Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis
in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?
- A. Metastases
- B. Excessive potassium intake
- C. Water intoxication
- D. Excessive administration of chloride
Correct Answer: D
Rationale: The correct answer is D: Excessive administration of chloride. Normal anion gap acidosis is commonly caused by an excessive intake of chloride-containing solutions like normal saline during treatment. This leads to an increase in the plasma chloride concentration, causing a decrease in the anion gap. Metastases (A) are not typically associated with normal anion gap acidosis. Excessive potassium intake (B) would not lead to normal anion gap acidosis but rather hyperkalemia. Water intoxication (C) can lead to dilutional hyponatremia but not normal anion gap acidosis.
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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: Correct Answer: C - Infiltration
Rationale:
1. Infiltration occurs when IV fluid leaks into surrounding tissues, causing edema.
2. Documenting infiltration is important for appropriate management.
3. Air emboli, phlebitis, and fluid overload are unrelated to edema around IV site.
Summary of Incorrect Choices:
A. Air emboli: This is a serious condition caused by air entering the bloodstream, not related to edema.
B. Phlebitis: Inflammation of the vein, usually presenting with redness and pain, not edema.
D. Fluid overload: Excess fluid volume in the body, leading to symptoms like shortness of breath, not edema.
When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water
and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
- A. Active transport of hydrogen ions across the capillary walls
- B. Pressure of the blood in the renal capillaries
- C. Action of the dissolved particles contained in a unit of blood
- D. Hydrostatic pressure resulting from the pumping action of the heart
Correct Answer: D
Rationale: Rationale: The correct answer is D. Hydrostatic pressure resulting from the pumping action of the heart causes water and electrolytes to move from the arterial capillary bed to the interstitial fluid. This occurs due to the force exerted by the heart's pumping action, pushing fluid out of the capillaries into the interstitial space. This process is known as filtration and is essential for maintaining fluid balance in the body.
Summary of other choices:
A: Active transport of hydrogen ions does not directly cause the movement of water and electrolytes between capillaries and interstitial fluid.
B: The pressure in renal capillaries specifically relates to the kidneys, not the general movement of water and electrolytes in the body.
C: The dissolved particles in blood do not directly contribute to the movement of water and electrolytes between capillaries and interstitial fluid.
The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics.
How should the nurse always start the process of insertion?
- A. Leave one hand ungloved to assess the site.
- B. Cleanse the skin with normal saline.
- C. Ask the patient about allergies to latex or iodine.
- D. Remove excessive hair from the selected site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Asking the patient about allergies to latex or iodine is crucial before starting the IV insertion process. This step ensures patient safety and prevents potential allergic reactions. Knowing the patient's allergies allows the nurse to select appropriate materials for the procedure, reducing the risk of complications.
Summary of Other Choices:
A: Leaving one hand ungloved is not recommended as it compromises infection control practices.
B: Cleansing the skin with normal saline is important but should come after confirming allergies to latex or iodine.
D: Removing excessive hair from the site is unnecessary and not a standard practice for starting the IV insertion process.
A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. Check your radial pulse twice a day
- C. Read food labels to determine sodium content
- D. Bake or grill the meat rather than frying it
Correct Answer: C
Rationale: The correct answer is C. Reading food labels to determine sodium content is important in managing mild hypernatremia. This allows the client to monitor and control their sodium intake, which can help prevent further elevation of sodium levels. Weighing oneself or checking the pulse does not directly address sodium intake. Choosing cooking methods like baking or grilling is more about reducing fat intake, not sodium.
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
- A. Agitation
- B. Kussmaul respirations
- C. Seizures
- D. Positive Chvosteks sign
Correct Answer: B
Rationale: The correct answer is B: Kussmaul respirations. In acute pancreatitis, metabolic acidosis can occur due to the release of pancreatic enzymes. Kussmaul respirations are deep, rapid breaths that help to blow off excess carbon dioxide in response to acidosis, aiming to correct the pH imbalance. Agitation (A) is a nonspecific symptom and not specific to acid-base imbalances. Seizures (C) are more commonly associated with electrolyte imbalances such as hyponatremia or hypocalcemia. Positive Chvostek's sign (D) is a clinical sign of hypocalcemia, not directly related to acid-base imbalances in acute pancreatitis.