Week 12 Sherpath Flashcards
Which findings would prompt the nurse to perform a focused cardiopulmonary assessment?
Select all that apply.
Medical history of a cardiovascular problem
Medical history of a respiratory problem
Signs and symptoms of decreased oxygenation
Signs and symptoms of activity intolerance
Signs and symptoms of increased peripheral perfusion
Medical history of a cardiovascular problem
Medical history of a respiratory problem
Signs and symptoms of decreased oxygenation
Signs and symptoms of activity intolerance
Which questions would the nurse include during the patient interview of a focused respiratory health assessment?
Select all that apply.
Have you ever smoked?
Have you had recent weight gain?
Do you use oxygen at home?
Do you have difficulty clearing secretions?
Do you have a cough? For how long?
Have you ever smoked?
Do you use oxygen at home?
Do you have difficulty clearing secretions?
Do you have a cough? For how long?
Which peripheral vascular assessment would the nurse perform when admitting a patient with impaired cardiac function?
Auscultating breath sounds
Auscultating an apical pulse
Inspecting skin color in the extremities
Measuring the chest for expansion
Inspecting skin color in the extremities
Which set of values would the nurse review to determine whether heart muscle injury has occurred?
Complete blood count (CBC) with differential
Lipid panel
Basic metabolic panel
Cardiac enzymes
Cardiac enzymes
Which information would the nurse expect to obtain from a chest x-ray prescribed for a patient with a cough and shortness of breath?
Select all that apply.
Hypoxia from diminished lung function
Areas of increased lung tissue density
Impaired electrical activity in the heart
Size of the heart
Atherosclerosis in heart blood vessels
Areas of increased lung tissue density
Size of the heart
Which health problem risk would be evaluated by obtaining a lipid panel?
Cardiac injury
Atherosclerosis
Fluid around heart
Blood electrolyte imbalances
Atherosclerosis
Match the pulmonary function test (PFT) with the measured element.
Air volume expelled with lungs maximally inflated
Air volume expelled in 1 second from start of FVC
Air volume left in lungs after forced expiration
Air volume left in lungs after normal expiration
Maximal flow rate in the middle of FVC maneuver
Answer choices
Functional residual capacity (FRC)
Residual volume (RV)
Forced vital capacity (FVC)
Forced expiratory flow (FEF)
Forced expiratory volume in 1 second (FEV1)
Air volume expelled with lungs maximally inflated
Forced vital capacity (FVC)
Air volume expelled in 1 second from start of FVC
Forced expiratory volume in 1 second (FEV1)
Air volume left in lungs after forced expiration
Residual volume (RV)
Air volume left in lungs after normal expiration
Functional residual capacity (FRC)
Maximal flow rate in the middle of FVC maneuver
Forced expiratory flow (FEF)
Which cues would the nurse expect to find in a patient with an inability to effectively pump blood to the tissues?
Select all that apply.
Dyspnea with exertion
Fatigue
Lower extremity edema
Crushing chest pain
Nausea and vomiting
Dyspnea with exertion
Fatigue
Lower extremity edema
Which condition would the nurse suspect in a postsurgical patient who is experiencing dyspnea with decreased breath sounds?
Chronic obstructive pulmonary disease (COPD)
Asthma
Atelectasis
Heart failure
Atelectasis
Which cues would the nurse expect in a patient with hypoxic myocardial tissue?
Select all that apply.
Fever
Dyspnea
Vomiting
Chest pain
Diaphoresis
Dyspnea
Vomiting
Chest pain
Diaphoresis
Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder?
Sputum characteristics
Pulse oximetry
Capillary refill
Respiratory rate
Sputum characteristics
Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment?
Select all that apply.
Are you having chest pain?
Have you had recent weight gain?
What type of work do you do?
How many pillows do you sleep with?
Do you ever experience dizziness?
Are you having chest pain?
Have you had recent weight gain?
How many pillows do you sleep with?
Do you ever experience dizziness?
Which questions would the nurse include as part of a focused respiratory health assessment?
Have you ever been exposed to hazardous materials at work?
Have you had recent weight gain?
Have you ever lost consciousness?
Do you take medications to prevent blood clots?
Have you ever been exposed to hazardous materials at work?
Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction?
Select all that apply.
They are released when death of cardiac cells occurs.
Elevated serum levels suggest cardiac damage.
There are “good” and “bad” types of cardiac enzymes.
Alterations in enzyme types may indicate infection.
Abnormally low levels are seen with decreased oxygenation.
They are released when death of cardiac cells occurs.
Elevated serum levels suggest cardiac damage.
The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding?
Hyperlipidemia
Hypoxia
Infection
Hemodilution
Hypoxia
When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition?
Hemodilution
Hypoxia
Infection
Hyperlipidemia
Hemodilution
Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?
Elevated levels increase the risk for atherosclerosis.
Abnormal levels can cause cardiac arrhythmias.
Reduced levels can result in decreased oxygen levels.
Normal levels suggest healing of muscle tissue.
Abnormal levels can cause cardiac arrhythmias.
Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?
Select all that apply.
Inspection
Palpation
Auscultation
Reflexes
Vital signs
Inspection
Palpation
Auscultation
Vital signs
Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia?
Dyspnea
Elevated arterial carbon dioxide level
Irregular heart rhythm
Chest pain
Dyspnea
Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia?
Select all that apply.
Chest pain
Dyspnea
Abnormal cardiac enzymes levels
Irregular heartbeat
Decreased breath sounds
Abnormal cardiac enzymes levels
Irregular heartbeat
Which postoperative complication can be prevented by regularly performing deep-breathing exercises?
Thrombus formation
Bronchospasm
Alveolar enlargement
Atelectasis
Atelectasis
Which delivery system would the nurse use when the health care provider prescribes a common low-flow system to deliver continuous oxygen at 2 L/min for a patient with pneumonia?
Nonrebreather mask
Bilevel positive airway pressure (BiPAP)
Nasal cannula
Ambu bag
Nasal cannula
Which alterations of oxygenation and perfusion may require supplemental oxygen therapy?
Select all that apply.
Increased respiratory rate
Decreased heart rate
Low oxygen saturation
Cyanosis
Elevated hemoglobin
Increased respiratory rate
Low oxygen saturation
Cyanosis
Match the type of oxygen mask to its description.
No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧
Reservoir bag present; room air is inspired with O2 delivered
Reservoir bag present; one-way valve prevents entry of exhaled air
No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Answer choices
Nonrebreather mask
Simple face mask
Partial rebreather mask
Venturi mask
No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧
Simple face mask
Reservoir bag present; room air is inspired with O2 delivered
Partial rebreather mask
Reservoir bag present; one-way valve prevents entry of exhaled air
Nonrebreather mask
No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Venturi mask
Which device would the nurse apply to a patient who has arrived unconscious and in respiratory arrest (is not breathing)?
Venturi mask
Ambu bag
Nasal cannula
Continuous positive airway pressure (CPAP) device
Ambu bag
Match the artificial airway tube with the correct situation.
Inserted in the patient’s nose to facilitate ease of suctioning
Inserted in mouth; maintains airway and breathing without ventilatory help
Inserted through the mouth for positive pressure mechanical ventilation
Inserted through trachea; provides ventilation when upper airway obstructed
Answer choices
Tracheostomy tube
Endotracheal tube
Oropharyngeal tube
Nasopharyngeal tube
Inserted in the patient’s nose to facilitate ease of suctioning
Nasopharyngeal tube
Inserted in mouth; maintains airway and breathing without ventilatory help
Oropharyngeal tube
Inserted through the mouth for positive pressure mechanical ventilation
Endotracheal tube
Inserted through trachea; provides ventilation when upper airway obstructed
Tracheostomy tube
Which guidelines would the nurse recall when inserting a nasopharyngeal tube?
Select all that apply.
The airway is inserted into the mouth over the tongue.
The length is measured from the tragus to the nostril plus 1 inch.
The airway is removed and changed at least every 24 hours.
Gentle to moderate force is applied when resistance is encountered.
The airway is lubricated before attempting insertion and inserted gently.
The length is measured from the tragus to the nostril plus 1 inch.
The airway is removed and changed at least every 24 hours.
The airway is lubricated before attempting insertion and inserted gently.
Which situations would indicate a need for the nurse to consider insertion of a pharyngeal airway?
Select all that apply.
Decreased level of consciousness
Inability to breathe effectively
Frequent suctioning needs
Loss of muscle tone
Requires mechanical ventilation
Decreased level of consciousness
Frequent suctioning needs
Loss of muscle tone
Which type of tube would a patient receiving general anesthesia require to maintain oxygenation?
Nasopharyngeal
Tracheostomy
Oropharyngeal
Endotracheal
Endotracheal
For which purpose would a chest tube be inserted in a patient injured in a car crash?
Provides oxygenation when respirations are impaired
Allows for removal of excessive airway secretions
Drains blood and fluid to promote full lung expansion
Keeps the airway open when there is airway damage
Drains blood and fluid to promote full lung expansion
Match the type of chest physiotherapy to its description.
Therapeutic positioning that facilitates gravity drainage from the lungs
Combines controlled coughing with deep breathing to maintain lung expansion
Helps a patient reach a set inhalation volume
Answer choices
Coughing/deep breathing
Postural drainage
Incentive spirometry
Therapeutic positioning that facilitates gravity drainage from the lungs
Postural drainage
Combines controlled coughing with deep breathing to maintain lung expansion
Coughing/deep breathing
Helps a patient reach a set inhalation volume
Incentive spirometry
Match the type of chest physiotherapy to its description.
Therapeutic positioning that facilitates gravity drainage from the lungs
Combines controlled coughing with deep breathing to maintain lung expansion
Helps a patient reach a set inhalation volume
Answer choices
Coughing/deep breathing
Postural drainage
Incentive spirometry
Therapeutic positioning that facilitates gravity drainage from the lungs
Postural drainage
Combines controlled coughing with deep breathing to maintain lung expansion
Coughing/deep breathing
Helps a patient reach a set inhalation volume
Incentive spirometry
Which actions are the nurse’s responsibilities during a chest tube insertion procedure?
Select all that apply.
Explaining the procedure to the patient
Positioning the patient
Ensuring that the drainage system is working properly
Administering a prescribed bronchodilator
Initiating oxygen therapy immediately before tube insertion
Positioning the patient
Ensuring that the drainage system is working properly
Match the pulmonary drug classification with the key principle of use.
Increase the diameter of the bronchi
Improve airway clearance
Decrease inflammation
Decrease the thickness of secretions
Answer choices
Corticosteroids
Anticholinergics
Mucolytics
Inhaled bronchodilators
Increase the diameter of the bronchi
Inhaled bronchodilators
Improve airway clearance
Anticholinergics
Decrease inflammation
Corticosteroids
Decrease the thickness of secretions
Mucolytics
Which finding indicates that the prescribed inhaled bronchodilator administered to a patient with chronic obstructive pulmonary disease (COPD) has been effective?
Decreased secretions
Decreased wheezing
Increased heart rate
Decreased body temperature
Decreased wheezing
Which action describes the primary rationale for administering a corticosteroid (methylprednisolone) to a patient with a pulmonary disease?
Treats the underlying infection
Decreases inflammation
Increases the diameter of the bronchi
Decreases the thickness of airway secretions
Decreases inflammation
Which patient changes would the nurse expect when medications used to treat pulmonary disease are effective?
Select all that apply.
Decreased symptoms
Fewer exacerbations
Increased exercise tolerance
Improved overall health status
Reduced laboratory testing requirement
Decreased symptoms
Fewer exacerbations
Increased exercise tolerance
Improved overall health status
Match the drug classification with the key assessment associated with evaluation of treatment.
Blood pressure.
Daily weights, intake and output
Heart rate and rhythm
Bleeding
Answer choices
Antiarrhythmics
Diuretics
Anticoagulants
Antihypertensives
Blood pressure.
Antihypertensives
Daily weights, intake and output
Diuretics
Heart rate and rhythm
Antiarrhythmics
Bleeding
Anticoagulants
Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)?
Select all that apply.
High oxygen levels can be toxic.
Use oxygen therapy only as absolutely needed.
Limit oxygen concentration to low-flow.
Do not smoke while using oxygen.
Avoid humidified oxygen.
High oxygen levels can be toxic.
Limit oxygen concentration to low-flow.
Do not smoke while using oxygen.
Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy?
Select all that apply.
Increased level of daily function
Slowed progression of the disease
Improved mental status
Increased activity tolerance
Decreased inflammation of the alveoli
Increased level of daily function
Improved mental status
Increased activity tolerance
Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia?
Teaching deep breathing exercises
Seeking readmission to the hospital for oxygen therapy
Suggesting counseling to overcome the unreasonable fear
Requesting a prescription for a high-flow nasal cannula
Requesting a prescription for a high-flow nasal cannula
Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube?
Select all that apply.
Obturator
Inner cannula
Bag-valve-mask (BVM) device
Blood pressure equipment
Tracheostomy care kit
Obturator
Inner cannula
Bag-valve-mask (BVM) device
Tracheostomy care kit
Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube?
“There will be a small incision made to help you breathe”
“This will help facilitate clearing secretions from your mouth and throat.”
“This will remain in place only as long as you are under general anesthesia.”
“Your nares will be lubricated to ease insertion.”
“This will help facilitate clearing secretions from your mouth and throat.”
Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider?
Excessive secretions
Reddened incision
Respiratory infection
Subcutaneous emphysema
Subcutaneous emphysema
Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary?
It facilitates gravity drainage of secretions.
It prevents atelectasis.
It removes mucus from the respiratory tract.
It drains fluid from the pleural space.
It prevents atelectasis.
Which type of chest physiotherapy involves percussion?
Aerobic exercise
Postural drainage
Incentive spirometry
Coughing/deep breathing
Postural drainage
The nurse would instruct a patient to hold each breath for
____ seconds when explaining coughing/deep breathing chest physiotherapy? Record your answer as two whole numbers separated by a hyphen.
Use numbers only.
3-5
Which route would the nurse use when administering medication to a patient with non–life-threatening lower airway inflammation?
Subcutaneous
Nasal
Intravenous
Inhalation
Inhalation
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing?
Decreases inflammation
Increases the diameter of the bronchi
Decreases the thickness of secretions
Protects against disease
Increases the diameter of the bronchi
Which medications would the nurse expect to be added to the patient’s drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital?
Select all that apply.
Corticosteroids
Antibiotics
Vaccines
Anticholinergics
Mucolytics
Corticosteroids
Antibiotics
Anticholinergics
Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication?
It promotes increased urine flow.
Low doses prevent blood clot formation.
It is needed to reduce high blood pressure.
It suppresses abnormal rhythms of the heart.
It suppresses abnormal rhythms of the heart.
Which interventions would the nurse implement when providing care for a patient prescribed a diuretic?
Select all that apply.
Applying antiembolic stockings
Monitoring daily weight
Monitoring intake and output
Elevating the head of the bed to the semi-Fowler position
Monitoring for bleeding tendencies
Monitoring daily weight
Monitoring intake and output
Which benefit is important for the nurse to include when educating a patient about antihypertensive medications?
Control an irregular heart rate
Reduce the risk for stroke
Reduce the risk for blood clots
Control swelling of the feet
Reduce the risk for stroke
Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease?
Select all that apply.
Diuretics
Anticoagulants
Antiarrhythmics
Calcium channel blockers
Bronchodilators
Diuretics
Anticoagulants
Antiarrhythmics
Calcium channel blockers
Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy?
Expect bleeding and bruising while taking the medication.
Limit intake of green, leafy vegetables.
Monitor blood pressure daily.
Take daily weights at the same time every day.
Limit intake of green, leafy vegetables.
Which patient health history finding would alert the nurse to the possibility of a fluid volume imbalance?
Weight loss of 5 kg over the past month
Weight gain of 2 kg since yesterday morning
Loss of appetite for the past few weeks
Occasional headaches
Weight gain of 2 kg since yesterday morning
Which laboratory results would a nurse expect when caring for a patient with vomiting and diarrhea who has developed rapid onset isotonic fluid volume deficit (FVD)?
Select all that apply.
Elevated red blood cell (RBC) levels
Increased blood urea nitrogen (BUN) and creatinine levels
Low serum osmolality
Decreased urine specific gravity
Decreased urine osmolality
Elevated red blood cell (RBC) levels
Increased blood urea nitrogen (BUN) and creatinine levels
Which datum would support the presence of fluid volume excess (FVE) in a patient with associated risk factors?
Weak, thready pulse
Weight loss of 1 kg since yesterday
Poor skin turgor
Crackles auscultated in lung bases
Crackles auscultated in lung bases
Match each laboratory test with the information it provides.
Indicator of overall renal function
Helps determine hydration status, useful in managing fluid requirements
Measure of the oxygen-carrying capacity of the blood
Measure of the concentration of solutes in the urine
Answer choices
Serum osmolality
Red blood cell (RBC), hemoglobin, hematocrit
Urine osmolality
Blood urea nitrogen, creatinine
Indicator of overall renal function
Blood urea nitrogen, creatinine
Helps determine hydration status, useful in managing fluid requirements
Serum osmolality
Measure of the oxygen-carrying capacity of the blood
Red blood cell (RBC), hemoglobin, hematocrit
Measure of the concentration of solutes in the urine
Urine osmolality
Which level on the dehydration scale would a nurse use to describe a patient with a weight loss of 8% of total body weight secondary to vomiting and diarrhea?
Mild dehydration
Moderate dehydration
Severe dehydration
Life-threatening dehydration
Severe dehydration
Which patients would a nurse conclude are experiencing fluid volume deficit (FVD)?
Select all that apply.
An 86-year-old woman with a fever who has dry mucous membranes and decreased urination
A 50-year-old man with mild hypertension and flat neck veins while seated who has lost 8% total body weight over a year’s time
An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel
A 75-year-old woman with orthostatic hypotension and tachycardia after an increase in her blood pressure medication dosage
A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor
An 86-year-old woman with a fever who has dry mucous membranes and decreased urination
An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel
A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor
Which sign or symptom in a patient with fluid volume deficit would be a result of decreased interstitial fluid?
Decreased skin turgor
Weak, thready pulse
Lightheadedness
Sunken fontanel in an infant
Decreased skin turgor
Which manifestation, specifically caused by an increase in interstitial fluids, would a nurse expect when caring for a patient who has developed fluid volume excess (FVE)?
Confusion
Dependent edema
Bounding peripheral pulses
Jugular vein distension
Dependent edema
Which degree of fluid volume excess (FVE) would a nurse document for an adult patient with a 5% weight gain over the last 24 hours because of fluid retention?
Mild FVE
Moderate FVE
Irreversible FVE
Severe FVE
Moderate FVE
Which laboratory results would a nurse expect in a patient who has developed a hypertonic fluid volume deficit?
Select all that apply.
Decreased urine specific gravity
Decreased hematocrit levels
Increased blood urea nitrogen (BUN) and creatinine levels
Low red blood cell (RBC) count
Elevated serum osmolality
Increased blood urea nitrogen (BUN) and creatinine levels
Elevated serum osmolality
Which questions would be appropriate for the nurse to ask to obtain fluid balance information?
Select all that apply.
“What types of fiber-containing food do you eat during a typical day?”
“Have you lost or gained weight recently?”
“Do you have a history of renal disease or diabetes mellitus?”
“Have you noticed swelling of your hands and feet?”
“Do you have any food allergies?”
“Have you lost or gained weight recently?”
“Do you have a history of renal disease or diabetes mellitus?”
“Have you noticed swelling of your hands and feet?”
Which patient assessments would suggest a significant fluid volume deficit (FVD) in an acutely ill patient brought into the urgent treatment center?
Select all that apply.
Hypertension
Elevated serum blood urea nitrogen (BUN) and creatinine -levels
Rapid, weak, thready pulse
Weight loss of 0.5 kg over the past 2 days
Dry, cracked lips and furrows on the tongue
Elevated serum blood urea nitrogen (BUN) and creatinine -levels
Rapid, weak, thready pulse
Dry, cracked lips and furrows on the tongue
Which amount of fluid would the nurse calculate has been lost by a patient with a fluid volume deficit reporting a 10 kg loss of total body weight in the last 48 hours as a result of vomiting and diarrhea?
1 liter of fluid
5 liters of fluid
10 liters of fluid
15 liters of fluid
10 liters of fluid
Which specific clinical findings would be expected by a nurse caring for an adult patient with isotonic fluid volume deficit (FVD)?
Select all that apply.
Hypotension
Flat neck veins when supine
Confusion
Low urine output
Slow, thready pulse
Hypotension
Flat neck veins when supine
Low urine output
Which rationale would explain the neurologic signs and symptoms caused by hypertonic fluid volume deficit?
Decreased serum osmolality causes water to shift out of brain cells by osmosis.
Decreased intracellular osmolality causes water to shift into the brain cells by osmosis.
Increased intracellular osmolality causes sodium to shift into the brain cells by osmosis.
Increased serum osmolality causes water to shift out of brain cells by osmosis.
Increased serum osmolality causes water to shift out of brain cells by osmosis.
Which sign or symptom suggests that a patient is experiencing hypertonic fluid volume deficit (FVD)?
Hypotension
Oliguria
Confusion
Dry mucous membranes
Confusion
Which type of fluid imbalance would a nurse suspect when the morning patient assessment reveals bounding peripheral pulses and jugular venous distention?
Increased interstitial fluids
Increased circulating volume
Increased intracellular volume
Increased transcellular volume
Increased circulating volume
A patient who received hypotonic intravenous (IV) fluids has developed the signs and symptoms of hypotonic fluid volume excess (FVE). Which neurologic signs or symptoms are consistent with this fluid imbalance?
Select all that apply.
Seizures
Paralysis
Tingling sensations in the lower extremities
Confusion
Facial numbness
Seizures
Confusion
Which explanation would a nurse give to a student regarding the primary cause of edema resulting from fluid volume excess?
Increased capillary permeability
Obstruction of lymphatic drainage
Decreased circulating plasma proteins
Increased hydrostatic pressure
Increased hydrostatic pressure
Which descriptions would a nurse provide when educating a patient about edema?
Select all that apply.
Edema is caused by excessive fluid in the interstitial space.
Edema develops when fluid moves into the intravascular space faster than it is absorbed.
Dependent edema occurs in the sacral area of patients on bedrest.
Edema causes tissue to become quite fragile.
Increased circulating plasma proteins are a major cause of edema.
Edema is caused by excessive fluid in the interstitial space.
Dependent edema occurs in the sacral area of patients on bedrest.
Edema causes tissue to become quite fragile.
Match the signs and symptoms to their underlying cause.
Increased interstitial fluid volume
Increased circulating fluid volume
Pulmonary edema
Answers Choices
Shortness of breath, cough
Edema of the ankles and feet
Bounding peripheral pulses and hypertension
Increased interstitial fluid volume
Edema of the ankles and feet
Increased circulating fluid volume
Bounding peripheral pulses and hypertension
Pulmonary edema
Shortness of breath, cough
Which assessments would the nurse closely monitor as indicators of changes in a patient’s fluid volume status?
Select all that apply.
Vital signs
Pain level
Daily weights
Bowel sounds
Intake and output
Vital signs
Daily weights
Intake and output
Which substances would the nurse include in a patient’s fluid intake tally at the end of 24 hours?
Select all that apply.
Intravenous fluids
A dish of cherry-flavored gelatin
A piece of toast
Supplemental enteral feedings
A small piece of chicken
Intravenous fluids
A dish of cherry-flavored gelatin
Supplemental enteral feedings
Which measurements would the nurse include in a patient’s fluid output tally at the end of the day?
Select all that apply.
Urine in a urinary catheter collection bag
A soft, formed stool
Emesis caused by a vomiting episode
A large volume enema
Free water flushes for enteral feedings
Urine in a urinary catheter collection bag
Emesis caused by a vomiting episode
Which items are commonly used as measuring tools for urine output?
Select all that apply.
Urine hat
Diaper
Urinal
Indwelling catheter
Wound dressing
Urine hat
Diaper
Urinal
Indwelling catheter
Which factors would a nurse consider when planning fluid intake for a patient on a 1200 mL fluid restriction plan?
Select all that apply.
Meals
Medications
Solid foods on menu plan
Intravenous (IV) fluid intake
Between-meal fluids
Meals
Medications
Intravenous (IV) fluid intake
Between-meal fluids
A patient has been placed on fluid restriction for management of fluid volume excess. Which actions would the nurse take to ensure the alert, adult patient is responsible and comfortable meeting the fluid restriction goals?
Keep water and other beverages away from the bedside and only distribute them to the patient on a schedule.
Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day.
Provide two-thirds of the fluid volume during the day and restrict the remaining one-third to be given with medications.
Assess and document all fluids consumed by the patient using an oral intake log kept at the bedside.
Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day.
Which action would the nurse take after noting that at 1:00 p.m. a patient on a fluid restriction has consumed 800 mL of the daily allotted 1200 mL?
Hold all fluid intake except for what is needed for administering medications and begin distributing remaining allotment at the evening meal.
Fill a water pitcher with 400 mL of water to be budgeted for medications and drinking for the remainder of the day.
Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day.
Give the patient 200 mL of fluid now and plan on giving the remaining 200 mL with the evening meal.
Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day.
Which related actions would be included when carrying out the nursing intervention “Provide water and a variety of fluids based on patient preferences” for a patient who requires oral fluid replacement?
Select all that apply.
Distribute fluid intake equally throughout the 24-hour day.
Encourage intake of caffeinated beverages.
Keep a pitcher of fresh water at the bedside at all times.
Determine which beverages the patient prefers.
Remove water and beverages during hours of sleep
Keep a pitcher of fresh water at the bedside at all times.
Determine which beverages the patient prefers.
Which questions would the nurse consider when choosing the intravenous (IV) site for a patient with a prescription to start IV fluids?
Select all that apply.
What is the condition of the patient’s veins?
What is the patient’s age?
How long is the patient to receive IV therapy?
What is the patient’s diagnosis?
Will family members be staying in the patient’s room?
What is the condition of the patient’s veins?
What is the patient’s age?
How long is the patient to receive IV therapy?
What is the patient’s diagnosis?
Which complication would a nurse need to monitor for when assigned a patient receiving 0.9% normal saline intravenously?
Hypovolemia
Hypernatremia
Cellular dehydration
Water intoxication
Hypernatremia
Match each intravenous (IV) fluid name to its corresponding category.
Hypotonic crystalloid
Isotonic crystalloid
Hypertonic crystalloid
Answer choices
0.45% normal saline (0.45% NS)
5% dextrose and 0.9% normal saline (D5 0.9 NS)
5% dextrose and water (D5W)
Hypotonic crystalloid
0.45% normal saline (0.45% NS)
Isotonic crystalloid
5% dextrose and water (D5W)
Hypertonic crystalloid
5% dextrose and 0.9% normal saline (D5 0.9 NS)
A patient receiving an intravenous (IV) crystalloid infusion reports that the IV site hurts. The nurse notes redness, swelling, and warmth at the IV site. Which complications would the nurse consider as a result of these signs and symptoms?
Select all that apply.
Collapsed vein
Phlebitis
Extravasation
Catheter-related infection
Infiltration
Phlebitis
Catheter-related infection
Which major uses of a central venous catheter (CVC) would a nurse recognize?
Select all that apply.
Long-term intravenous (IV) therapies
Short-term single IV therapy
Short-term intensive therapies
Administering hypertonic solutions
Administering nonirritating IV medications
Long-term intravenous (IV) therapies
Short-term intensive therapies
Administering hypertonic solutions
Which patients are candidates for blood or blood product administration?
Select all that apply.
A patient with missing clotting factors
A patient with drug-related destruction of red blood cells
A patient who is severely dehydrated
A patient with abdominal bleeding from trauma
A patient who has had recent major surgery
A patient with missing clotting factors
A patient with drug-related destruction of red blood cells
A patient with abdominal bleeding from trauma
A patient who has had recent major surgery
Which individuals are responsible for checking and verifying blood prior to administration?
Select all that apply.
Personnel in the blood bank
Nurse who picks up the blood from the blood bank
Two nurses at the patient’s bedside before initiating -transfusion
Shift nurse in charge
Primary health care provider
Personnel in the blood bank
Nurse who picks up the blood from the blood bank
Two nurses at the patient’s bedside before initiating -transfusion
The nurse must ensure that a blood product is infused within
_4___ hours after leaving the blood bank?
Use numbers only.
4
Which data reflect the priority assessments that a nurse would monitor when concerned that a patient may be developing a fluid volume imbalance?
Select all that apply.
The patient’s self-report of pain
The patient’s pulse and blood pressure
The patient’s weight changes over the past day
The patient’s cranial nerve status
The patient’s intake and output balance over the past 48 hours
The patient’s pulse and blood pressure
The patient’s weight changes over the past day
The patient’s intake and output balance over the past 48 hours
Which substances would a nurse need to include in the fluid intake tally?
Select all that apply.
Small volume enemas
Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
Which patient-related data would require entry of fluid output information on the electronic health record (EHR)?
Select all that apply.
The patient has a nasogastric (NG) tube attached to wall suction.
The patient is receiving bladder irrigations.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
The patient had a large volume enema this morning.
The patient has a nasogastric (NG) tube attached to wall suction.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs after receiving a “force fluids” prescription for a fluid volume deficit?
Select all that apply.
Ensuring the pitcher of water at the patient - bedside is refilled as required
Providing coffee and sodas at frequent intervals in addition to water
Providing ways to record intake of fluids to meet required levels
Tapering off fluid intake so the least amount is ingested before bedtime
Reminding the patient to drink throughout the day
Ensuring the pitcher of water at the patient - bedside is refilled as required
Providing ways to record intake of fluids to meet required levels
Tapering off fluid intake so the least amount is ingested before bedtime
Reminding the patient to drink throughout the day
Which factors would be included by the nurse when developing a 24-hour fluid budget for a patient with a 1000 mL fluid restriction?
Select all that apply.
Medications
Intravenous (IV) fluids
Solid foods consumed
Between-meal fluid sipping
Breakfast, lunch, and dinner
Medications
Intravenous (IV) fluids
Between-meal fluid sipping
Breakfast, lunch, and dinner
Which plan would a nurse suggest for the remainder of the 24-hour period for a patient on a 1000 mL per day fluid restriction who has consumed 700 mL as of 3:00 p.m.?
Allow the patient to consume another 300 mL right away and nothing more by mouth for the remainder of the 24-hour period.
Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep.
Remove all water and beverages from the room and allow the patient to consume 300 mL before going to sleep.
Give the patient 150 mL at 3:00 p.m. and the remaining 150 mL before the patient goes to sleep.
Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep.
The nurse suspects that a patient receiving an intravenous (IV) infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. For which reason would this IV solution cause this complication?
It is an isotonic solution.
It is a colloid solution.
It is a hypotonic solution.
It is a hypertonic solution.
It is a hypertonic solution.
Which intravenous (IV) site in infants is most commonly used?
The vein at the top of the foot
The vein at the bend of the elbow
The vein in the middle of the scalp
The jugular vein in the neck
The vein in the middle of the scalp
Which actions related to intravenous (IV) fluid administration are the responsibility of the registered nurse?
Select all that apply.
Verify that the fluid is appropriate for the patient.
Evaluate the effectiveness of IV therapy.
Monitor the patient for complications of IV therapy.
Comply with the 6 rights of safe medication administration.
Directly obtain the patient’s vital signs.
Verify that the fluid is appropriate for the patient.
Evaluate the effectiveness of IV therapy.
Monitor the patient for complications of IV therapy.
Comply with the 6 rights of safe medication administration.
Which complications would a nurse need to monitor for when caring for a patient receiving a hypertonic intravenous (IV) fluid?
Select all that apply.
Hypovolemia
Cellular dehydration
Circulatory overload
Water intoxication
Air embolism
Cellular dehydration
Circulatory overload
Air embolism
Which intravenous (IV) solution would a nurse use to prime the IV tubing when preparing to administer a blood product?
5% dextrose and water
0.45% normal saline
5% dextrose in 0.9% normal saline
0.9% normal saline
0.9% normal saline
Which procedural step failure would a nurse recognize as the most common cause of adverse blood transfusion events?
Incomplete documentation during the verification process
Failure to obtain informed consent prior to blood administration
Blood exceeds the 4-hour time limit after leaving the blood bank
Inappropriate identification prior to blood administration
Inappropriate identification prior to blood administration
During which time period would the nurse ensure extra vigilance when administering a blood product?
As the transfusion is started and within the first 15 minutes
Directly after the unit of blood has infused
1 to 2 hours after the transfusion has completed
Approximately 2 hours after starting a transfusion
As the transfusion is started and within the first 15 minutes
Which signs or symptoms of an adverse reaction would a nurse monitor for in a patient who is receiving a unit of blood?
Select all that apply.
Itching
Hypotension
Dyspnea
Fever
Pale, cool skin
Itching
Hypotension
Dyspnea
Fever
Which intervention would the nurse independently implement for a patient experiencing respiratory acidosis?
Increasing the rate of IV fluid administration
Encouraging deep breathing exercises
Encouraging breathing into a paper bag.
Administering a prescribed narcotic
Encouraging deep breathing exercises
Which nursing intervention is appropriate for all patients experiencing an acid-base imbalance?
Encouraging deep breathing exercises
Monitoring the arterial blood gas (ABG) analysis
Restricting fluids
Administering oxygen per prescription
Monitoring the arterial blood gas (ABG) analysis
Which nursing intervention would the nurse anticipate for a patient experiencing respiratory acidosis with chronic obstructive pulmonary disease (COPD)?
Administering an antipyretic
Administering breathing treatments
Increasing the patient’s oral fluid intake
Having the patient breathe into a paper bag
Administering breathing treatments
Which interventions would the nurse anticipate when caring for a patient experiencing metabolic acidosis?
Select all that apply.
Administering insulin
Administering potassium
Implementing seizure precautions
Administering sodium bicarbonate
Having mechanical ventilation available
Administering insulin
Administering potassium
Administering sodium bicarbonate
Having mechanical ventilation available
Which intervention would the nurse anticipate when caring for a patient experiencing metabolic alkalosis?
Administering insulin
Treating hyperkalemia
Implementing seizure precautions
Administering sodium bicarbonate
Implementing seizure precautions
Which intervention is appropriate for a patient experiencing metabolic acidosis?
Implementing seizure precautions
Administering glucose
Limiting ingestion of bicarbonate products
Having mechanical ventilation available
Having mechanical ventilation available
Which intervention would the nurse include in the plan of care for a patient experiencing respiratory alkalosis?
Restricting fluids
Administering bicarbonate
Administering antihypertensives
Having the patient breathe into a paper bag
Having the patient breathe into a paper bag
Which members of the health care team would the nurse include when planning a collaborative care conference about the acute phase of any acid-base imbalance?
Select all that apply.
Unlicensed assistive personnel
Physical therapist
Health care provider
Respiratory therapist
Occupational therapist
Health care provider
Respiratory therapist
Which interventions would the nurse independently implement for a patient experiencing respiratory acidosis?
Select all that apply.
Increasing the rate of IV fluid administration
Encouraging deep breathing exercises
Monitoring breath sounds
Providing emotional support
Administering a prescribed narcotic
Encouraging deep breathing exercises
Monitoring breath sounds
Providing emotional support
Which interventions would the nurse anticipate when caring for a patient experiencing metabolic alkalosis?
Select all that apply.
Administering potassium
Administering insulin
Implementing seizure precautions
Administering sodium bicarbonate
Administering diuretics
Administering potassium
Implementing seizure precautions
The nurse is caring for a patient admitted with metabolic alkalosis. Which intervention would the nurse anticipate when providing care to this patient?
Preparing for mechanical ventilation
Administering the prescribed sodium bicarbonate
Implementing seizure precautions
Holding foods rich in potassium
Implementing seizure precautions
Which intervention would the nurse anticipate when caring for a patient experiencing metabolic acidosis?
Administering antibiotics
Implementing seizure precautions
Providing incentive spirometry
Providing mechanical ventilation
Providing mechanical ventilation
Which solutions by the nurse are appropriate when caring for a patient with known hyponatremia?
Select all that apply.
Administer potassium supplements.
Increase oral fluid intake.
Instruct the patient to avoid sports drinks and drink mostly water.
Assist the patient to adhere to fluid restriction requirements.
Monitor intake and output.
Assist the patient to adhere to fluid restriction requirements.
Monitor intake and output.
Which nursing action is appropriate for a patient experiencing continued hypokalemia despite a week of treatment?
Instruct the patient not to take a diuretic until potassium levels are normal.
Instruct the patient to avoid salt substitutes.
Report laboratory values to the health care provider.
Instruct the patient to take potassium supplements with water only.
Report laboratory values to the health care provider.
Match the method of potassium replacement with the appropriate nursing action.
Administer with juice
Teach the use of salt substitutes
Never administer by push or bolus
Answer choices
Oral
Intravenous
Dietary
Administer with juice
Oral
Teach the use of salt substitutes
Dietary
Never administer by push or bolus
Intravenous
Which patients would benefit from administration of a calcium supplement?
Select all that apply.
A 20-year-old young adult with no health problems
A 55-year-old woman who has been through menopause
A 79-year-old male patient who resides in a nursing - home
A 35-year-old male marathon runner
A 72-year-old female patient who does not take any supplements
A 55-year-old woman who has been through menopause
A 79-year-old male patient who resides in a nursing - home
A 72-year-old female patient who does not take any supplements
Which foods would the nurse instruct the patient with hypercalcemia to avoid?
Select all that apply.
Milk
Yogurt
Spinach
Dried fruit
Sardines
Milk
Yogurt
Spinach
Sardines
Match the electrolyte imbalance with the appropriate nursing intervention.
Monitor intake and output and restrict intake of processed foods.
Monitor electrocardiogram (ECG) and restrict intake of bananas and potatoes.
Encourage oral fluid intake and physical activity.
Assess deep tendon reflexes.
Answer choices
Hyperkalemia
Hypercalcemia
Hyperphosphatemia
Hypermagnesemia
Monitor intake and output and restrict intake of processed foods.
Hyperphosphatemia
Monitor electrocardiogram (ECG) and restrict intake of bananas and potatoes.
Hyperkalemia
Encourage oral fluid intake and physical activity.
Hypercalcemia
Assess deep tendon reflexes.
Hypermagnesemia
Which foods would the nurse teach patients to avoid when diagnosed with hyperkalemia?
Select all that apply.
Broccoli
Cheese
Cabbage
Bananas
Milk
Broccoli
Cabbage
Bananas
Which electrolytes would a nurse monitoring cardiac telemetry recognize as critical to proper cardiac functioning?
Select all that apply.
Sodium
Calcium
Magnesium
Phosphates
Potassium
Magnesium
Phosphates
Potassium
Which primary purpose of cardiac monitoring would the nurse include in a teaching session for patients with electrolyte imbalances?
To prevent worsening of their imbalance
To be able to monitor when an imbalance is improved
To carefully monitor fluid status
To monitor for cardiac dysrhythmias
To monitor for cardiac dysrhythmias
Which statement regarding cardiac telemetry monitoring is accurate?
The nurse attaches the patient to a portable monitor and requests the patient to remain immobile.
The nurse attaches electrodes, which are connected to a portable monitor allowing for patient movement, to the patient’s chest.
A monitor must remain at the patient’s bedside, and the nurse must check the rhythm when assessing the patient.
The patient has periodic electrocardiograms (ECGs) performed, and the results are sent to the physician
The nurse attaches electrodes, which are connected to a portable monitor allowing for patient movement, to the patient’s chest.
Which level of potassium is considered a medical emergency that requires immediate monitoring with cardiac telemetry?
2.1 mEq/L
3.5 mEq/L
4.1 mEq/L
5.1 mEq/L
2.1 mEq/L
Which statement describes the purpose of dialysis?
Corrects electrolyte deficits
Corrects dehydration
Provides fluid and electrolyte balance
Replaces lost electrolytes
Provides fluid and electrolyte balance
Which concepts would a nurse include when teaching a patient requiring dialysis for an electrolyte imbalance?
Select all that apply.
Dialysis may be needed as a result of decreased renal - function.
Dialysis is always long term.
Dialysis replaces lost potassium.
Blood is drawn from the body and processed through -a series of filters to remove wastes.
Dialysis helps remove excess fluid and electrolytes.
Dialysis may be needed as a result of decreased renal - function.
Blood is drawn from the body and processed through -a series of filters to remove wastes.
Dialysis helps remove excess fluid and electrolytes.
For which reason are patients diagnosed with impaired renal function prescribed dialysis for the treatment of electrolyte imbalances?
Dialysis is required because of the effect of electrolytes on the patient’s cardiac activity.
The kidneys are unable to excrete increased electrolytes.
People with impaired renal function do not need to restrict electrolyte intake.
People with impaired renal function always have fluid volume deficit.
The kidneys are unable to excrete increased electrolytes.
Which intervention would a nurse anticipate for a patient with a blood pressure of 80/40 mm Hg who is scheduled for dialysis later in the day?
Renewed potassium supplement dosage
Intravenous (IV) fluid administration
Cancellation of dialysis
Increased oral fluid intake
Intravenous (IV) fluid administration
Which patient conditions would benefit from electrocardiogram (ECG) monitoring because of an electrolyte imbalance?
Select all that apply.
Hyponatremia
Hypokalemia
Hypophosphatemia
Hypocalcemia
Hypomagnesemia
Hypokalemia
Hypocalcemia
Hypomagnesemia
Which action would be taken by a nurse who is administering intravenous (IV) potassium to a patient who is experiencing acute hypokalemia?
Administering over a short period of time
Administering the dose by IV push
Administering the solution slowly
Administering to replenish fluid and electrolyte loss
Administering the solution slowly
Which parameter would a nurse monitor when providing care to a patient prescribed intravenous (IV) normal saline (NS) for a prolonged period?
Hyponatremia
Fluid volume excess
Hyperkalemia
Hypokalemia
Fluid volume excess
Which foods would a nurse teach the patient to avoid when prescribed a low sodium diet for hypernatremia?
Select all that apply.
Canned soup
Fresh vegetables
Sports drinks
Apples
Table salt
Canned soup
Sports drinks
Table salt
Which food item would a nurse who is providing education to a patient with hypermagnesemia teach the patient to avoid?
Table salt
Dairy products
Green, leafy vegetables
Canned or processed food
Green, leafy vegetables
Which instruction would a nurse give to a patient experiencing hypermagnesemia?
Avoid taking antacids.
Increase green, leafy vegetables.
Reduce the amount of sodium intake.
Increase fluid intake
Avoid taking antacids.
Which patient electrolyte level would require the nurse to prepare for cardiac monitoring?
A magnesium level of 52.2 mEq/L
A potassium level of 2.4 mEq/L
A calcium level of 4.22 mEq/L
A sodium level of 139 mEq/L
A potassium level of 2.4 mEq/L
Which electrolytes are critical for proper cardiac functioning and would be included in a teaching session on cardiac telemetry?
Select all that apply.
Sodium
Phosphate
Magnesium
Calcium
Potassium
Phosphate
Magnesium
Calcium
Potassium
Which advantage of cardiac telemetry would the nurse include when teaching a patient with an electrolyte imbalance?
Allows the patient’s cardiac activity to be monitored remotely without affecting the patient’s mobility
Provides ongoing assessment of the - patient’s electrolyte levels
Provides documentation for causes of cardiac dysrhythmias
Indicates which nursing interventions are needed to correct specific electrolyte abnormalities
Allows the patient’s cardiac activity to be monitored remotely without affecting the patient’s mobility
Which nursing actions would be implemented prior to a patient receiving a dialysis treatment?
Select all that apply.
Obtaining vital signs
Increasing oral fluid intake
Assessing laboratory data
Providing instruction about what the patient should - expect
Restricting oral intake 4 hours prior to the treatment
Obtaining vital signs
Assessing laboratory data
Providing instruction about what the patient should - expect
Which observation would the nurse expect after dialysis in a patient with a serum potassium level of 7.0 mEq/L?
There will be no change in the patient’s potassium level.
The serum potassium concentration will increase.
The serum potassium concentration will decrease.
What will happen to the serum potassium cannot be determined.
The serum potassium concentration will decrease
Which patient statement indicates understanding after a nurse completes education for a patient prescribed to receive dialysis to treat an electrolyte imbalance?
“Dialysis will improve my kidney function.”
“Dialysis will correct any fluid imbalances in the body.”
“Dialysis can correct my dangerously low electrolyte levels.”
“Dialysis removes excess wastes and electrolytes from my body.”
“Dialysis removes excess wastes and electrolytes from my body.”
Which questions would the nurse ask when conducting a health history assessment for a patient with a potassium imbalance?
Select all that apply.
“Do you have lactose intolerance?”
“Do you take a diuretic, such as furosemide?”
“Are you experiencing swelling in your feet?”
“Do you use a salt substitute on your food?”
“Do you eat canned meats or vegetables often?
“Do you take a diuretic, such as furosemide?”
“Do you use a salt substitute on your food?”
Which assessment finding would support the diagnosis of hypocalcemia?
Trousseau sign
Lethargy
Shallow respirations
Stupor
Trousseau sign
Which test would the nurse anticipate for a patient with hyperkalemia?
Urine specific gravity
Serum calcium
Electrocardiogram (ECG)
Urine osmolality
Electrocardiogram (ECG)
Which action would a nurse take when assessing for Trousseau sign?
Tap the skin over the facial nerve.
Have the patient exhale with a closed mouth and a pinched nose.
Cut the blood supply off with a blood pressure (BP) cuff.
Measure the BP of a patient standing and lying down.
Cut the blood supply off with a blood pressure (BP) cuff.
Match the physical assessment with the data indicating an electrolyte imbalance.
Spasm of the facial muscles when facial nerve is tapped
Spasm of the hand and wrist muscles after blood pressure cuff is inflated
Foot kicks wildly when patellar tendon is tapped
Answer Choices
Chvostek sign
Trousseau sign
Deep tendon reflex
Spasm of the facial muscles when facial nerve is tapped
Chvostek sign
Spasm of the hand and wrist muscles after blood pressure cuff is inflated
Trousseau sign
Foot kicks wildly when patellar tendon is tapped
Deep tendon reflex
Which cues would the nurse anticipate when assessing a patient with a serum sodium level of 152 mEq/L?
Select all that apply.
Hyperactive deep tendon reflexes
Confusion
Thirst
Lethargy
Seizures
Confusion
Thirst
Lethargy
Seizures
Which cues would a nurse expect in a patient with a serum potassium concentration of 3.1 mEq/L?
Select all that apply.
Confusion
Postural hypotension
Cardiac dysrhythmia
Decreased bowel sounds
Hyperactive deep tendon reflexes
Postural hypotension
Cardiac dysrhythmia
Decreased bowel sounds
Which cue would a nurse expect in a patient with severe hypocalcemia?
Stupor
Personality changes
Laryngospasm
Constipation
Laryngospasm
Which relevant cues would the nurse expect to observe when assessing a patient with hypomagnesemia?
Select all that apply.
Diaphoresis
Seizures
Cardiac dysrhythmia
Nystagmus
Tremors
Seizures
Cardiac dysrhythmia
Nystagmus
Tremors
Which laboratory test would the nurse anticipate for an alert patient who presents to the emergency department with severe bilateral lower extremity weakness, shallow respirations, and normal heart rate and rhythm?
Serum potassium
Urine specific gravity
Serum sodium
Serum calcium
Serum potassium
Which neurologic assessment, performed by tapping the side of the face, would the nurse perform for a patient with risk factors for hypocalcemia?
Level of consciousness exam
Trousseau sign
Electrocardiogram
Chvostek sign
Chvostek sign
Which specific questions would a nurse include in the assessment interview for a patient with hypermagnesemia?
Select all that apply.
“What type of laxatives do you use?”
“Have you had diarrhea recently?”
“Do you use over-the-counter antacids?”
“Do you have lactose intolerance?”
“Do you take a prescribed diuretic?”
“What type of laxatives do you use?”
“Do you use over-the-counter antacids?”
Which cues would a nurse assess a patient for based on a serum phosphate concentration of 3.1 mEq/L?
Select all that apply.
Tetany
Hyperreflexia
Decreased deep tendon reflexes
Muscle cramps
Shallow respirations
Tetany
Hyperreflexia
Muscle cramps
Which clinical manifestation would a nurse monitor for when providing care to a patient whose serum potassium level is 5.4 mEq/L?
Bradycardia
Hyperactive deep tendon reflexes
Lethargy
Emesis
Bradycardia
Which cue in a patient with end-stage renal disease would a nurse recognize as an indication of hyperphosphatemia?
Decreased blood pressure
Anorexia
Irritated and itchy eyes
Confusion
Irritated and itchy eyes
Place the steps the nurse uses to analyze arterial blood gas (ABG) levels in the correct order.
Evaluate the PaO2 and O2 saturation levels.
Evaluate whether or not compensation is occurring.
Evaluate the PaCO2 and HCO3– to determine if the imbalance is respiratory or metabolic.
Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range.
Evaluate the PaO2 and O2 saturation levels.
Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range.
Evaluate the PaCO2 and HCO3– to determine if the imbalance is respiratory or metabolic.
Evaluate whether or not compensation is occurring.
Match the arterial blood gas (ABG) parameters to their normal values.
7.35–7.45
35–45 mm Hg
80–100 mm Hg
22–26 mEq/L
Answer Choices
pH
PaCO2
PaO2
HCO3–
7.35–7.45
pH
35–45 mm Hg
PaCO2
80–100 mm Hg
PaO2
22–26 mEq/L
HCO3–
Which information would the nurse require regardless of the type of acid-base imbalance?
Urine output
Arterial blood gas (ABG) analysis
Skin turgor
Bowel sounds
Arterial blood gas (ABG) analysis
Which PaO2 value range indicates moderate hypoxemia?
20 to 40 mm Hg
40 to 60 mm Hg
60 to 80 mm Hg
80 to 100 mm Hg
40 to 60 mm Hg
Match the clinical manifestation for respiratory acidosis to the corresponding system.
Cardiovascular
Neurologic
Respiratory
Answer choices
Dyspnea
Headache
Tachycardia
Cardiovascular
Tachycardia
Neurologic
Headache
Respiratory
Dyspnea
Which acid-base imbalance manifests with tachypnea and lightheadedness?
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Respiratory alkalosis
Which neurologic cues are associated with metabolic acidosis?
Select all that apply.
Nausea
Confusion
Lethargy
Tachycardia
Anorexia
Confusion
Lethargy
Which acid-base imbalance may be associated with progression to seizures?
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Which conclusion would the nurse make when the ABG results for a patient suspected of having an acid-base imbalance reveal a decreased pH, increased PaCO2, and normal HCO3–?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Which actions would the nurse perform when analyzing ABG values for a patient suspected of having an acid-base imbalance?
Select all that apply.
Examining oxygenation status
Evaluating the pH
Assessing PaCO2 and HCO3–
Monitoring potassium
Determining compensation
Examining oxygenation status
Evaluating the pH
Assessing PaCO2 and HCO3–
Determining compensation
Which acid-base imbalance would the nurse suspect when providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3– 20 mEq/L?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Metabolic acidosis
Which assessments would the nurse perform in all patients experiencing an acid-base imbalance?
Select all that apply.
Skin turgor
Urine output
Bowel sounds
ABG analysis
Vital signs
ABG analysis
Vital signs
Which cardiovascular findings would the nurse anticipate in a patient with respiratory acidosis?
Select all that apply.
Tachycardia
Dysrhythmia
Hypotension
Dyspnea
Confusion
Tachycardia
Dysrhythmia
Which clinical manifestation would the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis?
Dyspnea
Tachypnea
Hypertension
Hypotension
Tachypnea
Which assessment finding would cause the nurse to suspect that a patient is experiencing metabolic acidosis?
Dyspnea
Kussmaul respirations
Polyuria
Muscle twitching
Kussmaul respirations
Which acid-base imbalance would the nurse suspect in a patient presenting with muscle twitching and tetany who experiences a seizure 10 minutes after hospital admission?
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
