A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the fol-
lowing findings is the priority for the nurse to assess?
-Deep tendon reflexes
-Cardiac rhythm
-Peripheral sensation
-Bowel sounds - ANSWER Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should first
assess the client's cardiac rhythm because this total serum calcium level is below the ex-
pected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets
of laboratory results indicates that the client has metabolic alkalosis?
-pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L
-pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 26 mEq/L
-pH 7.31, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 23 mEq/L
-pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L - ANSWER pH 7.51, PaO2
94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L
An elevated pH and HCO3- with a PaCO2 either elevated or within the expected reference
range indicates metabolic alkalosis.
1
, A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing
for complications, the nurse should recognize which of the following manifestations as a sign
of fluid overload?
-Increased urine specific gravity
-Hypoactive bowel sounds
-Bounding peripheral pulses
-Decreased respiratory rate - ANSWER Bounding peripheral pulses
The nurse should recognize that increased vascular volume results in full, bounding periph-
eral pulses.
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary
edema. Which of the following actions should the nurse take first?
-Assist with intubation
-Initiate high-flow oxygen therapy
-Administer a rapid-acting diuretic
-Provide cardiac monitoring - ANSWER Initiate high-flow oxygen therapy.
When using the airway, breathing, circulation approach to client care, the nurse should first
administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen
saturation above 90%.
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has ex-
perienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medi-
cations should the nurse prepare to administer?
-Sodium polystyrene sulfonate 30 g/day
-0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
2
lowing findings is the priority for the nurse to assess?
-Deep tendon reflexes
-Cardiac rhythm
-Peripheral sensation
-Bowel sounds - ANSWER Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should first
assess the client's cardiac rhythm because this total serum calcium level is below the ex-
pected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets
of laboratory results indicates that the client has metabolic alkalosis?
-pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L
-pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 26 mEq/L
-pH 7.31, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 23 mEq/L
-pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L - ANSWER pH 7.51, PaO2
94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L
An elevated pH and HCO3- with a PaCO2 either elevated or within the expected reference
range indicates metabolic alkalosis.
1
, A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing
for complications, the nurse should recognize which of the following manifestations as a sign
of fluid overload?
-Increased urine specific gravity
-Hypoactive bowel sounds
-Bounding peripheral pulses
-Decreased respiratory rate - ANSWER Bounding peripheral pulses
The nurse should recognize that increased vascular volume results in full, bounding periph-
eral pulses.
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary
edema. Which of the following actions should the nurse take first?
-Assist with intubation
-Initiate high-flow oxygen therapy
-Administer a rapid-acting diuretic
-Provide cardiac monitoring - ANSWER Initiate high-flow oxygen therapy.
When using the airway, breathing, circulation approach to client care, the nurse should first
administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen
saturation above 90%.
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has ex-
perienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medi-
cations should the nurse prepare to administer?
-Sodium polystyrene sulfonate 30 g/day
-0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
2
