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Med/Surg Exam 2 - Fluids, Electrolytes, ABG
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PaCO2 35, HCO3 18
ABG is likely?: pH 7.28, PaCO2 52, HCO3 29
ABG is likely?: pH 7.31, PaCO2 42, HCO3 20
for 48 hours, which ABG is likely?: pH 7.48, PaCO2 45, HCO3 29
likely?: pH 7.31, PaCO2 35, HCO3 18
fingers and around the mouth. The nurse would assess for what electrolyte imbalance?: Hypocalcemia
hypernatremia?: 50-year-old with pneumonia, diaphoresis, and high fevers
blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?: Ensure the client is safe from falls and check the most recent potassium level
sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor: bowel movements
and is admitted with cellulitis of the hand. The client's serum potas- sium level was 4. mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?: Question the results and redraw the specimen
maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?: Notify the physician of the urine output and hold the dose
of the following clients?: A client who is alcoholic receiving total par- enteral nutrition
level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge?: Broccoli, Nuts, Canned Salmon
days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment?: Magnesium
controlling phosphorus levels for a client in renal failure?: Take alu- minum-based antacids such as aluminum hydroxide (Amphojel) with or after meals
7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the follow- ing is the most appropriate nursing intervention?: Place client in high-Fowler's position
oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?: Encourage the client to rest and to use pursed-lip breathing technique
standing up to go to the bathroom. After assisting the client back to bed, the nurse
notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?: 0.9 NS at an open rate
treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?: pH of 7.33, PCO2 of 35, HCO3 of 17
intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?: Metabolic alkalosis
of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention?: Provide reassurance to the client and administer sedatives
client's diabetic ketoacidosis is deteriorating?: Deep tendon reflexes decreasing from +2 to +
is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropri- ate response by the nurse?: Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues.
the mouth. Which of the following findings indicates the serum calcium is low?: Positive Chvostek's sign
pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data,
of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider?: On auscultation, crackles and rales in all lung fields are noted.
intervention should be included in the plan of care?: Restrict the client's sodium in the diet.
intervention should be implemented?: Place on seizure precautions.
readings. Which client should the nurse assess first?: The client in normal sinus rhythm with a peaked T wave.
mouth and the tips of the fingers. Which intervention should be implement- ed first?: Tap the cheek about two (2) centimeters anterior to the ear lobe.
respirations in the client diagnosed with diabetic ketoacidosis (DKA)?: The lungs speed up to release carbon dioxide and increase the pH.
laboratory test should the nurse monitor?: Serum potassium
that the physician has documented "insensible fluid loss of approxi- mately 800 mL daily." The nurse understands that this type of fluid loss can occur through:: The skin
records, the nurse determines that which client is at risk for deficient fluid volume?: A client with a colostomy
that the client is experiencing a deficient fluid volume. Which assess- ment finding would the nurse note in a client with this condition?: Decreased central venous pressure (CVP)
records, the nurse determines that which client is at risk for excess fluid volume?: The client with renal failure
nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?: An increase in blood pressure
the client's record and determines that the client was at risk for developing the potassium deficit because the client:: Requires nasogastric suction.
potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?: U waves
prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?: Preparing the medication for bolus administration
that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:: Apples
notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium
ROM exercise (reabsorbs back into bones)
cramps, Twitching, Seizures
brain and nervous system
losses, SAIDH, edema, hyperglycemia
kidney failure, Cushing's syndrome
fatigue, n/v, headache
GI upset, edema
hypoparathyroidism
bone cancer
signs, muscle spasms, numbness/tingling in lips/fingers, GI upset
stones, lethargy
maintaining ICF
alkalosis
acidosis, salt substitutes, kidney failure
ness/cramps, constipation/ileus, hypotension
numb- ness/tingling, diarrhea, confusion
abuse
hypertension, tremors, seizures, increased DTR's
lethargy, respiratory and cardiac arrest
digestive juices
suction), CHF
in- take