Nokea
The nurse is teaching a group of students a potential cause of metabolic alkalosis. It would indicate a correct understanding if a student stated which condition could cause this acid-base imbalance?
- A. Hyperventilation
- B. Urinary retention
- C. Opioid toxicity
- D. Excessive vomiting
Correct Answer: D
Rationale: Excessive vomiting causes loss of hydrogen ions, leading to metabolic alkalosis.
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The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)?
- A. Oliguria
- B. Abdominal distention
- C. Muscle weakness
- D. Weak peripheral pulses
Correct Answer: A
Rationale: Oliguria indicates poor renal function, which can lead to potassium accumulation, requiring PHCP notification before IV potassium administration.
The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?
- A. Headache and nausea
- B. Scant blood on the AV fistula
- C. Potassium 3.7 mEq/L (mmol/L) [3.5-5.0 mEq/L, mmol/L]
- D. Hemoglobin 8.8 g/dL [Male: 14-18 g/dL; Female: 12-16 g/dL, Female 115-155 g/L Male 125-170 g/L]
Correct Answer: A
Rationale: Headache and nausea may indicate dialysis disequilibrium syndrome, a serious complication requiring immediate attention.
The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
- A. WBC 19,000 mm3 [5,000-10,000 mm3]
- B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)]
- C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL]
- D. Serum pH 7.33 [7.35-7.45]
Correct Answer: A
Rationale: Elevated WBC (19,000 mm3) suggests infection, a serious complication in peritoneal dialysis.
A nurse on a medical-surgical unit cares for a client who has just undergone a procedure for a Kock pouch as a treatment for bladder cancer. The initial nursing interventions for this client would include:
- A. Monitoring urine output, checking for indications of ostomy pouch leaks, and noting the size, shape, and color of the stoma.
- B. Speaking to the client's family and updating them regarding the client's status.
- C. Educating the client about stoma care and skincare.
- D. Irrigating the catheters as needed.
Correct Answer: A
Rationale: Initial interventions for a Kock pouch include monitoring urine output and stoma condition to ensure proper function and detect complications.
The nurse is assigned to care for a client with a sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which assessment findings does the nurse anticipate based on this lab result?
- A. Confusion
- B. Abdominal cramps
- C. Tall, peaked t-waves
- D. Hypoactive bowel sounds
- E. Nausea and vomiting
Correct Answer: A,B,E
Rationale: Hyponatremia causes confusion, abdominal cramps, and nausea/vomiting due to cerebral edema and gastrointestinal irritation.