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 A

Explanation

Choice A rationale: Patients with bulimia are at increased risk for developing metabolic alkalosis due to recurrent vomiting, which leads to loss of hydrochloric acid from the stomach and results in an elevated blood bicarbonate level.

Choice B rationale: Patients with COPD are more likely to develop respiratory acidosis due to retention of carbon dioxide, not metabolic alkalosis.

Choice C rationale: Patients with venous stasis ulcers do not have a direct association with metabolic alkalosis.

Choice D rationale: Patients on dialysis are more likely to experience metabolic acidosis due to impaired kidney function and inability to excrete acid effectively.

A. Prepare to administer a sedative. B. Prepare for mechanical ventilation. C. Massage the calf area for tenderness. D. Assess for indications of pulmonary embolism. E. None F. None

Correct Answer is D

Explanation

The correct answer isd. Assess for indications of pulmonary embolism.

Choice A rationale:

Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.

Choice B rationale:

Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.

Choice C rationale:

Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.

Choice D rationale:

Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a Paco2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

A patient has a serum phosphate level of 2.0 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.

A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.

A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

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

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?