Med Surge 4Th Edition

1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum. - correct answer : A The blood pressure indicates that the client may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the client's fluid intake but not as urgently as the hypotension. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: Physiological Integrity 2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments should the nurse carefully monitor? a. Increased total urinary output b. Elevation of serum hematocrit c. Decreased serum sodium level d. Rapid and unexpected weight loss - correct answer : C SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: Physiological Integrity 3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output - correct answer : B NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: Physiological Integrity 4. The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake? a. In the late evening hours b. If the oral mucosa feels dry c. When the client feels thirsty d. As soon as changes in level of consciousness (LOC) occur - correct answer : B An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older clients prefer to restrict fluids slightly in the evening to improve sleep quality. The client will not be likely to notice and act appropriately when changes in LOC occur. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance 5. The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan? a. Personality changes b. Frequent loose stools c. Facial muscle spasms d. Lower extremity weakness - correct answer : D Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Physiological Integrity 6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective? a. "I will try to drink at least eight glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast." - correct answer : D NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which are high in potassium. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Physiological Integrity 7. The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing? a. Restrict client's oral free water intake. b. Avoid use of electrolyte-containing drinks. c. Infuse a solution of 5% dextrose in 0.45% saline. d. Administer vasopressin (antidiuretic hormone, [ADH]). - correct answer : A To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the client's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: Physiological Integrity 8. The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a litre of IV fluid. - correct answer : B Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mmol, concentrations up to 60 mmol may be used for some clients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Physiological Integrity 9. The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client? a. Ventricular dysrhythmias b. Bradycardia c. Flatten T wave d. Prolonged P-R interval - correct answer : D NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank ECG changes in a client with hypokalemia include a tall peaked T-wave, prolonged P-R interval, ST depression, loss of P wave, widening QRS complex, ventricular fibrillation and standstill. Ventricular dysrhythmias, bradycardia, and flatten T wave are all possible changes with hypokalemia. DIF: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: Physiological Integrity 10. The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following interpretations would the nurse document? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis - correct answer : D The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Physiological Integrity 11. The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement? a. Notify the client's health care provider. b. Give the prescribed PRN lorazepam. c. Start the prescribed PRN oxygen at 2-4 L/minute. d. Encourage the client to take deep, slow breaths. - correct answer : A The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the client will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: Physiological Integrity 12. The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess? a. Pallor b. Edema c. Confusion d. Restlessness - correct answer : B Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: Physiological Integrity 13. The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema - correct answer : A Hypertonic solutions cause water retention, so the client should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: Physiological Integrity 14. The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client's condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg - correct answer : C Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the client's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: Physiological Integrity 15. The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would the nurse document? a. Metabolic acidosis b. Meta