You are caring for a patient who has a diagnosis of syndrome of
inappropriate antidiuretic hormone secretion (SIADH). Your
patients plan of care includes assessment of specific gravity
every 4 hours. The results of this test will allow the nurse to
assess what aspect of the patients health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status D
A specific gravity will detect if the patient has a fluid volume
deficit or fluid volume excess. Nutrition, potassium, and calcium
levels are not directly indicated.
You are caring for a patient admitted with a diagnosis of acute
kidney injury. When you review your patients most recent
laboratory reports, you note that the patients magnesium levels
are high. You should prioritize assessment for which of the
following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank painA
To gauge a patients magnesium status, the nurse should check
deep tendon reflexes. If the reflex is absent, this may indicate
high serum magnesium. Tachycardia, flank pain, and cool,
clammy skin are not typically associated with
hypermagnesemia.
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) Metabolic alkalosis
B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia D
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.
A patient with a longstanding diagnosis of generalized anxiety
disorder presents to the emergency room. The triage nurse notes
upon assessment that the patient is hyperventilating. The triage
nurse is aware that hyperventilation is the most common cause
of which acidbase imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS disturbances B
The most common cause of acute respiratory alkalosis is
hyperventilation. Extreme anxiety can lead to hyperventilation.
Acute respiratory acidosis occurs in emergency situations, such
as pulmonary edema, and is exhibited by hypoventilation and
decreased PaCO2. CNS disturbances are found in extreme
hyponatremia and fluid overload.
You are an emergency-room nurse caring for a trauma patient.
Your patient has the following arterial blood gas results: pH
7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret
these results?
A) Respiratory acidosis with no compensation
,B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
D
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The
PaCO3 is also low, which causes alkalosis. The bicarbonate is
low, which causes acidosis. The pH bicarbonate more closely
corresponds with a decrease in pH, making the metabolic
component the primary problem.
You are making initial shift assessments on your patients. While
assessing one patients peripheral IV site, you note edema around
the insertion site. How should you document this complication
related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid Overload C
Infiltration is the administration of nonvesicant solution or
medication into the surrounding tissue. This can occur when the
IV cannula dislodges or perforates the wall of the vein.
Infiltration is characterized by edema around the insertion site,
leakage of IV fluid from the insertion site, discomfort and
coolness in the area of infiltration, and a significant decrease in
the flow rate. Air emboli, phlebitis, and fluid overload are not
indications of infiltration.
You are performing an admission assessment on an older adult
patient newly admitted for end-stage liver disease. What
principle should guide your assessment of the patients skin
turgor?
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
, C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70. C
Inelastic skin is a normal change of aging. However, this does
not mean that skin turgor cannot be assessed in older patients.
Dehydration, not overhydration, causes inelastic skin with
tenting. Overhydration, not dehydration, causes the skin to
appear edematous and spongy.
The physician has ordered a peripheral IV to be inserted before
the patient goes for computed tomography. What should the
nurse do when selecting a site on the hand or arm for insertion
of an IV catheter?
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when
selecting a site.
C) Have the patient briefly hold his arm over his head before
insertion.
D) Leave the tourniquet on for at least 3 minutes. B
Ideally, both arms and hands are carefully inspected before
choosing a specific venipuncture site that does not interfere with
mobility. Instruct the patient to hold his arm in a dependent
position to increase blood flow. Never leave a tourniquet in
place longer than 2 minutes. The site does not necessarily need
to be devoid of hair.
A nurse in the neurologic ICU has orders to infuse a hypertonic
solution into a patient with increased intracranial pressure. This
solution will increase the number of dissolved particles in the
patients blood, creating pressure for fluids in the tissues to shift
into the capillaries and increase the blood volume. This process
is best described as which of the following?
A) Hydrostatic pressure
B) Osmosis and osmolality
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