Nokea
The nurse cares for a client with a serum sodium level of 152 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following assessment findings would be expected? Select all that apply.
- A. Lethargy
- B. Dry mucous membranes
- C. Tachypnea
- D. Cyanosis
- E. Excessive thirst
Correct Answer: A,B,E
Rationale: Hypernatremia causes lethargy, dry mucous membranes, and excessive thirst due to cellular dehydration.
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The nurse is caring for a client with polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals?
- A. Blood Pressure 128/63 mmHg
- B. Creatinine 2.3 mg/dL [0.6-1.2 mg/dL (53-106 mmol/L)]
- C. Proteinuria 2+
- D. Sodium 132 mEq/L [136-145 mEq/L (mmol/L)]
Correct Answer: A
Rationale: Controlled blood pressure (128/63 mmHg) indicates effective PKD management, as hypertension is a common complication.
The nurse is caring for a client with a phosphorus level of 5.3 mg/dL (1.71 mmol/L) [normal range: 3.0-4.5 mg/dL (0.97-1.45 mmol/L)]. The nurse identifies which of the following as possible causes of this condition? Select all that apply.
- A. tumor lysis syndrome
- B. hypoparathyroidism
- C. hypercalcemia
- D. renal failure
- E. anorexia
Correct Answer: A,B,D
Rationale: Tumor lysis syndrome, hypoparathyroidism, and renal failure cause hyperphosphatemia by increasing phosphate release or reducing excretion.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client.
Item 1 of 1
Progress Notes
Day 1
1700: Admitted from the emergency department with a small bowel obstruction. Nasogastric tube (NGT) was inserted with intermittent suction. Awaiting surgical consult.
Day 2
0900: Morning labs reviewed and orders were given. Still awaiting surgical consult.
Orders
Day 1:
• Insert nasogastric tube to low intermittent suction
• Insert a peripheral vascular access device
• nothing by mouth (n.p.o.) status
• consult surgery for evaluation
• continuous infusion of 0.9% sodium chloride (normal saline) 100 mL/hr
Day 2:
• potassium chloride 40 mEq via intravenous piggy-back x 1 dose
The nurse reviews the clinical data. The nurse prepares to implement the orders from day 2. Complete the following sentences by choosing from the list of options. Prior to the nurse administering the prescribed IV potassium, the nurse should....... The nurse should also.......... The nurse should infuse the IV potassium over. During the infusion, if the client should report pain at the vascular access device, the nurse should......
- A. ensure the client has adequate urine output.
- B. implement seizure precautions.
- C. initiate continuous cardiac monitoring
- D. 2 hours.
- E. 4 hours.
- F. stop the infusion.
- G. apply a warm compress to the vascular access device.
Correct Answer: A,C,E,F
Rationale: Adequate urine output and cardiac monitoring are essential before and during IV potassium infusion to prevent hyperkalemia. Infuse over 4 hours and stop if pain occurs to avoid complications.
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply.
- A. Aspirin overdose
- B. Pneumothorax
- C. Opioid overdose
- D. Anxiety
- E. Renal disease
Correct Answer: B,C
Rationale: Pneumothorax and opioid overdose impair ventilation, causing CO2 retention and respiratory acidosis.
The nurse has administered bumetanide to a client with pulmonary edema. Which of the following findings would indicate an adverse response to bumetanide?
- A. distended neck veins
- B. adventitious lung sounds
- C. leg cramps
- D. increase in urine output
Correct Answer: C
Rationale: Bumetanide, a loop diuretic, can cause hypokalemia, leading to leg cramps as an adverse response. Distended neck veins (A) and adventitious lung sounds (B) are signs of pulmonary edema, not adverse effects. Increased urine output (D) is an expected effect.