Nokea
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.
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You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You
and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your
colleague dismisses. What can this increase in creatinine indicate in older adults?
- A. Substantially reduced renal function
- B. Acute kidney injury
- C. Decreased cardiac output
- D. ) Alterations in ratio of body fluids to muscle mass
Correct Answer: A
Rationale: The correct answer is A: Substantially reduced renal function. In older adults, elevated serum creatinine levels can indicate impaired kidney function, as the kidneys may not filter waste products as efficiently. This can lead to a buildup of creatinine in the blood. Acute kidney injury (Choice B) is a sudden decline in kidney function and would typically present with a more significant increase in creatinine levels. Decreased cardiac output (Choice C) would not directly cause elevated creatinine levels. Alterations in the ratio of body fluids to muscle mass (Choice D) would not be a common cause of elevated creatinine levels in this scenario.
. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an exam
- A. Increased rate and depth of respirations
- B. ncreased urinary output
- C. Increased thirst and hunger
- D. ncreased release of acids from the kidneys
Correct Answer: A
Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client's arterial blood gas values show a pH within normal range (7.36), PaCO2 below normal (33 mm Hg), and HCO3 below normal (18 mEq/L), indicating a metabolic acidosis. To compensate for the acidosis, the client will hyperventilate, leading to increased rate and depth of respirations to blow off excess CO2 and attempt to normalize the pH. Options B, C, and D are incorrect because increased urinary output, thirst, hunger, and release of acids from the kidneys are not direct compensatory mechanisms for metabolic acidosis.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)
- A. Hypokalemia Flaccid paralysis with respiratory depression
- B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
- C. . Hyponatremia Decreased level of consciousness
Correct Answer: B
Rationale: The correct answer is B because hyperphosphatemia can lead to paresthesia with sensations of tingling and numbness due to its effect on nerve function.
A, hypokalemia causes muscle weakness but not flaccid paralysis with respiratory depression.
C, hyponatremia typically presents with symptoms such as confusion and seizures, not decreased level of consciousness.
The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of
respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the
alveoli. The nurse is describing what process?
- A. Diffusion
- B. Osmosis
- C. Active transport
- D. Filtration
Correct Answer: A
Rationale: The correct answer is A: Diffusion. In respiration, oxygen and carbon dioxide are exchanged between the alveoli and pulmonary capillaries through the process of diffusion. Here's the rationale:
1. Diffusion is the movement of molecules from an area of high concentration to an area of low concentration.
2. In the alveoli, oxygen moves from the air (higher concentration) into the blood (lower concentration) and carbon dioxide moves from the blood (higher concentration) into the air (lower concentration).
3. This exchange occurs passively, without the need for energy input, which is characteristic of diffusion.
Summary of other choices:
B: Osmosis involves the movement of water across a semi-permeable membrane, not gas exchange.
C: Active transport requires energy input to move molecules against their concentration gradient, not seen in gas exchange.
D: Filtration involves the movement of molecules through a membrane under pressure, not the passive movement of gases in respiration.
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
- A. Diarrhea and vomiting for 36 hours
- B. . Anxiety-induced hyperventilation
- C. Chronic obstructive pulmonary disease (COPD)
- D. Diabetic ketoacidosis and emphysema
Correct Answer: B
Rationale: The correct answer is B: Anxiety-induced hyperventilation. The arterial blood gas values show a pH of 7.48 (alkalosis) with low PaCO2 (respiratory alkalosis), which is consistent with hyperventilation due to anxiety. HCO3 is within normal range, ruling out metabolic causes. A: Diarrhea and vomiting would lead to metabolic acidosis with low pH and decreased HCO3. C: COPD would typically present with respiratory acidosis (high PaCO2) and normal to high HCO3. D: Diabetic ketoacidosis and emphysema would show metabolic acidosis with low pH and low HCO3.