Med Surg I EAQ Ch 6

Extracellular fluid is found mainly in which areas? Select all that apply. - answer1. Plasma 2. Lymph fluid 4. Cerebrospinal 5. Digestive secretions Which persons have a higher percentage of water weight? - answerOlder adults Which is an intravascular body fluid? - answerPlasma Which part of the body secretes aldosterone? - answerAdrenal glands Which food is the best choice of snack for a patient who is on a low-sodium diet? - answerAir-popped popcorn Which transport process is represented by the movement of oxygen from the alveoli to the pulmonary capillaries? - answerDiffusion Which electrolyte is most abundant in the body? - answerSodium (Na+) Which information will the licensed practical nurse (LPN) include when calculating a patient's total intake? Select all that apply. - answer1. 240 mL of ginger ale 2. 800 mL of 0.9% NaCl via intravenous (IV) line 3. 200 mL sodium phosphate enema 4. 20 mL of 0.9% NaCl IV flushes The nurse knows that water will follow which electrolyte? - answerSodium A patient's 2.2-pound weight gain can be attributed to what volume of additional fluids? - answer1 liter The nurse working at a long-term care facility has been informed that one of the residents has been vomiting for 24 hours. Which is the best place for the nurse to assess skin turgor on this resident during a physical assessment? - answerSternum The clinical instructor explains that encouraging older adult fluid intake at mealtime is most important for which reason? - answerOlder adults have a decreased sense of thirst and increased risk for dehydration. Which hormone is released by the adrenal glands and acts as a volume regulator? - answerAldosterone The licensed practical nurse (LPN) reviews the care plan for a resident and recognizes which measurements as the most accurate way to monitor electrolyte data? - answerLaboratory tests Which is not a transport process for water and solutes between fluid compartments? - answerActive mechanism After a patient has just consumed a foot-long submarine sandwich, the licensed practical nurse (LPN) explains to the patient that thirst is driven by which mechanism? - answerIncreased blood sodium concentration from cured meats Which sign or symptom of dehydration would the nurse assess for in an adult? - answerDark, concentrated urine, confusion, decreased blood pressure, and increased heart rate Which statement accurately explains why output is notably less than intake in a homeless patient with mild dehydration? - answerThe patient's kidneys are conserving fluids because of the condition of dehydration. Which wording would the nurse use to document edematous tissue that is full of fluid and not displaced when pressed? - answerBrawny Which is the first step in the process of collecting a 24-hour urine specimen for creatinine? - answerDiscard the first morning urine specimen. Which electrolytes are involved in nerve impulse conduction? Select all that apply. - answer1. Sodium 2. Calcium 4. Potassium 5. Magnesium While interviewing a patient suffering from nausea and vomiting, which information is most pertinent to address? Select all that apply. - answer1. Use of diuretics 2. Onset of vomiting 5. Change in mental alertness 6. Medical history of renal disease The nurse assigned to care for a patient who was admitted with pneumonia and respiratory acidosis would prioritize which aspect of care? - answerFluid intake and positioning for optimal gas exchange Which are examples of cations? Select all that apply. - answer1. Sodium 3. Potassium 4. Magnesium Which clinical manifestation would be an expected finding in a patient with fluid volume deficit? - answerHypotension Which statement best describes the cause for tea-colored urine? - answerThe influence of antidiuretic hormone (ADH) What is the last phase in the work of the kidneys? - answerTubular secretion Which test detects glomerular damage in the kidney? - answerUrine creatinine clearance A patient is receiving a 2-gram sodium diet because of severe lymphedema. The patient asks the nurse if a salt substitute is permitted. The nurse is aware that the health care provider needs to approve this request because of which potential electrolyte disorder? - answerHyperkalemia A patient is admitted with a blood sugar of 750 mg/dL, pH of 7.0, and a low HCO3 level. Which is the most likely cause of the patient's acid/base imbalance? - answerMetabolic acidosis Which arterial blood gas (ABG) results would the nurse expect when a patient admitted with pneumonia exhibits tachycardia, tachypnea, sweating, and confusion? - answerpH 7.33, normal bicarbonate (HCO3), elevated PaCO2 A transferred patient was receiving nasogastric enteral feedings that were recently stopped. The patient's laboratory values are as follows: sodium: 137; chloride: 99; calcium: 9; potassium: 3; magnesium: 1.6. What is the most likely cause of the patient's abdominal distension and vomiting? - answerHypokalemia Calculate the volume deficit (in liters) in a patient with a usual body weight of 150 pounds who currently weighs 143 pounds? Round your answer to the nearest whole number. - answer3 liters An older adult is admitted with symptoms of confusion, recent weight loss of 10 pounds, supine blood pressure of 115/80 mm Hg, and a standing blood pressure of 85/60 mm Hg. Which intervention does the nurse anticipate including in the initial plan of care? - answerInstitute fall precautions The nurse will expect the physician to order which medication for a patient exhibiting a bounding pulse, weight gain, and crackles upon auscultation of the lungs? - answerFurosemide The nurse would expect to document which finding in a plan of care for extracellular fluid volume excess? - answerHand vein engorgement The nurse is testing urine from a specimen left at room temperature for an entire shift. Which urine pH value would the nurse expect to find? - answer8.0 The licensed practical nurse (LPN) approaches a family member who is breathing very rapidly because the family member is at risk for developing which acid/base imbalance? - answerRespiratory alkalosis Which intervention is priority when caring for a patient in respiratory acidosis resulting from pneumonia? - answerEncourage hourly fluid intake. Blood gases reveal a low PaCO2, high pH, normal HCO3, and high PaO2. Which acid-base disturbance would the nurse suspect? - answerRespiratory alkalosis The nurse knows that a patient who weighs 5 more pounds today than yesterday has likely retained how much fluid? - answer2 liters Which factor places a patient at highest risk for respiratory acidosis after suspected heroin overdose with a respiratory rate of 6 breaths per minute? - answerRespirations are not adequate to remove CO2. The physician has ordered potassium 20 mEq intravenous (IV) push for a patient whose serum potassium level is 2.8 mEq/L. Which action would the nurse perform first? - answerClarify the order with the physician. On the third day after admission, the licensed practical nurse (LPN) notes a trend of steadily decreasing urinary output despite no changes to the intravenous (IV) fluid orders containing potassium. The patient is at risk for developing which disorder? - answerHyperkalemia The licensed practical nurse (LPN) would alert the registered nurse (RN) to which order for a patient diagnosed with congestive heart failure? - answerAdminister 10 mEq KCl by intravenous push (IVP) twice daily. Which skin characteristics reflect proper fluid balance in a healthy adult? Select all that apply. - answer2. Color consistent with ethnicity 5. Temperature warm to touch Which sites are most appropriate to assess skin turgor in an older adult patient? Select all that apply. - answer2. Sternum 3. Forehead A patient who has had prolonged nasogastric suctioning after abdominal surgery could possibly develop which symptoms of metabolic alkalosis? - answerIrritability and numbness of the fingers Which findings would the nurse expect in a patient experiencing fluid volume overload? Select all that apply. - answer1. Dyspnea 2. Bounding pulse