Test bank for lewis medical surgical nursing 12th edition

Test Bank For Lewis's Medical-Surgical Nursing, 12th Edition by Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances Harding: Lewis’s Medical-Surgical Nursing, 12th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data would be of most concern to the nurse? A. Urine output is 30 mL/hr. B. Blood pressure is 90/40 mm Hg. C. Oral fluid intake is 100 mL for 8 hours. D. Skin tenting over the sternum is prolonged. ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss from the burn injury. This finding 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 patient‘s fluid intake but not as urgently as the hypotension. 2. A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding? A. Serum hematocrit of 42% B. Serum sodium of 120 mg/dL C. Urinary output of 280 mL in 8 hours D. Reported weight gain of 2.2 pounds (1 kg) ANS: B Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention. 3. A patient with multiple draining wounds is admitted for hypovolemia. Which information would provide the most accurate way for the nurse to evaluate fluid balance? A. Skin turgor B. Daily weight C. Urine output D. Edema presence ANS: B 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. 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. 4. The home health nurse cares for an alert and oriented older adult patient who has a history of dehydration. Which instruction would the nurse give this patient? A. “Drink more fluids in the late evening.” B. “More fluids are needed if you feel thirsty.” C. “Increase the fluids if your mouth feels dry.” D. “If you feel confused, you need more fluids.” ANS: C An alert older 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 level of consciousness occur. 5. A patient who is taking a potassium-depleting diuretic for treatment of hypertension reports generalized weakness. Which action would the nurse to take? A. Assess for facial muscle spasms. B. Ask the patient about loose stools. C. Recommend the patient avoid drinking orange juice with meals. D. Suggest that the health care provider order a basic metabolic panel. ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia. 6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? A. “Iwill tryto drink at least 8 glasses of water every day.” B. “Iwill use a salt substitute to decrease my sodium intake.” C. “I will increase my intake of potassium-containing foods.” D. “Iwill drink apple juice instead of orange juice for breakfast.” ANS: D Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., 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. 7. A patient with new-onset confusion and hyponatremia is being admitted. Which action would the charge nurse take when making room assignments? A. Assign the patient to a semiprivate room. B. Assign the patient to a room near the nurse‘s station. C. Place the patient in a room nearest to the water fountain. D. Place the patient on telemetry to monitor for peaked T waves. ANS: B The patient would be placed near the nurse‘s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient would not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. 8. IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action would the nurse take? A. Administer the KCl as a rapid IV bolus. B. Infuse the KCl at a maximum rate of 10 mEq/hr. C. Discontinue cardiac monitoring during the infusion. D. Monitor deep tendon reflexes during the infusion. ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Cardiac monitoring would be continued while patient is receiving potassium because of the risk for dysrhythmias. Deep tendon reflexes are monitored during magnesium infusions, not potassium infusions. 9. A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient‘s serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy would the nurse question? A. Infuse 5% dextrose in water intravenously at 125 mL/hr. B. Administer IV morphine sulfate 4 mg every 2 hours PRN. C. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. D. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL. ANS: A Because the patient‘s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer‘s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction. 10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How would the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis ANS: D 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. 11. A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action would the nurse take? A. Give the prescribed PRN lorazepam (Ativan). B. Encourage the patient to take deep slow breaths. C. Start the prescribed PRN oxygen at 2 to 4 L/min. D. Administer the prescribed fluid bolus and insulin. ANS: D The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. 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. Lorazepam administration will slow the respiratory rate and increase the level of acidosis. 12. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation would the nurse expect? A. Pallor B. Edema C. Confusion D. Restlessness ANS: B The normal range for total protein is 6.4 to 8.3 g/dL. 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. 13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? A. Lung sounds B. Urinary output C. Peripheral pulses D. Peripheral edema ANS: A 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 a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. 14. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient‘s condition has improved? A. Hematocrit 28% B. Absence of skin tenting C. Decreased peripheral edema D. Blood pressure 110/72 mm Hg ANS: C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient‘s 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. 15. A patient who is lethargic with deep, rapid respirations has the following arterial blood gas(ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How would the nurse interpret these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. theABGs are inconsistentwith the other responses. 16. A patient who has been receiving diuretic therapy is admitted to the emergency departmentwith a serum potassium level of 3.0 mEq/L. the nurse would alert the health care provider immediately that the patient is on which medication? A. Digoxin (Lanoxin) 0.25 mg/day B. Ibuprofen 400 mg every 6 hours C. Lantus insulin 24 U every evening D. Metoprolol (Lopressor) 12.5 mg/day ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will need to do more assessment about the other medications, but they are not of asmuch concern with the potassium level. 17. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which action would the nurse include in the plan of care? A. Maintain the patient on bed rest. B. Auscultate lung sounds every 4 hours. C. Encourage fluid intake up to 4000 mLdaily. D. Monitor for Trousseau‘s and Chvostek‘s signs. ANS: C To decrease the risk for renal calculi, the patient would have a fluid intake of 3000 to 4000 mLdaily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patientswith hypercalcemia. Trousseau‘s and Chvostek‘s 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. 18. A patient with renal failure is on a low phosphate diet. Which food would the nurse removefrom the patient‘s food tray? A. Skim milk B. Grape juice C. Mixed green salad D. Fried chicken breast ANS: A 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 and juices are not high in phosphate and are not restricted. 19. A patient has a magnesium level of 1.3 mg/dL. Which information from the patient‘s healthhistory would help the nurse identify a likely cause of this value? A. Daily alcohol intake B. Dietaryprotein intake C. Dailymultivitamin use D. Occasional laxative use ANS: A Hypomagnesemia is associated with alcohol use. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels. 20. A patient asks the nurse why a peripherally inserted central catheter is needed to begin receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate? A. “The prescribed infusion can be given more rapidly when there is a central line.” B. “The hypertonic solution is more rapidly diluted when given through a central line.” C. “There is a decreased risk for infection when 25% dextrose is infused through a central line.” D. “The required blood glucose monitoring is based on samples obtained from a central line.” ANS: B The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered through a peripheral IV. 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. 21. Which action would the nurse take when caring for a patient who has a central venous accessdevice (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. Position thepatient‘s face toward the CVAD during injection cap changes. D. Obtain a prescription from the health care provider to change CVAD dressing. ANS: B The push-pause enhances theremoval of debris from theCVAD lumen and decreases therisk for clotting. To decrease infection risk, friction should be used when cleaning theCVAD insertion site. thedressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider‘s order is not necessary. thepatient should turn away from theCVAD during cap changes. 22. An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result would thenurse report to thehealth care provider immediately? A. K + 3.4 mEq/L (3.4 mmol/L) B. Ca+2 7.8 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) ANS: C The elevated serum sodium level is consistent with thepatient‘s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. thepotassium, phosphate, and calcium levels vary slightly from normal and should be reported, but do not require immediate action. 23. A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for thenurse to report to thehealth care provider? A. Oral temperature increased to 100.1F B. Decreased alertnesssince admission C. Weight gain of 2 pounds (1 kg) over 2 days D. Serum sodium level of 138 mEq/L (138 mmol/L) ANS: B The patient‘s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine thecause of thechange in LOC and theappropriate interventions. theweight gain, elevated temperature, and serum sodium level will be reported but do not indicate a need for rapid action to avoid complications. 24. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. thepatient seems confused and short of breath with peripheral edema. Which assessment would thenurse complete first? A. Skin turgor B. Heartsounds C. Mentalstatus D. Capillary refill ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in thecentral nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema. 25. A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that thepatient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action would the nurse take first? A. Notify thepatient‘s health care provider. B. Obtain an order to draw a potassium level. C. Review thehistoryof gastrointestinal upset on thechart. D. Teach thepatient about magnesium-containing antacids. ANS: A The health care provider should be notified immediately. thepatient has a history and manifestations consistent with hypermagnesemia. As theserum magnesium level increases, deep tendon reflexes are lost, followed by muscle paralysis and coma. Respiratory and cardiac arrest can occur. thenurse should check thechart for a recent serum magnesium level and make sure that blood is sent to thelaboratory for immediate electrolyte and chemistry determinations. Monitoring of potassium levels also is important for patients with renal failure, but thepatient‘s current symptoms are not consistent with hyperkalemia. Dialysis should correct thehigh magnesium levels. thepatient needs teaching about therisks of taking magnesium-containing antacids and further investigation of indigestion symptoms. 26. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. thepatient reports anxiety and incisional pain. thepatient‘s respiratory rate is 32 breaths/min, and thearterial blood gases (ABGs) indicate respiratory alkalosis with a normal arterial oxygen level. Which action would thenurse take first? A. Check to make sure thenasogastric tube is patent. B. Give thepatient thePRN IV morphine sulfate 4 mg. C. Notify thehealth care provider about theABG results. D. Teach thepatient to take slow, deep breaths when anxious. ANS: B The patient‘s respiratory alkalosis is likely caused by theincreased respiratory rate associated with pain and anxiety. thenurse‘s first action would be to medicate thepatient for pain. thehealth care provider may be notified about theABGs but is likely to instruct thenurse to medicate for pain. thepatient will not be able to take slow, deep breaths when experiencing pain. Checking thenasogastric tube can wait until thepatient has been medicated for pain. 27. Which action can theregistered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? A. Titrate vasoactive IV medications. B. Flush a saline lock with normal saline. C. Remove thecentral venous catheter. D. Verifyand administer blood products. ANS: B A LPN/VN has theeducation, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice. 28. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for thenurse to report to thehealth care provider? A. Stridor B. Fatigue C. Constipation for 4 days D. Numbness around thelips ANS: A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct thepatient‘s calcium level. theother data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm. 29. Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which action would thenurse complete first? A. Verifytheserum potassium level. B. Test for presence of Chvostek‘s sign. C. Observe for blood on theneck dressing. D. Confirm a prescription for thyroid replacement. ANS: B The patient‘s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of an urgent need to check thepotassium level, thethyroid replacement, or for bleeding. 30. A patient is admitted to theemergency department with severe fatigue and confusion. Which laboratory value requires themost immediate action by thenurse? A. Arterial blood pH is 7.32. B. Serum calcium is 18 mg/dL. C. Serum potassium is 5.1 mEq/L. D. Arterial oxygen saturation is 91%. ANS: B The serum calcium is well above thenormal level and puts thepatient at risk for cardiac dysrhythmias. thenurse should start cardiac monitoring and notify thehealth care provider. thepotassium, oxygen saturation, and pH are also abnormal, and thenurse should notify thehealth care provider about these values as well, but they are not immediately life threatening. 31. A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding would thenurse report to thehealth 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 theday. D. The patient reports feeling “sick to mystomach.” ANS: B The loss of thedeep tendon reflexes indicates that thepatient‘s magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and would be reported, but they are not as significant as theloss of deep tendon reflexes. thedecreased breath sounds suggest that thepatient needs to cough and deep breathe to prevent atelectasis. DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity 32. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data require themost rapid response by thenurse? A. The patient‘s radial pulse is 105 beats/min. B. There are crackles throughout both lung fields. C. There is sediment and blood in thepatient‘s urine. D. The patient‘s blood pressure increases to 142/94 mm Hg. ANS: B Crackles throughout both lungs suggest that thepatient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. theincreased pulse rate and blood pressure and theappearance of theurine should also be reported, but they are not as dangerous as thepresence of fluid in thealveoli. 33. The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action would thenurse expect to take first? A. Monitor ionized calcium level. B. Give oral calcium citrate tablets. C. Check parathyroid hormone level. D. Administer vitamin D supplements. ANS: A This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect thetotal serum calcium. A more accurate reflection of calcium balance is theionized calcium level. Most of thecalcium in theblood is bound to protein (primarily albumin). Alterations in serum albumin levels affect theinterpretation of total calcium levels. Low albumin levels result in a drop in thetotal calcium level, although thelevel of ionized calcium is not affected. theother actions may be needed if theionized calcium is also decreased. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning MSC:NCLEX: Safe and Effective Care Environment 34. A patient who comes to theclinic reports frequent, watery stools for 2 days. Which action would thenurse take first? A. Check thepatient‘s blood pressure. B. Observe theoral mucosa for dryness. C. Draw blood for serum electrolyte levels. D. Ask about extremity numbness or tingling. ANS: A Because thepatient‘s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is thehighest priority. theother actions are also appropriate but are not as essential as determining thepatient‘s perfusion status. 35. After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action would thenurse take first? A. Notify thehealth care provider. B. Offer reassurance to thepatient. C. Auscultate thepatient‘s breath sounds. D. Give prescribed PRN morphine sulfate IV. ANS: C The initial action would be to assess thepatient further because thehistory and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. theother actions may be appropriate, but further assessment of thepatient is needed before notifying thehealth care provider, offering reassurance, or administration of morphine. 36. After receiving change-of-shift report, which patient would thenurse assess first? A. Patient with serum sodium level of 145 mEq/L who is asking for water B. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes D. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates ANS: C The low magnesium level and neuromuscular irritability suggest that thepatient may be at risk for seizures. theother patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications. 37. The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for thenurse to report immediately to thehealth care provider? A. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% B. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% C. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% ANS: D ABGs with a decreased pH and increased PaCO2 indicate uncompensated respiratory acidosis and should be reported to thehealth care provider. theother values are normal, close to normal, or compensated. 38. The nurse observes that thepatient‘s central venous catheter insertion site is red and tender to touch. thepatient‘s temperature is 101.8F. What should thenurse plan to do? A. Discontinue thecatheter and culture thetip. B. Use thecatheter only for fluid administration. C. Change theflush system and monitor thesite. D. Check thesite more frequently for any swelling. ANS: A The information indicates that thepatient has a local and systemic infection caused by thecatheter, and thecatheter should be discontinued to avoid further complications such as endocarditis. Changing theflush system, continued monitoring, or using theline for fluids will not help prevent or treat theinfection.