Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Med-Surg HESI
Med Surg, Spring 2020
| Question | Answer | Rationale |
|---|---|---|
| A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. | 1.Blood transfusions 2.Metabolic alkalosis 3.Bleeding or hemorrhage 4.Decreased sodium excretion 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium | CKD, factors other than tissue breakdown that can cause hyperkalemia: blood transfusions, bleeding, hemorrhage, ingestion of potassium in medications, & failure to restrict dietary potassium. |
| A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. | 1.Dehydration 2.Hypertension 3.Physiological stress 4.Decreased blood volume 5.Decreased plasma osmolarity | ADH, or vasopressin. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress. |
| The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored? | 1. Edema 2.Bradycardia 3.Hypertension 4.Hyperkalemia | Hyperkalemia is the most significant adverse effect of triamterene, especially when it is used alone. A potassium-retaining diuretic, so the nurse needs to monitor the client for hyperkalemia. never use in conjunction with another potassium-retaining diu |
| A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? | 1.Weighs athletes before, during, and after football practice 2.Asks the athletes to take a salt tablet before football practice 3.Schedules fluid breaks every 30 minutes throughout practice 4.Tells the athletes to drink 16 oz (475 mL) of fluid per | Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent d |
| The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfa | 30mL | The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake |
| Which clients are most likely to be at risk for the development of third spacing? Select all that apply. | 1.The client with cirrhosis 2.The client with liver failure 3.The client with diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic kidney disease | Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless |
| The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? | 1.Hang the solution. 2.Contact the health care provider (HCP). 3.Check the client's daily laboratory results. 4.Ask the client if any liver study tests have ever been done. | The nurse must contact the HCP before administering the solution. Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis. |
| The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. | 1.10% dextrose in water 2.0.45% sodium chloride 3.5% dextrose in 0.9% saline 4.5% dextrose in 0.45% saline 5.5% dextrose in 0.225% saline 6.5% dextrose in lactated Ringer's solution | Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions. |
| The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. | 1.10% dextrose in water 2.0.45% sodium chloride 3.5% dextrose in 0.9% saline 4.5% dextrose in 0.45% saline 5.5% dextrose in 0.225% saline 6.5% dextrose in lactated Ringer's solution | Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. |
| The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? | 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D | normal calcium level is 9.0 to 10.5 mg/dL. calcium level of 6.0 mg/dL experiencing hypocalcemia. Prolonged bed rest can cause of hypocalcemia. Immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. |
| The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. | potassium level is 3.5 to 5.0 mEq/L. A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. ECG changes with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. | |
| The nurse is caring for a client with heart failure receiving high doses of a diuretic. On assessment, notes flat neck veins, muscle weakness, and diminished deep tendon reflexes. What signs would the nurse expect to note in a client with hyponatremia? | The normal serum sodium level is 135 to 145 mEq/L. Hyperactive bowel sounds indicate hyponatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted. | |
| A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural s | 1.Ensures that a close relative stays with the client 2.Makes a referral for a Catholic priest to visit the client 3.Removes the crucifix from the wall in the client's room 4.Administers the sacrament of the sick to the client if death is imminent 5 | |
| The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? | 1.Heparin 2.Platelets 3.Antibiotic 4.Clotting factors | During early phase of DIC, anticoagulants (esp heparin) are given to limit clotting & prevent rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring |
Created by:
Jlewis8775
Popular Clinical Skills sets