Nokea
A 65-year-old male patient was admitted to a medical-surgical unit 72 hours ago with pyloric stenosis; a nasogastric tube was inserted upon admission and has been on low intermittent suction since then. The nurse taking care of the patient notices that his potassium is very low and becomes concerned that the patient may be at risk for:
- A. Hypercalcemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia.
You may also like to solve these questions
The renin and angiotensin systems help to maintain the balance of sodium and water in the body. What other functions do these systems serve?
- A. Regulating hemoglobin levels
- B. Maintaining a healthy blood volume
- C. Releasing platelets when tissues are injured
- D. Lowering blood volumes
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct Answer: C
Rationale: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate.
A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct Answer: B
Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve.
The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
- B. Observe for swelling of the neck, tracheal deviation, and severe pain.
- C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Correct Answer: D
Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia.
The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is complaining of being 'short of breath.' The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. The labs reflect:
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.