Chapter 17 Flashcards
- You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
D) Fluid volume status
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank pain
A) Diminished deep tendon reflexes
You are working on a burns unit and one of your acutely ill patients is exhibiting signs
and symptoms of third spacing. Based on this change in status, you should expect the
patient to exhibit signs and symptoms of what imbalance?
A) Metabolic alkalosis
B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia
D) Hypovolemia
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the
emergency room. The triage nurse notes upon assessment that the patient is
hyperventilating. The triage nurse is aware that hyperventilation is the most common
cause of which acidbase imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS disturbances
B) Respiratory alkalosis
You are an emergency-room nurse caring for a trauma patient. Your patient has the
following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would
you interpret these results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
D) Metabolic acidosis with a compensatory respiratory alkalosis
You are making initial shift assessments on your patients. While assessing one patients
peripheral IV site, you note edema around the insertion site. How should you document
this complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
C) Infiltration
You are performing an admission assessment on an older adult patient newly admitted
for end-stage liver disease. What principle should guide your assessment of the patients
skin turgor?
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70.
C) Inelastic skin turgor is a normal part of aging.
The physician has ordered a peripheral IV to be inserted before the patient goes for
computed tomography. What should the nurse do when selecting a site on the hand or
arm for insertion of an IV catheter?
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when selecting a site.
C) Have the patient briefly hold his arm over his head before insertion.
D) Leave the tourniquet on for at least 3 minutes.
B) Consider potential effects on the patients mobility when selecting a site.
A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient
with increased intracranial pressure. This solution will increase the number of dissolved
particles in the patients blood, creating pressure for fluids in the tissues to shift into the
capillaries and increase the blood volume. This process is best described as which of the
following?
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport
B) Osmosis and osmolality
You are the surgical nurse caring for a 65-year-old female patient who is postoperative
day 1 following a thyroidectomy. During your shift assessment, the patient complains of
tingling in her lips and fingers. She tells you that she has an intermittent spasm in her
wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance
should you first suspect?
A) Hypophosphatemia
B) Hypocalcemia
C) Hypermagnesemia
D) Hyperkalemia
B) Hypocalcemia
A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse
states, A patient in renal failure partially loses the ability to regulate changes in pH. What
is the cause of this partial inability?
A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
B) The kidneys buffer acids through electrolyte changes.
C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH
You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient
may be at risk for what imbalance?
A) Hypercalcemia
B) Metabolic acidosis
C) Metabolic alkalosis
D) Respiratory acidosis
C) Metabolic alkalosis
The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
A) Leave one hand ungloved to assess the site.
B) Cleanse the skin with normal saline.
C) Ask the patient about allergies to latex or iodine.
D) Remove excessive hair from the selected site.
C) Ask the patient about allergies to latex or iodine.
A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Metabolic acidosis
A) Respiratory acidosis
One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?
A) Help distinguish hyponatremia from hypernatremia
B) Help evaluate pituitary gland function
C) Help distinguish reduced renal blood flow from decreased renal function
D) Help provide an effective treatment for hypertension-induced oliguria
C) Help distinguish reduced renal blood flow from decreased renal function