The nurse is providing care to a pt who is dx with multisystem fluid volume deficit. The pt is currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. The pt has a decreased urine output. Which pro
Natural compensatory mechanisms
The nurse is providing care to a pt whose serum calcium levels have increased since a surgical procedure performed three days prior. Which intervention should the nurse implement to decrease the risk for the development of hypercalcemia?
Encourage ambulation three times a day
Which intervention should the nurse implement for a pt whose serum phosphorus level is 2.0?
Encourage consumption of milk and yogurt
The nurse is providing care to a pt who is prescribed furosemide as part of the tx for CHF. The pt's sreum potassium is 3.4. Which food should nurse encourage the pt to eat based on this data?
Bananas
A pt is admitted to the ED for dehydration. The pt is 154 pounds. Which urine output indicate the rehydration efforts for this pt have been effective?
35mL/hr
An older pt, who appears intermittently confused, is admitted to the hospital after a fall. Based on the current data, which is the pt at an increased risk for developing?
Dehydration
The nurse is providing care to an older pt who is receiving IVF at 150cc/hr. The pt is currently exhibiting crackles in the lungs, SOB, and JVD. Which complication of IVF therapy does nurse suspect the pt is experiencing?
Fluid volume excess
A pt is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for this drug the nurse should provide to the pt?
It is needed to maintain skeletal, cardiac, and neuro activity
Which data collected by the nurse during the assessment process places the older pt at risk for dehydration?
Water intake of 2 glasses per day
The nurse is reviewing lab values for a female pt suspected of having a fluid imbalance. Which lab value evaluated by the nurse supports the dx of dehydration?
Serum osmolality 230
The nurse is analyzing the intake and output record for a pt being treated for dehydration. The pt weighs 176lb, and had a 24hr intake of 2,000mL and urine output of 1,200 mL. Based on this data, which conclusion by the nurse is most appropriate?
Treatment is effective and should continue.
Nurse is providing care to a pt who seeks emergency tx for headache and nausea. The pt works in a mill without air conditioning. The pt states, "I drink water several times each day but I seem to sweat more than I am able to replace." Which suggestions sh
Eat something salty when drinking water.
An older pt, who lives in a long term care facility, presents in the ED due to fever, N/V over the past two days. The pt denies thirst. The urine dipstick indicates a decreased urine specific gravity. Which medical dx should nurse anticipate when planning
Dehydration
Nurse receives shift report on a pediatric med-surg unit. The nurse has been assigned four pts for the shift. Which child does nurse plan to assess first based on the increased risk for dehydration?
A 15 month old child with tachypnea
Nurse is teaching a group of children and their parents about prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session?
I will have my child stop every 15-20 minutes during the activity for fluids.
The nurse is providing care to an adult pt admitted with dehydration and hyponatremia. Which medical condition supports the current nursing dx of Electrolyte Imbalance?
Hypotonic dehydration
The nurse is caring for a pt who is receiving IVF postop following cardiac sx. The nurse is aware that this pt is at risk for fluid volume excess. The family asks why the pt is at risk for this condition. Which response by the nurse is most appropriate?
Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of sx.
The nurse is providing care to a pt following hemodialysis. The pt is experiencing tachycardia and decreased urine output along with skin that is pale and cool to touch. Which goal of hemodialysis does the nurse determine the pt has not met based on curre
A reduction of extracellular fluid
The nurse is caring for a pt with CHF who is admitted to the Med-Surg unit with acute hypokalemia. Which prescribed medication may have contributed to the pt's current hypokalemic state?
Cortisol
The nurse is caring for a pt with a potassium level of 5.9. The provider prescribes both glucose and insulin for the pt. The pt's spouse asks, "Why is insulin needed?" Which response by nurse is most appropriate?
The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood.
A pt is admitted to the ED for fluid volume deficit. Which body system should the nurse focus to determine the cause of this imbalance when assessing this pt?
Gastrointestinal
The nurse is instructing a pt with heart failure about a prescribed sodium-restricted diet. Which pt statement indicates that additional teaching required?
I can use as much salt substitute as I want.
The nurse is planning care for the pt with acute renal failure. The nurse plans the pts care based on the nursing dx of Excess Fluid Volume. Which assessment data supports this nursing dx?
Pitting edema in lower extremities.
A pt with acute renal failure has JVD, lower ext edema, and elevated blood pressure. Based on this data, which nursing dx is most appropriate?
Excess Fluid Volume
Nurse is caring for a pt admitted with HTN and chronic renal failure who receives hemodialysis three times per week. The nurse is assessing the pt's diet and notes the use of salt substitutes. When teaching the pt to avoid salt subs, which rationale suppo
They can potentiate hyperkalemia.
The nurse is providing care to a pt who is exhibiting clinical manifestations of a fluid/electrolyte deficit. Based on this data, which health care provider prescriptions does nurse prepare to implement?
Initiate hypodermoclysis
Closely monitor pt's I&Os
Initiate IV therapy
A pt's serum sodium level is 150. Based on this data, which interventions should nurse plan for this pt?
Instruct on a low sodium diet.
Administer diuretics as prescribed.
The school nurse is preparing a class session for high school students on ways to maintain fluid balance during summer months. Which interventions should the nurse recommend?
Reduce the intake of coffee and tea.
Drink more fluids during hot weather.
Drink flat cola or ginger ale if vomiting.
The nurse is concerned that an older adult pt is at risk for developing acute renal failure. Which info in the pt's hx support the nurse's concern?
Diagnosed with hypotension.
Recent aortic valve replacement sx
Prescribed high doses of IV abx
The community nurse visits the home of a young child who is home from school because of sudden onset of N/V, and lethargy. The nurse suspects acute renal failure. Which clinical manifestations support the nurse's suspicions?
Edema
Hematuria
Elevated blood pressure.
The nurse is providing care for an adult pt who is admitted to the ED after passing out. The pt has been fasting and currently has ketones in the urine. Which acid-base imbalance should the nurse monitor the pt for based on current data?
Metabolic acidosis
The nurse is providing care to pt with the following lab values: pH-7.31, PaCO2-48, and a normal HCO3. Which condition should nurse plan care for based on current data?
Respiratory acidosis
The nurse is reviewing the latest ABGs for a pt with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated?
PaCO2 48
Which dx test should nurse anticipate when providing care to a pt dx with COPD to monitor acid-base balance?
ABG
Which pt statement indicates the need for additional education regarding the use of sodium bicarb to treat acidosis?
I should use the antacid for at least 2 months
The pt is receiving sodium bicarb IV for correction of acidosis secondary to diabetic coma. The nurse assess the pt to be lethargic, confused, and breathing rapidly. Which is the nurse's priority response to the current situation?
Continue to infusion, because the pt is still in acidosis, and notify the provider.
The nurse is planning care for an older pt with respiratory acidosis. Which intervention should the nurse include in this pt's plan of care?
Maintain adequate hydration.
The results of a pts ABG sample indicate an oxygen level of 72. Which should the nurse closely assess when providing care to this pt?
Cognition
The nurse is caring for a comatose pt with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this pt?
Determining recent eating behaviors
The nurse is analyzing the pt's ABG report, which reveals a pH of 7.15. The pt has just suffered a cardiac arrest. Which consequences of the pH value does the nurse consider for this pt?
Decreased cardiac output
The nurse is caring for a pt admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective?
Decreased depth of respirations
A pt with metabolic acidosis has been admitted to the unit from the ED. The pt is experiencing confusion and weakness. Which independent nursing intervention is the priority?
Protecting the pt from injury
The nurse is reviewing new orders provided by the health care provider for a critical care pt with metabolic acidosis. Which prescription should the nurse question?
Administer one ampule of sodium bicarb now.
The nurse is providing care to a pt who has been vomiting for several days.The nurse knows that the pt is at risk for metabolic alkalosis bc gastric secretions have which characteristics?
Gastric secretions are acidic.
Which is the priority nursing action when providing care to a pt who is admitted with metabolic alkalosis?
Monitoring oxygen saturation
The nurse is providing care to a pt who is admitted after a morphine overdose. Which acid-base imbalance should nurse plan this pt's care to reflect?
Respiratory acidosis
The nurse is providing care for a pt admitted to unit with respiratory failure and respiratory acidosis. Which data from the nursing hx is the probable cause for the pt's current dx?
Aspiration pneumonia
Which chronic lung condition noted in the pt's health hx supports the current dx of respiratory acidosis?
Cystic fibrosis
A pt is admitted to the ED for the tx of a drug OD causing acute respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current dx?
Oxycodone
Which clinical manifestation supports the nurse's plan of care focusing on chronic respiratory acidosis?
Daytime sleepiness
The nurse is providing care to a pt who is admitted to the hospital with sudden, severe abd pain. Which ABG supports the pt's current dx of respiratory alkalosis?
PH-7.47 and PaCO2 is 25.
The pt is admitted to the ED with symptoms of a panic attack. Based on this data, the nurse plans care for which health problem?
Respiratory alkalosis
The nurse completes DC teaching for a pt with an anxiety disorder. Which pt statement indicates correct understanding of info related to respiratory alkalosis?
I will see my counselor on a regular basis.
The nurse is reviewing the health care provider orders for a pt who is dx with respiratory alkalosis. Which prescription is appropriate for this pt's care needs?
Draw ABG
The nurse is providing care to a pt who is intubated and receiving mechanical vent after a MVA. The pt is fighting the vent and attempting to remove the endotracheal tube. Which nursing action decreases the pt's risk for developing respiratory alkalosis?
Administer a prescribed sedative.
Which risk factors exhibited by the pt presenting in the ED would place the pt at risk for metabolic acidosis?
Abd fistulas
Acute renal failure
Hypovolemic shock
A pt recently dx with DM is hospitalized in DKA after a religious fast. The pt tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religio
-Request a consult from a diabetes educator.
-Assess the meaning and context of fasting for this religion
-Encourage the pt to seek medical care if signs of DKA occur in the future.
The nurse is caring for the pt experiencing hypovolemic shock and metabolic acidosis. Which nursing actions are appropriate for this pt?
Administer sodium bicarb
Monitor EKG for conduction problems.
Keep the bed in the locked and low position.
The nurse is providing care to a pt who is admitted with manifestations of metabolic alkalosis. Which dx test findings support the admitting dx?
Blood pH 7.47 and bicarb 34
EKG changes consistent with hypokalemia.
Which nursing actions are appropriate when conducting an Allen test?
-Rest the pt's arm on the mattress
-Support the pt's wrist with a rolled towel.
-Press the pt's radial and ulnar arteries using the index and middle fingers.