A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?
-Deep tendon reflexes
-Cardiac rhythm
-Peripheral sensation
-Bowel sounds
Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG change
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis?
-pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L
-pH 7.48, PaO2 89 mmHg, PaCO2 30
pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L
An elevated pH and HCO3- with a PaCO2 either elevated or within the expected reference range indicates metabolic alkalosis.
A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?
-Increased urine specific gravity
-Hypoactive bo
Bounding peripheral pulses
The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses.
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first?
-Assist with intubation
-Initiate high-flow oxygen therapy
-Administer a rapid-acting diure
Initiate high-flow oxygen therapy.
When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer?
-Sodium polystyrene sulfona
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr an
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmHg, PaCO2 56 mmHg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances?
-Respiratory acidosis
Respiratory acidosis
Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
-Skin turgor
-Urine output
-Weight
-Mental status
Mental status
The greatest risk to this client is injury from a fall due to a decline in the client's mental status. Therefore, assessing the client's mental status is the nurse's priority.
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding?
-Sodium 152 mEq/L
-Chloride 102 mEq/L
-Magne
Potassium 6.1 mEq/L
Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.
While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take?
-Implement seizure precautions
-Administer phosphate
-Initiate diuretic therapy
-Prepare the client for
Implement seizure precautions.
The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury.
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?
-1 large hard boiled egg
-1 cup bran cereal
- 1/2 cup almo
1 large hard-boiled egg
One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?
-Hyperactive deep-tendon reflexes
-Increased bowel sounds
-Drowsiness
-Decreased blood pressure
Hyperactive deep-tendon reflexes
Hyperactive deep-tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling.
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?
-Urine output
Serum potassium 3.0 mEq/L
This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should repo
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?
- pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L
- pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L
- pH
pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
A pH below 7.35 is an indication of acidosis. HCO3- below 22 mEq/L is an indication of metabolic acidosis.
A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?
-"If my stockings feel tight, I'll just roll them down for a whil
When I sit down to watch television, I'll be sure to put my feet up."
Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating her feet will increase the return. The client should elevate her feet for at least 20 min sever
A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following food should the nurse recommend as containing the greatest amount of potassium?
-1/2 cup chopped celery
-1 cup plain yogurt
-1 slic
1 cup plain yogurt
One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?
-Dextrose 5% in 0.9% sodium chloride
-Dextrose 5% in lactated Ringer's
-3% sodium chloride
-0.45% s
0.45% sodium chloride
A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehyd
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?
-Hepatic failure
-Abdominal pain
-Slow peripheral pulses
-Increase in cardiac output
Slow peripheral pulses
This phosphorus level is below the expected reference range. The nurse should expect the client to have slow peripheral pulses. The nurse might also find that the client's pulses are difficult to find and easy to block.
A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?
-"I will eat more cheese because I can't drink mil
I will add broccoli and kale to my diet."
The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.
A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?
-Hemoglobin 20 g/dL
-Hematocrit 34%
-BUN 25 mg/dL
Urine specific gravity 1.050
Hematocrit 34%
The nurse should identify that a client who has fluid volume excess can have a hematocrit level that is below the expected reference range of 37 to 47% for females or 42 to 52% for males. Fluid volume excess can cause hemodilution and a dec
A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first?
-Monitor the client's bowel soun
Auscultate the client's lungs.
An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?
-Decreased muscle strength
-Decreased gastric motility
-Increased heart rate
-Increased blood pressure
Decreased muscle strength
The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea.
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective?
-BUN 26 mg/dL
-Serum sodium 138 mEq/L
-Hct 56%
-Urine specific gravity
Serum sodium 138 mEq/L
Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 138 mEq/L is within the expected reference range and indicates that the fluid therapy has been
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range i
PaCO2
The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO2 level due to hyperventilation.
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. Which o
Provide calming interventions.
The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and low
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?
-Confusion
-Peripheral edema
-Facial flushing
-Hyperreflexia
Confusion
A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur.
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
-Administer IV fluids to the client evenly over 24 hr
-Provide the
-Administer IV fluids to the client evenly over 24 hr
-Encourage the client to rise slowly when standing up
-Weigh the client every 8 hr
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?
-Hyperactive deep-tendon reflexes
-Orthostatic hypotension
-Rapid, deep respirations
-Stro
Orthostatic hypotension
The nurse should plan to monitor the client for orthostatic hypotension, which places him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider?
-Sodium 128 mEq/L
-Potassium 4.8 mEq/L
-Calcium 9.1 m
Sodium 128 mEq/L
This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.
A nurse is preparing to administer oral potassium for a client who has a
potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?
-Administer a hypertonic solution
-Repeat the potassium level
-Withhold the medication
-Moni
Withhold the medication.
The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the o
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?
-"I should conserve energy by limiting my physical
I will use the incentive spirometer every hour."
Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Therefore, using an incentive spirometer will promote adequate chest expansion.