1. The nurse is completing the physician's or- ders by preparing the patient's IV fluid thera- py. When infusing supplemental potassium, the nurse knows th... [Show More] at checking which of the following is the first priority before begin- ning the infusion?
Urine output Potassium level Tubing device Infusion device
2. When assessing a patient's altered fluid status, the nurse expects to assess/review which of the following? (Select all that ap- ply.)
A. Capillary refill and mucous membranes
B. Fluid intake and urine output
C. Hematocrit and electrolytes
D. Vital signs and skin turgor
3. What determines the acidity of substances such as body fluids?
Potassium level (Rationale:The potassium level should be checked be- fore beginning the infusion. The physician's order may need to be changed if the pa- tient's potassium is elevated. A potassium level out of the normal range is associated with dysrhythmias. Checking the infusion device or tubing date is not the first priority.
Urine output can be checked
during the infusion.)
ABCD
(Rationale:
The nurse should assess the hematocrit and electrolytes to determine imbalances and to facilitate appropriate inter- ventions. Review of the vi- tal signs, skin turgor, capil- lary refill, and mucous mem- branes will help the nurse
to determine the physiolog- ical response to the altered fluid status. Assessment of fluid intake and output is also essential in determin- ing the current patient status because intake and output measurements facilitate the achievement of optimal fluid status and guide intravenous therapy.)
The number of existing H+ ions
The fluid's pH measurement The amount of available HCO3 The number of existing H+ ions
The body's ability to trigger chemical reac- tions
(Rationale: Acidity or alkalini- ty of a solution is determined by its concentration of hydro- gen ions (H+). HCO3 (bicar- bonate base) is a by-product of a breakdown of H2CO3.
The term pH is the measure used to describe acid-base balance. The body is normal- ly associated with a variety of different chemical reactions.)
4. Hyponatremia is associated with a decrease Sodium
of which electrolyte? Phosphorus
Sodium Chloride Potassium
5. Hypokalemia is confirmed by what serum blood result?
Sodium 146 mEq/L
Potassium 5.5 mEq/L
Sodium 133 mEq/L
potassium 3.0 mEq/L
6. What pathology is responsible for metabolic acidosis?
A decrease in bicarbonate or an increase in
(Rationale: Hyponatremia is a result of an imbalance
in the electrolyte sodium. Hypokalemia results when there is a decrease in potas- sium levels; hypochloremia is associated with a decrease in chloride levels; hypophos- phatemia is associated with a decrease in phosphorus levels.)
Potassium 3.0 mEq/L (Rationale:Hypokalemia is confirmed by a serum potas- sium level of <3.5 mEq/L. Hy- perkalemia is an excess of potassium (>5 mEq/L), hy- pernatremia is an excess of sodium (>145 mEq/L), and hyponatremia is a deficiency of sodium (<135 mEq/L).)
A decrease in bicarbonate or an increase in hydrogen ions (Rationale: Metabolic acido-
hydrogen ions
A decrease of carbonic acid
An excess of HCO3 and/or a decrease in H+ ions
An increase of CO2
7. Which of the following concerning the mea- surement of intake and output is true for a patient admitted for dehydration?
Only foods that are consumed as liquids are included in intake calculations
When possible, intake and output should be measured rather than estimated
Liquid medications are not considered when calculating intake
sis is a proportionate deficit of bicarbonate in the extra- cellular fluid. This can occur as a result of an increase in acid components (H+) or a loss of bicarbonate. An ex- cess of HCO3 and/or a de- crease in H+ ions result in metabolic alkalosis. The poor excretion of CO2 is associat- ed with respiratory acidosis. A decrease of carbonic acid is a sign of respiratory alka- losis.)
When possible, intake and output should be measured rather than estimated. (Rationale: Intake and out- put should be measured rather than estimated when- ever possible in order to achieve accuracy. All foods that are liquid at room tem-
Health care agencies have adopted standard perature, and any liquid med-
volumes for common beverage containers
8. Which diagnostic test serves as the basis for determining acid-base imbalances?
Arterial blood gas (ABG) Specific gravity of urine
ications, are included in the calculation of intake. While there can appear to be a standardization, volumes for common food containers can vary, and so using agency designation of specific vol- umes is necessary.)
Arterial blood gas (ABG) (Rationale: Arterial blood gas studies are used to as-
sess and treat acid-base im- balance disorders. Specific
Serum potassium
Blood urea nitorgen (BUN)
9. The nurse begins caring for Rashid Ahmed, who was admitted from the emergency de- partment for dehydration and hypokalemia. The nurse recognizes which of the following assessment finding(s) as related to his de- hydration? (Select all that apply.) Decreased elasticity (skin turgor)
Moist mucous membranes Hypertension (BP 150/90) Decreased weight Dizziness and weakness Increased urinary output
10. The nurse begins Rashid Ahmed's nursing assessment. The nurse understands which of the following are significant when assess- ing for the presence of orthostatic hypoten- sion? (Select all that apply.)
Assessing a pulse rate increase of 10 beats per minute as soon as the client stands up Assessing a pulse of 90 when the client is
gravity of urine and blood area nitrogen may be or- dered to evaluate some as- pect of urinary function, and serum potassium is related to electrolyte status.)
Decreased weight Dizziness and weakness
Decreased elasticity (skin turgor)
(Rationale: Dehydration can result in weight loss. Weight loss of 1 kg is equivalent
to approximately 1 L of flu- id loss. Clients with dehydra- tion may complain of weak- ness and dizziness. A loss of elasticity during skin turgor assessment may indicate a change in hydration status.
Dehydrated clients may also exhibit a decrease in urine output, hypotension, and dry mucous membranes. Clients diagnosed with dehydration will not typically experience increased urine output, hy- pertension, or moist mucous membranes.)
Assessing a systolic blood pressure drop of 20 mm Hg or more after the client has stood for 2 minutes Assessing a pulse rate of 30 beats per minute or more af- ter the client has stood for 2 minutes
lying down after consuming caffeine Assessing a systolic blood pressure drop of 20 mm Hg or more after the client has stood for 2 minutes
Assessing a pulse rate of 30 beats per minute or more after the client has stood for 2 minutes
Assessing a diastolic drop of 10 mm Hg after the client has stood for 2 minutes Assessing a respiratory rate increase of 10 breaths per minute when the client is stand- ing
11. After completing the initial nursing assess- ment, the nurse recognizes Rashid Ahmed's
temperature of 38.5 C (101.3 F) white blood cell count of 21 x 109 hypokalemia of 3.1 mEq/L
pain rating of 4/10
as a priority finding, which would require the following additional intervention:
administer oral anitbiotic call to provider
complete daily weight provide additional intake
12. Rashid Ahmed requires education regard- ing fall prevention and safety. Which of the following client response(s) indicate further teaching is required? (Select all that apply.) I will use the call button when I need to use the restroom.'
'My significant other can help retrieve my urinal.'
'I will walk slowly to the bathroom.'
'I will wear my personal socks when ambu- lating.'
Assessing a diastolic drop of 10 mm Hg after the client has stood for 2 minutes
hypokalemia of 3.1 mEq/L call to provider (Rationale:The potassium level remains outside of nor- mal range, with an irregular heart rhythm. The remainder of the lab results are expect- ed findings associated with his current diagnosis of gas- troenteritis.)
'I will walk slowly to the bath- room.'
'I will wear my personal socks when ambulating.' 'I don't need my side rails while I am in bed.' (Rationale: The client re-
quires additional fall preven- tion teaching when verbaliz- ing the following: attempting to walk independently, utiliz-
'I will sit on the side of bed before attempting to stand.'
'I don't need my side rails while I am in bed.'
13. The nurse is providing care for Rashid Ahmed, who is receiving continuous IV flu- ids for dehydration. The nurse must first se- cure what information in preparation for ad- ministering the new order of IV potassium? (Select all that apply.)
The status of the client's IV reservoir The client's blood pressure
The client's activity level
The volume of the potassium piggyback The pump designated for infusion
The medication compatibility
ing regular socks, and keep- ing side rails down. Walking slowly will not eliminate the risk of a fall. Regular socks do not provide the nonslip advantage provided by non- skid socks. Side rails will pro- tect the client from falling out of bed if dizziness resumes. Using the call button, asking someone else to retrieve a urinal, and sitting on the side of the bed before attempting to stand are all beneficial.)
The status of the client's IV reservoir
The volume of the potassium piggyback
The pump designated for in- fusion
The medication compatibility (Rationale: The nurse as- sesses the status of the client's IV reservoir to ensure it is patent, secure, and with- out signs of infection or infil- tration. If any issues are pre- sent, the medication may not infuse properly or could con- tribute to the development
of IV complications. Medica-
tion compatibility is essential when administering any IV medications, such as potas- sium. The volume of the pig- gyback is necessary for pro- graming the pump. A pump is required for infusing potas-
14. The nurse is assessing Rashid Ahmed after admission to the medical unit. The nurse un- derstands which of the following are expect- ed outcomes following the administration of isotonic IV fluid? (Select all that apply.) Blood pressure values increase.
Heart rate of 100 resumes a normal rhythm. Capillary refill is greater than 3 seconds.
Urine output increases.
Weak peripheral pulses are present. Pain scale is reported as 4/10.
sium. Although vital signs are monitored frequently dur- ing the administration of IV potassium, blood pressure status would not impact the nurse's actions related to this infusion. Information about the client's activity level is not essential when preparing for the IV potassium administra- tion.)
Blood pressure values in- crease
Urine output increases (Rationale: An increase in blood pressure and an in- crease in urine output in- dicate a restoration of flu-
id status. The irregular heart rhythm was related to the electrolyte imbalances. Cap- illary refill of greater than 3 seconds and weak peripher- al pulses are related to de- hydration that is not resolved. Pain is not related to the ad- ministration of IV fluid._ [Show Less]