Very Easy
During an assessment of hydration status, the client tells the nurse that she drank 3 quarts of liquids the day before. What should the nurse ask next?
A. Are the liquids hot or cold?
B. How much salt do you add to your food?
C. What kinds of liquids do you usually drink?
D. Do you drink fluids with meals or between meals?
ANS:C
It is just as important to determine the types of fluids ingested as the amount because fluids vary widely in their osmolarity. In addition, some liquids such as those that contain alcohol or caffeine can contribute to fluid and electrolyte imbalances.
ason, a primary school student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two-week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?
A. Respiratory Acidosis, Uncompensated
B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Acidosis, Partially, Compensated
ANSWER: D
RATIONALE: The student was diagnosed with diabetes mellitus. The results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2).
Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
A. Positive Trousseau's sign
B. Positive Chvostek's sign
C. Tetany
D. Paresthesia
ANSWER: A
RATIONALE: In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed.
Dina’s grandmother has been suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?
A. Respiratory Alkalosis, Uncompensated
B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Alkalosis, Partially Compensated
ANSWER: C
RATIONALE: The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.
Miko is found comatose, having taken an unknown number of sleeping pills an unknown time before. An arterial blood sample yields the following values: pH 6.90, HCO3- 13 meq/liter and PaCO2 68 mmHg. This patient's acid-base status is most accurately described as:
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Simultaneous Respiratory and Metabolic Acidosis
D. Respiratory Acidosis with Complete Renal Compensation
ANSWER: C
RATIONALE: Whenever the PCO2 and HCO3 are abnormal in opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base disorder exists. When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist.
Sally is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is:
A. 22 mm Hg
B. 36 mm Hg
C. 48 mm Hg
D. 50 mm Hg
ANSWER: B
RATIONALE: The normal range for PaCO2 is from 35 to 45 mm Hg.
A 6-year-old girl, was rushed to the hospital following her mother's complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.6 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?
A Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
ANSWER: D
RATIONALE: Vomiting, hypokalemia, overdosage of NaHCO3 and NGT suctioning are considered risk factors of metabolic alkalosis
Megan, a mountaineer attempts an assault on a high mountain of Mt. Everest and reaches an altitude of 8,849 meters (29,032 ft) above sea level. What will happen to his arterial PCO2 and pH?
A. Both will be lower than normal.
B. The pH will rise and PCO2 will fall.
C. Both will be higher than normal due to the physical exertion.
D. The pH will fall and PCO2 will rise
ANSWER: B
RATIONALE: The mountaineer will suffer from a respiratory alkalosis. The decline in the PO2 with altitude will stimulate breathing to offset the hypoxia. Carbon dioxide is driven from the blood faster than it is produced in the tissues so PCO2 falls and pH rises.
A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?
A. Administering anti-inflammatory agents as prescribed.
B. Elevating the injured area to decrease venous return to the heart.
C. Keeping the skin clean and dry.
D. Applying warm packs initially to reduce edema.
ANSWER: A
RATIONALE: Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings, subsequently reducing pain. The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect.
A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?
A. Assessing urinary intake and output.
B. Obtaining the client's weight weekly at different times of the day.
C. Monitoring arterial blood gas (ABG) results.
D. Maintaining I.V. therapy at the keep-vein-open rate.
ANSWER: A
RATIONALE: For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. A normal urine output is considered normal not less than 30ml/hour. Concentrated urine denotes fluid deficit.