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The nurse reviews the electrolyte results of a client with chronic kidney disease and
notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value? Select all
that apply.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes
C, E
Rationale:
The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium
level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0
mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes
associated
with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS
complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in
hypokalemia. A prolonged ST segment occurs in hypocalcemia.
,The nurse is assigned to care for a group of clients. On review of the clients'
medical records, the nurse determines that which client is most likely at risk for a
fluid volume deficit?
A. A client with an ileostomy
B. A client with heart failure
C. A client on long-term corticosteroid therapy
D. A client receiving frequent wound irrigations
A
Rationale:
A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid
needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea,
conditions that cause increased respirations or increased urinary output, insufficient
intravenous fluid
replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client
with heart failure or on long-term corticosteroid therapy or a client receiving
frequent wound irrigations is most at risk for fluid volume excess.
,The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at
risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
B
Rationale:
Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids. This occurs in conditions resulting
in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive
transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via
nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of
hydrochloric acid. The remaining options are incorrect interpretations.
, A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10 breaths per
minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate
of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3-
D
Rationale:
Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase.
Symptoms experienced by the client would include a decrease in the respiratory rate
and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2
reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic
condition.
Recent Exam Actual Complete Real Exam Questions
And Correct Answers (Verified Answers) Already
Graded A+ | Guaranteed Success!! Newest Exam | Just
Released!!
The nurse reviews the electrolyte results of a client with chronic kidney disease and
notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value? Select all
that apply.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes
C, E
Rationale:
The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium
level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0
mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes
associated
with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS
complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in
hypokalemia. A prolonged ST segment occurs in hypocalcemia.
,The nurse is assigned to care for a group of clients. On review of the clients'
medical records, the nurse determines that which client is most likely at risk for a
fluid volume deficit?
A. A client with an ileostomy
B. A client with heart failure
C. A client on long-term corticosteroid therapy
D. A client receiving frequent wound irrigations
A
Rationale:
A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid
needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea,
conditions that cause increased respirations or increased urinary output, insufficient
intravenous fluid
replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client
with heart failure or on long-term corticosteroid therapy or a client receiving
frequent wound irrigations is most at risk for fluid volume excess.
,The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at
risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
B
Rationale:
Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids. This occurs in conditions resulting
in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive
transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via
nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of
hydrochloric acid. The remaining options are incorrect interpretations.
, A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10 breaths per
minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate
of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3-
D
Rationale:
Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase.
Symptoms experienced by the client would include a decrease in the respiratory rate
and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2
reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic
condition.
