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The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
Answer: a. The blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patients fluid intake but not as urgently as the hypotension.
A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for:
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss.
Answer: c. decreased serum sodium level.
SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.
When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate assessment to include is:
a. skin turgor.
b. daily weight.
c. presence of edema.
d. hourly urine output.
Answer: b. daily weight.
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake:
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur.
Answer: b. if the oral mucosa feels dry.
An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
A patient is taking potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as:
a. personality changes.
b. frequent loose stools.
c. facial muscle spasms.
d. generalized weakness.
Answer: d. generalized weakness.
Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?
a. I will try to drink at least 8 glasses of water every day.
b. I will use a salt substitute to decrease my sodium intake.
c. I will increase my intake of potassium-containing foods.
d. I will drink apple juice instead of orange juice for breakfast.
Answer: d. I will drink apple juice instead of orange juice for breakfast.
Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking?
a. Restrict patient's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in a 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).
Answer: a. Restrict patient's oral free water intake.
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the patients sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further.
Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a liter of IV fluid.
Answer: b. Infuse the KCl at a rate of 20 mEq/hour.
Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.
A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question?
a. Infuse 5% dextrose in water at 125 ml/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
Answer: a. Infuse 5% dextrose in water at 125 ml/hr.
Because the patients gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringers solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as:
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis
Answer: d. respiratory alkalosis
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
a. Notify the patient's health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Encourage the patient to take deep, slow breaths.
Answer: a. Notify the patient's health care provider.
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Ativan administration will slow the respiratory rate and increase the level of acidosis.
The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for:
a. pallor.
b. edema.
c. confusion.
d. restlessness.
Answer: b. edema.
Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is:
a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema.
Answer: a. lung sounds.
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved?
a. Hematocrit 28%
b. Good skin turgor
c. Absence of peripheral edema
d. Blood pressure 110/72 mm Hg
Answer: c. Absence of peripheral edema.
Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patients protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as:
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis
Answer: a. metabolic acidosis.
The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about:
a. oral digoxin (Lanoxin) 0.25mg daily
b. ibuprofen (Motrin) 400mg every 6 hours
c. metoprolol (Lopressor) 12.5mg orally daily
d. lantus insulin 24 U subcutaneously every evening
Answer: a. oral digoxin (Lanoxin) 0.25mg daily
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.
A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include:
a. maintaining the patient on bed rest.
b. auscultating lung sounds every 4 hours.
c. monitoring for Trousseaus and Chvosteks signs.
d. encouraging fluid intake up to 4000 mL every day.
Answer: d. encouraging fluid intake up to 4000 mL every day.
To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
When teaching a patient with renal failure about a low phosphate diet, the nurse will include information to restrict:
a. ingestion of dairy products.
b. the amount of high-fat foods.
c. the quantity of fruits and juices.
d. intake of green, leafy vegetables.
Answer: a. ingestion of dairy products.
Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.
A nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about:
a. daily alcohol intake
b. intake of dietary protein
c. multivitamin/mineral use
d. use of over-the-counter (OTC) laxatives
Answer: a. daily alcohol intake.
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium level.
A patient who has an infusion of 50% dextrose prescribed asks the nurse why a peripherally inserted central catheter must be inserted. Which explanation by the nurse is correct?
a. The prescribed infusion can be given much more rapidly when the patient has a central line.
b. There is a decreased risk for infection when 50% dextrose is infused through a central line.
c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
d. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
Answer: c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
Which action will the nurse include in the plan of care for a patient who has a central venous access device (CVAD)?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Have the patient turn the head toward the CVAD during injection cap changes.
Answer: b. Use the push-pause method to flush the CVAD after giving medications.
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the patient should turn away from the CVAD during cap changes.
A patient receiving isoosmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider?
a. K+3.4 mEq/L (3.4 mmol/L)
b. Ca+27.8 mg/dl (1.95 mmol/L)
c. Na+154 mEq/L (154 mmol/L)
d. PO4-3 4.8 mg/dl (1.55 mmol/L)
Answer: c. Na+154 mEq/L (154 mmol/L)
The elevated serum sodium level is consistent with the patients neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.
A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100ml/hr, has a nasogatric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider?
a. Serum sodium level of 138 mEq/L (138 mmol/L)
b. Gradually decreasing level of consciousness (LOC)
c. Oral temperature of 100.1 F with bibasilar lung crackles
d. Weight gain of 2 pounds (1 kg) above admission weight
Answer: b. Gradually decreasing level of consciousness (LOC)
The patients history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.
When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is:
a. skin turgor.
b. heart sounds.
c. mental status.
d. capillary refill.
Answer: c. mental status.
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.
A patient with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first?
a. Notify the health care provider.
b. Withhold the next scheduled dose of Maalox.
c. Review the magnesium level on the patient's chart.
d. Check the chart for the most recent potassium level.
Answer: c. Review the magnesium level on the patient's chart.
The patient has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The Maalox should be held, but more immediate action is needed to correct the patients decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for patients with renal failure, but the patients current symptoms are not consistent with hyperkalemia.
A postoperative patient who is receiving nasogastric suction is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Discontinue the nasogastric suctions for a few hours.
b. Notify the health care provider about the ABG results.
c. Teach the patient about the need to take slow, deep breaths.
d. Give the patient the PRN morphine sulfate 4 mg intravenously.
Answer: d. Give the patient the PRN morphine sulfate 4 mg intravenously.
The patients respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurses first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
Which of these actions can the nurse who is caring for a critically ill patient with multiple intravenous (IV) lines delegate to an experienced LPN?
a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patients nontunneled subclavian central venous catheter.
d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
Answer: b. Monitor the IV sites for redness, swelling, or tenderness.
An experienced LPN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.
Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patients bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.
Answer: a. The patient is experiencing laryngeal stridor.
Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the patients calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action.
Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. The nurse will immediately check for:
a. an elevated serum potassium level.
b. the presence of Chvosteks sign.
c. a decreased thyroid hormone level.
d. bleeding on the patients dressing.
Answer: b. the presence of Chvosteks sign.
The patients symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mEq/L.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%.
Answer: b. Serum calcium is 18 mEq/L.
The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life-threatening.
The following data are obtained by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling sick to my stomach.
Answer: b. The patellar and triceps reflexes are absent.
The loss of the deep tendon reflexes indicates that the patients magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.
The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields.
Answer: d. There are crackles audible throughout both lung fields.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.
