part 2

Question 1

Nursing Assessment - Respiratory System:

What can changes int he respiratory rate and depth indicate?

Answer 1

may be compensatory for an acid-base imbalance

Question 2

Nursing Assessment - Respiratory System:

What can tachypnea, dyspnea, crackles indicate?

Answer 2

fluid volume excess

Question 3

Nursing Assessment - Respiratory System:

What can be the cause of a life threatening laryngospasm?

Answer 3

hypocalcemia

Question 4

Other assessment findings?

Answer 4

skin turgor (pinching then tenting equals dehydration) (fingerprinting mean FVE) 
eyes
mouth
lips 
tongue
body weight (I&O)
lab values

Question 5

What is hypokalemia treated with?

Answer 5

KCl

Question 6

What are some ways KCl should never be prepared?

Answer 6

• Never give IV push
• never give concentrated (must dilute)
• Never add KCl to a hanging container
• IV rate can not exceed 10 mEq/hr through peripheral veins (if central line you can increase)

Question 7

What patients do you need to watch for hyperkalemia?

Answer 7

pt’s with renal failure

Question 8

What is hypokalemia frequently associated with?

Answer 8

ECF volume deficit and chloride loss

Question 9

Should K+ be given if pt is not appropriately urinating?

Answer 9

no - K+ is excreted primarily by the kidneys

Question 10

Whit what pt does KCl need to be adjusted?

Answer 10

renal impairment because it can cause hyperkalemia due to poor kidney function

Question 11

Should pt’s on dialysis be on a K+ protocol?

Answer 11

no

Question 12

What do nurses need to watch for when giving KCl via IV?

Answer 12

tissue infiltration
irritation (pt report)
tissue loss

Question 13

How long should 20 mEq of KCl take?

Answer 13

2 hours or more

never give more than 10 mEq per hour