Fluid and Electrolyte Balance and Acid/Base Balance
A client is admitted to the unit with a potassium level of 2.4mEq/L. The client with a potassium level of 2.4meq/L would exhibit symptoms of:
A. Peaked T waves
B. U waves
C. Muscle rigidity
D. Rapid respirations
B. U waves
The normal potassium level is 3.5-5.5 mEq/dl
A indicates elevated potassium level, C muscles are flaccid with hypokalemia and D respirations will be shallow not rapid
Which instructions should be given to a client taking alendronate sodium (Fosamax)?
A. Take the medication before arising
B. Force fluids while taking this medication
C. Remain upright for 30 minutes after taking this medication
D. Take the medication in conjunction with estrogen
C. Remain upright for 30 minutes after taking this medication
This drug causes gastric reflux, so you should remain upright and take it only with water
An 85 year old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
A. Dorsal hand
B. Feet
C. Back of the arm
D. Sternum
D. Sternum
This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging.
The client is admitted with hypokalemia. An IV of normal saline is infusing at 80 ml/hour with 10 mEq of KCI/hour. Prior to beginning the infusion the nurse should:
A. Check the sodium level
B. Check the magnesium level
C. Check the creatinine level
D. Check the calcium level
C. Check creatinine level
Client should be evaluated for renal function because regulation of potassium is primarily done within the kidneys
Which laboratory result would concern the nurse caring for a client who is receiving furosemide (Lasix)?
A. Potassium of 2.5
B. Sodium 140
C. Glucose 110
D. Calcium 8
A. Potassium of 2.5
The nurse is caring for client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
A. Checking for tetany like movements
B. Assessing breath sounds
C. Obtaining vital signs
D. Palpating pedal pulses
A. Checking for tetany like movements
Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
A. Urinary output of 60ml per hour
B. Respirations of 30 per minute
C. Absence of the knee-jerk reflex
D. Blood pressure of 150/80
C. Absence of knee-jerk reflex
The signs of toxicity to magnesium are oliguria (less than 30ml/hour urinary output), respirations less than 12 per minute, absence of deep tendon reflexes.
A 5 year old boy is being treated for an acute asthma attack using racemic epinephrine (epinephrine hydrochloride) nebulizer stat. Which finding indicates an adverse effect of this medication?
A. Excitability
B. Tremors
C. Heart rate 150
D. Nausea
C. Heart rate 150
Adverse effects of epinephrine include hypertension and tachycardia
The nurse is caring for a client with a nasogastric tube in place. Assessments of the aspirate reveals a pH of 2.0. Which is the appropriate action?
A. Document the finding
B. Notify the RN
C. Remove the NG tube and replace it
D. Turn the client side lying and reassess the aspirate
A. Document the finding
The finding is within normal rang for gastric aspirate of 0-4
The client presents to the unit with complains of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
A. pH of 7.45, CO2 of 45, HCO3 of 26
B. pH of 7.35, CO2 of 46, HCO3 of 27
C. pH of 7.34, CO2 of 30, HCO3 of 22
D. pH of 7.44, CO2 of 32, HCO3 of 25
B. pH of 7.35, CO2 of 46, HCO3 of 27
Client with respiratory acidosis will have a pH that is decreased and CO2 excretion will be inhibited due to the respiratory problems. The HCO3 will also be increased because the kidneys are the compensating organ.
A client with Leukemia is receiving oral prednisolone (prednisone) An expected side effect of its prolonged use is?
A. Weight loss
B. Decreased appetite
C. Hirsutism
D. Integumentary bronzing
C. Hirsutism
Hirsutism or facial hair is is a side effect of cortisone therapy
A client with diverticulitis has received nutritional discharge instructions for a high fiber diet. Which menu selection by the client would reinforce that the teaching was effective?
A. Spaghetti with meatballs and toast
B. Baked chicken and macaroni with cheese
C. Broccoli chicken stir fry and brown rice
D. Broiled liver and dinner oil
C. Broccoli chicken stir fry and brown rice
Has the highest amount of fiber
A client with metabolic acidosis associated with diabetes mellitus is admitted to the unit. A blood glucose of 250 mg/dl is present. Which symptom will most likely accompany ketoacidosis?
A. Oliguria
B. Polydipsia
C. Perspiration
D. Tremors
B. Polydipsia
A blood glucose level of 250 mg/dl is elevated. Symptoms of hyperglycemia are polyuria, polydipsia and polyphagia. The patient will also have a decreased sensorium and tachypnea
Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy?
A. Take at bedtime
B. Take the medication with juice
C. Report changes in appetite
D. Avoid the sunshine while taking the medication
B. Take the medication with juice
Lugol's solution is a soluble solution of potassium iodine and should be taken with juice because it is bitter to taste
A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
A. Pain is in the left upper quadrant of the abdomen
B. Client reports steatorrhea for the las three days
C. A serum amylase level of 366 U/L
D. Assessed diminished bowel sounds
A. Pain is in the left upper quadrant of the abdomen
An abnormal prothrombin time would receive priority due to the risk of hemorrhage with a liver biopsy.