Exam II Flashcards
A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply)
A. Green Beans B. Tomatoes C. Bananas D. Asparagus E. Raisins
B. Tomatoes
C. Bananas
E. Raisins
A nurse is caring for a client with hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
A. Lactated Ringer’s
B. Dextrose 5% in 0.9% sodium chloride
C. 0.45% sodium chloride
D. Dextrose 10% in water
C. 0.45% sodium chloride
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is responding effectively to treatment?
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
C. Urine specific gravity 1.020
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?
A. Hypothermia
B. Protruding eyeballs
C. Elevated blood pressure
D. Furrows in the tongue
D. Furrows in the tongue
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these are consistent with which of the following conditions?
Sodium 152 mEq/L Potassium 3.6 mEq/L Chloride 105 mEq/L Glucose 102 mg/dL BUN 18 mg/dL Creatinine 0.7 mg/dL \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
A. Renal failure
B. Low-protein diet
C. Dehydration
D. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Dehydration
A nurse is assessing a client with a Sodium level of 116 mEq/L. Which of the following findings should the nurse expect to find?
A. Nausea and vomiting
B. Extreme thirst
C. Flushed skin
D. Fever
A. Nausea and vomiting
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?
300mL
The time span in question is 2.5 hr.
120 + 120 + 60 = 300 mL infused.
120 mL/hr X 2.5 hr = 300 mL
A nurse is calculating the intake of a client during the past 9 hours. The client’s intake includes lactated Ringer’s IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL dextrose 5% in water. How many mL of intake should the nurse record?
2525 mL
Lactated Ringer’s 150 mL x 9 hr = 1350 mL
cefazolin = 100 mL
packed RBCs 275 mL + 250 mL = 525 mL
0.9% sodium chloride bolus 250 mL + 250 mL = 500 mL
ranitidine = 50 mL
Total intake = 2525 mL
A nurse is planning care for a client who has dehydration and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
A. Monitor the client’s intake and output every 6 hr.
B. Offer the client 240 mL (8 oz) of oral fluids every 4 hr.
C. Check the client’s IV infusion every 8 hr.
D. Administer furosemide to the client.
B. Offer the client 240 mL (8 oz) of oral fluids every 4 hr.
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse administer?
A. Lactulose
B. Sevelamer
C. Sodium polystyrene
D. Darbepoetin alfa
C. Sodium polystyrene
Hypernatremia
no “FRIED” food for you
Fever, flushed skin Restlessness Increase fluid retention Edema, extremely confused Decreased urinary output, dry mouth & skin
Hyponatremia
SALT LOSS
Seizures & stupor
Abdominal cramping, attitude changes (confusion)
Lethargic
Tendon reflexes diminished, trouble breathing
Loss of urine & appetite
Orthostatic hypotension, overactive bowel sounds
Shallow respirations (comes later due to skeletal weakness)
Spasms of the muscles
Pain ABCDE method
- Ask about pain regularly + assess pain systematically
- Believe patients
- Choose appropriate pain control
- Deliver interventions in a timely/coordinated manner
- Empower patients
Pain PQRSTU assessment data
- Palliative or provocative (what makes it better or worse?)
- Quality (sharp, dull, burning?)
- Region (location) … also, any Relief?
- Severity
- Timing (onset? constant or intermittent?)
- Effects of pain on U
Hypokalemia
MURDER
Muscle weakness Urine-oliguria,anuria Respiratory distress Decreased cardiac contractility ECG changes, peaked t-waves Reflexes-hyperreflexia, or areflexia
Hyperkalemia
MACHINE
Medication Acidosis Cellular destruction: burns, traumatic injury Hypoaldosteronism-Addison Intake-excessive Nephron-renal failure Ecretion-impaired
Potassium rich foods
Potatoes, pork Oranges Tomatoes Avocados Strawberries Spinach fIsh mUshrooms Musk melon= cantaloupe
Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply.
A. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician
B. Changing dressings that become wet or soiled
C. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client’s skin
D. Placing tissues and soiled dressings in paper bags
E. Placing capped needles and syringes in puncture-resistant containers
F. Keeping bedside table surfaces clean and dry
A. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician
B. Changing dressings that become wet or soiled
C. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client’s skin
F. Keeping bedside table surfaces clean and dry
