Question 1

Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L is most important for the nurse to report to the health care provider?

Accepted Answer

Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the patient's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action.

Question 2

When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is

Accepted Answer

Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.

Question 3

A patient receiving isoosmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider?

Accepted Answer

The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

Question 4

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for

Accepted Answer

The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

Question 5

Which of these actions can the nurse who is caring for a critically ill patient with multiple intravenous (IV) lines delegate to an experienced LPN?

Accepted Answer

An experienced LPN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

Question 6

The following data are obtained by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately?

Accepted Answer

The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

Question 7

Which action will the nurse include in the plan of care for a patient who has a central venous access device ( CVAD )?

Accepted Answer

The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the patient should turn away from the CVAD during cap changes.

Question 8

The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse?

Accepted Answer

Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

Question 9

A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider?

Accepted Answer

The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

Question 10

A patient with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first?

Accepted Answer

The patient has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The Maalox should be held, but more immediate action is needed to correct the patient's decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.

Question 11

A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse?

Accepted Answer

The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life-threatening.

Question 12

A postoperative patient who is receiving nasogastric suction is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Accepted Answer

The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

Quiz 17: Fluid, Electrolyte, and Acid-Base Imbalances