ADULT HEALTH - GI

Question 1

The nurse is informed in report that her client is at risk for developing hypercalcemia. Which signs and symptoms should the nurse assess the client for? Select all that apply

A. Irritability

B. Hypoactive bowel sounds

C. Decreased deep tendon reflexes

D. Shortened PR interval

Answer 1

Explanation

Answer: B and C

A is incorrect. If the client is at risk for hypercalcemia, the nurse would not monitor for irritability. The neuromuscular symptoms of hypercalcemia are weakness, flaccidity, and decreased deep tendon reflexes. If the client was at risk for hypocalcemia, the nurse would monitor for irritability.

B is correct. Hypoactive bowel sounds is a sign of hypercalcemia that the nurse would monitor for. Hypercalcemic clients have decreased peristalsis leading to hypoactive bowel sounds. This causes abdominal pain, nausea, and constipation.

C is correct. Decreased deep tendon reflexes are a sign of hypercalcemia that the nurse would monitor for. In hypercalcemic clients, everything slows down. The client may experience weakness, flaccidity, and decreased deep tendon reflexes.

D is incorrect. A shortened PR interval would not be observed in hypercalcemia. In hypercalcemia everything slows down - the nurse may note a prolonged PR interval. Other cardiovascular changes could include bradycardia, cyanosis, and deep vein thrombosis.

NCSBN Client Need: Physiological Adaptation

Topic: Fluid & Electrolyte Imbalances

Subject: Adult Health

Lesson: Fluids & Electrolyte

Question 2

The nurse is evaluating her patient’s lab results and notes that the potassium is 5.5 mEq/L. She reviews the telemetry monitor, looking for which of the following signs? Select all that apply.

A. Inverted T waves

B. Widened QRS interval

C. Tall, peaked T waves

D. Prominent U-waves

Answer 2

Explanation

Answer: B and C

A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia. In hyperkalemia, there are Tall, peaked T waves. Inverted T waves is a sign of hypokalemia.

B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes patients may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST segment, and tall, peaked T waves.

C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a very common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart block, ventricular fibrillation, or even asystole if left untreated.

D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia. Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Physiological adaptation

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 3

A 70-year-old client is seen in the outpatient clinic for perineal irritation due to urinary incontinence. Which of the following measures, if suggested to the client by the nurse, is most appropriate? Select all that apply.

A. Use extra-large incontinence briefs to provide for air movement.

B. Apply a generous amount of barrier cream.

C. Gently cleanse the perineum 2 to 3 times per day with warm water and pat dry.

D. Apply Bacitracin cream to the perineum.

E. Ambulate the patient to the bathroom every two hours.

Answer 3

Explanation

Choices B and C are correct. Protecting skin integrity by keeping the skin clean and protected from irritants, such as urine, is the most appropriate teaching.

Choice A is incorrect. Extra-large briefs may not fit well and could cause further irritation by rubbing the skin.

Choice D is incorrect. Bacitracin is an antibiotic cream. The patient in this scenario does not have infected skin, but rather skin irritation.

Choice E is incorrect. Scheduled toileting can help patients who are unable to get out of bed or reach the bathroom alone. The nurse can help ambulate the client to the bathroom every two to four hours. While going to the bathroom every few hours may help overflow incontinence, this answer in option E suggests that the patient such a specific type of incontinence. The question does not specify “overflow” incontinence. There are other types of incontinence (urge incontinence, stress incontinence) which may not be helped by scheduled toileting.
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Basic Care and Comfort
Reference:
Fundamentals of Nursing (Wilkinson/Barnett);Chapter 28: Urinary Elimination;Lesson: Urinary Incontinence

Question 4

When reviewing your client’s labs in the morning, you note that his magnesium level is 3.4 mEq/L. On exam, his reflexes are decreased. Which of the following actions is appropriate? Select all that apply.

A. Administer calcium gluconate.

B. Repeat another level stat and continue monitoring

C. Notify the healthcare provider.

D. Administer Sevelamer hydrochloride.

Answer 4

Explanation

Choices A and C are correct. This magnesium level is critically high and must be addressed immediately. Calcium gluconate is administered as a treatment for hypermagnesemia and is appropriate to deliver as ordered. The healthcare provider should be notified right away. Decreased reflexes, headaches, confusion, and hypotension, may be seen with moderate hypermagnesemia.

B is incorrect. It is not appropriate to repeat another level and simply continue to monitor this patient. The patient is exhibiting symptoms, and magnesium level is critically high and must be addressed immediately.

D is incorrect. Sevelamer hydrochloride is not an appropriate medication in this situation. Sevelamer hydrochloride is a phosphate binder administered for hypocalcemia.

NCSBN Client Need:

Topic: Physiological Integrity; Subtopic: Pharmacological therapies

Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Question 5

The nurse is attending a newly admitted patient with a diagnosis of Hyponatremia.Which of the following should the nurse expect to assess in this patient?

A. Orthostatic hypotension.

B. Blood serum sodium level 148 mEq/L

C. Muscle twitching.

D. Increased thirst.

Answer 5

Explanation

Choice A is correct. The nurse should assess the client for the presence of orthostatic hypotension. Orthostatic hypotension is often seen in association with hyponatremia. The presence of orthostatic hypotension usually indicates hypovolemic status. The nurse must assess the volume status while evaluating a client with hyponatremia because it helps to differentiate between hypovolemic, euvolemic, and hypervolemic hyponatremia. Separating these will help in planning nursing and treatment interventions.

Orthostatic or postural hypotension refers to a significant decrease in systolic blood pressure of greater than 20 mmHg or a reduction of at least ten mmHg in diastolic pressure upon 3 to 5 minutes of standing. Often, it indicates hypovolemia.

Hyponatremia refers to sodium level lower than 135 mEq/L. Hyponatremia may be secondary to several causes; however, it is possible to get clues regarding the cause of hyponatremia by determining the type of Hyponatremia. Sodium and water go together. Sodium tends to draw and keep water with it—the decrease in sodium relative to free water results in hyponatremia.

Hyponatremia is classified into three types:

By knowing the type of hyponatremia, appropriate treatment intervention can be planned.

Hypovolemic Hyponatremia: Correcthypovolemia with Isotonic (0.9%) Normal saline. In severe cases of symptomatic hypovolemic hyponatremia, 3% (hypertonic) saline is used.
Euvolemic Hyponatremia: Ask the client to restrict free water. Physicians may order medications such as demeclocycline or Tolvaptan.
Hypervolemic hyponatremia: Ask the client to restrict free water intake. Diuretics may be administered to clear retained fluid.

Choice B is incorrect. Normal sodium is 135-145 mEq/L. A sodium level of 148 mEq/L would be a result found in hypernatremia (high sodium), not hyponatremia.

Choice C is incorrect. Muscle twitching would be found more commonly in hypernatremia, not Hyponatremia. Muscle twitches are likely due to excess sodium leading to irregular contraction of muscles. Hypernatremia often involves dehydration, and acute hypernatremia may be associated with confusion, muscle twitches, and seizures.

Hyponatremia is typically asymptomatic unless it is acute or severe (<120 mEq/L). A sharp fall in serum sodium may cause a free water shift from the intravascular to the interstitial space, resulting in cerebral edema. In such cases, patients may present with symptoms of increased intracranial pressure such as nausea, vomiting, headache, agitation, lethargy, seizures, coma, or death.

Choice D is incorrect. Increased thirst occurs in hypernatremia due to the body’s attempt to increase fluid intake and balance sodium levels. This is not a common finding in hyponatremia.

Reference: (DiGiulio & Keogh, 2014, p. 407)

Question 6

The nurse is caring for a client with diarrhea and a chloride level of 115 mEq/L. Which medications does the nurse anticipate will be administered? Select all that apply.

A. Sodium Bicarbonate

B. Normal Saline

C. Lactated Ringers

D. Furosemide

E. Bumetanide

Answer 6

Explanation

Choices A and C are correct. This client has hyperchloremia, as their chloride level is 115 mEq/L, above the normal range of 96-106 mEq/L. Before delving into treatment modalities used in hyperchloremia, it is important to consider the frequent causes of hyperchloremia. Some of the common causes of hyperchloremia with proportional decreases in sodium include diarrhea, excessive sweating, nasogastric suction, fluid drainage, prolonged diuresis, third space loss, and hypoaldosteronism.

Client with diarrhea tends to have hyperchloremic metabolic acidosis. Sodium Bicarbonate ( Choice A) decreases the chloride level and is an appropriate choice in patients with severe hyperchloremic acidosis.

Isotonic fluids are often used to restore fluid volume in hypovolemic or dehydrated states. Normal saline and lactated Ringer’s are the two common isotonic IV fluids (same osmotic pressure as blood plasma). Hydration with an isotonic fluid is an essential component in treating hyperchloremia associated with diarrhea. First, however, the appropriate fluid must be chosen. Lactated Ringers ( Choice C) is the appropriate IV fluid for hydration in a client with hyperchloremia. Normal Saline should be avoided to prevent increasing the chloride level further.

Choice B is incorrect. Normal Saline, or 0.9% NaCl ( sodium chloride), contains chloride. Therefore, it would not be appropriate for the nurse to prepare to administer normal saline to this hyperchloremic client. A safer alternative is lactated Ringer’s.

Choices D and E are incorrect. Furosemide and Bumetanide are loop diuretics, often used to treat fluid retention (edema) in congestive heart failure, liver disease, or kidney disorders such as nephrotic syndrome. Loop diuretics often cause hypokalemic metabolic alkalosis that responds to the administration of potassium chloride. While these medications can reduce chloride levels, they can also aggravate the underlying problem of fluid deficits and hypokalemia in a patient with diarrhea. Therefore, these are not appropriate medications to administer to this client.

NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Medication administration

Question 7

The nurse is caring for a female client who is incontinent of urine. The MD orders an indwelling Foley catheter to be placed. Place the following actions in the correct order for the nurse to appropriately insert the Foley catheter:
Spread the labia and hold them open.
Secure the catheter to the patient, and initial the securement device with the date and time.
Cleanse the meatus from front to back on the right side, then left side, and down the center.
Insert the catheter and inflate the balloon.
Perform hand hygiene, identify the patient, explain the procedure to the patient, and prepare the insertion kit using sterile gloves.

Answer 7

Explanation

Answer: B, C, A, D, E

First: the nurse should perform hand hygiene, identify the client using 2 patient identifiers, explain the procedure to the client, and prepare the insertion tray using sterile gloves. Second: The nurse uses her nondominant hand (now dirty) to spread the labia and hold them open. Third: the nurse uses her dominant hand (sterile) to cleanse the meatus from front to back on the right side, then left side, then down the center. Fourth: the nurse will insert the catheter, wait for a urine return, and inflate the balloon. Last: the nurse will secure the catheter to the leg and place their initials, date, and time on the securement device.

NCSBN Client Need:

Topic: Reduction of Risk Potential

Subtopic: Potential for Complications of Diagnostic tests/Treatments/Procedures

Subject: Adult Health

Lesson: Genitourinary

Question 8

The nurse reviews lab values for a client and notes a serum sodium level of 125 mEq/L. The nurse knows that this sodium level could be attributed to which conditions? Select all that apply.

A. SIADH

B. Diabetes Insipidus

C. Addison’s disease

D. Psychogenic polydipsia

Answer 8

Explanation

Answer: A, C, and D

The normal sodium level is 135-145 mEq/L. This patient has a sodium level less than the normal range, and is hyponatremic.

A is correct. SIADH is a condition that can lead to hyponatremia. In SIADH, there is too much ADH. ADH causes water retention, and therefore too much water is retained. There is so much water retained in the vascular space, that the amount of sodium present is relatively less than it was before due to the volume. This is a relative hyponatremia.

B is incorrect. Diabetes Insipidus can lead to hypernatremia, not hyponatremia. In DI, there is not enough secretion of ADH. ADH causes water retention, and without enough of it, not a lot of water is retained. The body excretes massive amounts of clear urine, getting rid of huge amounts of fluid. The blood volume becomes very small, and the amount of sodium left in the blood is relatively large compared to before - thus creating a relative hypernatremia.

C is correct. Addison’s disease can lead to hyponatremia. In Addison’s disease there is decreased aldosterone secretion. Aldosterone functions to facilitate sodium reabsorption in the collecting ducts of the kidney. So, with less aldosterone, there is less sodium reabsorption, leading to less sodium - hyponatremia.

D is correct. Psychogenic polydipsia is a condition that can lead to hyponatremia. In this condition, the client cannot stop drinking water. They drink so much water, that they dilute their blood volume with free water. This large increase in free water causes a relative hyponatremia.

NCSBN Client Need: Physiological Adaptation

Topic: Fluid and Electrolyte Imbalances

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 9

Your client is a patient with low potassium levels and accelerated hypertension. The physician has listed the cause as “hyperaldosteronism.” Which of the following endocrine disorders cause an increased amount of aldosterone? Select all that apply.

A. Cushing’s disease

B. Addison’s disease

C. Conn’s syndrome

D. Pheochromocytoma

Answer 9

Explanation

Choices A and C are correct.

Cushing’s disease (Choice A) is caused by an increased secretion of adrenocorticotropic hormone (ACTH) from the pituitary gland. Increased ACTH causes increased stimulation and hyperplasia of the adrenal cortex. This leads to increased levels of both glucocorticoids(cortisol) and mineralocorticoids(aldosterone). The physician may order ACTH and Cortisol levels to establish the diagnosis of Cushing’s disease. Clinical symptoms include abdominal obesity, moon facies, neck hump, abdominal striae, increased blood glucose, secondary diabetes, hypertension, and Hypokalemia. Other manifestations include Osteoporosis and increased risk of fractures. Clients are prone to increased risk of infections because excess steroids (cortisol) cause immunosuppression.

Cushing’s disease accounts for 65 to 70 percent of all Cushing’s syndrome. Please do not confuse Cushing’s disease with Cushing’s syndrome (Cushing’s syndrome can be ACTH-dependent or ACTH-independent. It includes Cushing’s disease as well as other causes of increased cortisol and non-pituitary causes of increased ACTH. In non-pituitary, ACTH-independent Cushing’s syndrome cases, aldosterone levels may be low instead of high). Another entity called iatrogenic Cushing’s syndrome refers to a condition resulting from prolonged and excessive use of exogenous steroids. This is quite common due to the widespread use of steroids in many autoimmune diseases like Lupus, Rheumatoid arthritis, etc. Iatrogenic Cushing’s is associated with decreased ACTH due to negative feedback on the pituitary gland.

Conn’s disease (choice C), or primary hyper-aldosteronism, is a disease where increased secretion of aldosterone occurs due to hyperplasia or aldosterone-secreting tumors involving the cortex. Please see the adrenal anatomy below to understand the zones of hormone production. Hyperplasia of the entire adrenal cortex would produce both glucocorticoids(cortisol) and mineralocorticoids(aldosterone) whereas, hyperplasia/ tumor of zona glomerulosa alone would cause an increase in aldosterone without affecting cortisol levels. 24-hour urinary aldosterone levels help make the diagnosis of Conn’s syndrome.

The above two conditions (Cushing’s disease and Conns’ syndrome) lead to secondary hypertension because the aldosterone hormone increases sodium and water retention in the body. While retaining sodium, aldosterone causes loss of potassium via the kidneys. Hyperaldosteronism is, therefore, associated with Hypokalemia. Hypertension and Hypokalemia may help the physician suspect hyperaldosteronism.

Choice B is incorrect. Addison’s disease is autoimmune destruction of the adrenal cortex. The resulting adrenal insufficiency would cause low levels of cortisol and aldosterone. There is a reflex increase in ACTH due to feedback from the Adrenal gland. Clinical manifestations of Addison’s disease include fatigue, diarrhea, hyperpigmentation, and hypotension (opposite of hyperaldosteronism). Hypoaldosteronism can be associated with hyperkalemia (elevated potassium levels), hyponatremia (low sodium levels), and mild metabolic acidosis.

Choice D is incorrect. Pheochromocytoma is a tumor of Adrenal Medulla. Since medulla produces catecholamines, cancer involving this area is associated with high levels of Adrenaline and Nor-adrenaline. Adrenal medulla does not produce aldosterone. Therefore, secondary refractory hypertension in Pheochromocytoma is mediated by Catecholamine excess, not by aldosterone excess.

NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Physiological adaptation

Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Question 10

The nurse is caring for a client with a magnesium level of 1.1 mg/dL. Which signs and symptoms does the nurse closely monitor for? Select all that apply.

A. Diarrhea

B. Psychosis

C. Tetany

D. Decreased deep tendon reflexes

E. Cardiac arrhythmias

Answer 10

Explanation

Answer: B, C, and E

A is incorrect. While diarrhea can be an initial cause of hypomagnesemia, it is not an assessment finding indicative of magnesium levels already low. Once the client has low magnesium levels, they have decreased GI motility leading to constipation, not diarrhea.

B is correct. Psychosis is an assessment finding consistent with hypomagnesemia. This client’s magnesium level is below normal, 1.6-2.6 mg/dL, therefore the nurse will need to monitor for potential signs and symptoms of hypomagnesemia. From a neurological perspective this can range from confusion to psychosis.

C is correct. Tetany is another assessment finding consistent with hypomagnesemia for which the nurse should monitor. Other neuromuscular assessment findings consistent with hypomagnesemia, include numbness, tingling, seizures, and increased deep tendon reflexes.

D is incorrect. Decreased deep tendon reflexes is not an assessment finding consistent with hypomagnesemia, rather increased deep tendon reflexes would be. Remember, Magnesium calms the body, so when there are low levels of it the patient will be excitable - seizures, increased reflexes, and psychosis can occur.

E is correct. Cardiac arrhythmias can occur with hypomagnesemia due to alterations in the conductivity of heart muscle.

Question 11

The nurse is assigned the care of a client with a sodium level of 122 mEq/L. Which assessment findings does the nurse anticipate based on this lab result? Select all that apply.

A. Confusion

B. Abdominal cramps

C. Increased urine output

D. Hypoactive bowel sounds

E. Nausea and vomiting

Answer 11

Explanation

Answer: A, B, and E

A is correct. A sodium level of less than 135 mEq/L is indicative of hyponatremia - too little sodium in the blood. When sodium falls below 125 mEq/L, it is considered “severe” hyponatremia. Confusion is a common neurological symptom of acute or severe hyponatremia. Sodium plays a very important role in the brain, and low levels of this electrolyte can be devastating producing symptoms ranging from confusion, lethargy, and stupor, to seizures and cerebral edema

B is correct. Abdominal cramps is another symptom of hyponatremia. Because water follows sodium, when there are decreased levels of sodium in the blood there is decreased fluid. This creased a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping.

C is incorrect. Increased urine output is not a sign of hyponatremia. Decreased urine output rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. This is due to the relationship of sodium with water. With decreased levels of sodium, less water is pulled into the extracellular space and the intravascular volume is decreased causing decreased renal blood flow and therefore decreased urine output.

D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium plays an important role in muscle cells as well, and when levels are too low there is cramping, spasms, and hyperactive bowel sounds.

E is correct. Nausea and vomiting are common signs of low sodium levels in the blood or hyponatremia.

NCSBN Client Need: Physiological Adaptation

Topic: Fluid and Electrolyte Imbalances

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 12

The nurse is caring for an 82 year old male in end stage renal failure. Upon assessment, she notes dyspnea, and when auscultating his lungs hears crackles and rales. Which of the following signs and symptoms does she also expect? Select all that apply.

A. Distended neck veins

B. Weight gain

C. Bounding pulses

D. Hypotension

Answer 12

Explanation

Answer: A, B, and C

A is correct. A patient in end stage renal failure often experiences fluid volume excess due to their kidney dysfunction. The kidneys are unable to concentrate urine as they should, and therefore large volumes of fluid are retained causing a fluid volume excess. The nurse has appreciated dyspnea, rales, and crackles on her assessment, which are all signs of fluid volume excess due to increased fluid in the lungs. Distended neck veins are another sign of fluid volume excess she would expect to find. With the increased fluid volumes, veins of the neck appear distended. This can also be appreciated in the veins on the back of the hands.

B is correct. Weight gain is another sign of fluid volume excess that the nurse would expect to find. Due to fluid accumulation with end stage renal failure, large amounts of weight can be gained due to fluid.

C is correct. Bounding pulses are another sign of fluid volume excess that the nurse would expect to find. Due to fluid retention that occurs in end stage renal failure, there are larger than normal quantities of fluid in the vascular system leading to bounding pulses.

D is incorrect. Hypotension would not be expected in a patient with fluid volume excess. Where there are larger than normal volumes of fluid in the vascular system the patient is more likely to experience hypertension.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Basic care, comfort

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 13

The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL. What does the nurse surmise could be the underlying cause of this electrolyte abnormality? Select all that apply.

A. Renal failure

B. Alcoholism

C. Anorexia

D. Diarrhea

E. Hypothyroidism

Answer 13

Explanation

Answer: A

A is correct. The normal magnesium level is 1.6-2.6 mg/dL. This patient has a level of 3.2, and is experiencing hypermagnesemia. Renal failure can cause hypermagnesemia due to the fact that the process that keeps the levels of magnesium in the body at normal levels does not work properly in people with kidney dysfunction.

B is incorrect. Alcoholism is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. Hypomagnesemia is the most common electrolyte abnormality observed in alcoholic patients. There is a loss of magnesium from tissues and increased urinary loss, and chronic alcohol abuse depletes the total body supply of magnesium.

C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. This is due to malnutrition and a lack of dietary intake of magnesium.

D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. Magnesium is absorbed in the GI tract, and with diarrhea there is decreased absorption of magnesium leading to hypomagnesemia.

E is correct. Hypothyroidism is a risk factor for hypermagnesemia.

NCSBN Client Need: Reduction of Risk Potential

Question 14

The nurse is assigned to care for a client with a chloride level of 90 mEq/L. The nurse identifies which of the following as reasons for this electrolyte imbalance? Select all that apply.

A. Fluid volume excess

B. Metabolic acidosis

C. Vomiting

D. Constipation

E. Congestive heart failure

Answer 14

Explanation

Answer: A and C

A is correct. The normal level for chloride is 96-108 mEq/L. Since this client has a level of 90 mEq/L, which is below the normal range, they are experiencing hypochloremia. Fluid volume excess is a cause of hypochloremia. This is due to a dilutional effect. There is not actually less chloride in the blood, but because there is increased fluid volume, there is a dilutional effect causing a relative hypochloremia.

B is incorrect. Metabolic acidosis is not a cause of hypochloremia. Metabolic alkalosis instead can cause hypochloremia.

C is correct. Vomiting is a common cause of hypochloremia. The stomach acid is hydrochloric acid, or HCl. This acid contains large amounts of chloride, and when the client vomits and loses stomach acid, they lose chloride causing hypochloremia. This loss of HCl also causes metabolic alkalosis.

D is incorrect. Constipation does not cause hypochloremia. Diarrhea can cause hypochloremia due to excessive loss of gastrointestinal contents that contain chloride.

NCSBN Client Need: Reduction of Risk Potential

Topic: Laboratory Values

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 15

The nurse is assigned to care for a client with hypophosphatemia. Which complications of this electrolyte imbalance should the nurse assess for in the client? Select All That Apply.

A. Rhabdomyolysis

B. Seizures

C. Osteopenia

D. Fractures

E. Arrhythmias

Answer 15

Explanation

Choices A, B, C, D and E are correct.

A is correct. Rhabdomyolysis is a serious complication of hypophosphatemia. When a client is suffering from severe hypophosphatemia, the available phosphorus is used to generate ATP. Consequently, the muscle cells are unable to maintain membrane integrity, and rhabdomyolysis can form.

B is correct. Seizures are a serious complication of hypophosphatemia. This only occurs with very severe, or acute, hypophosphatemia where there is neurologic instability. Other findings can include numbness and reflexive weakness.

C is correct. Osteopenia is a serious complication of hypophosphatemia. This is because hypophosphatemia leads to incomplete bone mineralization and, therefore, over time, can cause osteopenia if it goes untreated.

D is correct. Fractures are a serious complication of hypophosphatemia. This is because hypophosphatemia leads to incomplete bone mineralization, which can cause fractures to clients’ bones under normal stress.

E is correct. Arrhythmias are a serious complication hypophosphatemia. This is because hypophosphatemia can lead to muscle damage in the heart.

NCSBN Client Need: Reduction of Risk Potential

Topic: Potential for Alterations in Body Systems

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 16

The nurse is reviewing the concept of third spacing with a new graduate nurse. She reviews which of the following conditions that put patients at risk for the development of third-spacing? Select all that apply.

A. Burns

B. Gastroenteritis

C. Pediatric patients

D. Alcoholism

Answer 16

Explanation

Answer: A and D

A is correct. Burns are a major cause of third-spacing. In third-spacing, fluid shifts into the interstitial space and remains there. This occurs in burns due to an increased capillary membrane permeability of the injured tissue.

B is incorrect. Gastroenteritis is not a cause of third-spacing. This is a gastrointestinal illness that can cause severe vomiting and diarrhea, but there is no tissue injury leading to third-spacing. Examples of risk factors for third-spacing are kidney disease, major trauma, burns, and sepsis.

C is incorrect. Pediatric patients are not more at risk for the development of third-spacing. Geriatric patients on the other hand are indeed at a higher risk for the development of third-spacing into their abdomen, pleural cavity, peritoneal cavity, and pericardial sac when injury occurs to these tissues.

D is correct. Alcoholism does in fact put patients at risk for the development of third-spacing. When injury occurs to the tissue of a patient with chronic alcoholism, they are more likely to develop third spacing into their abdomen, pleural cavity, peritoneal cavity, and pericardial sac when injury occurs to these tissues. This fluid is then useless, because it is not circulating and is unable to provide nutrients to the cells.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 17

The nurse is reviewing dietary teaching with a client who has hypercalcemia. Which foods should the nurse recommend the client avoid? Select all that apply.

A. Broccoli

B. 2% milk

C. Whole wheat pasta

D. Bananas

E. Seafood

Answer 17

Explanation

Answers: A, B, and E

Choices A and B are correct. Hypercalcemia can occur in various conditions such as primary hyperparathyroidism, malignancies, milk-alkali syndrome, medications, vitamin D toxicity, and sarcoidosis. Symptomatic hypercalcemia can lead to constipation, psychosis, polyuria, and dehydration. Clients with hypercalcemia should take some dietary precautions to reduce calcium intake. Broccoli is rich in calcium. It should therefore be avoided in clients with hypercalcemia. Milk is rich in calcium and should therefore be avoided in clients with hypercalcemia.

Choices C and D are incorrect. Whole wheat pasta is not a calcium-rich food. Bananas are particularly high in potassium, not calcium. The nurse does not need to instruct the client with hypercalcemia to avoid whole wheat pasta or bananas.

Choice E is also correct. Vitamin D is one substance that, along with parathyroid hormones, regulates a person’s calcium levels. Several kinds of seafood are rich in Vitamin D and should be avoided if hypercalcemia is a concern

Client Need: Physiological Integrity

Topic: Basic Care & Comfort

Subtopic: Nutrition and Oral Hydration

Lesson: Fluids & Electrolytes

Question 18

The nurse is reviewing clients laboratory findings and notes that one client has a serum calcium level of 7.2 mg/dL. The nurse knows which of the following clients are most likely to have this lab result? Select all that apply.

A. The patient with breast cancer and bone metastases

B. The patient with obesity

C. The patient with Vitamin D toxicity

D. The patient with hypoparathyroidism

E. Patient with chronic renal failure

Answer 18

Explanation

Answer: D and E

A is incorrect. The client with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to bone destruction from osteoclasts and the leak of calcium into blood. In addition, malignancies often cause “paraneoplastic hypercalcemia” by secreting substances called “PTH-related peptides” that have actions similar to Parathormone ( PTH).

B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in celiac and crohn’s disease patients, can cause hypocalcemia due to decreased absorption, but obesity would not cause this.

C is incorrect. The patient with Vitamin D toxicity would put a client at risk for hypercalcemia, or a serum calcium level greater than 10.2 mg/dL. This is due to the relationship between Vitamin D and calcium; Vitamin D enhances the absorption of calcium. Therefore, Vitamin D toxicity would lead to increased absorption of calcium and a hypercalcemic state.

D is correct. The client with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 8.4-10.2 mg/dL, so with this client’s level of 7.2 they have too little calcium in the blood. The client who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels, or hypocalcemia.

E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for hypocalcemia in kidney disease: increased phosphorus and decreased renal production of activated Vitamin D (1,25 Dihydroxy vitamin D). Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues and bones, causing hypocalcemia. The kidney is responsible for activating Vitamin D and restoring calcium balance. In the setting of renal diseases, one loses the capacity to activate vitamin D and calcium level drops. For these reasons, physicians often order phosphate binders to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/ ESRD.

NCSBN Client Need:

Topic: Reduction of Risk Potential

Subtopic: Diagnostic Tests

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 19

The nurse is caring for a client with a phosphorus level of 5.3 mg/dL. The nurse identifies which of the following as possible causes of this condition? Select all that apply.

A. Tumor lysis syndrome

B. Hypoparathyroidism

C. Hypercalcemia

D. Renal failure

E. Anorexia

Answer 19

Explanation

Choices A, B, and D are correct.

A is correct. This client has a phosphorus level of 5.3, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including phosphorus) are spilled out into the blood causing an increase in their serum levels.

B is correct. Hypoparathyroidism is a cause of hyperphosphatemia. The client who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels or hypocalcemia. Because calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus. Thus, hypoparathyroidism causes hyperphosphatemia.

C is incorrect. Hypercalcemia is a cause of hypophosphatemia. This client has a phosphorus level of 5.3, which is greater than the normal 3.0-4.5 mg/dL, not less than. Phosphorus and calcium have an inverse relationship, when there are high levels of calcium there are low levels of phosphorus. Thus, hypercalcemia would cause hypophosphatemia.

D is correct. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be excreted as readily as it normally would, and increased levels of phosphorus build up in the blood causing hyperphosphatemia.

E is incorrect. Anorexia is a cause of hypophosphatemia due to poor dietary intake.

Question 20

The nurse is reviewing the results of her patient’s basic metabolic panel and notes a potassium level of 5.7 mEq/L. She knows that which of the following conditions could cause this result? Select all that apply.

A. Cushing’s disease

B. Continuous NG tube suction

C. Severe dehydration

D. Hyperinsulinism

Answer 20

Explanation

Answer: C

The normal level for potassium is 3.5 to 5. This patient has a potassium level of 5.7, indicating hyperkalemia.

A is incorrect. Cushing’s disease is likely to cause hypokalemia, not hyperkalemia. In this disease the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting patients with Cushing’s disease at risk for excessive potassium losses leading to hypokalemia.

B is incorrect. The patient with an NG tube to continuous suction is likely to experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the patient becomes hypokalemic.

C is correct. Severe dehydration is a potential cause of hyperkalemia. When a patient is severely dehydrated (from vomiting, diarrhea, profuse sweating, etc.), potassium is lost and large amounts of fluid are lost. While this patient is experiencing a fluid volume deficit, the concentration of potassium in their blood is elevated, which is why they are hyperkalemic.

D is incorrect. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin is a hormone secreted by the pancreas that facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells and the serum potassium level drops causing hypokalemia.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Physiological adaptation

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 21

A client with benign prostatic hyperplasia is post-operative from transurethral resection of the prostate and is now on continuous bladder irrigation. On assessment, the nurse notes that the drainage from the catheter has stopped. Which intervention is most appropriate?

A. Reinsert a new catheter

B. Increase the infusion rate of the irrigation

C. Attempt to dislodge a clot

D. Contact the urologis

Answer 21

Explanation

Choice C is correct. Initially, the nurse should inspect the catheter for a possible clot.

If present, the nurse may remove the clot by either gentle aspiration of the lump or irrigation through the out-port.

Choices A, B, and D are incorrect. It is not necessary to replace the apparatus at this point. Increasing the flow may lead to bladder distention and pain. The nurse should not contact the physician without exhausting independent intervention first.

Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 22

The nurse is assisting in the placement of an indwelling Foley catheter in a male patient. The nurse knows to inflate the balloon on the catheter at which step in the procedure?

A. Upon meeting resistance

B. As soon as urine is observed in the tubing

C. After advancing to the point of bifurcation

D. After fully advancing the length of the catheter

Answer 22

Explanation

Answer: C

A is incorrect. It is not appropriate to inflate the balloon on the catheter upon meeting resistance. In a male client, this could cause serious trauma to the urethra. The nurse must ensure that the catheter is fully inside the bladder before the balloon is inflated.

B is incorrect. It is not appropriate to inflate the balloon on the catheter as soon as urine is observed in the tubing. The catheter will not be fully in the bladder as soon as urine is observed, and inflating the balloon at this point would cause trauma.

C is correct. The nurse should inflate the balloon on the catheter once she reaches the point of bifurcation. This is achieved by slowly advancing the catheter, observing the tubing for urine to appear, and then continuing to advance to the point of bifurcation after urine is observed. This will ensure the balloon is in the bladder before the nurse inflates it.

D is incorrect. It is not appropriate to fully advance the length of the catheter in every client. The length of the urethra and distance to the bladder will vary, and therefore the catheter will be advanced different lengths depending on the client. Fully advancing the catheter could result in an excessive length of the catheter sitting in the bladder, which can cause pain and irritation to the client.

NCSBN Client Need:

Topic: Reduction of Risk Potential

Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures

Question 23

Which risk factor relating to fluid and electrolyte imbalances is accurately paired with its specific fluid or electrolyte disorder? Select all that apply.

A. Hypermagnesemia: Alcoholism

B. Hypomagnesemia: Cushing’s syndrome

C. Hyperkalemia: Renal failure

D. Hypokalemia: Hypomagnesemia

E. Hypernatremia: Dehydration

F. Hyponatremia: Diarrhea

G. Hypercalcemia: Hypoparathyroidism

H. Hypocalcemia: Hypomagnesemia

Answer 23

Explanation

Choices C, D, E, F, and H are correct.

The risk factors/causes of fluid and electrolyte imbalances that are paired accurately are:

Hyperkalemia: Renal failure (Choice C) is correct. Hyperkalemia is a common finding seen in renal failure and may be life-threatening. Adequate kidney function is necessary to excrete potassium. End-stage renal disease (ESRD) is often characterized by hyperkalemia, fluid overload, metabolic acidosis, and pulmonary congestion. Dialysis is indicated in ESRD to eliminate excess fluid, excess acid, and excess potassium.

Hypokalemia: Hypomagnesemia (Choice D) and Hypocalcemia: Hypomagnesemia (Choice H) are correct. Hypomagnesemia is often associated with hypokalemia and hypocalcemia. Untreated hypomagnesemia may lead to treatment-refractory hypokalemia. The mechanism for hypomagnesemia-induced hypokalemia involves increased urinary potassium wasting via collecting duct cells due to a reduction in intracellular magnesium.

Hypomagnesemia can also cause hypocalcemia. Magnesium is necessary for the production and release of parathyroid hormone. Magnesium deficiency results in decreased production of parathyroid hormone and consequently, secondary hypocalcemia.

It is important to always look for and correct hypomagnesemia when treating hypokalemia, and hypocalcemia.

Hypernatremia: Dehydration (Choice E) is correct. Dehydration results in loss of free water more than the sodium and often, causes hypovolemic hypernatremia. Hypernatremia increases serum osmolality. Increased osmolality triggers Anti-Diuretic Hormone (ADH) release. ADH helps the body to conserve water and concentrates the urine.

Hyponatremia: Chronic Diarrhea (Choice F) is correct. Hypovolemic hyponatremia can occur with chronic diarrhea or persistent nausea/ vomiting. Chronic diarrhea results in loss of sodium and water. Ensuing decreased intravascular fluid volume triggers ADH release. ADH causes kidneys to retain free water further aggravating hyponatremia.

Choice A is incorrect. Alcoholism leads to hypomagnesemia, not hypermagnesemia. Hypermagnesemia is an uncommon electrolyte imbalance. Risk factors/ causes of hypermagnesemia include renal failure, adrenal insufficiency (Addison’s disease), hypothyroidism, drugs like Lithium, and increased intake of magnesium salts/ magnesium-containing laxatives.

Choice B is incorrect. A risk factor that is associated with hypomagnesemia is alcoholism, not Cushing’s syndrome. Other risk factors of hypomagnesemia include refeeding syndrome, diuretic use, and proton pump inhibitor (PPI) use.

Choice G is incorrect. Hypoparathyroidism causes hypocalcemia, not hypercalcemia. Decreased parathyroid hormone (PTH) results in decreased calcium and increased phosphorous.

Some risk factors/ causes associated with hypercalcemia include hyperparathyroidism, thiazide diuretics, malignancy (myeloma, metastatic cancer), milk-alkali syndrome, vitamin d toxicity, and sarcoidosis.

Reference:
Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 24

The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone Secretion. Does the nurse know that which of the following nursing actions is the most important?

A. Assess the patient’s mental status

B. Provide oral hygiene

C. Keep accurate intake and output measurements

D. Reduce stress and discomfort

Answer 24

Explanation

Choice A is correct. When caring for a patient with SIADH, the nurse should carefully monitor for changes in mental status and level of consciousness. SIADH causes excess free water retention and hyponatremia, which may lead to confusion and behavioral changes. These alterations in the mental state may also lead to seizures. Patients with SIADH may also experience cardiac dysrhythmias.

Choice B is incorrect. Nurses should always assist their patients in caring for their oral hygiene, especially when suffering from SIADH. However, providing oral health is not the priority nursing intervention in this situation.

Choice C is incorrect. SIADH creates alterations in a patient’s fluid and electrolyte balance, and thus nurses must keep accurate accounts of all intake and outputs. However, monitoring the patient’s mental status is more important.

Choice D is incorrect. While reducing pain and stress is an essential part of nursing care, monitoring a patient with SIADH for mental status and LOC changes is of higher priority.

NCSBN client need |Topic: Physiologic Adaptation, Illness management
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co

Question 25

The nurse is reviewing a client’s chart and notes that the physician mentioned “increased ADH” in his note. For which of the following conditions might a patient’s Anti-Diuretic hormone (ADH) level be increased?

A. Nephrogenic Diabetes Insipidus

B. Type I Diabetes Mellitus

C. Hypopituitarism

D. Primary Hyperthyroidism

Answer 25

Explanation

The Correct Answer is A. ADH ( Anti-Diuretic Hormone) level is increased in the client with nephrogenic diabetes insipidus. Here, the pathology lies in the kidney. ADH level is abnormal or increased. This is in contrast to “Neurogenic” ( Central) Diabetes Insipdus, which results from decreased production of ADH from the pituitary.

ADH is a hormone that regulates water balance. Increased ADH resulted in increased thirst and increased free water retention. A combination of these two factors leads to dilutional hyponatremia. Decreased ADH leads to reduced appetite and urinary loss of open water ( polyuria). A combination of decreased thirst and polyuria leads to Hypernatremia.

“Nephrogenic” diabetes insipidus is a condition where the renal collecting tubules have diminished responsiveness to ADH. The pituitary function is normal. Decreased responsiveness of collecting tubules leads to a reflex increase in ADH levels.

ADH levels are also inappropriately increased in SIADH ( Syndrome of Inappropriate Anti-Diuretic Hormone). While SIADH can lead to hyponatremia by retention of free water, diabetes insipidus lead to Hypernatremia by loss of excessive open water.

Choice B is incorrect. Type I Diabetes mellitus is associated with decreased insulin levels. Hyperglycemia can manifest with “Polyuria” due to glucose-induced osmotic diuresis, and it has nothing to do with ADH regulation.

Choice C is incorrect. Hypopituitarism ( decreased pituitary function) is expected to cause reduced ADH levels and can lead to “neurogenic” or “Central” Diabetes Insipidus.

Choice D is incorrect. Primary Hyperthyroidism resulted in increased thyroid hormone ( Thyroxine) and decreased TSH (Thyroid Stimulating Hormone) level. It does not affect ADH. Untreated Hypothyroidism, however, may lead to SIADH ( increased ADH level).

NCSBN Client Need

Topic: Physiological Adaptation; Subtopic: Reduction of Risk Potential

Reference: Fundamentals of Nursing

Question 26

Your client is being scheduled for cardiac catheterization. His medications include Amlodipine for hypertension and Metformin for diabetes. Which of the following is/are essential nursing intervention(s) for the client before he proceeds to cardiac catheterization? Select all that apply.

A. Verify if the client has any allergies.

B. Check client’s Blood Urea Nitrogen (BUN) and Creatinine.

C. Hold the client’s Metformin.

D. Administer Acetaminophen.

Answer 26

Explanation

Choices A, B, and C are correct. It is essential to verify if a patient has any allergies before a procedure. This is true with any system, as one must know if there are medications that are unsafe to administer to the patient. But, it is an especially important step for a cardiac catheterization to make sure the patient is not allergic to iodinebecause an iodine-based dye is used during cardiac catheterization to visualize the vessels. Should you discover that the patient is allergic to iodine, contact the health care provider immediately, and do not administer the dye. Physicians may order diphenhydramine and prednisone protocol to minimize the risk of allergy with the iodinated contrast.

Checking the patient’s Blood Urea Nitrogen and Creatinine (Choice B) is essential before cardiac catheterization. Contrast-induced nephropathy (contrast-induced acute tubular necrosis) is a condition where the iodinated contrast damages renal tubules. Clients with pre-existing renal insufficiency are more prone to comparison associated renal damage. Therefore, it is crucial to make sure the client’s renal function is not too low before a contrast agent is given. If the client’s renal function is small, the physician may order intravenous hydration before the procedure to minimize the chances of renal damage.

Metformin (Choice C) can cause lactic acidosis in patients with chronic renal failure and acute kidney injury. Because severe kidney injury is a possibility with iodinated contrast, the FDA recommends holding Metformin on the day of administration of contrast and 48 hours after.

Choice D is incorrect. Acetaminophen is not usually prescribed for patients before cardiac catheterization. It does not minimize the risk of contrast-induced nephropathy. The most useful strategy to decrease the risk of contrast-induced neuropathy in those with baseline chronic kidney disease is per-procedural hydration. This is accomplished by initiating intravenous (IV) fluid with 0.9% normal saline at 1 ml/kg/hr for six to 12 hours before the procedure and continuing after the process.

NCSBN Client Need:
Topic: Reduction of Risk potential

Reference: DeWit, S. C., Stromberg, H., & Dallred, C. Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Question 27

Which of the following patients should the nurse screen for possible urinary retention? Select All That Apply.

A. A 78-year-old man diagnosed with an enlarged prostate.

B. An 83-year-old woman on bed rest.

C. A 75-year-old woman with vaginal prolapse.

D. An 89-year-old man patient with dementia.

E. A 73-year-old woman on antihistamines to treat allergies.

F. A 90-year-old man with difficulty walking to the restroom.

G. An 80-year-old African American man with benign prostate hyperplasia, on prazosin.

Answer 27

Explanation

Choices A, C, and E are correct. Urinary retention occurs when urine is produced normally but is not entirely emptied from the bladder. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman) or from the use of medications with anticholinergic side effects.

The bladder muscle (detrusor smooth muscle) ‘s primary function is to “contract” and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function. Therefore, urinary retention has been described with the use of drugs with anticholinergic activity.

Calcium channel blockers can also lead to urinary retention by directly impairing the contractility of the detrusor muscle. Excessive urinary retention eventually results in “overflow” incontinence.

Choices B, D, F, and G are incorrect. All these answer options (immobility, dementia, walking difficulty, alpha-adrenergic blockers) may place the patients at risk for urinary incontinence, not urinary retention.

Patients with benign prostatic hypertrophy are often placed on alpha-adrenergic agonists like prazosin, doxazosin, or terazosin to facilitate bladder emptying (Choice G). However, one predominant side effect of these drugs is urinary incontinence, not retention. A study found that alpha-blockers increased the risk of urinary incontinence in older African American men by fivefold. In the normal setting, stimulation of alpha-adrenergic receptors causes bladder outlet resistance. Blocking these alpha-adrenergic receptors with medications (prazosin) leads to decreased bladder outlet resistance and, accordingly, to incontinence.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Basic Care and Comfort
Reference
The Art and Science of Person-Centered Nursing Care (Wolters/Klewer); Chapter 36: Urinary Elimination; Lesson: Frequency of Urination`

Question 28

The nurse is caring for a client who latest lab results show a serum calcium level of 13.2 mg/dL. Which medication does the nurse expect to administer based on this lab result? Select all that apply.

A. Phosphorus

B. Calcitonin

C. Vitamin D

D. IV calcium gluconate

E. IV Bisphosphonates

Answer 28

Explanation

Answer: A, B and E

A is correct. The normal serum calcium level is 8.4-10.2 mg/dL. This client has a high serum calcium level, or hypercalcemia. Phosphorus is a medication the nurse would expect to administer to treat hypercalcemia. Phosphorus and calcium have an inverse relationship, so by increasing the serum level of phosphorus the nurse can decrease the serum level of calcium. Oral phosphate is the preferred method of administering phosphorus. If given IV, Calcium Phosphate forms and precipitates in the tissues. This “precipitation phenomenon” reduces serum calcium levels very quickly.

B is correct. Calcitonin is a medication the nurse would expect to administer to treat hypercalcemia. Calcitonin is a thyroid hormone that decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

C is incorrect. Vitamin D should be avoided in hypercalcemia. Vitamin D enhances the absorption of calcium and can therefore increase the level of serum calcium, which we do not want to do when the client’s level already high.

D is incorrect. IV calcium gluconate is given to patients that are hypocalcemic, not hypercalcemic. It can treat the tetany that occurs when a client is severely hypocalcemic. It can also be given to protect the cardiac muscle if a client has severe hyperkalemia or hypermagnesemia.

E is correct. Bisphosphinates are intravenous osteoporosis drugs which can quickly lower calcium levels, and are often used to treat hypercalcemia due to cancer.

NCSBN Client Need: Pharmacological and Parenteral therapies

Topic: Expected Actions/Outcomes

Subject: Medication administration

Lesson: Fluids & Electrolytes