NR 222/ NR222 Exam 4 (New 2026/ 2027 Update) Health and Wellness Guide |Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain.

NR 222/ NR222 Exam 4 (New 2026/ 2027 Update) Health and Wellness Guide |Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain. Q. A client with cardiac failure is found to have excess extracellular fluid of normal tonicity. What life-threatening complication is this client most likely to suffer: Pulmonary Edema ANSWER -The most likely life-threatening complication that can occur in a client who has excess extracellular fluid of normal tonicity is pulmonary edema. The excess fluids may filter out of the pulmonary blood vessels and pool in the pulmonary tissue, causing pulmonary edema. -Coma and seizures are likely complications of hypernatremia and hyponatremia. -Hypovolemic shock is seen in conditions associated with extracellular fluid depletion. Q. Which client being cared for by the nurse is at the highest risk of developing respiratory acidosis? Client with Hypokalemia, pulmonary fibrosis, salicylate overdose, or client with COPD: COPD ANSWER -Chronic respiratory acidosis is most commonly caused by COPD. -Hypokalemia, pulmonary fibrosis, and salicylate overdose do not predispose a client to respiratory acidosis. Hypokalemia can lead to cardiac dysrhythmias. -Pulmonary fibrosis can result in respiratory arrest, and salicylate overdose results in central nervous system changes. Q. Which food item does the nurse include in the diet plan of a patient with magnesium deficiency? Milk, Broccoli, Brazil nuts, or dark green leafy vegetables: Dark Green Leafy Vegetables ANSWER -Dark-green leafy vegetables are rich in magnesium. -Milk is rich in phosphate and calcium, not magnesium. -Broccoli is rich in calcium, not magnesium. -Brazil nuts are rich in potassium, not magnesium Q. Which of the following activities can you delegate to nursing assistive personnel (NAP)? ANSWER -Measuring oral intake and urine output -Preparing intravenous (IV) tubing for routine change -Reporting an IV container that is low in fluid -Changing an IV fluid container -Reporting an electronic infusion device alarm 1. Measure oral intake and urine output 2. Reporting an IV container that is low in fluid 3. Reporting an electronic infusion device alarm Q. The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body? ANSWER - The lungs, liver, kidneys or intestines The lungs -The lungs are responsible for the excretion of carbonic acid from the body in the form of exhaled carbon dioxide. Thus, the lungs help to maintain the acid-base balance of the body. -The liver is not involved in the excretion of metabolic acids and carbonic acid, and has no role in acid-base balance of the body. -Kidneys help in the excretion of all acids except for carbonic acid. They play an important role in fluid and electrolyte balance. -The intestine is not involved in the excretion of metabolic acids and carbonic acid, and has no role in acid-base balance of the body Q. The nurse is caring for a client diagnosed with chronic heart failure. The nurse understands that the client is at risk of developing extracellular fluid volume excess. Which clinical findings would the nurse observe in this client? ANSWER ankle edema, postural hypotension, overnight weight loss, overnight weight gain, neck veins full (distended) when upright 1. Ankle edema 2. Overnight weight gain 3. Neck veins full (distended) when upright -Chronic heart failure can cause extracellular fluid volume excess due to decreased renal output caused by elevated aldosterone. It can result in fluid retention manifested as ankle edema and weight gain. -The neck veins may feel full on palpation when the client is in upright position. -Postural hypotension occurs when there is extracellular fluid volume deficit and not with excess of extracellular fluid volume. -Weight loss is observed when there is extracellular fluid volume deficit and not with excess extracellular fluid volume Q. Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an adult lose through feces: ANSWER 100 mL -The fluid loss occurs through the skin, lungs, gastrointestinal tract, and kidneys. -Even though the fluid intake would be 3 to 6 liters, only 100 mL of fluid is lost through feces. -The rest of the fluid is absorbed by the gastrointestinal system Q. The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump: ANSWER 167 mL/hour 1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167 mL/hr (if infusion pump accepts decimals, program it to 166.7 mL/hr) Q. The nurse is caring for a client who is undergoing intravenous fluid therapy to correct dehydration. What measures should the nurse take to prevent complications related to IV lines? ANSWER -Order a nursing assistant to regulate intravenous flow. -Inspect intravenous site and check for client complaints. -Review the type and amount of intravenous fluid ordered. -Perform hand hygiene when handling intravenous devices. -Plan for intravenous therapy at any preferred rate for all clients. 1. Inspect intravenous site and check for client complaints 2. Review the type and amount of intravenous fluid ordered 3. Perform hand hygiene when handling intravenous devices -Inspecting intravenous site and checking client complaints help to identify tenderness, pain, or burning that may be an early indication of phlebitis. -Reviewing the type and amount of intravenous fluid ordered helps to ensure administration of correct intravenous fluids at an appropriate rate. -Performing hand hygiene when handling intravenous devices helps to prevent transmission of microorganisms and spread of infection. -The skill of regulating intravenous flow should not be ordered to a nursing assistant. -Intravenous therapy should be planned based on accurate mathematical calculations as per the health care provider's orders to obtain correct intravenous flow rate for client safety Q. As the nurse is assessing the caseload of clients for the day, which of the clients would she expect to be at the highest risk of developing dehydration? ANSWER - A 78 year old client with dementia - A 47 year old client with hyperthyroidism - A 53 year old client with pulmonary embolism - A 32 year old client with respiratory infection A 78 year old client with dementia -Older clients are at risk for dehydration because of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink -Clients who are in their 30s, 40s, or 50s with hyperthyroidism, pulmonary embolism, and respiratory infection are not at great risk for dehydration Q. A client is receiving treatment for chronic diarrhea. The nurse advises the client to eat food items rich in potassium. What is the reason behind promoting a potassium-rich diet? ANSWER - improves smooth, skeletal and cardiac muscle function - necessary for production of ATP - decreases muscle wasting - acts as a cofactor for various enzymes Improves skeletal, smooth and cardiac muscle function -Potassium is required for normal functioning of smooth, skeletal, and cardiac muscles as it helps to maintain resting membrane potential. -Phosphate is required for production of ATP, not potassium. -Potassium does not decrease muscle wasting. -Magnesium acts as a cofactor for various enzymes. Q. Obesity places patients at an increased surgical risk because of which of the following factors? ANSWER - risk for bleeding is increased - ventilatory capacity is reduced - fatty tissue has a poor blood supply - metabolic demands are increased Ventilatory capacity is reduced -A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. -A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia Q. The primary reason that family members should be included when the nurse teaches the patient preoperative exercises is so they can: ANSWER -Coach and encourage the patient after surgery. -Demonstrate to the patient at home. -Relieve the nurse by getting the patient to do the exercises every 2 hours. -Practice with the patient while he or she is waiting to be taken to the operating room. Coach and encourage the patient after surgery Patients may need support from family to be motivated to return to their previous state of health. The family may also have better retention of preoperative teaching and will be with the patient and able to help them in their recovery Q. In the postanesthesia care unit (PACU) the nurse notes that the patient is having difficulty breathing and suspects an upper airway obstruction. The nurse would first: ANSWER -Suction the pharynx and bronchial tree. -Give oxygen through a mask at 4 L/min. -Ask the patient to use an incentive spirometer. -Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward -Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. -Suctioning the bronchial tree or providing oxygen does not alleviate an upper airway obstruction Q. Because an older adult is at increased risk for respiratory complications after surgery, the nurse should: ANSWER -Withhold pain medications and ambulate the patient every 2 hours. -Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. -Orient the patient to the surrounding environment frequently and ambulate the patient every 2 hours. -Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control -Adequate pain control is important to allow participation in postoperative exercises such as turning, deep coughing, and deep breathing to prevent respiratory complications You are caring for a patient after surgery who underwent a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (APTT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform: -Notify the surgeon -Maintain intravenous (IV) fluid infusion and prepare to give volume replacement -Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes -Wean oxygen therapy -Provide comfort through bathing Notify the surgeon, maintain intravenous (IV) fluid infusion and prepare to give volume replacement, monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes -A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. -Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the patient's status. You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated: -Infection: Notify surgeon and anticipate administration of antibiotics. -Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. -Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. -Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently Malignant hyperthermia: notify the surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium) and monitor vital signs frequently -Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. -Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. -Dantrolene sodium (Dantrium) is a skeletal muscle relaxant that is used to treat this complication. After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take: -Reinforce to the patient to remain in bed or on the stretcher -Raise the side rails and keep the bed or stretcher in the high position -Determine if the patient has any allergies to latex -Obtain informed consent immediately after sedative administration Reinforce to the patient to remain in bed or on the stretcher -It is important for patient safety in patients who have been given sedatives to inform them of the importance of remaining in bed after preoperative sedatives are administered. -It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. -Informed consent should be obtained and allergy assessment done before sedative administration The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement: -Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas -Having a latex allergy cart available at all times -Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified -Scheduling the latex-sensitive patient for the last operative case of the day Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified -Identifying patients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. -Having all necessary equipment easily accessible to staff is necessary to ensure that all items are available when needed. -It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive patient for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive patient's operation. A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia: -Loss of sensation at the surgical site -Reduction of fear and anxiety and need for assistance with airway patency and ventilation -Amnesia and relief of pain -Monitoring in phase I recovery Amnesia and relief of pain -Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, and relief of pain while maintaining airway patency and ventilation independently along with stable vital signs and rapid recovery. -Loss of sensation at the surgical site is an effect of local anesthesia. These patients usually only go through phase II recovery You have been given the following postoperative patients to care for on your shift. Based on the information provided, which patient should you see first: -A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 -A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85% -A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic -A 48-year-old following total knee replacement who needs help repositioning in bed A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85% -The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Select appropriate components of a safe and effective hand-off: -Vital signs, the type of anesthesia provided, blood loss, and level of consciousness -Uninterrupted time to review the recent pertinent events and ask questions -Verification of the patient using one identifier and the type of surgery performed -Review of pertinent events occurring in the operating room -(OR) while at the nurses' station Vital signs, the type of anesthesia provided, blood loss, and level of consciousness -A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the OR and the PACU before coming to the postoperative nursing unit. -Proper identification of the patient requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. -Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the patient's bedside. A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39°C (102°F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because: -They need to get the patient into the operating room (OR) quickly to start the surgery because of the low blood pressure. -The surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery. -The nurse anticipates the need for a fluid bolus to increase the patient's BP. -The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate. The surgery may need to be delated to check the patient's WBC count and investigate the source of fever before surgery -The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. The surgery may need to be delayed until the source of the fever is treated A nurse is working in an ambulatory care setting and is ready to discharge a patient who is wheelchair dependent. The patient underwent dilation of an esophageal stricture. Her postanesthesia recovery score for ambulatory patients (PARSAP) score is 16. Her family is ready to go and eager to make the long road trip home. In determining if it is safe for the patient to be discharged at this time, the nurse should decide the following: -The PARSAP score must be 18 or higher before being discharged -The patient's family is capable to care for her, and she understands her discharge instructions; thus the nurse proceeds with discharge. -Since the patient hasn't been drinking much, the nurse is not concerned that she is unable to void and proceeds with discharge. -Since the patient was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score. Since the patient was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score -The PARSAP is an important functional screen to assess the function of the ambulatory surgery patient. -The total score must be at least 18 for a patient to be discharged to home, unless the patient is not walking or is unable to use extremities before surgery A patient is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include: -Intermittent pneumatic compression stockings -Vitamin K therapy. -Subcutaneous heparin or enoxaparin (Lovenox). -Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline. Intermittent pneumatic compression stockings -Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk patients. -Vitamin K therapy creates a higher risk for clotting -The goal INR should not be 5 times higher than baseline You are caring for a 65-year-old patient 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action: -Stop exercise immediately and have him sit in a nearby chair -Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise -Tell him that he needs to walk further to reach a heart rate of 120. -Have him walk slower; he has reached his maximum Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise -The patient's maximum heart rate with exercise should be 220-65 = 155. He is still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis Metabolic acidosis -The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first: -Serum albumin -Serum sodium -Hematocrit -Serum potassium Serum potassium Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness Which of these patients do you expect will need teaching regarding dietary sodium restriction: -An 88-year-old with a fractured femur scheduled for surgery -A 65-year-old recently diagnosed with heart failure -A 50-year-old recently diagnosed with asthma and diabetes -A 20-year-old with vomiting and diarrhea from gastroenteritis A 65-year-old recently diagnosed with heart failure -Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. -Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse. You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid: -Tap water or bottled water -Fluid that has sodium (salt) in it -Fluid that has K+ and HCO3- in it -Coffee or tea, whichever they prefer Fluid that has sodium (salt) in it -Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced You assess four patients. Which patient is at greatest risk for the development of hypocalcemia: -56-year-old with acute kidney renal failure -40-year-old with appendicitis -28-year-old who has acute pancreatitis -65-year-old with hypertension and asthma 28-year-old who has acute pancreatitis -People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. -This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids Assessment findings consistent with intravenous (IV) fluid infiltration include: -Edema and pain -Streak formation -Pain and erythema -Pallor and coolness -Numbness and pain Edema and pain, pallor and coolness -Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area Which of the following defining characteristics is consistent with fluid volume deficit: -A 1-lb (0.5 kg) weight loss, pale yellow urine -Engorged neck veins when upright, bradycardia -Dry mucous membranes, thready pulse, tachycardia -Bounding radial pulse, fl at neck veins when supine Dry mucous membranes, thready pulse, tachycardia -The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. -ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. -Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. -ECV deficit causes dark yellow urine rather than pale yellow, which is normal Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl: -Auscultate dependent portions of lungs -Check color of urine -Assess muscle strength -Check skin turgor over sternum or shin Auscultate dependent portions of lungs -Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume -Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. -Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. -Skin turgor is not a reliable assessment of ECV deficit in older adults. While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action: -Notify a health care provider -Insert an indwelling catheter -Alert the blood bank -Stop the transfusion Stop the transfusion -Development of chills, tachycardia, and flushing during a blood transfusion is an indication of an acute hemolytic reaction. -You stop the transfusion immediately so no more of the incompatible blood reaches the patient The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid: -Flat neck veins -Tachycardia -Hypotension Incorrect -Oliguria Oliguria -Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing: -Notify her health care provider that she is hyperventilating -Provide frequent oral care to keep her mucous membranes moist -Ask her to breathe slower and help her to calm down and relax -Assess her for pain and request an order for a sedative Provide frequent oral care to keep her mucous membranes moist -Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. -Rapid breathing can make oral mucous membranes dry and cracked Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record: -700 mL -900 mL -1000 mL -1100 mL 1000mL Add one half the volume of ice chips to other intake to calculate total intake The nurse is caring for a client who has an accumulation of fluid in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids: -Serum -Plasma -Peritoneal fluid -Synovial fluid -Cerebrospinal fluid Peritoneal fluid, Synovial fluid, Cerebrospinal fluid -Transcellular fluids are secreted by epithelial cells. Fluid collection between the two layers of the peritoneum is an example of transcellular fluid. -Fluid collection in the synovial space of a joint is secreted by the epithelial cells and is also an example of transcellular fluid. -Cerebrospinal fluid is colorless fluid present in the brain and spinal cord. -Serum and plasma are constituents of intravascular fluid which is a part of extracellular fluids. The senior nurse is teaching a group of nursing students about palliative surgical procedures. Which surgical procedures are included in this category: -Colostomy -Appendectomy -Repair of cleft palate -Resection of nerve roots -Debridement of necrotic tissue colostomy, resection of nerve roots, debridement of necrotic tissue -Palliative surgery reduces the intensity of the disease or its symptoms, but is not intended to be curative. -Colostomy, nerve root resection, and debridement of necrotic tissue are examples of palliative surgery. -Colostomy is done for diversion of the fecal passage due to obstruction or necrosis of the distal part of the gastrointestinal tract. -Nerve root resection is usually done for relieving symptoms related to irritation of the particular nerve. -Debridement of necrotic tissue reduces the dead tissues and promotes healing. -Appendectomy is an ablative surgery; it removes a diseased body part. A repair of cleft palate is a constructive surgery to restore the function lost or reduced as a result of congenital anomalies A nurse is examining a client with hypocalcemia. Which clinical findings should the nurse assess for during the assessment: -Abdominal distension -Positive Chvostek's sign -Positive Trousseau's sign -Muscle twitching and cramping -Bilateral muscle weakness in quadriceps Positive Chvostek's sign, positive Trousseau's sign, muscle twitching and cramping -Hypocalcemia occurs due to low serum calcium level. It increases neuromuscular excitability, and can cause a positive Chvostek's sign. -Chvostek's sign refers to the contraction of facial muscles when a facial nerve is tapped. -Trousseau's sign refers to the carpal spasm in response to hypoxia. This sign is positive in hypocalcemia. -In addition, muscle twitching and cramping can be noted. -Abdominal distension is noted in case of hypokalemia along with muscle weakness. -Bilateral muscle weakness in the quadriceps is noted in the case of imbalances of serum potassium levels. A nurse is teaching a group of clients about the importance of fluid and electrolyte balance in a health awareness program. Which common causes of hypokalemia would the nurse educate the clients about: -Diarrhea -Acute oliguria -Repeated vomiting -Calcium-deficient diet -Glucocorticoid therapy Diarrhea, repeated vomiting, Glucocorticoid therapy -Hypokalemia is a low potassium concentration in the blood that results from the loss of potassium. This can occur in clients with diarrhea or repeated vomiting. -Glucocorticoid therapy can also result in potassium loss from the body and cause hypokalemia. -Acute oliguria decreases the loss of potassium from the body and results in increased concentration of potassium or hyperkalemia. -A calcium-deficient diet can cause decreased intake and absorption of calcium, thus resulting in hypocalcemia. A client who is latex-sensitive is scheduled for a cholecystectomy. What special precautions are required for the client: -Use stopcocks to inject the medications. -Draw the medications from well-closed vials. -Remove all latex products from the operating room. -Use a nonlatex breathing circuit with a plastic mask and bag. -Schedule the surgery as the last case of the day Use stopcocks to inject the medication, remove all latex products from the operating room, use a nonlatex breathing circuit with a plastic mask and bag -Special care should be taken for a client who has a latex sensitivity. -Using stopcocks to inject drugs rather than latex ports reduces the chances of a latex allergy reaction. -Removing all latex products from the operating room helps to prevent severe reactions in the client. -Using a nonlatex breathing circuit with a plastic mask and bag helps to prevent latex reactions. All of the contents must be latex free. -Medication should not be drawn from well-closed vials as it increases the chances of latex allergic reactions. Medications should be drawn directly from opened vials. -Scheduling the surgery as the first case of the day in the operating room ensures that any latex dust has been removed from the room overnight by ventilation. A client who has not been eating for more than a week presents with abdominal pain. On examination, the client is found to be confused and disoriented. Which metabolic event is most likely responsible for such presentation: -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis Metabolic acidosis -Not eating for longer than 3 days leads to a breakdown of fatty acids for energy production, which leads to the development of ketone bodies, resulting in metabolic acidosis. -The manifestations include decreased level of consciousness, abdominal pain, cardiac dysrhythmias, and increased rate and depth of respirations. -Metabolic alkalosis usually occurs either due to conditions associated with bicarbonate excess or increased excretion of metabolic acids. -Respiratory acidosis is seen in conditions associated with alveolar hypoventilation. -Respiratory alkalosis occurs as a result of alveolar hyperventilation. A client who was started on intravenous (IV) fluids to correct dehydration develops shortness of breath. On auscultation, the nurse finds crackles in the dependent portion of the lungs and dependent edema. Which interventions are appropriate in correcting the fluid and electrolyte imbalance in the client: -Aspirate fluid from lungs -Reduce the IV flow rate -Elevate the foot end of bed -Notify the primary health care provider -Administer diuretics if prescribed Reduce the IV flow rate, notify the primary health care provider, administer diuretics if prescribed -The client's presentation is suggestive of circulatory overload due to IV fluids. The flow rate of the intravenous solution should be reduced to prevent further worsening of circulatory overload. -The primary health care provider should be notified to obtain further instructions. -Diuretics should be administered to promote excretion of excess fluid through urine. -Aspiration of fluid from the lungs may not help as there is fluid excess. -The head end of the bed should be elevated to promote chest expansion and breathing The nurse is caring for a client who has suffered burns on the chest and back. The nurse suspects that the client has developed extracellular fluid volume deficit. Which clinical findings are likely to be seen in the client: -Hypotension -Cold, clammy skin -Sudden weight gain -Dry mucous membranes -Crackles in dependent portion of lungs Hypotension, cold clammy skin, dry mucous membranes -Hypotension is caused due to less intake of fluid and sodium volume as compared to the output. -Decreased body fluid volume can cause cold clammy skin. -The decrease in body fluid due to extracellular fluid volume deficit causes dryness of mucous membranes. -Sudden weight gain is observed in case of extracellular fluid volume excess, due to increased volume of body fluids. -Crackles in dependent portion of lungs can be observed in cases of extracellular fluid volume excess, due to increased volume of body fluids A client is scheduled for surgery. A nurse is administering preoperative medications to the client. What else does the nurse do after the administration of preoperative medications: -Give the client water to sip. -Restrict the client from leaving the bed. -Sign the client's consent form. -Restrict the client from leaving the bed Restrict the client from leaving the bed -After administering preoperative medications, the nurse should restrict the client from leaving the bed. -Preoperative medications cause sedation, which increases the risk of fall. -Nothing is allowed by mouth as it increases the risk of aspiration. -The consent form is signed and metal items are removed before the administration of preoperative medications A client is suffering from syndrome of inappropriate secretion of antidiuretic hormone (SIADH). For which electrolyte disturbance should the nurse evaluate the client: -Hypernatremia -Hyponatremia -Hemoconcentration -Increased serum osmolality Hyponatremia -Clients with inappropriate secretion of antidiuretic hormone (SIADH) have excess antidiuretic hormone (ADH) secretion. Therefore, the client is most likely to have hyponatremia due to excess retention of water from the kidney, which is disproportionate to salt retention. -SIADH is not related to hypernatremia. SIADH is most likely found in deficiency of ADH (diabetes insipidus). -Hemoconcentration is seen in conditions associated with extracellular water depletion. -In conditions associated with excess ADH, there is a decrease in serum osmolality What client preparation is needed on the day of surgery involving general anesthesia: -Ask the client to wear personal nightwear. -Provide a partial bath. -Instruct the client to drink clear liquids. -Ask the client to tie hair with clips Provide a partial bath -A partial bath is refreshing and relaxes the client. -The client should wear a clean hospital gown; personal nightwear is restricted in an operating room. -The client should be fasting and is not provided with clear liquids to drink. -The client should remove all clips from the hair, as they can cause burns due to electrocautery. Obesity places clients at an increased surgical risk because of which of the following factors: -The thicker adipose tissue makes it harder to close the wound -Risk for bleeding is increased. -Ventilatory capacity is reduced. -Fatty tissue has a poor blood supply -Metabolic demands are increased. The thicker adipose tissue makes it harder to close the wound, ventilatory capacity is reduced, fatty tissue has a poor blood supply -A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. -A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia. -It is often difficult to close the surgical wound of a patient who is obese because of the thick adipose layer; thus he or she is at risk for dehiscence (opening of the suture line) and evisceration (abdominal contents protruding through surgical incision) A client presents with muscle twitching and cramping. On examination, the health care provider diagnoses the client with calcium deficiency. What dietary instructions should the nurse give to this client: -Supplement with vitamin D. -Avoid broccoli and oranges -Increase the intake of dairy products. -Increase the intake of canned fish with bones. -Increase consumption of dark leafy green vegetables Supplement with vitamin D, Increase the intake of dairy products, increase the intake of canned fish with bones -Hypocalcemia or low levels of calcium can manifest as muscle twitching and cramping. The signs and symptoms can be treated by providing adequate calcium in the diet. -Vitamin D facilitates the absorption of calcium from the intestines; therefore, vitamin D should be supplemented in the diet. -Dairy products, canned fish with bones, broccoli, and oranges are good sources of calcium, and their intake should be promoted. -Dark green vegetables are rich in magnesium, not calcium When caring for a client undergoing intravenous therapy, the nurse observes redness and swelling around the IV catheter insertion site. A purulent drainage is also present. What immediate actions should the nurse perform: -Apply pressure to the dressing over the site -Raise the head of the bed and administer oxygen -Remove the catheter and preserve for culture. -Start a new intravenous line in another extremity. -Clean the site with alcohol and apply sterile dressing Remove the catheter and preserve for culture, start a new intravenous line in another extremity, clean the site with alcohol and apply sterile dressing -The assessment findings show a possibility of infection; therefore, the catheter should be removed and preserved for culture. Antibiotics can be prescribed based on the culture reports. -As there is redness and swelling at the site, a new intravenous line should be started in a different extremity. -To avoid the spread of infection, cleaning the site with alcohol and applying a sterile dressing is necessary. Applying pressure to the dressing over the site is performed in case of bleeding from the site and not because of infection. -Raising the head of the bed and administering oxygen should be considered in case of circulatory overload of intravenous solution A client develops a mild allergic reaction during blood transfusion. How should the nurse manage this allergic reaction: -Administer vasoconstrictors -Administer sympathomimetics -Administer corticosteroids -Administer antihistamines Administer antihistamines -Mild allergic reactions during blood transfusion are managed by administering antihistamines. -Antihistamines prevent the release of histamine from the cells, thereby preventing the allergic reaction from getting worse. -Epinephrine (sympathomimetics) is used only in clients with anaphylaxis. -Corticosteroids usually do not have an immediate action and they are usually not required for mild allergic reactions. -Vasopressors are required only during sepsis related to blood transfusion What would be the most effective way for a nurse to validate informed consent: -Determine from the health care provider what was discussed with the client -Ask the family whether the client understands the procedure. -Check the chart for a completed and signed consent form. -Ask the client what he or she understands regarding the procedure Ask the client what he or she understands regarding the procedure Informed consent in the health care setting is a process whereby a client is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done. -Asking the family does not provide information about client understanding of the procedure. -A signed informed consent form does not always indicate that the client has understood the teaching. -Asking the health care provider about previous discussions does not give information about the client's understanding Why are older adults prone to dehydration: -Water absorption from their GI tract decreases -They sweat more in hot weather. -Their lungs evaporate more water during respiration -The ability of their kidneys to concentrate urine decreases The ability of their kidneys to concentrate urine decreases A postoperative client complains of pain. What available actions would relieve pain in the client: -Assist the client in repositioning -Administer regional analgesia. -Administer nonsteroidal antiinflammatory drugs (NSAID). -Apply hot packs on the incision site. -Administer opioid analgesics. Administer regional analgesia, administer nonsteroidal antiinflammatory drugs (NSAID), assist the client in reposistioning, administer opioid analgesics A nurse works in an ambulatory surgical center. The nurse checks the vital signs of clients in the preoperative period. What would the vital signs indicate: -Client's stability -Correction of abnormalities -Fear and stress -Health of the client -Baseline for intraoperative assessment Client's stability, health of the client, baseline for intraoperative assessment -In the preoperative period, the nurse checks for the client's vital signs to ensure health and stability. It also serves as a baseline for intraoperative assessment. -The vital signs do not indicate correction of abnormalities. -The vital signs do not assess for fear and stress of the client A nurse is training a team of junior nurses about acid-base balance. Which statements discussed by the nurse are appropriate: -Clients with kidney disease have difficulty excreting metabolic wastes -The kidneys excrete all acids produced in the client's body -Clients with obstructive lung diseases may have more acid in the blood -Clients experience deeper respirations when the carbon dioxide level in the blood rises -Clients experience shallow respirations when the carbon dioxide level in the blood rises Clients with kidney disease have difficulty excreting metabolic wastes, clients with obstructive lung diseases may have more acid in the blood, clients experience deeper respirations when the carbon dioxide level in the blood rises An older client who is admitted in the postsurgery care unit has decreased bladder capacity. What can the nurse do to help the client avoid a urinary tract infection: -Ensure the client attempts to void urine every 2 hours -Determine baseline urinary output for 24 hours. -Keep the call light and bedpan within easy reach of the client -Turn or reposition the client every 2 hours -Instruct the client to notify the nurse immediately when he or she experiences bladder fullness Ensure the client attempts to void urine every 2 hours, keep the call light and bedpan within easy reach of the client, instruct the client to notify the nurse immediately when he or she experiences bladder fullness A client has a pH value of 7.25. What are the possible pathological and physiological changes that may occur in this client: -Enzyme dysfunction -Pruritis -Anemia -Impaired hemoglobin function -Death Enzyme dysfunction, impaired hemoglobin function, death A pH of 7.25 indicates acidosis in the client. The normal pH value ranges between 7.35 and 7.45. Any deviation from this range will lead to improper functioning of cellular enzymes because enzymes are active only at a certain pH level. A low pH level also interferes with the normal functions of hemoglobin including oxygen carrying capacity and may even result in death. Anemia and pruritis are usually not the direct consequences of acidosis. Anemia may have multifactorial causes. Pruritis is usually a result of allergic reactions. A client develops acute intravascular hemolytic transfusion reaction following transfusion with incompatible blood. What treatment strategies should be included in the client's management: -Stop the transfusion immediately. -Maintain the BP at the normal range. -Avoid keeping the IV line connected. -Administer diuretics. -Insert an indwelling urinary catheter Stop the transfusion immediately, maintain the BP at the normal range, administer diuretics, insert an indwelling urinary catheter -When a client develops acute intravascular hemolytic transfusion reaction due to a mismatched transfusion, the transfusion should be immediately stopped to prevent further worsening of the condition. The blood bag and transfusion set should be saved for further investigation. -The blood pressure should be maintained to the normal range to ensure perfusion to vital organs. -To maintain urinary flow, the nurse may administer diuretics if prescribed. An indwelling urinary catheter may be inserted for hourly monitoring of urine output. -The IV line has to be kept open by infusing normal saline through new tubing A client is being assessed for factors that may increase the risk of surgery. Which medical conditions increase the risk of surgery? -Diabetes mellitus -Upper respiratory tract infection -Fever -Obstructive sleep apnea -Headache Diabetes mellitus, upper respiratory tract infection, fever, obstructive sleep apnea -Diabetes mellitus increases the risk of developing infection and delays wound healing. -Upper respiratory tract infections increase the risk of respiratory complications during anesthesia. -Fever increases the risk of fluid and electrolyte imbalance. -Obstructive sleep apnea may lead to airway obstruction if opioids are administered. -A headache does not increase the risk of surgery A nurse is caring for a client who is at risk of developing deep vein thrombosis. How should the nurse care for this client: -Apply elastic stockings. -Administer anticoagulants per the health care providers orders. -Teach leg exercises. -Limit fluid intake. -Ambulate and make the client sit frequently Apply elastic stockings, administer anticoagulants per the health care providers orders, teach leg exercises -Applying elastic stockings helps to increase the venous return and prevent venous pooling. -Administering anticoagulants helps in preventing formation of clots. -Leg exercises promote venous return and prevent the blood from pooling in the extremities. -Limiting fluid intake may cause dehydration. -Ambulation may dislodge any clot formed and result in formation of emboli The nurse is caring for a client who has an intravenous line for fluid therapy. Which potential complications should the nurse be vigilant about while assessing the client: -Pallor -Bleeding -Phlebitis -Infection -Jaundice Bleeding, Phlebitis, Infection -Bleeding at the venipuncture site is a potential complication of intravenous therapy, which can be noted as oozing or slow seepage of blood at the site. -Phlebitis, which is characterized by tenderness, pain, or burning is an inflammation of the inner layer of a vein. -Infection is a potential complication of intravenous therapy if aseptic measures were not taken during the procedure. -Pallor is not a potential complication of intravenous therapy and can occur in other conditions like reduced hemoglobin. -Jaundice, characterized by yellowish discoloration of skin, is not a potential complication of intravenous therapy and can occur in other conditions like hepatitis The nurse works at a blood bank. Which diseases is the nurse supposed to screen in blood donors: -HIV -Syphilis -Hepatitis C -Gonorrhea -Cytomegalovirus HIV, Syphilis, Hepatitis C -HIV, syphilis, and hepatitis C, are blood-borne infections and may spread from the donor blood to the recipient. Therefore, the donor blood has to be screened for these infections to reduce transmission. -Gonorrhea and cytomegalovirus are not routinely screened as these are not transmitted through blood and blood products A client develops an anaphylactic reaction following initiation of a blood transfusion. Which primary drug does the nurse use for the client: -Epinephrine -Vasopressor -Antihistamine -Glucocorticoid Epinephrine -Blood transfusions may cause anaphylactic reactions. -Epinephrine is the drug of choice as it relieves all of the clinical features of anaphylaxis. -Vasopressors do not control the dyspnea and wheezing of anaphylaxis. They are used to control blood pressure. -Antihistamines and glucocorticoids may be used as adjuvants to epinephrine but they are not the primary drugs for anaphylaxis -People with severe allergies carry "EPI-pens" A nurse is caring for an 89-year-old client. The client is very weak and refuses to eat. Intravenous therapy is planned to restore fluid and electrolyte balance. A nurse performs a venipuncture and initiates the prescribed fluid therapy. After a few hours, the nurse finds that the client has developed phlebitis. What should the nurse do: -Assess if the IV system is intact. -Stop infusion and discontinue the IV line. -Start a new IV line in another extremity. -Apply a cold compress at the site. -Monitor vital signs and lab reports of serum levels Stop the infusion and discontinue the IV line, start a new IV line in another extremity -Phlebitis is the inflammation of the inner layer of veins. In this case, the nurse should stop the infusion and discontinue the IV line. -If continued IV therapy is necessary, the nurse should start a new IV line in the other extremity or at a proximal site. -The nurse assesses the intactness of the IV system only if there is bleeding at the venipuncture site. -The nurse applies a cold compress if there is infiltration or extravasation. -Monitoring vital signs or lab reports of serum levels is done if there is a circulatory overload of IV solution. A client is suffering from a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone. What does the nurse interpret about the client's condition: -Hypercalcemia -Hyperkalemia -Hypermagnesemia -Hypernatremia Hypercalcemia -Increased levels of parathyroid hormone may cause shifting of the calcium from the bones to the extracellular space, leading to hypercalcemia. -Hyperkalemia or reduced potassium levels and hypernatremia or reduced sodium levels occur during cancer chemotherapy, and not before initiating therapy. -Hypermagnesemia is seen either due to excess intake of magnesium-rich food or during renal insufficiency due to reduced renal excretion A client is scheduled for surgery. The client has a history of epileptic seizures and has been taking phenytoin (Dilantin) for a prolonged period of time. What is the risk for this client: -Electrolyte imbalances -Bleeding and bruising -Hypoglycemia -Anesthesia complications Anesthesia complications -Prolonged use of phenytoin can alter metabolism of anesthetic agents and may lead to complications. The client may require a smaller or larger dose of the anesthetic agent for the desired effect. -Phenytoin does not cause electrolyte imbalances, hemorrhage, or hypoglycemia. A client has had chronic diarrhea for 3 months. He also suffers from repeated bouts of vomiting. A nurse sends the client's samples for laboratory studies. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find on the client during examination: -Signs of digoxin toxicity at normal digoxin levels -Positive Chvostek's sign -Hyperactive reflexes -Numbness of circumoral region -Bilateral muscle weakness Signs of digoxin toxicity at normal digoxin levels, Bilateral muscle weakness -In hypokalemia, the client experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. -Signs of digoxin toxicity at normal digoxin levels are also seen. -Positive Chvostek's sign, hyperactive reflexes, and numbness of the circumoral region are signs of hypocalcemia A client has a partial pressure of carbon dioxide (PaCO2) of 30 mm Hg. What does this value indicate about the client's condition: -CO2 has accumulated in the blood. -The PaCO2 is lower than normal. -The client is hypoventilating. -The client has impaired renal function. The PaCO2 is lower than normal -PaCO2 is the measure of the partial pressure of carbon dioxide in the blood and measures how well the lungs are excreting carbon dioxide produced during cellular metabolism. -The normal value ranges from 35 to 45 mm of Hg. The client has a value lower than normal. -A high PaCO2 indicates accumulation of carbon dioxide in the blood, caused by hypoventilation. -The PaCO2 value denotes lung function; the bicarbonate (HCO3-) indicates kidney function. Which of the following defining characteristics is consistent with fluid volume deficit: -Bounding radial pulse, flat neck veins when supine -A 1-lb (0.5 kg) weight loss in one week, pale yellow urine -Engorged neck veins when upright, bradycardia -Dry mucous membranes, thready pulse, tachycardia Dry mucous membranes, thready pulse, tachycardia -The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. -ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. -Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. -ECV deficit causes dark yellow urine rather than pale yellow, which is normal Which surgical complication does the nurse assess for in a client who took gingko prior to surgery: -Respiratory depression -Hypoglycemia -Electrolyte imbalances -Postoperative bleeding Postoperative bleeding -Use of herbal medicine may produce complications in surgery. Gingko can affect platelet activity and increase susceptibility to postoperative bleeding. -Hypoglycemia can happen to a client with diabetes mellitus who has been without food or drink for several hours in preparation for surgery. -Electrolyte imbalances can happen in clients with predisposing electrolyte disorders such as end-stage renal disease. -Respiratory depression can occur in clients who have underlying respiratory disorders such as chronic obstructive pulmonary disease. The nurse is reviewing the arterial blood gas report of a client. Which is correct regarding partial pressure of carbon dioxide (PaCO2): -PaCO2 is a measure of how well the lungs are excreting CO2 -PaCO2 is a measure of how well the kidneys are excreting metabolic acids -PaCO2is a measure of how well gas exchange is occurring in the lungs. - PaCO2 is the ability of hemoglobin to carry as much O2 as possible PaCO2 is a measure of how well the lungs are excreting CO2 -The partial pressure of carbon dioxide or PaCO2 measures how well the lungs are excreting CO2 produced by the cells during metabolism. -A higher than normal PaCO2 level indicates the accumulation of carbon dioxide in the blood. -A low PaCO2 indicates excessive excretion of carbon dioxide. -Bicarbonate (HCO3-) measures how well the kidneys are excreting metabolic acids. -Partial pressure of oxygen (PaO2) measures how well gas exchange occurs in the lungs. -Oxygen saturation (SaO2) is the percentage of hemoglobin that carries as much O2 as possible. A client suffering from gastroenteritis has tachycardia, hypotension, oliguria, and dark-colored urine. The lab reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine. What is the probable electrolyte disturbance in the client: -Low levels of sodium in the body -Low levels of potassium in the body -Decreased extracellular fluids with normal tonicity -Combined hypernatremia and extracellular volume depletion Decreased extracellular fluids with normal tonicity -Clients with gastroenteritis may have tachycardia, hypotension, oliguria, and dark-colored urine. If there is also an increased hematocrit, elevated blood urea nitrogen and increased specific gravity, it indicates extracellular volume depletion with isotonicity. -Clients with low levels of sodium or hyponatremia usually present with confusion, nausea, vomiting, seizures, and lab reports indicating lower serum osmolality. -Clients with low levels of potassium or hypokalemia present with bilateral muscle weakness, abdominal distention, decreased bowel sounds, and constipation. -If the client had coexisting increased serum osmolality and serum sodium levels above 145 mEq/L, then the client would have symptoms of both hypernatremia and extracellular volume depletion. The nurse is caring for a client with generalized body edema. Which hormones directly influence renal fluid excretion: -Renin -Aldosterone -Angiotensin II -Antidiuretic hormone -Atrial natriuretic peptide Aldosterone, Antidiuretic hormone, Atrial natriuretic peptide -Aldosterone promotes reabsorption of sodium and water from the kidney and also facilitates excretion of potassium and hydrogen ions. -Antidiuretic hormone is responsible for reabsorption of water from the kidney. -Atrial natriuretic peptide facilitates the urinary excretion of sodium and water. -Renin and angiotensin have no direct action on renal fluid excretion and absorption; however they indirectly exert their actions through aldosterone A client reports nausea, has little interest in eating, and has increased salivation. How does the nurse relieve nausea in the client: -Promote excessive intake of oral fluids -Administer antiemetics -Avoid sudden position changes -Provide a comfortable environment -Provide oral care every 2 hours avoid sudden position changes, provide a comfortable environment, provide oral care every 2 hours -Nausea, little interest in eating, and increased salivation suggest gastric irritation. -Sudden changes in the position of the client should be avoided, as this can worsen the nausea. -A comfortable, clean environment that is free from odors, noise, and vibrations helps relieve nausea. -Providing oral care every 2 hours promotes oral hygiene. -Antiemetics should be administered only if prescribed by the primary health care provider. -Oral fluids should not be given beyond the tolerability of the client as they may cause vomiting The nurse is reviewing the laboratory reports of a patient who is scheduled for surgery and suspects that the patient has an increased risk of bleeding. Which laboratory finding supports the nurse's conclusion: -Prothrombin time (PT)—11 seconds -Platelet count—100,000 cells/mm3 -International normalized ratio (INR)—0.86 -Partial Thromboplastin Time (PTT) - 35 seconds Platelet count 100,000 cells/mm3 -The normal platelet count is 150,000-400,000 cells/mm3. However, the patient has a platelet count of 100,000 cells/mm3 indicating an increased risk of hemorrhage. -The normal prothrombin time is 11 to 12.5 seconds. Therefore, the patient's PT is in the normal range. -The normal international normalized ratio (INR) is 0.86 to 1.27. Therefore, the patient's INR is normal. -The normal partial thromboplastin time is 30 to 40 seconds. The patient has a partial thromboplastin time of 35 seconds, which is normal. Which food allergy indicates that a client is susceptible to latex allergy: -Banana -Kiwi -Pineapple -Chestnuts -Oranges -avocados Kiwi, chestnuts, avocados -The client with an allergy to kiwi fruit, chestnuts, and avocados shows a cross-sensitivity to latex. If the client has an allergy to these foods, then the client needs to be assessed for latex allergy as well. -Allergies to oranges and pineapples do not show a cross-sensitivity to latex. What are the responsibilities of a scrub nurse in managing the care of a client during surgery: -Hands instruments to the surgeon -Assists in applying sterile drapes -Counts the sponges and instruments -Reviews the preoperative assessment -Implements the plan of care Hands instruments to the surgeon, assists in applying sterile drapes, counts the sponges and instruments -The scrub nurse assists in applying sterile drapes, counts the sponges and instruments, and hands instruments to the surgeon during the surgical procedure. -Reviewing the preoperative assessment and implementing the plan of care are responsibilities of the circulating nurse