Med Surg Adaptive Quizzing and Rationale
The nurse is planning care for a patient with a new diagnosis of hypercalcemia resulting from treatment
for hypocalcemia. Which change to the plan of care should the nurse anticipate?
- weight bearing exercises
A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of
weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra
calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium
gluconate, and administering a thiazide diuretic are all appropriate for hypocalcemia; therefore these
actions should be removed from the plan of care, not added
The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular
fluid accumulation?
1.A patient with drainage from a rectal fistula
2.A patient with osmotic diuresis
3.A patient with renal impairment
4.A patient with an intestinal obstruction
3
Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma,
and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is
impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and
intestinal obstruction result in a loss of body fluid.
A patient asks why the primary health care provider prescribed a b-type natriuretic peptide (BNP).
Which response by the nurse is accurate?
1.It is a diagnostic procedure to rule out urine retention.
2.It is a blood test that is elevated in patients with hyponatremia.
3.It is a blood test that shows if there is excess fluid in the heart.
4.It is an x-ray that helps determine the presence of stomach ulcers.
3
,BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to
diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure
increases because of increased venous return and hypernatremia. The test gives no information to rule
out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine
hyponatremia.
The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The
results are: pH 7.32; PaCO 2 52; HCO 3- 24. What does the nurse interpret these results to mean?
respiratory acidosis
Normal pH is 7.35 to 7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO 2 is 35 to 45
mm Hg. Because the HCO 3- is normal and the PaCO 2 is elevated, the source of the acidosis is
respiratory. The patient is in respiratory acidosis.
The nursing instructor is discussing peripherally implanted catheters (PICC) with a nursing student.
Which nursing student statement would indicate a need for further teaching?
Blood pressure should not be taken on an arm with a PICC line because inflation of the cuff can lead to
the risk of vein damage or thrombosis. Nurses do need to check for phlebitis for up to 10 days after the
PICC is inserted. PICC lines are typically used for access for up to six months, and they can be left longer.
PICC lines have fewer side effects than central venous catheters.
The nurse is caring for a patient with acute kidney failure due to severe dehydration. When evaluation
of the arterial blood gases is done, what condition does the nurse likely interpret the findings to
indicate?
metabolic acidosis
Renal failure will make the blood more acidic because of the inability of the kidneys to excrete acid.
Therefore the nurse suspects that the patient would develop metabolic acidosis. Metabolic alkalosis is
caused by excess bicarbonate intake and a potassium deficit. Respiratory acidosis is caused by
hypoventilation. Respiratory alkalosis is caused by hyperventilation.
A patient has been admitted for dehydration. What is a priority nursing intervention?
, a) Perform daily weights.
b) Reorient the patient hourly.
c) Restrict sodium intake to 2 grams per day.
d) Provide continuous oxygen saturation monitoring
A
Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would
indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid
volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of
body water. This patient is not disoriented, and that is not a common assessment finding in the patient
with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not
need to be restricted.
When assessing a patient admitted with nausea and vomiting, which finding supports a determination of
deficient fluid volume?
General restlessness
Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular
fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion
and later coma. Polyuria, decreased pulse, and difficulty breathing do not support a determination of
deficient fluid volume.
A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse
determine is the probable reason for the increase in phosphate levels in this patient?
Chemotherapy
Insulin therapy
The nurse is planning care for a patient with a new diagnosis of hypercalcemia resulting from treatment
for hypocalcemia. Which change to the plan of care should the nurse anticipate?
- weight bearing exercises
A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of
weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra
calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium
gluconate, and administering a thiazide diuretic are all appropriate for hypocalcemia; therefore these
actions should be removed from the plan of care, not added
The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular
fluid accumulation?
1.A patient with drainage from a rectal fistula
2.A patient with osmotic diuresis
3.A patient with renal impairment
4.A patient with an intestinal obstruction
3
Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma,
and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is
impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and
intestinal obstruction result in a loss of body fluid.
A patient asks why the primary health care provider prescribed a b-type natriuretic peptide (BNP).
Which response by the nurse is accurate?
1.It is a diagnostic procedure to rule out urine retention.
2.It is a blood test that is elevated in patients with hyponatremia.
3.It is a blood test that shows if there is excess fluid in the heart.
4.It is an x-ray that helps determine the presence of stomach ulcers.
3
,BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to
diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure
increases because of increased venous return and hypernatremia. The test gives no information to rule
out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine
hyponatremia.
The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The
results are: pH 7.32; PaCO 2 52; HCO 3- 24. What does the nurse interpret these results to mean?
respiratory acidosis
Normal pH is 7.35 to 7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO 2 is 35 to 45
mm Hg. Because the HCO 3- is normal and the PaCO 2 is elevated, the source of the acidosis is
respiratory. The patient is in respiratory acidosis.
The nursing instructor is discussing peripherally implanted catheters (PICC) with a nursing student.
Which nursing student statement would indicate a need for further teaching?
Blood pressure should not be taken on an arm with a PICC line because inflation of the cuff can lead to
the risk of vein damage or thrombosis. Nurses do need to check for phlebitis for up to 10 days after the
PICC is inserted. PICC lines are typically used for access for up to six months, and they can be left longer.
PICC lines have fewer side effects than central venous catheters.
The nurse is caring for a patient with acute kidney failure due to severe dehydration. When evaluation
of the arterial blood gases is done, what condition does the nurse likely interpret the findings to
indicate?
metabolic acidosis
Renal failure will make the blood more acidic because of the inability of the kidneys to excrete acid.
Therefore the nurse suspects that the patient would develop metabolic acidosis. Metabolic alkalosis is
caused by excess bicarbonate intake and a potassium deficit. Respiratory acidosis is caused by
hypoventilation. Respiratory alkalosis is caused by hyperventilation.
A patient has been admitted for dehydration. What is a priority nursing intervention?
, a) Perform daily weights.
b) Reorient the patient hourly.
c) Restrict sodium intake to 2 grams per day.
d) Provide continuous oxygen saturation monitoring
A
Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would
indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid
volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of
body water. This patient is not disoriented, and that is not a common assessment finding in the patient
with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not
need to be restricted.
When assessing a patient admitted with nausea and vomiting, which finding supports a determination of
deficient fluid volume?
General restlessness
Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular
fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion
and later coma. Polyuria, decreased pulse, and difficulty breathing do not support a determination of
deficient fluid volume.
A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse
determine is the probable reason for the increase in phosphate levels in this patient?
Chemotherapy
Insulin therapy
