Ver Easy
With which client should the nurse be most alert for the development of overhydration?
A. 65-year-old client who has diabetes mellitus and chronic hypertension
B. 45-year-old client who self-medicates with sodium-containing antacids for indigestion
C. 75-year-old client receiving blood replacement therapy with 3 units of packed red blood cells
D. 80-year-old client 1 day postoperative from abdominal surgery who has an NG tube to continuous suction
ANS:C
Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from the interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.
Pedro, a cigarette vendor was brought to the emergency department of a hospital after he fell into the ground and hurt his left leg. He is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen his pain. Suddenly, he started complaining that he is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean?
A. Respiratory Alkalosis, Uncompensated
B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Alkalosis, Partially Compensated
ANSWER: A
RATIONALE: The primary disorder is acute respiratory alkalosis (low CO2) due to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation.
A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included in the care plan of Mark for his patient?
A. Administering I.V. and oral fluids.
B. Clustering necessary activities throughout the day.
C. Assessing color, odor, and amount of sputum.
D. Monitoring serum albumin and total protein levels.
ANSWER: A
RATIONALE: The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs. Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion rates will vary depending on clinical status.
Which client is at greatest risk for hypokalemia?
A. 65-year-old with diabetes mellitus
B. 55-year-old with Addison’s disease
C. 45- year-old with Cushing’s disease
D. 35-year-old with diabetes insipidus
ANS:C
In Cushing’s disease, the person has an excess of glucocorticoids, especially cortisol. Cortisol has some action of aldosterone, resulting in an increased reabsorption of sodium and water while enhancing the excretion of potassium. Therefore, any client with cortisol excess, whether from Cushing’s disease or from exogenous cortisol, is at high risk for development of hypokalemia.
Lito is a 59-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?
A. Respiratory Acidosis, Uncompensated
B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Acidosis, Partially Compensated
ANSWER: B
RATIONALE: The patient has respiratory acidosis (raised carbon dioxide) resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation.
Noah’s mother is seen in the emergency department at a community hospital. He admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the gentleman at risk for if medical attention is not provided?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
ANSWER: C
RATIONALE: Salicylate overdose causes a high anion gap metabolic acidosis in both children and adults. Adults commonly develop a mixed acid-base disorder as a respiratory alkalosis due to direct respiratory centre stimulation occurs as well. This second disorder is uncommon in children.
Jeron is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?
A. Prevention of fluid volume excess
B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction
ANSWER: B
RATIONALE: For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance.
In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
ANSWER: D
RATIONALE: NGT suctioning, vomiting, hypokalemia and overdosage of NaHCO3 are considered risk factors of metabolic alkalosis.
Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?
A. Administering sodium chloride I.V.
B. Encouraging slow, deep breaths.
C. Preparing to administer sodium bicarbonate.
D. Administer low-flow oxygen therapy.
ANSWER: B
RATIONALE: The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Encourage the patient to breathe slowly and deeply. Speak in a low, calm tone of voice. Provide a safe environment. May help reassure and calm the agitated patient, thereby aiding the reduction of respiratory rate. Assists the patient to regain control.
Which intervention for the client with overhydration-induced confusion is most likely to relieve the confusion?
A. Measuring intake and output
B. Slowing the IV flow rate to 50 mL/hour
C. Administering diuretic agents as prescribed
D. Placing the client in modified Trendelenburg position (feet and legs elevated; head and chest flat)
ANS:C
Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating the fluid excess is the best way to reduce confusion.