A nurse is caring for a client on the medical-surgical unit. Laboratory Results. Vital Signs - Day 1 - 1200: Temperature 100.9°F (38.2°C), Respiratory Rate 26/min, Heart Rate 109/min, Blood Pressure 89/58 mmHg, Pain Score 9/10. Day 2 - Medication Administration - 0700: Temperature: 98.6°F (37°C), Heart Rate 98/min, Respiratory Rate 20/min, Record, Pain Score: 2/10, Blood Pressure 111/62 mmHg. Nurses' Notes - Vital Signs. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Hypocalcemia.

Hypernatremia.

Hyperkalemia.

Potential Condition. Action to Take 1: Prepare to check a serum albumin level. Action to Take 2: Request a STAT ECG. Parameters to Monitor 1: Serum bicarbonate level. Parameters to Monitor 2: Intake and Output.

Answer and Explanation

The Correct Answer is A

Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.

Rationale:

Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.

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Correct Answer is B

Explanation

Respiratory acidosis.

Choice A rationale:

Metabolic alkalosis occurs when there is an increase in pH and bicarbonate (HCO₃⁻) levels, which is not the case here. The pH value in this scenario is 7.22, indicating acidosis.

Choice B rationale:

Respiratory acidosis results from the retention of carbon dioxide (PaCO₂) in the blood, leading to a decrease in pH. In this case, the pH is low (7.22), and the PacO₂ is elevated (68 mm Hg), supporting the diagnosis of respiratory acidosis.

Choice C rationale:

Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels, along with a possible negative base excess. However, in this scenario, the base excess is -2, which does not indicate metabolic acidosis.

Choice D rationale:

Respiratory alkalosis occurs when there is a decrease in PaCO₂, leading to an increase in blood pH. The ABG values provided (pH 7.22, PacO₂ 68 mm Hg) are not consistent with respiratory alkalosis.

A. Sweet Potatoes. B. Bananas. C. Grapes. D. Watermelon.

Correct Answer is ["A","B","D"]

Explanation

The correct answer is choices A, B, and D. Here are the rationales for each choice:

Choice A rationale:

Sweet potatoes are an excellent source of potassium. One medium sweet potato contains about 542 mg of potassium, making it a great option for a high-potassium diet.

Choice B rationale:

Bananas are well-known for their high potassium content. A medium banana provides approximately 451 mg of potassium, which is beneficial for maintaining proper muscle and nerve function.

Choice C rationale:

Grapes are not particularly high in potassium compared to other fruits. They contain some potassium, but not enough to be considered a significant source for a high-potassium diet.

Choice D rationale:

Watermelon is a good source of potassium. Two wedges of watermelon contain about 640 mg of potassium, making it a suitable choice for increasing potassium intake.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PacO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L.

Correct Answer is B

Explanation

A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? Select all that apply.

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which drug should the nurse consider that might have contributed to the patient's health problem?

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?