing regularly. Change the injection caps at regular intervals. Cleanse around the catheter insertion site. Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed, and the catheter site should be regularly cleansed; these steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices. A patient is recovering from a surgical procedure with pain rating at a 10 on a scale of 0-10 and has a nasogastric (NG) tube draining copious amounts of contents. The patient's respiratory rate is 32. What condition is this patient at greatest risk for? b) Mixed respiratory and metabolic alkalosis A mixed acid-base disorder is a condition in which two or more disorders that affect the acid-base balance are present at the same time. Septicemia causes respiratory alkalosis, which causes acid-base imbalance. Metabolic alkalosis also affects the acid-base balance. Thus septicemia and metabolic alkalosis are examples of a mixed acid-base disorder. Hypoxia causes respiratory alkalosis. Overdose of sedatives causes respiratory acidosis. Diabetic ketoacidosis results in metabolic acidosis. An example of a mixed acidosis is a patient in severe shock with poor perfusion and hypoventilation. Mixed alkalosis can occur in a patient hyperventilating because of postoperative pain and losing acid secondary to NG suctioning. The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output, which is the major route of excretion for magnesium. An older adult patient is admitted with pneumonia. Why would it be important for the nurse to closely monitor fluid and electrolyte balance in this patient? Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults. Older adults, with less muscle mass and more fat content, have less body water than younger adults. In the older adult, body water content averages 45% to 55% of body weight, leaving them at a higher risk for fluid-related problems than young adults. Renal function, level of consciousness, and severe illnesses are not relevant in this instance. The nurse is caring for a patient with sickle cell anemia. What common electrolyte imbalance should the nurse carefully assess the patient for that is commonly associated with this disease? increased phosphate levels Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis. A patient's potassium level is 2.9 meq/L. Which health care provider order should the nurse expect? Continuous ECG monitoring Hypokalemia can cause lethal ventricular rhythms. Therefore continuous cardiac monitoring should be expected. Patients with hypokalemia are at risk for digoxin toxicity. The nurse should watch for signs of digoxin toxicity and question an increase in dosage. KCL infusion must be diluted and given at a rate not to exceed 10 meq/hour. 40 meq KCL in 100 cc of fluid is too concentrated and should be given over at least two hours. To prevent bolusing, KCL should never be added to an IV bag that already is hanging. When assessing a patient with a multilumen central venous catheter, the nurse notices that the cap is off one of the lines. The patient is showing signs of respiratory distress and is hypotensive and tachycardic. Which action would the nurse take immediately? give oxygen Rationale The cap off the central line could allow entry of air into the circulation. For an air embolus, the priority is to administer oxygen. Next, the catheter is clamped and the patient is positioned on the left side with the head down. Then the health care provider is notified. IV fluid is not needed in this scenario and could worsen the patient's respiratory status. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. A patient is diagnosed with Guillain-Barré syndrome. Which complication does the nurse anticipate? Respiratory acidosis Guillain-Barré syndrome is a disease of the respiratory system that causes hypoventilation. Hypoventilation increases the concentration of carbonic acid, which results in respiratory acidosis. Metabolic acidosis, metabolic alkalosis, and respiratory alkalosis are not caused by Guillain-Barré syndrome. A patient was admitted with abdominal pain, nausea, and severe diarrhea. Based on this information, the nurse assesses this patient for which primary acid-base imbalance? metabolic acidosis Because gastric secretions are rich in hydrochloric acid, the patient with severe diarrhea will lose significant amounts of bicarbonate and is at increased risk for metabolic acidosis and a fall in pH. Metabolic alkalosis, respiratory alkalosis, and respiratory acidosis will not occur as a result of increased loss of bicarbonate. STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.