Nokea
The nurse is caring for a client with severe hypokalemia. The physician has prescribed IV potassium to be administered at $10 \mathrm{mEq} / \mathrm{hr}$. The client complains of burning along the vein. What should the nurse do?
- A. Seek a physician's prescription to dilute the infusion.
- B. Switch to an oral formulation.
- C. Increase the speed of transfusion.
- D. Change the electrolyte.
Correct Answer: A
Rationale: Treatment of severe hypokalemia requires treatment with IV infusion of potassium. Clients may experience burning along the vein with IV infusion of potassium in proportion to the infusion's concentration. If the client can tolerate the fluid, consult with the physician about diluting the potassium in a larger volume of IV solution. Oral potassium may not be enough in severe cases hypokalemia. Hypokalemia requires treatment with potassium and not any other electrolyte.
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A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?
- A. Hypervolemia
- B. Hypercalcemia
- C. Hypomagnesemia
- D. Hypermagnesemia
Correct Answer: C
Rationale: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
The emergency department (ED) nurse is caring for a client with a possible acid- base imbalance. The physician has prescribed an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
- A. $\mathrm{PaO}_2$
- B. $\mathrm{PO}_2$
- C. Carbonic acid
- D. Bicarbonate
Correct Answer: D
Rationale: Arterial blood gas (ABG) results are the main tool for measuring blood $\mathrm{pH}, \mathrm{CO}_2$ content $\left(\mathrm{PaCO}_2\right)$, and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. $\mathrm{PaO}_2$ and $\mathrm{PO}_2$ are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
- A. Kidney and liver
- B. Heart and lungs
- C. Lungs and kidney
- D. Pancreas and stomach
Correct Answer: C
Rationale: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving $\mathrm{CO}_2$ by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?
- A. Osmosis
- B. Passive diffusion
- C. Facilitated diffusion
- D. Active transport
Correct Answer: D
Rationale: Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.
The nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?
- A. A 7-year-old with a fracture tibia
- B. A 65-year-old with a myocardial infarction
- C. A 52-year-old with diarrhea
- D. A 72-year-old with a total knee repair
Correct Answer: C
Rationale: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.