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The nurse at a family picnic on a hot day in July is aware that which person is at greatest risk for dehydration while playin
c. 72yo grandmother who is 15 pounds overweight.
* An older adult has less total body water than a younger adult.
* Many older adults have decreased thirst sensation.
* Older adults may have difficulty with walking or other motor skills neede
A nurse is assessing a client who is using PCA following a thoracotomy. The client is SOB, appears restless, and has a RR of
c. Provide calming interventions.
* The client's RR is above the expected range. Calming the client should decrease the RR, which will cause the client's CO2 levels to increase to the expected levels of 35-45 mmHg, and lower the pH to expected le
that he is "feeling weak in the legs." Which of the following actions should the nurse take first?
a. Monitor the client's
c. 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
While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions shou
a. Implement seizure precautions.
* The client is at risk for seizures due to low excitation threshold as a result of decreased calcium level (normal reference range = 8.5-10.5 mg/dL). The nurse should initiate seizure precautions to prevent inju
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expec
c. Slow peripheral pulses.
* This phosphorus level is below the expected reference range (2.5-4.5 mg/dl). The nurse should expect the client to have slow peripheral pulses and might find that the client's pulses are difficult to find and easy to
A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the following lab values should the nur
b. Hematocrit 34%.
* The nurse should identify that a client who has fluid volume excess can have a Hct level that is below the expected reference range of 35 to 44.5% for females and 38 to 50% for males. Fluid volume excess can cause hemodilut
A nurse is reviewing the medical record of a client who has DM and is receiving regular insulin by continuous IV infusion to
c. Serum K+ 3.0 mEq/L.
* The expected reference range for serum K+ is 3.5-5.5 mEq/L. Therefore, this patient has hypokalemia, which is a serious complication when a pt with DKA is receiving insulin.
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following lab findings
b. Serum Na+ 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.
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His RR is 36/min and he appears v
* Decreased PaCO2 in respiratory alkalosis due to hyperventilation.
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
a. Skin turgor.
d. Mental status.
* The greatest risk to the client is injury from a fall due to a decline in the client's mental status.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following is the priority for the nurs
b. Cardiac rhythm.
* When using the ABC 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 (8.5-10.5 mg/dL). Hypocalcemia can cause ECG c
A nurse is providing teaching to a client who has heart failure and is receiving furosemide. Which of the following foods sho
b. 1 cup plain yogurt.
* Contains 380g of potassium.
* Celery contains 132g.
* 1 slice of whole grain bread contains 60g.
* Cooked tofu contains 164g.
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
c. Withhold the medication.
* The greatest risk with hyperkalemia = bradycardia, hypotension, and life-threatening cardiac complications. Hyperkalemia = >5.0 mEq/L. Priority action = withhold and notify provider.
A nurse is caring for a client who requires NG suctioning. Which of the following sets of lab results indicates that the clie
a. pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L
* An elevated pH (>7.45) with an elevated PaCO2 (or within expected reference range sometimes) indicates metabolic alkalosis.
A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse sh
c. Bounding peripheral pulses.
* 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 followin
b. Initiate high-flow oxygen therapy.
* When using the ABC approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5-6 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
b. 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
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,
a. Respiratory acidosis.
* Status asthmaticus causes inadequate gas exchange, resulting in low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range.
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a
d. Potassium 6.1 mEq/L
* Hyperkalemia (K+ >5.0 mEq/L) can cause a prolonged PR intervale, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurs
a. 1 large hard-boiled egg.
* bran cereal, almonds, and cooked spinach contain magnesium levels greater than 100 mg, whereas the hard-boiled egg only contains 5 mg.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?
a. Hyperactive deep-tendon reflexes.
* Hyperactive DTR is an expected finding of hypomagnesemia, along with muscle cramps, numbness, and tingling.
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic
d. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L
* A pH <7.35 is an indication of acidosis. HCO3- <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 stat
c. "When I sit down to watch television, I'll be sure to put my feet up."
* Elevating the feet will increase the venous return to the heart. The client should elevated feet for at least 20 minutes several times a day.
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 anticip
d. 0.45% NaCl.
*A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution, such as 0.45% NaCl to provide free water and treat cellular dehydration, which promotes waste elim
A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the
d. "I will add broccoli and kale to my diet."
* Broccoli and kale are good source of non-dairy calcium.
* Vitamin D is necessary for calcium absorption and is unlikely to trigger an allergic reaction in a client with a dairy allergy.
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?
a. Decreased muscle strength.
* The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea.
* The nurse should expect increased, not decreased, gastric motility, including abdominal cramps and diarrhe
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?
* Hypotension with respiratory acidosis due to vasodilation.
* Facial flushing and warmth are manifestations of METABOLIC acidosis. Pale, dry skin is a manifestation of respiratory acidosis.
* Hyporeflexia is a manifestat
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should t
a. Administer IV fluids to the client evenly over 24 hr.
d. Encourage the client to rise slowly when standing up.
e. Weigh the client every 8 hr.
* Excessive fluid loss is treated with prescribed IV replacement fluids. Do not administer
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 clie
b. Orthostatic hypotension.
* Manifestation of hypokalemia.
* Hyporeflexia occurs with hypokalemia, along with weak hand grip strength.
* Weakening of the respiratory muscles and shallow respirations are manifestations of hypokalemia.
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which
a. Sodium 128 mEq/L
* SODIUM THINK NEURO!! 128 is below expected reference range (135-145). Monitor for weakened respiratory effort after reporting to provider!
* Potassium expected reference range = 3.5-5
* Calcium expected reference ran
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the
d. "I will use the incentive spirometer every hour."
* Respiratory depression and limited chest expansion are both causes of respiratory acidosis.
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