Practice Questions39. The nurse is caring for a client with heart failure. On assessment, the nursenotes that the client is dyspneic, and crackles are audible on auscultation. What additionalmanifestations would the nurse expect to note in this clientif excess fluid volume is present?1. Weight loss and dry skin2. Flat neck and hand veins and decreased urinary output3. An increase in blood pressure and increased respirations4. Weakness and decreased central venous pressure (CVP) 40. The nurse reviews a client’s record and determines that the client is at risk fordeveloping a potassium deficit if which situation is documented? Get answer to your question and much more 41. The nurse reviews a client’s electrolyte laboratory report and notes that thepotassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nursewatch for on the electrocardiogram (ECG) as a result of the laboratory value?Select all that apply. Get answer to your question and much more 42. Potassium chloride intravenously is prescribed for a client with heart failureexperiencing hypokalemia. Which actions should the nurse take to plan for NCLEX QUESTIONSFLUID AND ELECTROLYTES1.The nurse is caring for a client with heart failure. On assessment, the nurse notesthat the client is dyspneic and crackles are audible on auscultation. What additionalsigns would the nurse expect to note in this client if excess fluid volume is present?1. Weight loss2. Flat neck and hand veins3. An increase in blood pressure4. Decreased central venous pressure (CVP)3. An increase in blood pressure 2.The nurse is preparing to care for a client with a potassium deficit. The nursereviews the client's record and determines that the client was at risk for developingthe potassium deficit because of which situation? Get answer to your question and much more 3.The nurse reviews a client's electrolyte laboratory report and notes that thepotassium level is 2.5 mEq/L. Which pattern would the nurse note on theelectrocardiogram as a result of the laboratory value? Get answer to your question and much more 4.The nurse provides instructions to a client with a low potassium level about thefoods that are high in potassium and tells the client to consume which foods?Selectall that apply. Get answer to your question and much more The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. weight loss and dry skin B. flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure C. An increase in blood pressure and increased respirations. Which diagnostic tests will help to identify any altered fluid balance in the body? Select all A. Blood culture and Sensitivity B. CMP C. Sputum culture and sensitivity D. Urine and serum osmolality E. CBC B. CMP D. Urine and serum osmolaluty E. CBC The client with fluid volume deficit has been recieiving 0.9% sodium chloride IV infusion at 50 mL/hr for the past 4 hrs. Which assessment finding indicates that the client is developing fluid volume overload? A. Less than 3 second cap. refill B. Crackles upon auscultation on the bases of the lungs C. Poor skin turgor upon assessment D. BP of 100/50 mmHg B. Crackles upon auscultation on the bases of the lungs The nurse reviews a clients record and determines that the client is at risk for developing a potassium deficit if which situation is documented? A. Sustained Tissue Damage B. Required NG suction C. Has a history of Addisons disease D. Uric acid level of 9.4 mg/dL In a patient with sodium imbalances, the primary clinical manifestations are related to alterations in what body system? A. Kidneys B. Cardiovascular system C. Musculoskeletal system D. Central nervous system D. Central Nervous System ABG results for your patient yield the following results: pH 7.47, Pa CO2 38 mm Hg, HCO3 28 mm Hg. These findings indicate: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis ABG results for your patient yield the following results: pH 7.32, Pa CO2 40 mm Hg, HCO3 20 mm Hg. These findings indicate: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid base imbalance? A.Respiratory acidosis from inadequate ventilation B.Respiratory alkalosis from anxiety and hyperventilation C.Metabolic acidosis from calcium loss due to broken bones D.Metabolic alkalosis from taking analgesics containing base products The patient has had COPD for years, and his ABGs usually show hypoxia (PaO2 <60 mm Hg or SaO2 <88%) and hypercapnia (PaCO2 >45 mm Hg). Which ABG results show movement toward respiratory acidosis and further hypoxia indicating respiratory failure? pH 7.35, PaO2 62 mm Hg, PaCO2 45 mm Hg b. pH 7.34, PaO2 45 mm Hg, PaCO2 65 mm Hg c. pH 7.42, PaO2 90 mm Hg, PaCO2 43 mm Hg d. pH 7.46, PaO2 92 mm Hg, PaCO2 32 mm Hg b. pH 7.34, PaO2 45 mm Hg, PaCO2 65 mm Hg
IV Fluid : Lactated Ringers Solution
A patients ABG results include the following: pH7.32, Pao2 84 mmHg, PaCo2 49 mm Hg, and SaO2 84%. For what should the nurse assess the patient? A. tetany B. tachypnea C. pleural friction rub D. Kussmaul respirations B. tachypnea The arterial blood gas analysis indicates respiratory acidosis. Tachypnea is defined as a rapid respiratory rate and indicates respiratory distress. Tetany occurs in metabolic alkalosis. A pleural friction rub is a creaking or grating sound heard during auscultation of the lungs and indicates inflamed pleural surfaces that are rubbing together. Kussmaul respirations are commonly seen in metabolic acidosis and are abnormally deep, very rapid sighing respirations. Twenty-four hours after a patient had a tracheostomy, the tube is accidentally dislodged after a coughing episode. Which action should the nurse take first? A. Call the health care provider. B. Place the obturator in the tracheostomy tube. C. Position the patient in a semi-Fowler’s position. D.Grasp the retention sutures to spread the tracheostomy opening. D. grasp the retention suture to spread the tracheostomy opening. all of the actions are indicated, but d needs to be done first. Two days ago, the client was admitted to the acute care unit with severe dyspnea, fatigue, weakness, and crackles in both lung bases, but he has improved during hospitalization. The nurse is preparing to provide discharge teaching for the client. Which health teaching would the nurse include? Select all that apply. A. Continue to use pursed lip breathing at home to help promote respiratory effort B. Be sure to use oxygen therapy at home as needed, especially when you go out C. Carefully plan and pace your daily activities with rest periods between activities D. Locate a community pool to join so that you can swim at least 3 times a week. E. Report any ankle or foot swelling to your PCP F. Drink plenty of fluids to stay hydrated and keep your secretions thinner G. Begin a structured smoking cessation program as soon as possible. A,B,C,E,F,G. All of these health teaching points are important for the client, including a need to monitor for lower extremity edema which could indicate cor pulmonale, which is right-sided heart failure. The client needs to stop smoking and drink adequate fluids for general health and for thinning secretions. A client with CHF is about to take a dose of furosemide (Lasix). Which of the following K level, if noted in the client's record, should be reported before giving the due medication? A. 5.1 mEq/L B. 4.9 mEq/L C. 3.9 mEq/L D. 3.3 mEq/L A client went to the ER with sudden onset of high fever and diaphoresis. Serum Na was one of the lab tests taken. Which of the following values would you expect to see? a. 130 mEq/L b. 148 mEq/L c. 143 mEq/L d. 139 mEq/L The nurse is reviewing the lab results of a client receiving digoxin (lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following? a. give the next dose b. notify the physician c. check the clients pulse rate d. increase the next dose as ordered A 56 year old normally healthy patient at the clinic is diagnosed with bacterial community-acquired pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to: a. amoxicillin. b. erythromycin. c. sulfonamides. d. cephalosporins. B. erthromycin If the patient is allergic to macrolides (erythromycin), doxycycline would be prescribed. The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? a. Barrel-shaped chest b.Paradoxical respirations c.Hyperresonance on percussion d.Localized decreased breath sounds A patient is admitted to the ED with a severe exacerbation of asthma. Which finding is of the most concern to the nurse? a. unable to speak and sweating profusely b. PaO2 of 80 and PaCo2 of 50 c. presence of inspiratory and expiratory wheezing d. peak expiratory flow rate at 60% of personal best. A) Unable to speak and sweating profusely During a severe exacerbation of asthma the patient may not be able to speak (or may speak in words, not sentences) because of difficulty breathing; the patient may also be perspiring profusely. Other indicators of severe asthma include absence of wheezing because of limited airflow; arterial blood gas results with decreased PaO2 (< 80 mm Hg) and increased PaCO2 (> 48 mm Hg); and peak expiratory flow rate at or below 40% of personal best. The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage COPD? a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3− 30 mEq/L b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3− 18 mEq/L c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3− 25 mEq/L d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3− 35 mEq/L Answer: A pH 7.32 - acidosis PaCO2 58 mm Hg- acidosis PaO2 60 mm Hg- LOW O2 HCO3− 30 mEq/L- alkalosis In later stage COPD, the patient will have a low or low normal pH, a high normal or above normal PaCO2, and a high normal or above normal HCO3-. This indicates compensated respiratory acidosis, as the patient has chronically retained CO2 and the kidneys have conserved HCO3- to increase the pH to near or within the normal range. A nurse is teaching a client who is starting to take an ace inhibitor to treat hypertension . the nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of this medication A- Persistent Cough B- Frequent Urination C- Constipation D- Tendon Pain A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular hear rate. which of the following actions should the nurse take first? A- obtain clients current weight B-Determine the time of the last digoxin dose C- Check the clients urine output D- Review serum electrolyte Values D- Review serum electrolyte Values weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. the first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias for hypokalemia A nurse in an emergency department is caring for a client who had an anterior MI . the clients history reveals she Is 1 week postoperative following an open cholecystectomy . the nurse should recognize that which of the following interventions is contraindicated. A- administering IV Morphine Sulfate B- Assisting with thrombolytic therapy C- administering oxygen at 2 L/min via nasal cannula D-helping the client to the bedside commode b. The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching A- " your level of activity intolerance will not change" B- " you will be able to stop taking immunosuppressant's after 12 months C- " after 6 months you will no longer need to restrict your sodium intake" D- "You might no longer be able to feel chest pain" A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first. A- tell the client to report vision changes B- elevate the head of the clients bed C- Start a peripheral IV D- Initiate Seizure precautions b. The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation. a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potential complication A- Guillain- Barre syndrome B- Valvular Disease C- Ventricular Depolarization D- Myelodysplastic syndrome b. Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium. A nurse is caring for a client who had an onset of chest pain 24hr ago. the nurse recognize that an increase in which of the following is diagnostic of myocardial infarction (MI) A- C Reactive protein B- Myoglobin C- Creatine Kinase- MB D-Homocysteine c. Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury. a nurse is assessing a client who has dilated cardiomyopathy. which of the following findings should the nurse expect A-weight loss B- pericardial rub C- tracheal deviation D- dyspnea on exertion |
On assessment, the nurse notes that the patient is dyspneic and crackles are audible
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