Nokea
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 of which acidbase imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Increased PaCO2
- D. CNS disturbances
Correct Answer: B
Rationale: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.
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You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note that the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?
- A. Hypernatremia
- B. Hypomagnesemia
- C. Hypophosphatemia
- D. Hypercalcemia
Correct Answer: D
Rationale: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patient's presentation is inconsistent with hypophosphatemia.
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this 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. Air emboli, phlebitis, and fluid overload are not indications of infiltration.
A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
- D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Correct Answer: D
Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: You can induce Chvostek's sign by tapping the patient's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek's sign, but hypocalcemia is the primary electrolyte imbalance associated with this sign.
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 to allow digestive enzymes to accumulate.
Correct Answer: B
Rationale: The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started too rapidly. Digestive enzymes are not a relevant consideration.