NSG3313 ADULT HEALTH 1 FINAL EXAM UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
Electrolyte Values
Answer:
Electrolytes (focus on Extracellular volume) Sodium (lives outside our cells)
- 135 - 145 mEq/L Assess neurologic (HA, Confusion, Lethargy [hyponatremia],
Excitement [Hypernatremia] ---Seizure, Coma, Death) Low Na = Hypertonic Solutions
Hypernatremia = Hypotonic Solutions Potassium (lives inside cell)
- 3.5 - 5.0 Cardiac (effects contractibility, plays role in excitation & muscle potential)
Hypokalemia (<3.5) EKG waveforms -> flattened T-waves Hyperkalemia (.5.0) EKG
waveforms-> Peak T-waves Calcium
- 9.0 - 10.5 Bones & Skeletal Muscle Phosphorous
- 3.0 - 4.5 Magnesium
- 1.3 - 2.1
Question:
ABG Parameters **Know these Values**
Answer:
ABG Parameters:
- pH = 7.35 - 7.45
- pCO2 = 35 - 45 mmHg
- HCO3 = 22 - 26 mEq/L
- PaO2 >80% (Partial O2 in blood)
- SaO2 >94%
Question:
Labs measuring kidney function
Answer:
Urinalysis - UA - examines color, clarity, pH, microscopic sediment, cloudy, WBCs,
bacteria Cultures - looks for bacterial growth and sensitivities to antibiotics Specific
Gravity - 1.005-1.025 - density of urine concentration compared to distilled water
- High = Dehydrated
- Low = Overhydrated 24hr urine collection - detects and evaluates the progression of
kidney disease Creatinine= 0.7 - 1.3 mg/dL BUN= 7-20 mg/dL BUN: Creatinine Ratio =
10-20:1 GFR =60-100 mL/min Creatinine Clearance= 24hr urine collection Volume of
urine * urine creatinine serum creatinine
,Question:
Lab Tests for Evaluating Fluid Status
Answer:
Lab Tests for Evaluating Fluid Status
- Osmolarity - 300 mOsm/L (can be taken via serum levels)
- Urine Specific Gravity- 1.010- 1.025 (measures the function of kidneys)
- When increases = Dehydration
- When decreases = over hydrated
- B.U.N. - 10-20 mg/dL Kidney Function **BUN - Good representation of Kidney function
but is slow to fluctuate
- Creatinine - 0.7-1.3 mg/dL Tests **Creatinine - Less dependable but faster to react
(Increases as kidney function gets worse)
- Hct - hematocrit
- Men- 42-52%
- Women- 35-47%
- High = Dehydration
- Low = Overhydration
Question:
A nurse is caring for a client who is in the oliguric-anuric stage of kidney injury. The
client reports diarrhea, a dull headache, palpitations, and muscle tingling and
weakness. Which of the following actions should the nurse take first?
A. Administer an analgesic to the client.
B. Check the client's electrolyte values.
C. Measure the client's weight.
D. Restrict the client's protein intake.
Answer:
B. Check the client's electrolyte values. The nurse should check the client's most recent
potassium value b/c these findings are manifestations of hyperkalemia, which can lead
to cardiac
dysrhythmias. Administering an analgesic for a dull headache, measuring the client's
weight to monitor fluid balance, & restricting protein intake to manage the acute
kidney injury are all important but using the urgent vs non-urgent prioritization, there
is another action that is first.
,Question:
The nurse is assessing a client for local complications of intravenous therapy. Which
are local complications? Select all that apply.
A. Phlebitis
B. Extravasation
C. Infection
D. Air embolism
E. Hematoma
Answer:
A. Phlebitis
B. Extravasation
C. Infection
E. Hematoma Rationale:Local complications of intravenous therapy include infiltration
and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the
needle. Infections can be local or systemic. Systemic complications occur less frequently
but are usually more serious than local complications and include circulatory overload,
air embolism, and febrile reaction.
Question:
When caring for a client who has risk factors for fluid and electrolyte imbalances,
which assessment finding is the highest priority for the nurse to follow up?
A. Mild confusion
B. Weight loss of 4 lb
C. Irregular heart rate
D. Blood pressure 96/53 mm Hg
Answer:
C. Irregular heart rate Rationale:Irregular heart rate may indicate a potentially
life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances
may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost,
confusion may occur with dehydration and hyponatremia, and blood pressure is
slightly lower than normal (though not life threatening); in each case, following up on
potential cardiac dysrhythmias is a higher priority.
, Question:
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a
3-day history of vomiting?
A. pH: 7.45, PaCO2:
32 mm Hg, HCO3-:
21
B. pH: 7.28, PaCO2:
25 mm Hg, HCO3: 15
C. pH: 7.34, PaCO2:
60 mm Hg, HCO3: 34
D. pH: 7.55, PaCO2:
60 mm Hg, HCO3-: 28
Answer:
D. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Rationale:The client's ABG would likely
demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance
characterized by a high pH (decreased H+ concentration) and a high plasma
bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+.
A common cause of metabolic alkalosis is vomiting or gastric suction with loss of
hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only
gastric fluid is lost. The other results do not represent metabolic alkalosis.
Question:
A client with cancer is being treated on the oncology unit for bilateral breast cancer.
The client is undergoing chemotherapy. The nurse notes the client's serum calcium
concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse
should suspect that the
A. client's diet is lacking in calcium-rich food products.
B. client has a history of alcohol abuse.
C. malignancy is causing the electrolyte imbalance.
D. client may be developing hyperaldosteronism.
Answer:
C. malignancy is causing the electrolyte imbalance. Rationale:The client's laboratory
findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration
>10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are
malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia
through a variety of
mechanisms. The client's calcium level is elevated; there is no indication that the
client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not
associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
Calcium (Ca) Range = 9.0 - 10.5 mg/dL
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
Electrolyte Values
Answer:
Electrolytes (focus on Extracellular volume) Sodium (lives outside our cells)
- 135 - 145 mEq/L Assess neurologic (HA, Confusion, Lethargy [hyponatremia],
Excitement [Hypernatremia] ---Seizure, Coma, Death) Low Na = Hypertonic Solutions
Hypernatremia = Hypotonic Solutions Potassium (lives inside cell)
- 3.5 - 5.0 Cardiac (effects contractibility, plays role in excitation & muscle potential)
Hypokalemia (<3.5) EKG waveforms -> flattened T-waves Hyperkalemia (.5.0) EKG
waveforms-> Peak T-waves Calcium
- 9.0 - 10.5 Bones & Skeletal Muscle Phosphorous
- 3.0 - 4.5 Magnesium
- 1.3 - 2.1
Question:
ABG Parameters **Know these Values**
Answer:
ABG Parameters:
- pH = 7.35 - 7.45
- pCO2 = 35 - 45 mmHg
- HCO3 = 22 - 26 mEq/L
- PaO2 >80% (Partial O2 in blood)
- SaO2 >94%
Question:
Labs measuring kidney function
Answer:
Urinalysis - UA - examines color, clarity, pH, microscopic sediment, cloudy, WBCs,
bacteria Cultures - looks for bacterial growth and sensitivities to antibiotics Specific
Gravity - 1.005-1.025 - density of urine concentration compared to distilled water
- High = Dehydrated
- Low = Overhydrated 24hr urine collection - detects and evaluates the progression of
kidney disease Creatinine= 0.7 - 1.3 mg/dL BUN= 7-20 mg/dL BUN: Creatinine Ratio =
10-20:1 GFR =60-100 mL/min Creatinine Clearance= 24hr urine collection Volume of
urine * urine creatinine serum creatinine
,Question:
Lab Tests for Evaluating Fluid Status
Answer:
Lab Tests for Evaluating Fluid Status
- Osmolarity - 300 mOsm/L (can be taken via serum levels)
- Urine Specific Gravity- 1.010- 1.025 (measures the function of kidneys)
- When increases = Dehydration
- When decreases = over hydrated
- B.U.N. - 10-20 mg/dL Kidney Function **BUN - Good representation of Kidney function
but is slow to fluctuate
- Creatinine - 0.7-1.3 mg/dL Tests **Creatinine - Less dependable but faster to react
(Increases as kidney function gets worse)
- Hct - hematocrit
- Men- 42-52%
- Women- 35-47%
- High = Dehydration
- Low = Overhydration
Question:
A nurse is caring for a client who is in the oliguric-anuric stage of kidney injury. The
client reports diarrhea, a dull headache, palpitations, and muscle tingling and
weakness. Which of the following actions should the nurse take first?
A. Administer an analgesic to the client.
B. Check the client's electrolyte values.
C. Measure the client's weight.
D. Restrict the client's protein intake.
Answer:
B. Check the client's electrolyte values. The nurse should check the client's most recent
potassium value b/c these findings are manifestations of hyperkalemia, which can lead
to cardiac
dysrhythmias. Administering an analgesic for a dull headache, measuring the client's
weight to monitor fluid balance, & restricting protein intake to manage the acute
kidney injury are all important but using the urgent vs non-urgent prioritization, there
is another action that is first.
,Question:
The nurse is assessing a client for local complications of intravenous therapy. Which
are local complications? Select all that apply.
A. Phlebitis
B. Extravasation
C. Infection
D. Air embolism
E. Hematoma
Answer:
A. Phlebitis
B. Extravasation
C. Infection
E. Hematoma Rationale:Local complications of intravenous therapy include infiltration
and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the
needle. Infections can be local or systemic. Systemic complications occur less frequently
but are usually more serious than local complications and include circulatory overload,
air embolism, and febrile reaction.
Question:
When caring for a client who has risk factors for fluid and electrolyte imbalances,
which assessment finding is the highest priority for the nurse to follow up?
A. Mild confusion
B. Weight loss of 4 lb
C. Irregular heart rate
D. Blood pressure 96/53 mm Hg
Answer:
C. Irregular heart rate Rationale:Irregular heart rate may indicate a potentially
life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances
may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost,
confusion may occur with dehydration and hyponatremia, and blood pressure is
slightly lower than normal (though not life threatening); in each case, following up on
potential cardiac dysrhythmias is a higher priority.
, Question:
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a
3-day history of vomiting?
A. pH: 7.45, PaCO2:
32 mm Hg, HCO3-:
21
B. pH: 7.28, PaCO2:
25 mm Hg, HCO3: 15
C. pH: 7.34, PaCO2:
60 mm Hg, HCO3: 34
D. pH: 7.55, PaCO2:
60 mm Hg, HCO3-: 28
Answer:
D. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Rationale:The client's ABG would likely
demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance
characterized by a high pH (decreased H+ concentration) and a high plasma
bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+.
A common cause of metabolic alkalosis is vomiting or gastric suction with loss of
hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only
gastric fluid is lost. The other results do not represent metabolic alkalosis.
Question:
A client with cancer is being treated on the oncology unit for bilateral breast cancer.
The client is undergoing chemotherapy. The nurse notes the client's serum calcium
concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse
should suspect that the
A. client's diet is lacking in calcium-rich food products.
B. client has a history of alcohol abuse.
C. malignancy is causing the electrolyte imbalance.
D. client may be developing hyperaldosteronism.
Answer:
C. malignancy is causing the electrolyte imbalance. Rationale:The client's laboratory
findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration
>10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are
malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia
through a variety of
mechanisms. The client's calcium level is elevated; there is no indication that the
client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not
associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
Calcium (Ca) Range = 9.0 - 10.5 mg/dL
