Med Surg Exam 1

Which patients are at risk for fluid volume excess? A. 64 year old male with a diagnosis of kidney failure B. 46 year old male who is training for a marathon C. 35 year old male with diarrhea and vomiting for the past 2 days D. 83 year old female with a diagnosis of a stroke and has trouble talking - correct answer A Which solution is considered a hypertonic IV solution? A. 0.9% sodium chloride B. Total parenteral nutrition C. 0.45% sodium chloride D. Lactated Ringers solution - correct answer B What happens to the size of cells within the tissues when an isotonic IV solution is administered? A. Cells enlarge B. Cells shrink C. The size of the cells remain unchanged - correct answer C True or False: The principle intracellular cation in the body is sodium. - correct answer False A nurse is planning care for a client with a fluid volume deficit. Which of the following are appropriate nursing actions? (Select all that apply) A. Administer a diuretic B. Turn the patient at least ever two hours C. infuse a hypertonic IV solution as ordered D. Teach the patient to sit on the side of bed first before standing E. Assess the patient's level of consciousness and mental status - correct answer B, D, E The nurse recognizes which of the following statements are true regarding Fluid Volume Deficit/dehydration in older adults? (Select all that apply) A. The kidneys are less able to concentrate urine B. Diuretics and laxative use can increase fluid loss C. The perception of thirst increases with age in older adults D. Poor skin turgor is a reliable indicator of dehydration in the elderly E. Lack of air conditioning in hot weather is a risk factor for fluid volume deficit - correct answer A, B, E Tachycardia is present in which type of fluid imbalance? A. Fluid volume excess B. Fluid volume deficit C. Both fluid volume excess and fluid volume deficit - correct answer C Decreased serum osmolality is present in which type of fluid imbalance? A. Fluid volume excess B. Fluid volume deficit C. Both fluid volume excess and fluid volume deficit - correct answer A Jugular vein distention is present in which type of fluid imbalance? A. Fluid volume excess B. Fluid volume deficit C. Both fluid volume excess and fluid volume deficit - correct answer A Mr. Smith is a patient who has been admitted to a nursing unit with a diagnosis of heart failure resulting in fluid volume excess. Upon entering his room Mr. Smith complains of difficulty breathing. What should be the nurse's first action? A. Contact the primary care provider B. Assess his fluid status by obtaining a daily weight C. Elevate the head of bed and obtain an oxygen saturation level D. Administer a diuretic to help correct his diagnosis of a fluid volume excess - correct answer C The nurse is assigned to care for all of the following patients. Which patient is at risk for hypokalemia? (select all that apply) A. 64 year old with a diagnosis of kidney failure B. 35 year old with diarrhea and vomiting for the past 2 days C. 83 year old with a hypertension who uses salt substitutes D. 26 year old in a motor vehicle accident who received 3 units of blood E. 19 year old with a history of anorexia, laxative abuse, and diuretic use - correct answer B, E Which body system is associated with the most severe consequences due to imbalances in sodium? A. Renal B. Respiratory C. Neurologic D. Gastrointestinal - correct answer C Increased thirst is a symptom of which disorders? Select all that apply A. Dehydration B. Cerebral edema C. Hypernatremia D. Hypophosphatemia E. Hypomagnesaemia - correct answer A, C A patient with a fluid volume deficit is monitored for his fluid volume status with hourly measurements of his urine output. Which clinical finding should the nurse report to the primary care provider? A. Urine output of 30 mLs at 10am and 25 mLs at 11am B. Urine output of 100 mLs at 10am and 75 mLs at 11am C. Urine output of 45 mLs at 10 am and 60 mLs at 11am D. Urine output of 50 mLs at 10am and 100 mLs at 11am - correct answer A True or False: A phosphate deficiency usually occurs along with low serum potassium and calcium levels. - correct answer False The nurse is caring for a patient who manifests muscle weakness that first began in the legs and has progressed to include weakness in the arms. Based on this information, what statement can be made about imbalances in potassium? A. These can be symptoms associated only with hypokalemia B. These can be symptoms associated only with hyperkalemia C. These symptoms are not related to imbalances in potassium D. These symptoms can occur in either hypokalemia or hyperkalemia - correct answer D Which food source is high in potassium? A. Eggs B. Pears C. Spinach D. Whole wheat - correct answer C When caring for a patient who is receiving potassium supplements, the nurse recognizes the need to do which of the following actions? A. Encourage the patient to use salt substitutes with meals B. Give oral potassium by diluting it in fruit juice or cold water C. Give potassium as a slow IV push medication over 1-2 minutes D. Monitor SpO2 levels (oxygen saturation) when administering via the IV route - correct answer B A nurse is caring for a patient who has dysrhythmias. Which laboratory result would the nurse expect to see for this patient? A. Sodium 165 mEq/L B. Potassium 6.8 mEq/L C. Hematocrit 40% D. Glucose 60 mL/dL - correct answer B Which clinical indicator would be expected in a patient with severe third spacing of fluids? A. Decreased serum osmolality B. Fever greater than 101 F C. Orthostatic hypotension D. Jugular vein distention - correct answer C A patient develops acute renal failure. Which acid-base imbalance should the nurse anticipate? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis - correct answer D A 23-year old patient is found unresponsive with a respiratory rate of 6 per minute after a narcotic overdose. Which acid-base imbalance should the nurse anticipate? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis - correct answer D The nurse is assessing a patient with chronic alcoholism for signs of hypocalcaemia. Which action should the nurse take to assess for Trouseeau's signs? A. inflate a blood pressure cuff on the upper arm above systolic pressure for 2 to 5 minutes B. Tap the facial nerve in front of the ear and observe for contraction of the facial muscles C. Monitor neurological function including mental status and level of consciousness D. Asses for numbness and tingling around the mouth and in the hands and feet - correct answer A Which disorder should the nurse recognize as a risk factor for hypocalcemia? A. diabetes mellitus B. Hypoparatyroidism C. Myasthenia Gravis D. Raynaud's Disease - correct answer B