MCA1 Exam 2 – Questions With Verified Solutions
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Terms in this set (115)
While performing patient teaching Renal calculi may occur as a complication of
regarding hypercalcemia, which hypercalcemia.
statements are appropriate (select all
that apply.)? Weight-bearing exercises can help keep calcium in
Select all that apply. the bones.
Have patient restrict fluid intake to The patient should increase daily fluid intake to 3000
less than 2000 mL/day. to 4000 mL.
Renal calculi may occur as a A daily fluid intake of 3000 to 4000 mL is necessary
complication of hypercalcemia. to enhance calcium excretion and prevent the
formation of renal calculi, a potential complication of
Weight-bearing exercises can help hypercalcemia. Tums are a calcium-based antacid
keep calcium in the bones. that should not be used in patients with
hypercalcemia. Weight-bearing exercise does
The patient should increase daily fluid enhance bone mineralization.
intake to 3000 to 4000 mL.
Any heartburn can be managed with
an as needed calcium-containing
antacid.
,You are admitting a patient with Metabolic alkalosis
complaints of abdominal pain, nausea,
and vomiting. A proximal bowel Because gastric secretions are rich in HCl acid, the
obstruction is suspected. Which acid- patient who is vomiting will lose a significant amount
base imbalance do you anticipate in of gastric acid and be at an increased risk for
this patient? metabolic alkalosis.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Which action is most important for the During removal of the catheter, have the patient
nurse to take when caring for a patient perform the Valsalva maneuver.
with a subclavian triple-lumen
catheter? The nurse should withdraw the catheter while the
patient performs the Valsalva maneuver to prevent an
Change the injection cap after the air embolism. Injection caps should be changed at
administration of IV medications. regular intervals but not routinely after medications.
Flushing should be performed with at least a 10-mL
Use a 5-mL syringe to flush the syringe to avoid excess pressure on the catheter. If
catheter between medications and resistance is encountered during flushing, force
after use. should not be applied. The push-pause method is
preferred for flushing catheters but not used if
During removal of the catheter, have resistance is encountered during flushing.
the patient perform the Valsalva
maneuver.
If resistance is met when flushing, use
the push-pause technique to dislodge
the clot.
,Which nursing intervention is most Monitor daily weight and intake and output.
appropriate when caring for a patient
with dehydration? Measuring weight is the most reliable means of
detecting changes in fluid balance. Weight loss
Monitor skin turgor every shift. would indicate the dehydration is worsening,
whereas weight gain would indicate restoration of
Auscultate lung sounds every 2 hours. fluid volume.
Monitor daily weight and intake and
output.
Encourage the patient to reduce
sodium intake.
You are caring for a patient receiving Phosphorus falling to 2.1 mg/dL
calcium carbonate for the treatment
of osteopenia. Which serum Calcium has an inverse relationship with phosphorus
laboratory result would you identify as in the body. When phosphorus levels fall, calcium
an adverse effect related to this rises, and vice versa. Because hypercalcemia rarely
therapy? occurs as a result of calcium intake, the patient's
phosphorus falling to 2.1 mg/dL (normal, 2.4-4.4
Sodium falling to 138 mEq/L mg/dL) may be a result of the phosphate-binding
effect of calcium carbonate.
Potassium rising to 4.1 mEq/L
Magnesium rising to 2.9 mg/dL
Phosphorus falling to 2.1 mg/dL
, You are caring for a patient admitted Partially compensated respiratory acidosis
with a diagnosis of chronic obstructive
pulmonary disease (COPD) who has A low pH (normal, 7.35-7.45) indicates acidosis. In a
the following arterial blood gas patient with respiratory disease such as COPD, the
results: pH 7.33, PaO2 47 mm Hg, patient retains carbon dioxide (normal, 35-45 mm
PaCO2 60 mm Hg, HCO3 32 mEq/L, Hg), which acts as an acid in the body. For this
and O2 saturation of 92%. What is the reason, the patient has respiratory acidosis. The
correct interpretation of these results? elevated HCO3 indicates a partial compensation for
the elevated CO2.
Fully compensated respiratory
alkalosis
Partially compensated respiratory
acidosis
Normal acid-base balance with
hypoxemia
Normal acid-base balance with
hypercapnia
The nurse on a medical-surgical unit A patient with nasogastric tube suction
identifies which patient as having the
highest risk for metabolic alkalosis? Excessive nasogastric suctioning may cause
metabolic alkalosis. Brain injury may cause
A patient with a traumatic brain injury hyperventilation and respiratory alkalosis. Type 1
diabetes mellitus (diabetic ketoacidosis) is associated
A patient with type 1 diabetes mellitus with metabolic acidosis. Acute respiratory failure may
lead to respiratory acidosis.
A patient with acute respiratory failure
A patient with nasogastric tube
suction
Save
Terms in this set (115)
While performing patient teaching Renal calculi may occur as a complication of
regarding hypercalcemia, which hypercalcemia.
statements are appropriate (select all
that apply.)? Weight-bearing exercises can help keep calcium in
Select all that apply. the bones.
Have patient restrict fluid intake to The patient should increase daily fluid intake to 3000
less than 2000 mL/day. to 4000 mL.
Renal calculi may occur as a A daily fluid intake of 3000 to 4000 mL is necessary
complication of hypercalcemia. to enhance calcium excretion and prevent the
formation of renal calculi, a potential complication of
Weight-bearing exercises can help hypercalcemia. Tums are a calcium-based antacid
keep calcium in the bones. that should not be used in patients with
hypercalcemia. Weight-bearing exercise does
The patient should increase daily fluid enhance bone mineralization.
intake to 3000 to 4000 mL.
Any heartburn can be managed with
an as needed calcium-containing
antacid.
,You are admitting a patient with Metabolic alkalosis
complaints of abdominal pain, nausea,
and vomiting. A proximal bowel Because gastric secretions are rich in HCl acid, the
obstruction is suspected. Which acid- patient who is vomiting will lose a significant amount
base imbalance do you anticipate in of gastric acid and be at an increased risk for
this patient? metabolic alkalosis.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Which action is most important for the During removal of the catheter, have the patient
nurse to take when caring for a patient perform the Valsalva maneuver.
with a subclavian triple-lumen
catheter? The nurse should withdraw the catheter while the
patient performs the Valsalva maneuver to prevent an
Change the injection cap after the air embolism. Injection caps should be changed at
administration of IV medications. regular intervals but not routinely after medications.
Flushing should be performed with at least a 10-mL
Use a 5-mL syringe to flush the syringe to avoid excess pressure on the catheter. If
catheter between medications and resistance is encountered during flushing, force
after use. should not be applied. The push-pause method is
preferred for flushing catheters but not used if
During removal of the catheter, have resistance is encountered during flushing.
the patient perform the Valsalva
maneuver.
If resistance is met when flushing, use
the push-pause technique to dislodge
the clot.
,Which nursing intervention is most Monitor daily weight and intake and output.
appropriate when caring for a patient
with dehydration? Measuring weight is the most reliable means of
detecting changes in fluid balance. Weight loss
Monitor skin turgor every shift. would indicate the dehydration is worsening,
whereas weight gain would indicate restoration of
Auscultate lung sounds every 2 hours. fluid volume.
Monitor daily weight and intake and
output.
Encourage the patient to reduce
sodium intake.
You are caring for a patient receiving Phosphorus falling to 2.1 mg/dL
calcium carbonate for the treatment
of osteopenia. Which serum Calcium has an inverse relationship with phosphorus
laboratory result would you identify as in the body. When phosphorus levels fall, calcium
an adverse effect related to this rises, and vice versa. Because hypercalcemia rarely
therapy? occurs as a result of calcium intake, the patient's
phosphorus falling to 2.1 mg/dL (normal, 2.4-4.4
Sodium falling to 138 mEq/L mg/dL) may be a result of the phosphate-binding
effect of calcium carbonate.
Potassium rising to 4.1 mEq/L
Magnesium rising to 2.9 mg/dL
Phosphorus falling to 2.1 mg/dL
, You are caring for a patient admitted Partially compensated respiratory acidosis
with a diagnosis of chronic obstructive
pulmonary disease (COPD) who has A low pH (normal, 7.35-7.45) indicates acidosis. In a
the following arterial blood gas patient with respiratory disease such as COPD, the
results: pH 7.33, PaO2 47 mm Hg, patient retains carbon dioxide (normal, 35-45 mm
PaCO2 60 mm Hg, HCO3 32 mEq/L, Hg), which acts as an acid in the body. For this
and O2 saturation of 92%. What is the reason, the patient has respiratory acidosis. The
correct interpretation of these results? elevated HCO3 indicates a partial compensation for
the elevated CO2.
Fully compensated respiratory
alkalosis
Partially compensated respiratory
acidosis
Normal acid-base balance with
hypoxemia
Normal acid-base balance with
hypercapnia
The nurse on a medical-surgical unit A patient with nasogastric tube suction
identifies which patient as having the
highest risk for metabolic alkalosis? Excessive nasogastric suctioning may cause
metabolic alkalosis. Brain injury may cause
A patient with a traumatic brain injury hyperventilation and respiratory alkalosis. Type 1
diabetes mellitus (diabetic ketoacidosis) is associated
A patient with type 1 diabetes mellitus with metabolic acidosis. Acute respiratory failure may
lead to respiratory acidosis.
A patient with acute respiratory failure
A patient with nasogastric tube
suction
