NURS 320 Exam 1 Questions and Correct Answers A+ Pass

NURS 320 Exam 1 Questions and Correct Answers A+ Pass On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect? A)Third spacing B)This is normal and expected after a burn and it is benign C)Document this finding as non-pitting abdominal edema D)Intravascular compartment syndrome - A You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values. Which patient is at more risk for an electrolyte imbalance? A)An 8 month old with a fever of 102.3 'F and diarrhea B)A 55 year old diabetic with nausea and vomiting C)A 5 year old with RSV D)A healthy 87 year old with intermittent episodes of gout - A The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance. A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient? A)Restrict fluid intake and monitor daily weights B)Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output C)Administer hypotonic IV fluid and administer sodium tablets. D)No interventions are expected - B The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells. After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A)Potassium level of 2.2 B)Potassium level of 5.6 C)Magnesium level of 2.3 D)Phoshorus level of 2.0 - A Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings. Which patient below would have a potassium level of 5.5? A)A 76 year old who reports taking lasix four times a day B)A patient with Addison's disease C)A 55 year old woman who have been vomiting for 3 days consistently D)A patient with liver failure - B A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease. You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true? A)This is known as Trousseau's Sign and is present in patients with hypocalemia B)This is known as Trousseau's Sign and is present in patients with HYPERcalemia C)This is known as Chvostek's Sign D)The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure - A The correct answer is "this is known as Trousseau's Sign and is present in patients with hypocalemia". Patient's with hypokalemia may present with a positive Trousseau's and Chvostek sign. Which patient is at most risk for hypomagnesemia? A)A 55 year old chronic alcoholic B)A 57 year old with hyperthroidism C)A patient reporting overuse of anatacids and laxatives D)A 25 year old suffering from hypoglycemia - A