Ch. 18- NCLEX Saunders Book Ch. 8 & 9 Flashcards
8-1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
a. Weight loss and dry skin
b. Flat neck and hand veins and decreased urine output
c. An increase in blood pressure and increased respirations
d. Weakness and decreased central venous pressure
(CVP)
c. An increase in blood pressure and increased respirations
8-2. The nurse reviews a client’s record and understands that the client is at risk for developing a potassium deficit if which situation is documented?
Laboratory Results
-Tests and Results-
Uric acid 9.4 mg/dL
Potassium 3.2 mEq/L
-Reference Range-
2.7-8.5 mg/dL
3.5-5.0 mEq/L
a. Sustained tissue damage
b. Requires nasogastric suction
c. Uric acid level of 9.4 mg/dL
d. Has a history of Addison’s disease
b. Requires nasogastric suction
8-3. The nurse reviews the electrolyte laboratory results for a client with heart failure taking furosemide. Which patterns would the nurse watch for on the electrocardiogram (ECG) based on the laboratory results? (Select all that apply.)
Laboratory Results
-Tests and Result-
Potassium 2.5 mEq/L
Sodium 140 mEq/L
-Reference Range-
3.5-5.0 mEq/L
135-145 mEq/L
a. U waves
b. Absent P waves
c. Inverted T waves
d. Depressed ST segment
e. Widened QRS complex
a. U waves
c. Inverted T waves
d. Depressed ST segment
8-4. Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia.
Which actions would the nurse take to assist the RN with preparation and administration of the potassium? (Select all that apply.)
a. Obtain an intravenous (IV) infusion pump.
b. Monitor urine output during administration.
c. Monitor the IV site for signs of infiltration or phlebitis.
d. Explain to the client that the medication is given by IV push.
e. Ensure that the bag is labeled with the volume of potassium in the solution.
a. Obtain an intravenous (IV) infusion pump.
b. Monitor urine output during administration.
c. Monitor the IV site for signs of infiltration or phlebitis.
e. Ensure that the bag is labeled with the volume of potassium in the solution.
8-5. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
a. Twitching
b. Hypoactive bowel sounds
c. Negative Trousseau’s sign
d. Hypoactive deep tendon reflexes
a. Twitching
8-6. The nurse is caring for a client with Crohn’s disease who has a calcium level of 8 mg/dL. Which patterns would the nurse watch for on the electrocardiogram? (Select all that apply.)
Laboratory Results
-Test and Result-
Calcium 8 mg/dL
-Reference Range-
9-10.5 mg/dL
a. Peaked T wave
b. Widened T wave
c. Prominent U wave
d. Prolonged QT interval
e. Prolonged ST segment
d. Prolonged ST segment
e. Widened QRS complexes
8-7. The nurse reviews the electrolyte results of a client with chronic kidney disease. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory values? (Select all that apply.)
Laboratory Results
-Tests and Results-
Potassium 5.7 mEq/L
Sodium 132 mEq/L
-Reference Range-
3.5-5.0 mEq/L
135-145 mEq/L
a. ST depression
b. Prominent U wave
c. Tall peaked T waves
d. Prolonged ST segment
e. Widened QRS complexes
c. Tall peaked T waves
e. Widened QRS complexes
8-8. Which client is at risk for the development of a sodium level at 130 mEq/L?
Laboratory Results
-Test and Result-
Sodium 130 mEq/L
-Reference Range-
135-145 mEq/L
a. The client who is taking diuretics
b. The client with hyperaldosteronism
c. The client with Cushing’s syndrome
d. The client who is taking corticosteroids
a. The client who is taking diuretics
8-9. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. When assisting with assessment, the nurse notes that the client has flat neck veins, generalized muscle weak-ness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia?
a. Muscle twitches
b. Decreased urine output
c. Hyperactive bowel sounds
d. Increased specific gravity of the urine
c. Hyperactive bowel sounds
8-10. The nurse reviews a client’s laboratory report and notes that the clients serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?
Laboratory Results
-Test and Result-
Phosphorus 1.8 mg/dL
-Reference Range-
3.0-4.5 mg/dL
a. Malnutrition
b. Renal insufficiency
c. Hypoparathyroidism
d. Tumor lysis syndrome
a. Malnutrition
8-11. The nurse is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800 mL daily.” The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion?
a. Urine output
b. Wound drainage
c. Integumentary output
d. The gastrointestinal tract
c. Integumentary output
8-12. The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
a. A client with an ileostomy
b. A client with heart failure
c. A client on long-term corticosteroid therapy
d. A client receiving frequent wound irrigations
a. A client with an ileostomy
8-13. The nurse assisting in caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
a. Weight loss and poor skin turgor
b. Lung congestion and increased heart rate
c. Decreased hematocrit and increased urine output
d. Increased respirations and increased blood pressure
a. Weight loss and poor skin turgor
8-14. On review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess?
a. The client taking diuretics who has tenting of the skin
b. The client with an ileostomy from a recent abdominal surgery
c. The client who requires intermittent gastrointestinal suctioning
d. The client with kidney disease that developed as a complication of diabetes mellitus
d. The client with kidney disease that developed as a complication of diabetes mellitus
8-15. Which client is at risk for the development of a potassium level of 5.5 mEq/L?
Laboratory Results
-Test and Result-
Potassium 5.5 mEq/L
-Reference Range-
3.5-5.0 mEq/L
a. The client with colitis
b. The client with Cushing’s syndrome
c. The client who has been overusing laxatives
d. The client who has sustained a traumatic burn
d. The client who has sustained a traumatic burn
9-1. The nurse is informed of the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCOz of 20 mEq/L. The nurse analyzes these results as indicating which condition?
Laboratory Results
-Tests and Results-
рН 7.45
Pco2 30 mm Hg
HCO, 20 mEq/L
-Reference Range-
7.35-7.45
35-45 mm Hg
21-28 mEq/L
a. Metabolic acidosis, compensated
b. Respiratory alkalosis, compensated
c. Metabolic alkalosis, uncompensated
d. Respiratory acidosis, uncompensated
b. Respiratory alkalosis, compensated
9-2. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
b. Metabolic alkalosis
9-3. A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse is informed of the results and expects to note which finding?
a. A decreased pH and an increased Pco2
b. An increased pH and a decreased Pco2
c. A decreased pH and a decreased HCO3-
d. An increased pH and an increased HCO3-
d. An increased pH and an increased HCO3-
9-4. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Po2 = 72 mm Hg, Pco2 = 32 mm Hg, and HCO3 = 28 mEq/L. Which conclusion about the client would the nurse make?
-Tests and Results-
pH 7.53
Pco2 32 mm Hg
Poz 72 mm Hg
HCO3 28 mEq/L
-Reference Range-
7.35-7.45
35-45 mm Hg
80-100 mm Hg
21-28 mEq/L
a. The client has acidotic blood.
b. The client is probably overreacting.
c. The client is fluid volume overloaded.
d. The client is probably hyperventilating.
d. The client is probably hyperventilating.
9-5. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Which patterns did the nurse observe? (Select all that apply.)
a. Respirations that are shallow
b. Respirations that are increased in rate
c. Respirations that are abnormally slow
d. Respirations that are abnormally deep
e. Respirations that cease for several seconds
b. Respirations that are increased in rate
d. Respirations that are abnormally deep
9-6. A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Pcoz is 90 mm Hg, and HCO3 is 22 mEq/L . The nurse recognizes the results as indicating which condition?
Laboratory Results
-Tests and Results-
pH 7.12
Pco2 90 mm Hg
HCO3 22mEq/L
-Reference Range-
7.35-7.45
35-45 mm Hg
21-28 mEq/L
a. Metabolic acidosis with compensation
b. Respiratory acidosis with compensation
c. Metabolic acidosis without compensation
d. Respiratory acidosis without compensation
d. Respiratory acidosis without compensation
9-7. The nurse notes that a client’s arterial blood gas
(ABG) results reveal a pH of 7.50 and a Pcoz of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? (Select all that apply.)
Laboratory Results
-Tests and Results-
pH 7.50
Pcoz 30 mm Hg
-Reference Range-
7.35-7.45
35-45 mm Hg
a. Nausea
b. Confusion
c. Bradypnea
d. Tachycardia
e. Hyperkalemia
f. Light-headedness
a. Nausea
b. Confusion
d. Tachycardia
f. Light-headedness
9-8. The nurse reviews the blood gas results of a client with atelectasis with the RN. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings?
Laboratory Results
-Tests and Results-
pH
PCO2
Ро2
НСОз
-Reference Range-
7.35-7.45
35-45 mm Hg
80-100 mm Hg
21-28 mEq/L
a. pH 7.25, Pco2 50 mm Hg
b. pH 7.35, Pco2 40 mm Hg
c. pH 7.50, Pco2 52 mm Hg
d. pH 7.52, Pco2 28 mm Hg
a. pH 7.25, Pco2 50 mm Hg
9-9. The nurse is assisting with caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pcoz of 30 mm Hg.
The nurse understands that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
Laboratory Results
-Tests and Results-
pH 7.50
Pco2 30 mm Hg
Magnesium 1.8 mEq/L
Sodium 145 mEq/L
Potassium 3.0 mEq/L
Phosphorus 3.0 mg/dL
-Reference Range-
7.35-7.45
35-45 mm Hg
1.8-2.6 mEq/L
135-145 mEq/L
3.5-5.0 mEq/L
3.0-4.5 mg/dL
a. Magnesium level of 1
b. Sodium level of 145 mEq/L
c. Potassium level of 3.0 mEq/L
d. Phosphorus level of 3.0 mg/dL
c. Potassium level of 3.0 mEq/L
9-10. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?
a. Respiratory acidosis from inadequate ventilation
b. Respiratory alkalosis from anxiety and hyperventilation
c. Metabolic acidosis from calcium loss due to broken bones
d. Metabolic alkalosis from taking analgesics containing base products
a. Respiratory acidosis from inadequate ventilation
