Nokea
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool, clammy skin
- D. Acute flank pain
Correct Answer: A
Rationale: To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.
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The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, pH 7.3, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Mixed acid-base disorder
Correct Answer: D
Rationale: Patients can simultaneously experience two or more independent acid-base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3 concentration immediately suggests a mixed disorder, making the other options incorrect. The pH of 7.28 indicates acidosis, and the elevated PaCO2 suggests a respiratory component, while the normal HCO3 suggests no metabolic compensation, pointing to a mixed disorder.
You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?
- A. Metabolic alkalosis
- B. Hypermagnesemia
- C. Hypercalcemia
- D. Hypovolemia
Correct Answer: D
Rationale: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.
The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
- A. Cimetidine
- B. Maalox
- C. Potassium chloride elixir
- D. Furosemide
Correct Answer: A
Rationale: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.
You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
- A. Hypertension
- B. Kussmaul respirations
- C. Increased DTRs
- D. Shallow respirations
Correct Answer: D
Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.
You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply.
- A. Milk
- B. Beef
- C. Poultry
- D. Green vegetables
- E. Liver
Correct Answer: A,C,E
Rationale: If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged. Beef and green vegetables are not particularly high in phosphate compared to the other options.