F/E & Acid Base
Evaluation of successful resolution of a fluid volume deficit may be demonstrated by which of the following?
1. The client demonstrates an absence of postural hypotension and tachycardia
2. The client adheres to prescribed dietary sodium restrictions
3. The client maintains weight loss
4. The client maintains a serum Na above 145 mEq
1.When you are in a fluid volume deficit your blood pressure goes down and pulse goes up
A patient with an open fracture of the left tibia and soft tissue damage underwent a surgical reduction and fixation of the tibia with debridement of nonviable tissue and drain placement. When assessing the patient during the postoperative period, the nurse will be most concerned about
1. fever with chills and night sweats.
2. light yellow drainage from the wound.
3. pain on movement of the affected limb.
4. discoloration around the affected area.
Answer: 1
Rationale: Fever, chills, and night sweats are suggestive of osteomyelitis. The other clinical manifestations are typical after a fracture repair.
To promote safety in the care of a client receiving internal radiation therapy the nurse would:
1. Restrict visitors who may have an upper respiratory infection
2. Assign only male care givers to the client
3. Plan nursing activities to decrease nurse exposure
4. Talk to the client at least 3 feet away
Correct Answer: 3. You get your act together before you ever go into the room and hurry up and get out
A nurse is caring for a client in labor. The nurse determines that the client is on the 2nd stage of labor when which of the following assessments is noted?
1.The client begins to expel clear vaginal fluid
2.The contractions are regular
3.The membranes have ruptured
4.The cervix is dilated completely
Correct Answer: 4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
1. take a hot bath.
2. rest in an air-conditioned room
3. increase the dose of muscle relaxants.
4. avoid naps during the day
Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
Ms. Stone is admitted with a serum magnesium deficit. Which of the following nursing diagnosis would be most appropriate?
1. High risk for injury R/T increased neuromuscular irritability
2. High risk for injury R/T fractures secondary to loss of calcium
3. Fluid volume deficit R/T dehydration
4. Activity intolerance R/T skeletal muscle weakness
1. When you are in a magnesium deficit your muscles are rigid and tight and you might just go ahead and have a seizure.
When obtaining assessment data from a patient with a microcytic, hypochromic anemia, you question the patient about
1. folic acid intake.
2. dietary intake of iron.
3. a history of gastric surgery.
4. a history of sickle cell anemia.
2. dietary intake of iron.
Iron deficiency anemia is a type of microcytic, hypochromic anemia.
Which of the following measures should the nurse take while a client has a radium implant for the treatment of uterine cancer?
1. Evaluate the position of the applicator every two hours
2. Place on a low residue diet to decrease bowel movements
3. Encourage the use of the bedside commode every 1-2 hours
4. Decrease fluid intake to decrease radiation in bladder
Correct Answer: 2. You want them on a low fiber diet because if they eat too much fiber their bowel will extend and push out the implant
Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child’s history, the nurse considers which information to be most important?
1.A fever that started 3 days ago
2.Lack of interest in food
3.A recent episode of pharyngitis
4.Vomiting for 2 days
Correct Answer: 3. A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
1. A low respiratory
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury
Answer B.
This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Ms. Fair is a 77 year old female. Her husband reports that she has had a poor appetite over the past two weeks, with occasional nausea and vomiting. When placed on a cardiac monitor various abnormal heart beats are noted. Based on this data, the nurse would suspect that Ms. Fair is experiencing.
1. Hyponatremia
2. Hypermagnesemia
3. Hypercalcemia
4. Hypokalemia
4. Hypokalemia-The clues are poor appetite, vomiting, heart all of those things only point to one electrolyte and what’s the electrolyte? Potassium.
A patient with a herniated intravertebral disk undergoes a laminectomy and diskectomy. Following the surgery, the nurse should position the patient on the side by
1. elevating the head of the bed 30 degrees and having the patient extend the legs while turning to the side.
2. turning the patient's head and shoulders and then the hips, keeping the patient centered in the bed.
3. having the patient turn by grasping the side rails and pulling the shoulders over.
4. having another nurse to help turning the entire body as a unit.
Answer: 4
Rationale: Logrolling is used to maintain correct body alignment after laminectomy. The other positions will create misalignment of the spine.
A client with lung cancer and bone metastasis is grimacing and states, “I am a little uncomfortable, may I have something for pain?” Which of the following should the nurse do first before administering pain medication?
1. Check the chart to determine last medication
2. Encourage client to refocus on something pleasant
3. Notify doctor that medication is not working
4. Assess severity and location of pain
Correct Answer: 4. Bone metastisis is one of the worst kinds of pain, you would not hold off on the pain medicine.
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
Correct Answer: 3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
1. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
2. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss."
3. "It must be hard to accept the permanency of your paralysis."
4. "You'll first regain use of your legs and then your arms."
Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
The nurse is caring for a thoracotomy client, one day post operative on 40% humidified oxygen. ABG results are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on this information, which of the following nursing actions would be best?
1. Position in high fowlers and encourage coughing, evaluate airway patency
2. Place in prone position and request respiratory therapy to perform postural drainage and percussion therapy
3. Call the doctor and advise him of the ABGs; anticipate increase in oxygen percentage
4. Administer anti-anxiety agent and assist the client with a rebreathing device to increase oxygen levels
1.If you had just had a thoracotomy would you be taking nice big deep breaths? No. So what would you be retaining? CO2 which makes your PCO2 go up which makes your pH go down. I’m acidotic aren’t I?
Which individual is at high riskfor a vitamin B12 deficiency anemia?
1. A 47-year-old man who had a gastrectomy
2. A 34-year-old woman who is pregnant with vaginal spotting
3. A 26-year-old woman who complains of heavy menstrual periods
4. A 15-year-old girl who is a vegetarian
Answer: 1. A 47-year-old man who had a gastrectomy (removal of the stomach)
There are many causes of Vit B12 deficiency. The most common cause is pernicious anemia, a disease in which the gastric mucosa is not secreting intrinsic factor (IF) because of antibodies being directed against the gastric parietal cells or IF itself.
A client on chemotherapy has a WBC count of 1200 mm. Based on this data, which of the following nursing actions should the nurse take first?
1. Check temperature q4h
2. Monitor urine output
3. Assess for bleeding gums
4. Obtain an order for blood cultures
Correct Answer 1.Watch the temperature. If temperature goes up then you order the blood cultures
When developing a plan of care for a male adolescent, the nurse considers the child’s psychosocial needs. During adolescence, psychosocial development focuses on:
1.Becoming industrious
2.Establishing an identity
3.Achieving intimacy
4.Developing initiative
Correct Answer 2: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from the family. Becoming industrious is the developmental task of the school-age child, achieving intimacy is the task of the young adult, and developing initiative is the task of the preschooler.
A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?
1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray.
3. Increase oxygen saturation with exercise
4. A widened diaphragm noted on the chest x-ray
Answer B.
Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, - hypercapnia,
- dyspnea on exertion and at rest
- oxygen desaturation with exercise
- and the use of accessory muscles of respiration.
Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
It is 0600 and a client is scheduled for a cardiac catheterization at 0800. Laboratory work completed five days ago showed: K 3.0 mEq/L, Na 148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps. Which nursing action should be implemented at this time?
1. Hold 0700 dose of spironolactone (Aldactone)
2. Encourage eating bananas for breakfast
3. Call the physician to suggest a stat K level
4. Call for a twelve lead ECG
3. Since it is a heart cath what electrolyte am I most concerned about, potassium. This lab work was done five days ago and today my patient is having muscle weakness and cramps well if it was 3.0 five days ago and they’re having those kind of symptoms today, I’ll bet it’s even lower. If you send a patient like that to a heart cath could it kill them? Yes, so you don’t send them.
A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to
1. muscle spasms.
2. meniscus injury.
3. repetitive strain injury.
4. carpal tunnel syndrome.
Correct Answer: 3
Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and numbness of the hand.
A client is admitted to the outpatient unit in the Cancer Center for his chemotherapy. He is lethargic, weak, pale. His WBC count is 3000. Which of the following nursing interventions would be most important for the nurse to implement?
1. Establish emotional support
2. Position for physical comfort
3. Maintain respiratory isolation
4. Hand washing prior to care
Correct Answer: 4.You should be most worried about infection because white count is too low. Hand washing is the number one way to break the chain of infection
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?
1.Encourage the client's coach to continue to encourage breathing exercises
2.Encourage the client to continue pushing with each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife
Correct Answer: 4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.
A female client with a suspected brain tumor is scheduled for computed tomography (CT) with contrast. What should the nurse do when preparing the client for this test?
1. Immobilize the neck before the client is moved onto a stretcher.
2. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
3. Place a cap over the client's head.
4. Administer a sedative as ordered.
Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.