Rasmussen MDC 2 SECOND TEST, questions and answers, verified

Rasmussen MDC 2 SECOND TEST, questions and answers, verified A patient is suffering from nausea, vomiting, and diarrhea, what electrolyte imbalance would you expect? HYPOKALEMIA The nurse notes a positive CHVOSTEKS sign in her patient, which electrolyte imbalance is the patient suffering from? HYPOCALCEMIA CHVOSTEKS sign is contraction of facial muscles provoked by lightly tapping over the facial nerve anterior to the ear as it crosses the zygomatic arch. This induces twitching of the homolateral facial muscles due to hyperexcitability of the nerve. Trosseau's sign latent tetany is most commonly positive in the setting of hypocalcemia.[1] The sign is observable as a carpopedal spasm induced by ischemia secondary to the inflation of a sphygmomanometer cuff, commonly on an individual's arm, to 20 mmHg over their systolic blood pressure for 3 minutes. A patient is suffering from dehydration which fluids would you expect to administer? ISOTONIC A patient is suffering from a bowel obstruction and is currently being treated with an NG tube, what imbalance? METABOLIC ACIDOSIS Which imbalance would result in aspirin toxicity? METABOLIC ACIDOSIS or respiratory alkalosis (Aspirin has a direct effect on the respiratory center in the brain leading to hyperventilation.) A patient suffering from diarrhea would have which imbalance? METABOLIC ACIDOSIS A patient suffering from an anxiety attack would be suffering from which imbalance? RESPIRATORY ALKALOSIS (HYPERVENTILATION) Your patient is suffering from HYPOmagnesmia and HYPOcalcemia what assessment technique would be positive? TYROUSSEAU'S Sign A patient just had surgery and is receiving IV pain medication, which acid base balance is he at risk for? Respiratory Acidosis A patient is battling End Stage Liver Cancer, which acid base imbalance would you expect to see? Metabolic Acidosis A 3-year-old is admitted to the emergency department for choking on a hotdog, what acid base imbalance could we expect? RESPIRATORY ACIDOSIS (cant breathe) A patient is diagnosed with metabolic acidosis, what treatment would be expected to be ordered? HYDRATION A patient is admitted with tachycardia, hypotension, cough, and fever with 100 mL output in 12 hours. HYPOvolemia A patient is suffering from nausea, vomiting, and diarrhea, what fluids would you administer? ISOTONIC A patient is admitted with an exacerbation of asthma, what is the priority diagnosis? SECURE AIRWAY A patient is diagnosed with HYPERnatremia, what symptoms would you expect to see? INCREASE THIRTS A patient is diagnosed with HYPOkalemia, foods can you recommend to this patient? BANANAS A patient is suffering from respiratory alkalosis, what assessment finding is consistent? Low to Normal Blood Pressure A patient has an NG tube intermittent suction, what acid base imbalance is she at risk for? METABOLIC ALKALOSIS (you're getting acids of the stomach out) ----LAB VALUE HYPOKALEMIA----- A patient is suffering from diarrhea due to food poisoning, what acid base imbalance would you expect? METABOLIC ACIDOSIS A patient is showing tall T waves on the EKG, what acid base imbalance is occurring? METABOLIC ACIDOSIS What intervention is appropriate for a patient with Metabolic Acidosis? Replace fluids and electrolytes A patient is suffering from metabolic acidosis, which symptom is appropriate? Kussmauls respirations (is characterized by a deep, rapid breathing pattern. It is typically an indication that the body or organs have become too ACIDIC. In an attempt to expel carbon dioxide, which is an acidic compound in blood, the body starts to breathe faster and deeper.) A patient reports 4 lbs. weight gain, what would be the suspected diagnosis? HYPERVOLEMIA Trousseau's sign is elicited by? Using a blood pressure cuff to the patients arm The first step in interpreting an ABG is to label the ? PH Aspirin toxicity can result in 2 acid base imbalances. TRUE (causes high anion gap metabolic acidosis and respiratory alkalosis.) Which body systemS works to correct the acid base imbalance? LUNGS AND KIDNEYS What is the best way to help reduce the spread of infection? proper hand washing A patient has hypoparathyroidism what lab value would the RN expect? Decreased Calcium A patient is suffering from DKA what electrolyte imbalance would you expect to see? HYPERKALEMIA What is the normal range for sodium? 136_145 What is the normal range for sodium? 136-145 A patient is suffering from dehydration what nursing diagnosis would NOT be included in the plan? fluid volume overload A patient is suffering from HYPOkalemia, what lab value would you expect to see? hypocalcemia What is the normal range of Magnesium? 1.8-2.6 What is the normal range of Chloride? 98-106 What is the minimum of urine per day to excrete toxic waste? 400-600mL A patient is suffering from dehydration which is referred to as? hypovolemia A patient is suffering from HYPOkalemia, how would we administer potassium? infusion pump A patient presents with HYPOmagnesmia, we know this can be a result of the following? ALCOHOLISM (alcohol drunks magnesium) A patient presents with dehydration, this can be caused by which of the following? food poisoning A patient is taking Lasix for CHF we know this can result in which electrolyte imbalance? HYPOKALEMIA (Lasix kicks out potassium) A patient presents with nausea and vomiting over the past 72 hrs., what would be a priority intervention? Obtain IV access and administer IV fluids A nurse understands that dehydration is caused by which of the following? fever (fever dehydrates) A common cause of fluid overload would be which of the following? long-term corticosteroid therapy A construction worker with excessive sweating is at risk for? hyponatremia (sweat is salty, you're loosing it) Sarah has the following lab values, what is she suffering from? Na-150, K-2.5. HYPERnatremia and HYPOkalemia A patient with HYPOvolemia would have which of the following lab values? decreased urine sodium Which of the following causes fluid overload? CHF heart failure A patient is suffering from dehydration, what is the priority lab to monitor? SODIUM A patient is being put on fluid restriction what is important in monitoring for this patient? DAILY WEIGHT What electrolyte is within extracellular fluid? SODIUM (salt outside, bananas inside) What electrolyte is within INtracellular fluid? POTASIUM (salt outside, bananas inside) How many mL of fluid per day is excreted by exhalation? 300mL A patient has just had an ileostomy after colon cancer surgery, what is he at risk for? DEhydration A patient with fluid volume deficit would benefit from which intervention? FALL precautions Signs of dehydration include which of the following? low BP Signs of fluid volume overload include? EDEMA Common Causes of Sodium loss include EXCESIVE DIAPHORESIS (sweating) Common causes of HYPERkalemia include Potassium sparing diuretics Common causes of HYPOkalemia include vomiting and diarrhea What medication should we watch with potassium imbalance? DIGOXIN Common Causes of HYPOcalcemia include CHRONS DISEASE Common causes of HYPERcalcemia include hyperthyroidism Which patient is at highest risk for calcium loss? post-menopausal women A patient is suffering from HYPOkalemia what is the priority intervention? POTASSIUM=PUMPS THE HEART Initiate TELEMETRY monitoring (Telemetry monitoring is when healthcare providers monitor the electrical activity of your heart for an extended time. Electrical signals control your heartbeat.) A patient has potassium infusing IV and sates its burning and his skin is swelling, what is your priority intervention? STOP THE IV INMEDIATELY Severe HYPOkalemia can cause which of the following? paralytic ILEUS What is the priority assessment for a patient with fluid overload? repiratory assessment A patient is suffering from edema in the lower extremities what NON pharmalogical interventions can be initiated? Elevate extremities on 3 pillows above the heart A patient is suffering from HYPOnatremia, what is priority? initiate SEIZURES precautions -------SALT=SEIZURES----- Risk factors for acid base imbalances. COPD, liver failure, pancreatitis, emphysema, asthma Respiratory alkalosis symptoms dizziness. bloating. feeling lightheaded. numbness or muscle spasms in the hands and feet. discomfort in the chest area. confusion. dry mouth. tingling in the arms. Respiratory acidosis symptoms headache. anxiety. blurred vision. restlessness. confusion. metabolic alkalosis symptoms Confusion (can progress to stupor or coma) Hand tremor. Lightheadedness. Muscle twitching. Nausea, vomiting. Numbness or tingling in the face, hands, or feet. Prolonged muscle spasms (tetany) metabolic acidosis symptoms rapid and shallow breathing. confusion. fatigue. headache. sleepiness. lack of appetite. jaundice. increased heart rate.