Nokea
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- A. Monitor daily hemoglobin and hematocrit values.
- B. Administer furosemide (Lasix) intravenously.
- C. Encourage the client to take deep breaths.
- D. Teach the client fall prevention measures.
Correct Answer: D
Rationale: The correct answer is D: Teach the client fall prevention measures. In metabolic alkalosis, the client may experience muscle weakness and confusion, increasing the risk of falls. Teaching fall prevention measures is essential to ensure the client's safety. Monitoring hemoglobin and hematocrit values (A) is not directly related to managing metabolic alkalosis. Administering furosemide (B) is not appropriate for metabolic alkalosis. Encouraging deep breaths (C) may not address the underlying cause of the alkalosis.
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A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)
- A. A 36-year-old who is malnourished
- B. A 42-year-old with uncontrolled diabetes
- C. A 76-year-old who is prescribed antacids
- D. 50-year-old with hyperparathyroidism
Correct Answer: C
Rationale: The correct answer is C because antacids contain aluminum or magnesium, which can bind with phosphorus and decrease its absorption, leading to hypophosphatemia. Malnourishment (choice A) can cause hypophosphatemia due to inadequate intake, uncontrolled diabetes (choice B) is associated with hyperphosphatemia, and hyperparathyroidism (choice D) can lead to hyperphosphatemia due to increased calcium levels.
While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct Answer: A
Rationale: The correct answer is A: Client with pancreatitis who has continuous nasogastric suctioning. Pancreatitis can lead to gastrointestinal losses of potassium, and continuous nasogastric suctioning can further exacerbate this potassium loss, putting the client at risk for hypokalemia. The other choices are incorrect because:
B: ACE inhibitors can cause hyperkalemia, not hypokalemia.
C: Blood transfusions can lead to hyperkalemia due to the potassium content in blood products.
D: Uncontrolled diabetes and a serum pH level of 7.33 are not directly associated with hypokalemia.
You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are
outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
- A. Increased serum sodium
- B. Decreased serum potassium
- C. Decreased hemoglobin
- D. Increased platelets
Correct Answer: A
Rationale: The correct answer is A: Increased serum sodium. High serum sodium levels trigger the release of antidiuretic hormone (ADH) from the pituitary gland to help retain water in the body and maintain fluid balance. This is a physiological response to prevent further dehydration. Decreased serum potassium (choice B), decreased hemoglobin (choice C), and increased platelets (choice D) do not directly stimulate the release of ADH. Hence, they are incorrect choices in this scenario.
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Increased PaCO2
- D. CNS disturbances
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.
You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?
- A. Respiratory acidosis with no compensation
- B. Metabolic alkalosis with a compensatory alkalosis
- C. Metabolic acidosis with no compensation
- D. Metabolic acidosis with a compensatory respiratory alkalosis
Correct Answer: D
Rationale: To interpret the given ABG results:
1. pH <7.35 indicates acidosis.
2. PaCO2 <35 indicates respiratory alkalosis.
3. HCO3 <22 indicates metabolic acidosis.
Therefore, the ABG results show metabolic acidosis (low pH, low HCO3) with compensatory respiratory alkalosis (low PaCO2). This means the body is trying to compensate for the metabolic acidosis by decreasing PaCO2 through hyperventilation. Option D is correct. Options A, B, and C are incorrect as they do not align with the ABG results and the principles of acid-base balance.