ch 8 Flashcards
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day
ANS: A
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
ANS: B
Positive Chvostek sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58
ANS: C
Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland
ANS: B
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness
ANS: D
Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.
The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal disease
d. Adrenal insufficiency
ANS: C
When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.
The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention?
a. Raise bed side rails due to potential decreased level of consciousness and
confusion.
b. Examine sacral area and patient’s heels for skin breakdown due to potential
edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and
seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg
muscles.
ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes
ANS: B, C, D
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine.
ANS: A, B, F
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.
