Question 1

Which action can the registered nurse (RN)who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Accepted Answer

An experienced LPN/LVN 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 2

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused.The patient complains of "just blowing up" and has peripheral edema and shortness of breath.Which assessment should the nurse complete first?

Accepted Answer

Increases in extracellular fluid (ECF)can lead to swelling 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 increases in ECF,these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

Question 3

A patient is admitted to the emergency department with severe fatigue and confusion.Laboratory studies are done.Which laboratory value 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 are also abnormal,and the nurse should notify the health care provider about these values as well,but they are not immediately life threatening.

Question 4

After receiving change-of-shift report,which patient should the nurse assess first?

Accepted Answer

The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures.The other patients have mild electrolyte disturbances and/or symptoms that require action,but they are not at risk for life-threatening complications.

Question 5

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate,which finding should the nurse 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 6

An older patient receiving iso-osmolar continuous tube feedings develops restlessness,agitation,and weakness.Which laboratory result should the nurse report to the health care provider immediately?

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 normal but do not require immediate action by the nurse.The phosphate level is normal.

Question 7

A patient is receiving a 3% saline continuous IV infusion for hyponatremia.Which 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 8

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

Accepted Answer

The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF)excess,ECF deficit,hyponatremia,hypernatremia,hypokalemia,or metabolic alkalosis.Further diagnostic information is needed 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 9

The nurse is caring for a patient who has a central venous access device (CVAD).Which action by the nurse is appropriate?

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.The patient should turn away from the CVAD during cap changes.

Question 10

During the admission process,the nurse obtains information about a patient through the physical assessment and diagnostic testing.Based on the data shown in the accompanying figure,which nursing diagnosis is appropriate?

Accepted Answer

The patient's muscle cramps and low serum calcium level indicate that the patient is at risk for seizures and/or tetany.The other diagnoses are not supported by the data because the skin turgor is good.The lungs are clear,arterial blood gases are normal,and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.

Question 11

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and 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.

Question 12

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

Accepted Answer

Hypocalcemia can cause laryngeal stridor,which may lead to respiratory arrest.Rapid action is required to correct the patient's calcium level.The other data are also consistent with hypocalcemia,but do not indicate a need for as immediate action as laryngospasm.

Question 13

Following a thyroidectomy,a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately?

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 14

A patient comes to the clinic complaining of frequent,watery stools for the last 2 days.Which action should the nurse take first?

Accepted Answer

Because the patient's history suggests that fluid volume deficit may be a problem,assessment for adequate circulation is the highest priority.The other actions are also appropriate,but are not as essential as determining the patient's perfusion status.

Question 15

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Accepted Answer

The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion,including embolism and pneumothorax.The other actions may be appropriate,but further assessment of the patient is needed before notifying the health care provider,offering reassurance,or administration of morphine.

Question 16

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition.Which action should the nurse take next?

Accepted Answer

This patient with chronic malnutrition is likely to have a low serum albumin level,which will affect the total serum calcium.A more accurate reflection of calcium balance is the ionized calcium level.Most of the calcium in the blood is bound to protein (primarily albumin).Alterations in serum albumin levels affect the interpretation of total calcium levels.Low albumin levels result in a drop in the total calcium level,although the level of ionized calcium is not affected.The other actions may be needed if the ionized calcium is also decreased.

Question 17

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox)at home for indigestion.The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes.Which action should the dialysis nurse take first?

Accepted Answer

The health care provider should be notified immediately.The patient has a history and manifestations consistent with hypermagnesemia.The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations.Dialysis should correct the high magnesium levels.The patient needs teaching about the risks of taking magnesium-containing antacids.Monitoring of potassium levels also is important for patients with renal failure,but the patient's current symptoms are not consistent with hyperkalemia.

Quiz 13: Nursing Management: Fluid,electrolyte and Acidbase Imbalances

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN) ?