Ch. 18- Study Guide Flashcards
- The patient is experiencing hyperkalemia. What treatment does the nurse anticipate?
a. Intravenous (IV) calcium
b. Fluid restrictions
c. Foods high in potassium
d. Administration of loop diuretics
d. Administration of loop diuretics
- Following thyroid surgery, the patient reports nausea and a tingling sensation around nose, mouth, ears, fingers, and toes. The nurse observes muscle spasms in the patient’s feet and hands. What is the most important sign/ symptom for the nurse to observe for and report?
a. Respiratory distress
b. Altered mental status progressing to seizure
c. Polyuria and excessive thirst
d. Positive Chvostek’s sign
a. Respiratory distress
- Which patient has the greatest risk for dehydration?
a. 30-year-old female with vomiting and diarrhea
b. 72-year-old obese male with a fever and anorexia
c. 2-year-old with an ear infection and vomiting
d. 45-year-old underweight female with influenza
b. 72-year-old obese male with a fever and anorexia
- The nurse offers to take an older neighbor to the grocery store. As they are shopping, the neighbor tells the nurse that, “My doctor told me to watch my salt intake.” Which items in the shopping cart would the nurse suggest they put back on the shelf? (Select all that apply.)
a. Cheddar cheese
b. Ketchup
c. Oranges
d. Pretzels
e. Frozen TV dinner
a. Cheddar cheese
b. Ketchup
d. Pretzels
e. Frozen TV dinner
- The nurse sees that the patient is scheduled to have a potassium supplement. In addition to the last potassium level, what would the nurse assess before administering the potassium?
a. Urinary output
b. Blood pressure
c. Respiratory rate
d. Hematocrit level
a. Urinary output
- The nurse notes that a resident who lives in a long-term care center has poor fluid intake and spends most of the day dozing in a chair. Based on this observation, which subjective report is the resident most likely to report?
a. Shortness of breath
b. Constipation
c. Nausea
d. Headache
b. Constipation
- A patient with diabetes reports nausea and headache and he appears lethargic. The nurse observes that he is breathing very deeply and rapidly. Based on the assessment findings and the laboratory results, what does the nurse suspect?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
b. Metabolic acidosis
- The patient is encouraged by his doctor to eat foods that are rich in potassium. Which lunch tray would be the best?
a. Seafood salad with crackers and strawberries with whipped cream
b. Egg salad on whole grain bread with coffee and potato chips
c. Grilled white toast with tomato soup and orange juice
d. Pork cutlet with milk gravy and mushrooms and melon salad
d. Pork cutlet with milk gravy and mushrooms and melon salad
- The nurse is supervising a new nurse who will administer IV potassium to a patient. When would the supervising nurse intervene?
a. New nurse delegates unlicensed assistive personnel (UAP) to obtain an infusion controller
b. New nurse checks the HCP’s prescription for the dose, route and time of medication
c. New nurse draws dose with a sterile needle and syringe and scrubs the IV insertion port
d. New nurse calls pharmacy to find out when the potassium infusion will be ready
c. New nurse draws dose with a sterile needle and syringe and scrubs the IV insertion port
- Earlier in the shift a patient with severe diarrhea seemed irritable, anxious, and twitchy. The RN calls from the patient’s room and asks that a vial of calcium gluconate be brought to the room immediately. In addition, to the calcium gluconate, which emergency equipment would the LPN/LVN try to quickly obtain for patient with a very low calcium?
a. Chest tube insertion tray and oxygen mask
b. IV pump and IV normal saline for bolus
c. Automated external defibrillator
d. Tracheotomy tray and a resuscitation bag
d. Tracheotomy tray and a resuscitation bag
- The nurse is assessing an older adult and observes dry mucous membranes, increased heart rate, decreased blood pressure, and poor skin turgor. The patient seems mildly confused and continuously asks for water. What would the nurse do first?
a. Assess the patient for additional signs of dehydration.
b. Offer the patient a glass of water and reassess in several hours.
c. Count the respirations and assess for additional signs of respiratory acidosis.
d. Call the supervising RN and the HCP and report assessment findings.
a. Assess the patient for additional signs of dehydration.
- What is the best food source for calcium?
a. Milk
b. Meat
c. Whole grains
d. Green leafy vegetables
a. Milk
- The patient has experienced a prolonged episode of diarrhea. Which clinical observation is consistent with the development of metabolic acidosis?
a. Increased perspiration
b. Increased respiratory rate
c. Increased urinary output
d. Decreased heart rate
b. Increased respiratory rate
- The patient has had chronic obstructive pulmonary disease (COPD) for a number of years.
Which set of arterial blood gas values indicates that the patient is in respiratory acidosis?
a. pH 7.35, Paco, 40, O, saturation 96%
b. pH 7,40, Paco, 45, O, saturation 95%
c. pH 7.30, Paco, 50, O, saturation 93%
d. pH 7.48, Paco, 55, O, saturation 98%
c. pH 7.30, Paco, 50, O, saturation 93%
- While in the delivery room with his wife, the father-to-be begins to develop an anxiety reaction and lightheadedness. Which intervention does the nurse use to prevent respiratory alkalosis?
a. Coach panting respirations.
b. Provide nasal oxygen.
c. Have him breathe into a paper bag.
d. Have him cough and deep-breathe.
c. Have him breathe into a paper bag.
- A child has gotten into the medicine cabinet in the home and ingested the remaining contents of an aspirin (acetylsalicylic acid) bottle. Which acid-base imbalances does the nurse expect to observe as a result of excessive aspirin ingestion?
a. Metabolic acidosis and respiratory alkalosis
b. Metabolic alkalosis and respiratory acidosis
c. Respiratory acidosis and metabolic acidosis
d. Respiratory alkalosis and metabolic alkalosis
a. Metabolic acidosis and respiratory alkalosis
- The patient has had continuous gastric suction.
The nurse recognizes that acid-base imbalances can occur with this treatment. Which laboratory data confirms metabolic alkalosis?
a. pH elevated, Paco, normal, and HCO, elevated
b. pH elevated, Paco, elevated, and HCO, decreased
c. pH decreased, Paco, decreased, and HCO,- decreased
d. pH decreased, Paco, normal, and HCO,- decreased
a. pH elevated, Paco, normal, and HCO, elevated
- What is the best way for the nurse to determine the patient’s fluid balance?
a. Assess vital signs.
b. Weigh the patient daily.
c. Monitor IV fluid intake.
d. Check diagnostic test results.
b. Weigh the patient daily.
- The patient used excessive antacids, which resulted in a serum sodium level of 150 mEq/L (150 mmol/L). Why would the HCP instruct the nurse to give an IV hypotonic solution?
a. To correct intracellular dehydration
b. To correct intravascular volume
c. To increase the sodium level
d. To pull fluid from the cells
a. To correct intracellular dehydration
- The nurse is caring for a postoperative patient.
Which solution is the HCP most likely to prescribe to replace the fluid deficiency related to the patient’s NPO (nothing by mouth) status in the pre- and postoperative period?
a. Hypotonic solution
b. Hypertonic solution
c. Isotonic solution
d. Parental nutrition
c. Isotonic solution
- What purposes do the electrolytes serve in the body? (Select all that apply.)
a. Maintenance of normal body metabolism
b. Regulation of water balance in the body
c. Regulation of water and electrolyte contents within cells
d. Formation of hydrochloric acid in gastric juice
e. Transportation of nutrients to cells and waste products from cells
a. Maintenance of normal body metabolism
b. Regulation of water balance in the body
c. Regulation of water and electrolyte contents within cells
d. Formation of hydrochloric acid in gastric juice
- The patient has been placed on a low-sodium diet to assist in the treatment of hypertension.
Which patient statement indicates an understanding of the diet teaching?
a. “Cheese is a good between-meal snack for me.”
b. “It is okay for me to eat at my favorite seafood restaurant.”
c. “In order for me to eat enough vegetables, I can prepare canned peas and corn.”
d. “I use a lot of fresh vegetables, although I should give up table salt.”
d. “I use a lot of fresh vegetables, although I should give up table salt.”
- Which patient has the greatest risk for developing hypokalemia?
a. Has a small bowel obstruction
b. Has renal failure
c. Consumes excessive alcohol
d. Takes prescribed loop diuretic
d. Takes prescribed loop diuretic
- The nurse is monitoring an older patient who is receiving a fluid bolus for dehydration. The nurse notices that the patient suddenly has a slight cough and seems a little short of breath. The patient reports, “I’m okay.” What would the nurse do first?
a. Notify the RN and the HCP.
b. Auscultate the lungs and assess for fluid overload.
c. Stop the bolus infusion and establish a saline lock.
d. Weigh the patient and compare to baseline.
b. Auscultate the lungs and assess for fluid overload.
- The nurse receives notification from the laboratory that a patient’s potassium level is 6 mBq/L (6 mmol/L). The nurse has paged the HCP and is awaiting a call back. What would the nurse do first?
a. Attach the patient to a cardiac monitor.
b. Encourage foods and fluids that contain potassium.
c. Prepare a dose of intravenous calcium gluconate.
d. Check medications that could affect potassium levels.
a. Attach the patient to a cardiac monitor.
- The nurse is checking the laboratory data of a woman who is at risk for osteoporosis.
Which electrolyte value is most relevant to this condition?
a. Sodium level
b. Calcium level
c. Potassium level
d. Phosphorus level
b. Calcium level
- The nurse hears in report that the patient has been receiving aluminum hydroxide to correct an electrolyte imbalance. Which electrolyte level would the nurse check to evaluate the efficacy of the medication?
a. Phosphorus level
d. Magnesium level
c. Bicarbonate level
d. Calcium level
a. Phosphorus level
- The nurse is caring for a patient who had surgery on the parathyroid glands. Which electrolyte level in the low-normal range is the greatest concern?
a. Calcium
b. Sodium
c. Potassium
d. Magnesium
a. Calcium
- The patient has a medical diagnosis of diabetic ketoacidosis. Which clinical manifestation indicates that the blood buffer system is exhausted?
a. Urinary output is decreased.
b. Respiratory rate is increased.
c. Heart rate is decreased.
d. pH is increased.
b. Respiratory rate is increased.
- The patient is on mechanical ventilation. The arterial blood gas results indicate that the patient has respiratory alkalosis. What would the nurse do first?
a. Suction the airway for excessive secretions or a mucus plug.
b. Notify the RN or the HCP.
c. Check the ventilator settings and compare to the orders.
d. Deliver breaths using a bag-valve-mask with high-flow oxygen.
c. Check the ventilator settings and compare to the orders.
- The patient needs to have accurate intake and output recorded for every shift. Which sensible fluid losses must be included in the output?
Select all that apply.
a. Diarrhea stools
b. Hemovac drainage
c. Contents from an ileostomy bag
d. Secretions from nasogastric suction
e. Drainage from indwelling urinary catheter bag
f. Water in the water-seal chamber of the chest tube
a. Diarrhea stools
b. Hemovac drainage
c. Contents from an ileostomy bag
d. Secretions from nasogastric suction
e. Drainage from indwelling urinary catheter bag
- The nurse is supervising a nursing student who is inserting an intravenous (IV) catheter.
Which action prompts the supervising nurse to intervene?
a. Student looks for vein in the forearm distal to a dialysis shunt
b. Student palpates a vein by pressing to feel a soft, bouncy resistance.
c. Student removes the tourniquet after 30 seconds of looking for a vein
d. Student looks for a vein in the most distal area of the nondominant arm.
a. Student looks for vein in the forearm distal to a dialysis shunt
- The RN initiates a blood transfusion and then the LPN/ LVN is assigned to monitor patient.
An hour after the transfusion is started, the patient reports nausea, “not feeling right” and demonstrates wheezing. What would the LPN/ LVN do first?
a. Notify the RN who started the transfusion.
b. Take vital signs and auscultate lung sounds.
c. Stop the transfusion and keep vein open with normal saline.
d. Slow the transfusion and observe for other signs of distress.
c. Stop the transfusion and keep vein open with normal saline.
- The patient has an IV infusion of normal sa-line. The patient reports mild discomfort at the insertion site and the nurse observes the skin is pale, edematous, feels cool to the touch, and the flow rate is sluggish. What would the nurse do?
a. Reposition the arm.
b. Increase the flow rate.
c. Call the HCP.
d. Discontinue the IV.
d. Discontinue the IV.
- The nurse meets resistance while attempting to flush an intermittent saline lock with 10 mL of saline. Which action would the nurse take first?
a. Reposition arm and increase the force.
b. Assess for kinks or clamped tubing.
c. Remove the saline lock and reestablish.
d. Flush with low-dose heparin solution
b. Assess for kinks or clamped tubing.
