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A patient who has small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the healthcare provider about which assessment finding?
- A. Reported weight gain
- B. Serum hematocrit of 42%
- C. Serum sodium level of 120 mEq/L
- D. Total urinary output of 280 mL during the past 8 hours
Correct Answer: C
Rationale: The correct answer is C, a serum sodium level of 120 mEq/L. Hyponatremia is the most important finding to report in SIADH. SIADH causes water retention and a decrease in serum sodium levels. Hyponatremia can lead to confusion and other central nervous system effects and requires treatment. Adequate kidney function is indicated by a urinary output of at least 30 mL/hr. A hematocrit level of 42% is normal. Weight gain is expected due to water retention in SIADH.
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After receiving change-of-shift report, which patient should the nurse assess first?
- A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
- B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
- C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
- D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
Correct Answer: C
Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
- A. K+ 3.4 mEq/L (3.4 mmol/L)
- B. Ca+2 7.8 mg/dL (1.95 mmol/L)
- C. Na+ 154 mEq/L (154 mmol/L)
- D. PO4-3 4.8 mg/dL (1.55 mmol/L)
Correct Answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
- A. Grape juice
- B. Milk carton
- C. Mixed green salad
- D. Fried chicken breast
Correct Answer: B
Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.
How should the nurse interpret the following arterial blood gas results for a patient who had a tracheostomy placed after a motor vehicle crash: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The patient's pH of 7.48 indicates alkalosis, and the low PaCO2 of 32 mm Hg suggests a respiratory cause. The HCO3 level is normal, ruling out metabolic causes. Therefore, the correct interpretation is respiratory alkalosis. Options A, B, and C are incorrect as they do not align with the pH and PaCO2 values provided.
The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
- A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
- B. Only foil balloons will be used for the child's birthday party.
- C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
- D. An epinephrine auto-injector will be on hand to treat allergic reactions.
Correct Answer: C
Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.