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A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Assess the client's dietary intake of foods high in potassium.
- B. Assess the client's neuromuscular status.
- C. Assess the client's fluid intake and output.
- D. Read food labels to determine sodium content.
Correct Answer: D
Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health.
Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.
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A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg.
What does the ABG reflect?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. A low pH (7.21) indicates acidosis. The elevated PaCO2 (64 mm Hg) indicates respiratory acidosis, as high CO2 levels lead to carbonic acid formation, decreasing pH. The normal HCO3 (24 mm Hg) suggests compensation for the respiratory acidosis. Other choices are incorrect as they do not align with the ABG values provided. Metabolic alkalosis (B) would have a high pH and HCO3, respiratory alkalosis (C) would have a high pH and low PaCO2, and metabolic acidosis (D) would have a low pH and HCO3.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?
- A. avoid carrying your grandchild with the arm that has the central catheter.
- B. Be sure to place the arm with the central catheter in a sling during the day
- C. Flush the peripherally inserted central catheter line with normal saline daily.
- D. You can use the arm with the central catheter for most activities of daily living.
Correct Answer: A
Rationale: The correct answer is A: "Avoid carrying your grandchild with the arm that has the central catheter." This is important because carrying a child can put strain on the arm where the catheter is inserted, increasing the risk of dislodging or damaging the catheter. It is crucial to protect the integrity of the catheter site to prevent complications such as infection or bleeding.
Choice B is incorrect because placing the arm with the central catheter in a sling during the day is unnecessary and could restrict the client's mobility and lead to discomfort.
Choice C is incorrect because flushing the PICC line with normal saline should be done by a healthcare professional and not the client themselves.
Choice D is incorrect because using the arm with the central catheter for most activities of daily living can increase the risk of accidental dislodgment or damage to the catheter. It is important to be cautious and limit certain activities to protect the catheter and maintain its function.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm.
- B. Assess urine color, amount, and specific gravity each day.
- C. Encourage the client to drink at least 1 liter of fluids each shift.
- D. Dangle the client on the bedside before ambulating.
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury.
A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration.
B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury.
C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is
a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition
(TPN) has been started. Why would you know to start the infusion of TPN slowly?
- A. Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
- B. Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started
too aggressively.
- C. Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
- D. Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate
Correct Answer: B
Rationale: The correct answer is B: Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Patient with pancreatitis may have depleted levels of phosphorus due to malnutrition, and rapid initiation of TPN can further decrease phosphorus levels, leading to hypophosphatemia. This can result in respiratory failure, muscle weakness, and arrhythmias.
Choice A is incorrect because patients receiving TPN are not specifically at risk for hypercalcemia due to rapid initiation of calories. Choice C is incorrect because rapid fluid infusion can lead to hypernatremia, not related to TPN initiation. Choice D is incorrect because the rationale provided for slow initiation is not related to digestive enzymes but rather to prevent hypophosphatemia in malnourished patients.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Depth of respirations
- B. Bowel sounds
- C. Grip strength
- D. Electrocardiography
Correct Answer: A
Rationale: The correct assessment for the nurse to complete first is A: Depth of respirations. Potassium and magnesium levels are crucial electrolytes that can affect cardiac function. Hypokalemia (low potassium) and hypomagnesemia (low magnesium) can lead to cardiac dysrhythmias. Checking the depth of respirations can provide valuable information on the client's respiratory status and potential respiratory distress due to electrolyte imbalances. This assessment takes precedence as addressing respiratory issues promptly is essential to prevent further complications. Assessing bowel sounds (B), grip strength (C), and electrocardiography (D) are important but not as immediate as assessing respiratory status in this scenario.