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

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

Rationale:

A. Expect urination to increase. B. Expect to feel weak and dizzy. C. Take the medication before going to sleep. D. Report swelling of the face or hands. E. Monitor body weight daily.

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

Explanation

A, D, and E.

Choice A rationale:

Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.

Choice B rationale:

Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.

Choice C rationale:

Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.

Choice D rationale:

Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.

Choice E rationale:

Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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.

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

Explanation

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

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?

The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

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's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?