Acid/Base
Which risk factors exhibited by the client presenting in the emergency department (ED) would place the client at risk for metabolic acidosis? Select all that apply.
A) Diarrhea
B) Chronic obstructive pulmonary disease
C) Pneumonia
D) AKI
E) Hypovolemic shock
A. Diarrhea
D. AKI
E. Hypovolemic shock
The nurse receives a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client should the nurse plan to assess first based on an increased risk for dehydration?
A) A 4-year-old child with a broken leg
B) A 15-month-old child with tachypnea
C) A 16-year-old child with migraine headaches
D) A 10-year-old child with cellulitis of the left leg
B) A 15-month-old child with tachypnea
The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with CKD. Which interventions should the nurse emphasize when planning this client's care? Select all that apply.
A) Monitor B-type natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
E) Monitor intake and output.
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply.
A) Limit exercise to 15 minutes a day
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
D) Wear elastic hose
E) Limit fluid intake
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?
A) Encourage use of nonaffected arm to feed self, bathe, and dress.
B) Speak in normal conversational pattern and tones.
C) Provide complete care.
D) Talk loudly and distinctly.
A) Encourage use of nonaffected arm to feed self, bathe, and dress.
A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets these findings as indicative of which condition?
A) Metabolic acidosis
B) Respiratory alkalosis
C) Respiratory acidosis
D) Metabolic alkalosis
C) Respiratory acidosis
The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare provider prescribes both glucose and insulin for the client. The client's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate?
A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood."
B) "Insulin is safer than other medications that can lower potassium levels."
C) "The insulin lowers his blood sugar levels and causes the extra potassium to be excreted."
D) "The insulin will help his kidneys excrete the extra potassium."
A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood."
What is the most frequent complication during hemodialysis?
A) Hemorrhage
B) Hypotension
C) Infection
D) Hypertension
B) Hypotension
The nurse is documenting assessment findings on a client with angina. Which term should the nurse use to describe chest pain that occurs at night and is unrelated to activity?
A) Nonanginal pain
B) Prinzmetal angina
C) Unstable angina
D) Stable angina
B) Prinzmetal angina
What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus or embolus?
A) Intracerebral stroke
B) Subarachnoid stroke
C) Hemorrhagic stroke
D) Ischemic stroke
D) Ischemic stroke
During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern?
A) Daily ingestion of a banana with breakfast
B) Daily weight consistent
C) Daily use of sodium bicarbonate for gastric upset
D) Daily use of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritic pain
C) Daily use of sodium bicarbonate for gastric upset
Which of the following statements is correct with regard to hypercalcemia?
A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
B) Hypercalcemia is often a result of hyperparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
C) Hypercalcemia is often a result of hypoparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
D) Hypercalcemia is often a result of hypoparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
The nurse is planning care for a client admitted with a diagnosis of heart failure. Based on this diagnosis, which type of kidney failure is the client at an increased risk for experiencing?
A) Prerenal hypovolemia
B) Intrarenal glomerular injury
C) Intrarenal acute tubular necrosis
D) Prerenal low cardiac output
D) Prerenal low cardiac output
The nurse is caring for a client who has had a myocardial infarction. The client states, "I have been smoking for 35 years, what good will quitting do?" Which response is best?
A) "Your risk of continued coronary artery disease will decrease by half when you stop."
B) "Quitting will enhance the effects of your medications."
C) "Your medications will not work if you smoke."
D) "Quitting will ensure you don't develop any complications."
A) "Your risk of continued coronary artery disease will decrease by half when you stop."
The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session?
A) Improve muscle strength
B) Maintain cardiopulmonary function
C) Improve endurance
D) Maintain joint flexibility
D) Maintain joint flexibility
pH 7.49 PaCO2 31 HCO3 25
What is Respiratory alkalosis
The nurse recognizes these as signs/symptoms of hypocalcemia
Tetany, numbness/tingling lips, arrhythmias, increased bowel sounds, excitability
The nurse is preparing to administer a hemodialysis treatment for a client diagnosed with chronic kidney disease (CKD). Which laboratory values should the nurse anticipate prior to the client's treatment? Select all that apply.
A) Increased blood urea nitrogen (BUN)
B) Decreased potassium
C) Decreased phosphorus
D) Increased calcium
E) Increased creatinine
A) Increased blood urea nitrogen (BUN)
E) Increased creatinine
Risk factors unique to women
Early menopause
Oral contraceptive use
The nurse understands interventions/assessment of the stroke client at risk for aspiration includes: (Select all that apply)
A. Client should be upright at 90 degrees when eating
B. Assess the client for coughing, choking
C. Have suction equipment available at the bedside
D. Assess lung sounds q shift and prn
E. Oxygen at 2 liters at all times
The nurse understands interventions/assessment of the stroke client at risk for aspiration includes: (Select all that apply)
A. Client should be upright at 90 degrees when eating
B. Assess the client for coughing, choking
C. Have suction equipment available at the bedside
D. Assess lung sounds q shift and prn
pH 7.33 PaCO2 48 HCO3 23
What is respiratory acidosis?
The nurse recognizes which of the following lab values requiring intervention:
A. Potassium 3.7
B. Calcium 8.6
C. Magnesium 1.5
D. Phosphorus 3.4
C. Magnesium 1.5
A client with a history of hypertension is diagnosed with chronic kidney disease (CKD). When the client asks the nurse how this disease developed, which response by the nurse is the most appropriate?
A) "Thickening of the kidney structures and gradual death of nephrons has led to this diagnosis."
B) "Cysts have compressed your renal tissue and destroyed your kidneys, causing this diagnosis."
C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis."
D) "Immune complexes have formed in your kidney tissue, causing inflammation that has led to this diagnosis."
C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis."
MONA stands for
Morphine
Oxygen
Nitro
Aspirin
Risk factors for stroke
HTN
Heart disease
Diabetes
Sleep apnea
Ethnicity
Elevated cholesterol
Smoking
Substance abuse
Sickle cell