Which heart wall changes would the nurse expect in a patient with damage to the epicardium?

-Impaired secretion of serous fluid. -Increased friction during heart contractions.

Which information would the nurse include when teaching about the heart?

The heart has two atrial chambers and two ventricular chambers. The heart pumps oxygenated blood to all parts of the body. The heart plays a role in tissue oxygenation.

Which trigger of inspiration would the nurse include when teaching a patient with a chronic respiratory disease about the breathing process?

Impulses in the respiratory center of the brain

Which statement describes the role of the phrenic nerve during the inspiratory phase of respiration?

Stimulates the diaphragm to move downward

In which order does the process of inspiration and expiration occur? The respiratory center in the brain sends an impulse to nerves. The phrenic nerve stimulates the diaphragm to move downward, and the intercostal nerve causes the intercostl Muscl cont

The chest cavity expands, causing decreased intraalveolar pressure. Atmospheric pressure exceeds intraalveolar pressure, causing air to move into the respiratory tract and the lungs to fill with air. The diaphragm relaxes, and intraalveolar

Which factors influence the binding of oxygen to hemoglobin?

pH 2,3 BPG Temperature Carbon dioxide

Which factors that control blood vessel diameter would the nurse include when teaching about factors affecting oxygenation and perfusion?

Oxygen Hormones Nitrous oxide Prostaglandins

For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?

Oxygen saturation (SpO2) less than 90%

When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?

Appropriate data clustering Accurate and thorough data collection

Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.

- ineffective airway clearance - impaired gas exchange - ineffective peripheral tissue perfusion - acute pain - activity intolerance - anxiety

patient scheduled for a cardiac catheterization, the patient voices anxiety. Assessment findings are: temperature 98.3°F, respirations 24 breaths per minute, and blood pressure 150/80 mm Hg. Which patient-centered goal

Patient will report a decrease in anxiety with a respiratory rate of 16 to 20 breaths per minute before surgery.

Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?

Patient will maintain a patent airway throughout the day.

Which goal would the nurse develop for a patient with extremities that are cool to touch, inability to perform activities of daily living without frequent rest, and cyanotic nail beds?

Patient will maintain oxygen saturation (SpO2) at 92% or greater on room air by the end of the shift.

Which goal statement meets all goal-writing criteria?

Patient will maintain SpO2 at 92% on room air or greater with activity within 48 hours.

Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment?

Are you having chest pain? Have you had recent weight gain? What type of work do you do? How many pillows do you sleep with? Do you ever experience dizziness?

Which questions would the nurse include as part of a focused respiratory health assessment?

Have you ever been exposed to hazardous materials at work?

Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction?

They are released when death of cardiac cells occurs. Elevated serum levels suggest cardiac damage.

Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?

Abnormal levels can cause cardiac arrhythmias.

Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?

-Inspection. -Palpation. -Auscultation. -Vital signs.

Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia?

Abnormal cardiac enzymes levels Irregular heartbeat

Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)?

High oxygen levels can be toxic. Limit oxygen concentration to low-flow. Do not smoke while using oxygen.

Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy?

Increased level of daily function Improved mental status Increased activity tolerance

Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia?

Requesting a prescription for a high-flow nasal cannula

Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube?

Obturator Inner cannula Bag-valve-mask (BVM) device Tracheostomy care kit

Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube?

“This will help facilitate clearing secretions from your mouth and throat.”

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing?

Increases the diameter of the bronchi

Which medications would the nurse expect to be added to the patient’s drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital?

Corticosteroids Antibiotics Anticholinergics

Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication?

It suppresses abnormal rhythms of the heart.

Which interventions would the nurse implement when providing care for a patient prescribed a diuretic?

Monitoring daily weight Monitoring intake and output

Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease?

Diuretics Anticoagulants Antiarrhythmics Calcium channel blockers

Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy?

Limit intake of green leafy vegetables

You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover.

Restlessness and anxiety are indications of hypoxia. Confusion, disorientation, and altered consciousness are indications of hypoxia. Increases in pulse, respiration, and blood pressure Having difficulty breathing and looking blue are i

An elderly woman is hospitalized with pneumonia and anemia and has a history of heart failure. She is weak and has a poor cough effort. Her cu

Anemia. Increased secretions with weak cough. Impaired cardiac function. Pneumonia.

Which of the following patients would have the greatest potential for an alteration in respiration?

A 44-year-old woman with anemia.

Help

Options

Question

In which order does blood flow through the heart?
Deoxygenated blood enters the right atrium via the superior vena cava, inferior vena cava, and coronary sinus.
Blood passes through the tricuspid valve to the right ventricle.

click to flip

focusNode

Didn't know it?
click below

Knew it?
click below

Don't know

Question

Which response would the nurse give to a patient with weak right ventricular systole who asks “What is wrong with my heart?”

Remaining cards (426)

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

BSN 206 Week 9-13

Question	Answer
In which order does blood flow through the heart? Deoxygenated blood enters the right atrium via the superior vena cava, inferior vena cava, and coronary sinus. Blood passes through the tricuspid valve to the right ventricle.	Blood enters the lungs via the pulmonary arteries, and gas exchange occurs through the pulmonary capillary system. Blood moves through the mitral valve to the left ventricle. Blood flows through pulmonary veins to the left atrium. aortic valve->aort
Which response would the nurse give to a patient with weak right ventricular systole who asks “What is wrong with my heart?”	“The right side of your heart is not pumping with enough force to propel an adequate amount of blood to the lungs.”
Which heart wall changes would the nurse expect in a patient with damage to the epicardium?	-Impaired secretion of serous fluid. -Increased friction during heart contractions.
Which information would the nurse include when teaching about the heart?	The heart has two atrial chambers and two ventricular chambers. The heart pumps oxygenated blood to all parts of the body. The heart plays a role in tissue oxygenation.
Which trigger of inspiration would the nurse include when teaching a patient with a chronic respiratory disease about the breathing process?	Impulses in the respiratory center of the brain
Which statement describes the role of the phrenic nerve during the inspiratory phase of respiration?	Stimulates the diaphragm to move downward
In which order does the process of inspiration and expiration occur? The respiratory center in the brain sends an impulse to nerves. The phrenic nerve stimulates the diaphragm to move downward, and the intercostal nerve causes the intercostl Muscl cont	The chest cavity expands, causing decreased intraalveolar pressure. Atmospheric pressure exceeds intraalveolar pressure, causing air to move into the respiratory tract and the lungs to fill with air. The diaphragm relaxes, and intraalveolar
Which factors influence the binding of oxygen to hemoglobin?	pH 2,3 BPG Temperature Carbon dioxide
Which acute respiratory disorder may decrease oxygenation?	Pneumonia
Which factors that control blood vessel diameter would the nurse include when teaching about factors affecting oxygenation and perfusion?	Oxygen Hormones Nitrous oxide Prostaglandins
increasing fatigue and inability to perform (ADLs). the patient walks slowly, stopping repeatedly to rest; oxy saturation drops as walking progresses; respiratory rate is elevated; no adventitious breath sounds are heard; and the patient denies pain.	Activity Intolerance
For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?	Oxygen saturation (SpO2) less than 90%
When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?	Appropriate data clustering Accurate and thorough data collection
Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.	- ineffective airway clearance - impaired gas exchange - ineffective peripheral tissue perfusion - acute pain - activity intolerance - anxiety
patient scheduled for a cardiac catheterization, the patient voices anxiety. Assessment findings are: temperature 98.3°F, respirations 24 breaths per minute, and blood pressure 150/80 mm Hg. Which patient-centered goal	Patient will report a decrease in anxiety with a respiratory rate of 16 to 20 breaths per minute before surgery.
Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?	Patient will maintain a patent airway throughout the day.
Which goal would the nurse develop for a patient with extremities that are cool to touch, inability to perform activities of daily living without frequent rest, and cyanotic nail beds?	Patient will maintain oxygen saturation (SpO2) at 92% or greater on room air by the end of the shift.
Which goal statement meets all goal-writing criteria?	Patient will maintain SpO2 at 92% on room air or greater with activity within 48 hours.
Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder?	Sputum characteristics
Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment?	Are you having chest pain? Have you had recent weight gain? What type of work do you do? How many pillows do you sleep with? Do you ever experience dizziness?
Which questions would the nurse include as part of a focused respiratory health assessment?	Have you ever been exposed to hazardous materials at work?
Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction?	They are released when death of cardiac cells occurs. Elevated serum levels suggest cardiac damage.
The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding?	Hypoxia
When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition?	Hemodilution
Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?	Abnormal levels can cause cardiac arrhythmias.
Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?	-Inspection. -Palpation. -Auscultation. -Vital signs.
Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia?	Dyspnea
Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia?	Abnormal cardiac enzymes levels Irregular heartbeat
Which postoperative complication can be prevented by regularly performing deep-breathing exercises?	Atelectasis
Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)?	High oxygen levels can be toxic. Limit oxygen concentration to low-flow. Do not smoke while using oxygen.
Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy?	Increased level of daily function Improved mental status Increased activity tolerance
Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia?	Requesting a prescription for a high-flow nasal cannula
Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube?	Obturator Inner cannula Bag-valve-mask (BVM) device Tracheostomy care kit
Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube?	“This will help facilitate clearing secretions from your mouth and throat.”
Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider?	Subcutaneous emphysema
Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary?	It prevents atelectasis.
Which type of chest physiotherapy involves percussion?	Postural drainage
The nurse would instruct a patient to hold each breath for seconds when explaining coughing/deep breathing chest physiotherapy? Record your answer as two whole numbers separated by a hyphen.	3-5
Which route would the nurse use when administering medication to a patient with non–life-threatening lower airway inflammation?	Inhalation
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing?	Increases the diameter of the bronchi
Which medications would the nurse expect to be added to the patient’s drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital?	Corticosteroids Antibiotics Anticholinergics
Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication?	It suppresses abnormal rhythms of the heart.
Which interventions would the nurse implement when providing care for a patient prescribed a diuretic?	Monitoring daily weight Monitoring intake and output
Which benefit is important for the nurse to include when educating a patient about antihypertensive medications?	Reduce the risk for stroke
Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease?	Diuretics Anticoagulants Antiarrhythmics Calcium channel blockers
Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy?	Limit intake of green leafy vegetables
You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover.	Restlessness and anxiety are indications of hypoxia. Confusion, disorientation, and altered consciousness are indications of hypoxia. Increases in pulse, respiration, and blood pressure Having difficulty breathing and looking blue are i
An elderly woman is hospitalized with pneumonia and anemia and has a history of heart failure. She is weak and has a poor cough effort. Her cu	Anemia. Increased secretions with weak cough. Impaired cardiac function. Pneumonia.
Which of the following patients would have the greatest potential for an alteration in respiration?	A 44-year-old woman with anemia.
Which of the following, if exhibited by the patient, is a late sign of hypoxia?	Cyanosis
Which of the following would lead to an increase in oxygen demand?	A fever.
What nursing intervention is appropriate for the patient with a large amount of sputum?	Encourage the patient to cough every hour while awake.
Which assessment parameters indicate the need for oral suction?	Unusual restlessness. Gagging. Gurgling and adventitious lung sounds. Evidence of emesis in the mouth. Persistent coughing that fails to clear airway. Weakness and lethargy accompanied by drooling.
The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP?	Performing oral suctioning.
The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect?	Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter.
The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed?	“Because oral secretions are thick, suction settings should always be set on high.”
Which of the following patients is most likely to experience some difficulty with effective coughing?	The patient who is postoperative for abdominal surgery.
Which of the following patients should be assessed for a worsening clinical situation?	The patient with presence of blood in the secretions.
Which of the following patients may likely require oropharyngeal suctioning?	A patient who had maxillofacial surgery. A patient who had trauma to the mouth. A patient with impaired swallowing from neurological injury. A patient with an artificial airway who requires oral hygiene.
Which of the following should NOT be delegated to nursing assistive personnel (NAP)?	Nasotracheal suctioning.
The nurse desires to suction the patient’s left main-stem bronchus. In what position should the patient be placed?	Turn the patient’s head to the right.
The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning?	"A 1- to 2- minute interval should be allowed between suctioning passes."
A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate?	“Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia.
The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure?	Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on
Which of the following is a potential complication for a patient who is having nasotracheal suctioning?	A significant drop in oxygen concentration. A decrease in heart rate. Dysrythmias.
She is heavily sedated. This patient is at risk for airway occlusion.	True
She is heavily sedated. This patient's risk factors for respiratory problems include history of smoking, her illness, and her age.	true
She is heavily sedated. She is receiving an intravenous infusion at 100 mL per hour. Intravenous fluids may affect this patient's respiratory status.	true
For a patient with an endotracheal tube on mechanical ventilation, preoxygenation is unnecessary before suctioning because the ventilator will maintain the patient's oxygen levels.	False
Which of the following statements regarding nasotracheal suctioning are true?	Sterile technique is required. Suction should be applied intermittently as the catheter is removed. The suction catheter should be rotated as it is withdrawn.
The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following actions would indicate a break in sterile technique?	places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nons glove. uses the same suction catheter to suction the oral cavity followed by the endotracheal tube and then discards the suction
Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is:	preoxygenating the patient. offsetting the volume of oxygen lost during the suction procedure. compensating for the interruption in mechanical ventilation.
When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity?	Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.
When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery?	Assessing that the reservoir bag stays inflated
What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min?	Adjust the float ball on the flow meter to 3 L/min
When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate?	Assessing for proper placement of the mask on the patient's face.
When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing?	Ensuring that a mist is always present
What would the nurse do first when preparing to begin oxygen therapy for a patient?	Review the medical prescription for delivery method and flow rate.
When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury?	Inspect all electrical equipment in the patient's room for the presence of safety-check tags.
When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely?	Place a No Smoking sign at the entrance to the house.
What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home?	Assess the patient's emotional readiness and physical ability to provide autonomous care.
Which statement by the patient would indicate that he or she understands the safe use of oxygen?	I'll alert the nurse immediately if I have any increased difficulty breathing.
What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy?	Observing the six rights of medication administration.
What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula?	Regularly measure and trend the patient's pulse oximetry (SpO2) values.
Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed?	To provide the correct amount of oxygen to the patient
What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula?	Ensure that humidification is present.
What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient?	Oxygen flow meter setting
Which cue would prompt the nurse to select a hypothesis of Bowel Incontinence for a patient?	Intermittent soiling from soft feces
Which hypothesis would the nurse develop for a patient who states, “I can’t stand to look at the stoma or this colostomy bag”?	disturbed body image
Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Diarrhea?	quick transit time reducing water absorption
The nurse would consider which pathophysiologic factor when caring for a patient with dementia whose bed linens are soiled several times a day?	Impaired neurologic status
Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools?	Diarrhea
The nurse would develop a hypothesis of Risk for Impaired Skin Integrity for which patient?	A patient with an ostomy created from the ileum
Which patient situation would the nurse prioritize as the most critical?	Choking on food, closing airway
The nurse recognizes that the outcome of “Patient will pass soft stools daily during rehabilitation” directly applies to which hypothesis?	Constipation
Which member of the multidisciplinary team would the nurse include in caring for a patient who has impaired manual dexterity for toileting?	Physical therapist
Which solution would the nurse consider for a patient with flatulence who is in traction?	Avoidance of foods that produce gas
Which overall goal would the nurse focus on while caring for a patient with severe diarrhea?	Prevent dehydration.
Which overall goal would the nurse select for a patient who has occasional fecal incontinence?	Maintain intact skin.
Which elimination outcome indicates the nurse has considered the physical abilities of the patient in a coma?	The patient will have intact skin after each bowel movement.
Which hypothesis is associated with the patient outcome “Patient will defecate without burning or pain while hospitalized”?	Hemorrhoid
Which cues would prompt the nurse to select a hypothesis of Risk for Constipation for a patient?	Has poor fluid intake Is on complete bed rest
Which cues would prompt the nurse to develop the hypothesis of Impaired Self-Toileting for a patient?	Weakness in left leg Paralysis of the lower extremities Hemiparesis on the right side
Which cues support the nurse formulating a hypothesis of Constipation for a patient?	“My stools are like little hard stones.” “I watch a lot of movies for entertainment.” “I frequently take an opioid medication for my back pain.”
Which multidisciplinary team members would the nurse likely collaborate with when caring for a patient who has constipation from a low-fiber diet and pain medications and needs assistance with self-toileting from hip surgery?	Health care provider Nutritionist/dietitian Physical therapist
Which goals would the nurse select for a patient with frequent watery stools?	Patient will pass soft stool within 48 hours. Patient will defecate formed stool within 24 hours of treatment. Patient will have two fewer episodes of diarrhea within 24 hours.
Which solutions would the nurse select for a patient with diarrhea caused by Clostridium difficile (C. diff)?	Fluid measures Isolation precautions Intake and output monitoring
Which hypotheses relate to the outcome of patient will pass soft, formed stools?	Constipation Diarrhea Fecal Impaction
Place the steps in order that the nurse would take when determining outcomes for a patient who cannot control bowels. 1. Organize and link cues gathered through patient observation and physical assessment findings for bowel elimination.	2. Make connections among the cues that relate to bowel elimination. 3. Develop the hypothesis Bowel Incontinence and other related hypotheses 4. Prioritize hypotheses. 5. Develop expected outcomes for bowel elimination.
For which patient would the nurse obtain this piece of equipment? (bedside commode)	For which patient would the nurse obtain this piece of equipment? (bedside commode)
Which action would the nurse take when the unlicensed assistive personnel (UAP) obtains this piece of equipment for a patient with a hip fracture? bedpan	c. Help the UAP obtain the correct piece of equipment.
Which assessment cues would alert the nurse that the patient with diarrhea is declining?	Has two more episodes of liquid stools Exhibits dry mucous membranes Exhibits poor skin turgor
Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating?	Moist, blue
Which action would the nurse take for a patient with a newly formed bowel diversion?	Which action would the nurse take for a patient with a newly formed bowel diversion?
Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient’s bowel elimination needs?	Record intake and output for a frail older adult.
Which action would the nurse take for a patient whose ostomy stoma is speckled white?	Notify the health care provider.
Based on the image below, which type of enema is the nurse administering to a patient? (Commercial enema preparation)	Hypertonic
Which action would the nurse take if there are concerns during administration of the enema?	If the patient cannot hold the enema solution, place the patient on a bedpan.
Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent?	“I should take the medicine for no more than 72 hours.”
For which constipated patient would the nurse administer a laxative?	One who is allergic to opiates
Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant?	Senna
For which patient would the nurse likely insert the nasogastric (NG) tube pictured here?	One who needs gastric decompression
For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance?	Gastric lavage
Which action would the nurse take first when there is no movement of fluid in the patient’s nasogastric tube and the patient’s abdomen is becoming distended?	Irrigate the tube with normal saline.
Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health?	a. "Because I am 50, I need to have a fecal occult blood test every year." e. "Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now."
Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health?	c. Walking stimulates intestinal muscle contraction. e. Usually 6 to 8 glasses of fluid should be consumed per day.
Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated?	a. Monitor intake and output. e. Weigh daily. f. Assess skin turgor.
Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating?	a. Heart rate drops to 56 beats/min d. Blood pressure elevates from 120/60 to 142/66 mm Hg
Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy?	a. Measure the stoma. b. Assess the pouch seal. d. Gently wash the stoma and peristomal area with water.
Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient?	Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient?
Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration?	a. Fever c. Congested lung sounds d. Shortness of breath
After how many enemas would the nurse notify the health care provider when the patient’s bowel return for cleansing enemas is still brown? Record your answer as a whole number. enemas	3
Place the steps of ostomy care for a patient in the correct order.	1. Remove and dispose of the used ostomy pouch. 2. Cleanse the area surrounding the stoma. 3. Assess the integrity of the stoma and peristomal skin 4. Measure the stoma. 5. Prepare the new pouch to fit stoma 6. Apply the new pouch
Which question would the nurse ask to gather cues about drug-related issues for bowel elimination?	“Are you using any herbal supplements?”
Which finding would the nurse categorize as an expected finding for an abdominal assessment?	Nonprotruding midline umbilicus
Which information would the nurse share with the patient about how blood can be detected in a guaiac test?	The stool sample is exposed to a special chemical that changes color when blood is present.
Which action by the new nurse while performing an abdominal assessment would cause the charge nurse to intervene?	Palpates a pulsating midline mass
Which action would the nurse take when performing an abdominal assessment?	Palpates the area of pain last
Which expected assessment cue would the nurse find upon palpation of the abdomen?	Painless
Which diagnostic study would help determine whether there is bleeding in the patient’s stomach?	Esophagogastroduodenoscopy
Which information would the nurse include in a teaching session about a lower gastrointestinal (GI) series?	It is a type of radiographic (x-ray) study.
Which cues would be anticipated in a patient with flatulence and bloating?	Abdominal tenseness on palpation Reports passing excessive gas through the rectum Reports of abdominal pressure
Which bowel assessment findings would the nurse report as unexpected?	Rebound tenderness present Steatorrhea Clay-colored, round stool
Which findings would cause the nurse to document “active” bowel sounds?	Gurgling Soft Sounds every 5 to 15 seconds Irregular pattern
How long would the nurse auscultate the abdomen before documenting no or absent bowel sounds?	5min
Place in the correct order the steps to perform a complete assessment of bowel function.	Interview Inspection Auscultation Palpation
Which patient requires immediate medical attention?	A patient with a hard, boardlike abdomen
Which cue is irrelevant for a patient with a bowel alteration?	Type of hypertension
The nurse caring for a patient suffering from chronic constipation must be aware of which potential complication?	Fecal impaction
Which cause is the likely reason a patient on long-term antibiotic therapy is experiencing frequent, foul-smelling diarrhea?	Clostridium difficile
Which location in the medical record would the nurse check to determine the date of the patient’s last bowel movement?	Graphic chart
Which characteristic describes bowel sounds auscultated in a patient with constipation?	Fewer than five per minute
Which factors could be potential sources of a patient’s flatus?	History of recent abdominal surgery Use of bran for fiber Presence of milk intolerance Current diet
The nurse understands that patients may experience diarrhea due to which causes?	Psychological stress Antibiotic use Enteral nutrition
Which cues suggest bowel alteration due to impaction?	Has not had a bowel movement in 4 days Has palpable hard fecal mass Has continuous leakage of liquid stool
Which patients are immediate concerns?	A teenager with absent bowel sounds A young child with diarrhea who develops dehydration An older adult who is positive for Clostridium difficile (C. diff) stool culture
Match each bowel alteration to its cause.	Prolonged constipation Impaction Paralyzed rectum muscles Incontinence Slowed peristalsis Constipation Increased peristalsis Diarrhea
Place the organs of the gastrointestinal tract in the sequence through which a food item travels.	Mouth Esophagus Stomach Intestines Rectum Anus
The gastrointestinal tract has which function?	Absorption of nutrients and fluids
Which structure is the primary organ that aids in defecation?	Large intestine
Place in order the segments of the small and large intestines.	Duodenum Jejunum Ileum Cecum Colon Rectum
Which function does defecation serve?	Expels feces
Which processes are functions of the large intestine?	Secretion Elimination Absorption
Which information is accurate regarding the structure and function of the esophagus?	Is a collapsible tube that transports a food bolus Connectss the pharyns to the stomach
Which factors can affect a patient’s bowel movements?	Dietary intake medication use pain rercent surgery
Which information regarding the frequency of bowel movements is accurate?	Varies from person to person
Which amount of fluid (in ounces) is recommended for an adult to maintain healthy bowel elimination?	64oz
Which question addresses psychological factors that can affect a patient’s bowel elimination?	Is the patient experiencing stress?
Which medications would increase the patient’s risk for constipation?	Opioids Antacids Iron supplements
Which type of intestinal movement would a patient with a paralytic ileus have?	None
Which information would the nurse share with a patient who has a loop colostomy?	"After your bowels heal, they will be reattached"
Place the types of ostomies in order based on the consistency of stool formed (from least formed/liquid to most formed/solid).	Ileostomy Ascending colostomy Transverse colostomy Descending colostomy Sigmoid colostomy
Which type of procedure creates no stoma on the patient‘s abdomen?	Ileoanal pouch
Which characteristics are typical of a loop colostomy?	Has one stoma with two openings Has mucus drain from the distal end of the stoma Has stool drain from the proximal end of the stoma Is usully created in an emergency
Stool drainage from a sigmoid colostomy has which characteristics?	Well-formed Well-regulated
Which type of ostomy causes the patient to lose a large amount of water, electrolytes, and digestive enzymes through a stoma?	Ileostomy
Which type of ostomy is the nurse describing when using this image?	Ileoanal pouch
From which area would the nurse observe stool draining in a double-barrel colostomy?	Proximal end
The nurse recognizes which findings as normal in a urine specimen from a healthy adult?	-Creatinine -Electrolytes -Ammonia -Urea
Place the anatomic structures in the order through which urine passes as it moves from the kidneys to the exterior of the body.	Renal pelvis Ureter Bladder Internal urethral sphincter External urethral sphincter Urinary meatus
Which process is directly affected by nephron damage?	Regulation of blood components
Urinary continence depends on adequate muscle tone of which structures?	-Bladder -Urethral sphincters -Pelvic floor
The nurse is caring for a patient who has developed urinary retention. While reviewing the patient’s medications, the nurse recognizes which medication type as known to contribute to the risk of developing urinary retention?	Drugs that act on the autonomic nervous system
Which alterations in urinary function are typical with certain surgical and diagnostic procedures?	-Temporary urine retention with anesthesia -Changes in urine color with procedures causing bleeding -Urinary retention with procedures causing urethral swelling
A patient newly diagnosed with kidney disease is learning about basic kidney functions during a patient education session. Which statements would the nurse include?	-The kidneys regulate electrolytes and fluid in the blood. -The kidneys help maintain the body's red blood cell count. -The kidneys help regulate blood pH.
Which cues support the hypothesis of Urinary Retention?	Bladder palpable after voiding Urinary frequency Diagnosis of prostate enlargement
pregnant patient, the nurse recognizes the cues of urinary frequency and small volume urine leakage as supportive of the hypothesis of Urinary Incontinence. Knowledge of which physiologic process provides the rationale for this hypothesis?	A hormone causes relaxation of urethral sphincters.
urine output of 350 mL in the past 24 hours is evaluating the previously selected hypothesis of Impaired Kidney Function. Which new cues in the patient chart indicate a need to begin the clinical judgment process again and create a new hypothesis?	Serum creatinine level within expected range Specific gravity of urine above the expected range Urinalysis negative for protein Serum blood urea nitrogen (BUN)/creatinine ratio within expected range
A patient involved in a motor vehicle accident is transferred to your facility. Multiple patient problem hypotheses are generated. Which hypothesis is the highest priority?	Impaired Airway Clearance
Match the solution to the expected patient outcome. Fewer urine leakage episodes within 48 hours Incontinence trigger education Decreased residual urine volume after void within one day Bladder emptying technique education	No urinary tract infections (UTIs) one month from hospital discharge Education about UTI prevention No perineal redness two weeks from hospital discharge Skin care barrier cream use training
Which solutions would the nurse generate for a hypothesis of Impaired Kidney Function?	Monitor serum creatinine and blood urea nitrogen (BUN) levels. Assess for swelling in extremities. Monitor for cardiac arrhythmia.
The nurse recognizes which physiologic connection between Kegel exercises and improved urinary continence?	Urethral sphincter tone increases.
Which rationale would the nurse recognize for placing a patient in the high-Fowler position to facilitate urination in a bedpan?	Increases intraabdominal pressure
The nurse provides education about fluid intake to a patient worried about recurrent urinary tract infections (UTIs). Which statement by the patient indicates that teaching was successful?	"High fluid intake flushes out my urinary system and reduces my chances of getting a UTI."
The UAP is assisting the nurse in the care of a patient with an indwelling urinary catheter. Which instruction would the nurse provide to the UAP to prevent urine from flowing back into the sterile bladder?	Hang the patient's urine collection bag below the patient's mattress on a nonmovable part of the bed frame.
A nurse is caring for a patient with continuous urinary bladder irrigation. Which cue indicates a complication of urinary bladder irrigation and warrants further investigation and action by the nurse?	Decrease in hourly catheter output
Which evaluation outcome indicates that a male patient with urinary incontinence using a condom catheter is improving?	Previously macerated perineal skin shows signs of healing.
Which equipment would the nurse use to collect a nonsterile urine sample from an ambulatory hospitalized female patient with limited manual dexterity?	Urine hat
A sterile urine sample via catheterization is prescribed for a patient who is temporarily unable to provide a clean catch sample. Which type of urinary catheter will the nurse use to obtain the sample?	Straight catheter
The nurse is evaluating the effectiveness of teaching a patient to independently collect a clean catch midstream urine sample for a suspected urinary tract infection (UTI). Which action by the patient indicates that further teaching is needed?	Grasps the rim of the specimen cup with the forefinger inside the cup and the thumb outside the cup
A urinalysis is performed for a patient with suspected dehydration. The nurse recognizes that which urinalysis result correlates with fluid volume deficit?	Elevated specific gravity
A patient has a standard creatinine clearance test ordered. Which information would the nurse include when teaching a patient about the test?	It is a 24-hour urine collection. All urine must be collected during the designated time period once the test starts.
Match the urinary function diagnostic test with its description. High-frequency sound waves used to visualize anatomic structures Ultrasound Invasive internal exam of the urethra and bladder with lighted device Cystoscopy	Detailed x-ray cross-sectional images of the urinary system Computed tomography (CT) X-ray using contrast medium to visualize kidneys, ureters, and bladder Intravenous pyelogram
Match the urinary pattern alteration to its corresponding cue.	Urine output <50 to 100 mL/24 hrs Anuria Urine output <400 mL/24 hrs Oliguria Urine output >2500 mL/24 hrs Polyuria Excessive urination at night Nocturia
Which conditions are general risk factors for developing urinary incontinence?	Older age Immobility Pregnancy
Which potential cause of kidney failure is prerenal?	Low cardiac output
Place the spread of a urinary tract infection in ascending anatomical order.	Contamination of the urinary meatus by a pathogen Spread to the urethra, causing urethritis Spread to the urinary bladder, causing cystitis Spread to the ureters, causing ureteritis (rare) Spread to the kidneys, causing pyelonephritis
Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized?	patient carries her urinary drainage bag like a purse under her arm as she ambulates. patient is being transferred in a wheelchair, he places the drainage bag in his lap. The NAP places a patient’s drainage bag on a lowered side rail or on the floor.
Which of the following are true regarding the impact of aging related to urinary elimination?	Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder.
During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern?	The kidneys assist in the detoxification of medication metabolites.
The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed?	"The nurse may use clean technique to insert an indwelling catheter."
53 patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the nurse’s best response?	"What medications are you taking and when?"
68-female patient knee replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The health care provider has ordered an indwelling catheter to be inserted preoperatively. Which catheter should the nurse choose?	14 French, 5-mL balloon, latex catheter.
A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter?	To determine urinary retention.
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate?	It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment.
A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take?	Advance catheter another 1 to 2 inches and inflate balloon.
The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time?	Leave the catheter in the vagina as a landmark and insert another sterile catheter.
The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter:	Sterile cotton balls. Antiseptic solution. Water-soluble lubricant. Sterile forceps.
Reasons for lack of urine after inserting a straight catheter include:	The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient.
watching a nurse catheterize a female patient with an indwelling catheter. indicates a break in sterile technique? inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt with the same catheter.	The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra.
Which of the following actions associated with urinary catheterization could cause a potential problem?	Keeping the foreskin retracted after catheterization.
40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient?	16 French, 5-mL balloon
As part of catheter insertion assessment, where should the nurse palpate?	Above the symphysis pubis.
indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance.	Ask the patient to take slow deep breaths while inserting the catheter slowly.
The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse’s best action?	Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate.
The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed?	“The bedside drainage bag should only be emptied when it is full.”
The NAP documents “Peri-care given” next to “Urinary Catheter” on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP:	stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing.
Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter?	The patient’s urine appears cloudy with a foul odor.
Identify the indicators of a UTI:	Fever. Complaints of pain with urination (dysuria). Lower abdominal pain. Cloudiness of the urine.
Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter?	Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Gently aspirate the syringe plunger if water remains in the balloon.
indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction appropriate	"This is a normal occurrence after having a catheter in place for more than several days."
If a patient's indwelling catheter is removed at 0900, the patient should be due to void by:	1500 to 1700 (3:00 PM to 5:00 PM)
Which of the following is the best example of documentation on a patient with a urinary catheter?	Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag.
reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding?	"I will measure and record the patient’s intake and output." "I will apply ultrasound gel above the patient’s symphysis pubis." "I should point the scanner head downward toward the bladder."
The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan?	p who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. A patient who complains she is having urinary incontinence and never had this problem before. A patient who is postoperative for urological surgery.
he gel, pointing it in a downward direction toward the bladder. The nurse wipes the abdomen of the gel and documents the procedure. What error(s) occurred in the performance of the skill?	The length of time between the patient voiding and performing the bladder scan. The timing of pressing and releasing the scan button. Cleaning of the scanner head.
Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required?	A patient with PVR measurements of 125 mL and 150 mL.
The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse’s best action?	Have the patient void and measure the volume, then perform straight catheterization.
What aspect of skill performance, if any, was in error?	The nurse disconnected the drainage tubing from the catheter.
The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse’s best response?	"This prevents the irrigating solution from going down into your drainage bag rather than into your bladder."
The nurse palpates the patient’s bladder and finds it is distended and there has not been any change in the amount of urine in the last 2 hours in the drainage bag. The patient’s vital signs are within normal limits. What is the nurse’s best action?	Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order.
A patient returned from urological surgery with closed continuous bladder irrigation. The patient’s vital signs are within normal limits. The patient’s wife voices concern regarding the “bloody-red” appearance of the drainage.	"This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days."
The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate?	hand hygiene and donning clean gloves. Priming the infusion tubing with irrigating solution. Calculating urinary output as the amount of irrigant infused subtracted from the amount in the drainage bag. Monitoring and emptying the drainage bag
preoperative teaching for a patient who is having urological surgery. The nurse informs the patient he will likely require closed bladder irrigation following the surgery. The patient asks what the purpose is for bladder irrigation.	"Bladder irrigation may be used to instill medication into the bladder." "Irrigating the bladder prevents any clots or sediment from blocking urinary drainage."
Which cues would the nurse expect in a patient whose hypothesis is Electrolyte Imbalance secondary to hypokalemia?	Cardiac arrhythmia Hypotension Poor muscle tone Edema Poor skin turgor
Which electrolyte imbalance would a nurse expect in a patient with the cues of anorexia, nausea, and vomiting, and a hypothesis of Electrolyte Imbalance?	Hypercalcemia
Which hypothesis would a nurse generate for a patient who has acute pain and muscle cramps and a serum sodium level of 140 mEq/L, potassium of 2.8 mEq/L, calcium of 4.5 mEq/L, and magnesium of 2.0 mEq/L?	Hypokalemia
Which outcome statement would be accurate for the nurse to include in the plan of care of a patient experiencing nausea, vomiting, and diarrhea who is at risk for an electrolyte imbalance?	Patient’s serum potassium level will be within the normal range of 3.5 to 5.0 mEq/L during the hospitalization.
Match the outcome Patient’s serum sodium level will be within normal limits within 48 hours. 135–145 mEq/L Patient’s serum potassium level will be within normal limits within 48 hours. 3.5–5.0 mEq/L	Patient’s serum calcium level will be within normal limits within 48 hours. 8.4–10.2 mg/dL Patient’s serum magnesium level will be within normal limits within 48 hours. 1.5–2.0 mEq/L
Which outcome would a nurse include when concerned about skin integrity in a patient with hypovolemic hyponatremia who continues to exhibit poor skin turgor and reports redness and irritation to the skin?	Patient will report altered sensation or pain at risk areas as soon as noted.
Which laboratory test would the nurse anticipate for an alert patient who presents to the emergency department with severe bilateral lower extremity weakness, shallow respirations, and normal heart rate and rhythm?	Serum potassium.
Which neurologic assessment, performed by tapping the side of the face, would the nurse perform for a patient with risk factors for hypocalcemia?	Chvostek sign.
Which specific questions would a nurse include in the assessment interview for a patient with hypermagnesemia?	-"What type of laxatives do you use?" -"Do you use over the counter antacids?"
Which cues would a nurse assess a patient for based on a serum phosphate concentration of 3.1 mEq/L?	tetany hyperreflexia muscle cramps
Which clinical manifestation would a nurse monitor for when providing care to a patient whose serum potassium level is 5.4 mEq/L?	Bradycardia
Which cue in a patient with end-stage renal disease would a nurse recognize as an indication of hyperphosphatemia?	Irritated and itchy eyes
Which patient conditions would benefit from electrocardiogram (ECG) monitoring because of an electrolyte imbalance?	Hypokalemia Hypocalcemia Hypomagnesemia
Which action would be taken by a nurse who is administering intravenous (IV) potassium to a patient who is experiencing acute hypokalemia?	Administering the solution slowly
Which parameter would a nurse monitor when providing care to a patient prescribed intravenous (IV) normal saline (NS) for a prolonged period?	Fluid volume excess
Which foods would a nurse teach the patient to avoid when prescribed a low sodium diet for hypernatremia?	Canned soup Sports drinks Table salt
Which food item would a nurse who is providing education to a patient with hypermagnesemia teach the patient to avoid?	Green, leafy vegetables
Which instruction would a nurse give to a patient experiencing hypermagnesemia?	Avoid taking antacids.
Which patient electrolyte level would require the nurse to prepare for cardiac monitoring?	A potassium level of 2.4 mEq/L
Which electrolytes are critical for proper cardiac functioning and would be included in a teaching session on cardiac telemetry?	Phosphate Magnesium Calcium Potassium
Which advantage of cardiac telemetry would the nurse include when teaching a patient with an electrolyte imbalance?	Allows the patient’s cardiac activity to be monitored remotely without affecting the patient’s mobility
Which nursing actions would be implemented prior to a patient receiving a dialysis treatment?	Obtaining vital signs Assessing laboratory data Providing instruction about what the patient should expect
Which observation would the nurse expect after dialysis in a patient with a serum potassium level of 7.0 mEq/L?	The serum potassium concentration will decrease.
Which patient statement indicates understanding after a nurse completes education for a patient prescribed to receive dialysis to treat an electrolyte imbalance?	“Dialysis removes excess wastes and electrolytes from my body.”
Which serum sodium concentration would the nurse identify as hyponatremia?	130 mEq/L
Which condition would a nurse suspect when caring for a patient with a serum potassium concentration of 4 mEq/L and a serum sodium concentration of 150 mEq/L?	Hypernatremia
Which factors would the nurse identify as increasing a patient’s risk for hypovolemic hyponatremia?	Diuretics Emesis Diarrhea
Which disease process would the nurse identify as the cause of a patient’s serum potassium concentration of 5.3 mEq/L?	Severe infection
Which prescription would the nurse question for a patient experiencing hypokalemia?	Loop diuretic prescription
Which serum potassium concentrations would the nurse identify as hyperkalemia in the patient’s medical record?	5.4 mEq/L 5.8 mEq/L
Which nursing statement is accurate when providing education to a postmenopausal patient who is at risk for hypercalcemia?	“It is important for us to monitor your serum parathyroid levels.”
Which serum calcium concentrations would the nurse identify as abnormal?	7.9 mg/dL 8.4 mg/dL 10.6 mg/dL
Which factor would the nurse identify as a primary cause of hypocalcemia?	Protein depletion
Which factors are potential causes of hypomagnesemia?	- Loop and thiazide diuretics usage - crohns disease - gastrointestinal suctioning
Which finding in the patient’s medical history requires the nurse to provide education about hypermagnesemia?	Leukemia
Which causes would the nurse include when providing patient education to a patient diagnosed with hypermagnesemia associated with an increased intake of magnesium?	- antacid use - magnesium- containing laxatives
Which cause related to an increased excretion of phosphate would a nurse include in a teaching session of a patient with hypophosphatemia?	Diabetic ketoacidosis
Which type of drug would a nurse include in the teaching session about drug-related hyperphosphatemia?	Cathartics
Which causes associated with poor intake of phosphate would a nurse include in a teaching session of a patient with hypophosphatemia?	- phosphate binding antacids - alcoholism - malabsorption syndrome
Which hypothesis would a nurse generate when caring for a patient with the relevant cues of dyspnea, crackles audible on lung auscultation, and weight gain of over 1.8 kg over the past 24 hours?	Fluid volume excess
Which hypothesis would a nurse develop when generating solutions for a patient preparing to undergo a major abdominal surgery?	Risk for fluid imbalance
nausea and vomiting for 3 days, become increasingly lethargic, a urine output of less than 30 mL/hour, a very poor oral intake assessment finds dry mucous membranes, low blood pressure, tachycardia, lethargy, cool, pale skin. hypothesis is appropriate?	Impaired Fluid Intake
A patient has Impaired Fluid Intake due to decreased circulating volume observed by the nurse as low blood pressure, thready pulse, tachycardia, decreased urine output, and thirst. Which statement represents a measurable, patient-centered outcome?	The patient will consume at least 100 mL of fluids every hour for a 12-hour shift.
A patient has fluid volume excess due to increased fluid retention, observed by the nurse as edema, decreased urine output, dyspnea, and activity intolerance. Which outcomes would be appropriate for the nurse to include when generating solutions?	The patient will consume no more than 1500 mg of sodium in a 24-hour period. The patient will maintain a urinary output of greater than 30mL per hour for 24 hours. The patient will be able to walk 50 feet without dyspnea by the end of a 12-hour shift.
Which outcome statement is most appropriate to achieve and maintain fluid balance?	The patient’s intake and output will be approximately equal during a 24-hour day.
Which laboratory results would a nurse expect in a patient who has developed a hypertonic fluid volume deficit?	- increased blood urea nitrogen (BUN) and creatinine levels - elevated serum osmolality
Which questions would be appropriate for the nurse to ask to obtain fluid balance information?	- Have you lost or gained weight recently?" - "Do you have a history of renal disease or diabetes mellitus?" - "Have you noticed swelling of your hands and feet
Which patient assessments would suggest a significant fluid volume deficit (FVD) in an acutely ill patient brought into the urgent treatment center?	- elevated BUN and creatinine levels - rapid, weak, thready pulse - dry, cracked lips and furrows on the tongue
Which amount of fluid would the nurse calculate has been lost by a patient with a fluid volume deficit reporting a 10 kg loss of total body weight in the last 48 hours as a result of vomiting and diarrhea?	10 liters of fluid 1 liter of fluid weighs 1kg
Which specific clinical findings would be expected by a nurse caring for an adult patient with isotonic fluid volume deficit (FVD)?	- hypotension - flat neck veins when supine - low urine output
Which rationale would explain the neurologic signs and symptoms caused by hypertonic fluid volume deficit?	Increased serum osmolality causes water to shift out of brain cells by osmosis.
Which sign or symptom suggests that a patient is experiencing hypertonic fluid volume deficit (FVD)?	confusion
Which type of fluid imbalance would a nurse suspect when the morning patient assessment reveals bounding peripheral pulses and jugular venous distention?	Increased circulating volume
A patient who received hypotonic intravenous (IV) fluids has developed the signs and symptoms of hypotonic fluid volume excess (FVE). Which neurologic signs or symptoms are consistent with this fluid imbalance?	- seizures - confusion
Which explanation would a nurse give to a student regarding the primary cause of edema resulting from fluid volume excess?	Increased hydrostatic pressure
Which descriptions would a nurse provide when educating a patient about edema?	- Edema is caused by excessive fluid in the interstitial space. -Dependent edema occurs in the sacral area of patients on bedrest. - Edema causes tissue to become quite fragile.
Match the signs and symptoms to their underlying cause.	Increased interstitial fluid volume Edema of the ankles and feet Increased circulating fluid volume Bounding peripheral pulses and hypertension Pulmonary edema Shortness of breath, cough
Which data reflect the priority assessments that a nurse would monitor when concerned that a patient may be developing a fluid volume imbalance?	The patient’s pulse and blood pressure The patient’s weight changes over the past day The patient’s intake and output balance over the past 48 hours
Which substances would a nurse need to include in the fluid intake tally?	Nasogastric (NG) tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications
Which patient-related data would require entry of fluid output information on the electronic health record (EHR)?	The patient has a nasogastric (NG) tube attached to wall suction. The patient has an indwelling urinary catheter in place. The patient has a surgical wound drain on his abdomen.
Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs after receiving a “force fluids” prescription for a fluid volume deficit?	pitcher of water at the patient bedside is refilled as required record intake of fluids to meet required levels Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day
Which factors would be included by the nurse when developing a 24-hour fluid budget for a patient with a 1000 mL fluid restriction?	Medications Intravenous (IV) fluids Between-meal fluid sipping Breakfast, lunch, and dinner
Which plan would a nurse suggest for the remainder of the 24-hour period for a patient on a 1000 mL per day fluid restriction who has consumed 700 mL as of 3:00 p.m.?	Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep.
The nurse suspects that a patient receiving an intravenous (IV) infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. For which reason would this IV solution cause this complication?	It is a hypertonic solution.
Which intravenous (IV) site in infants is most commonly used?	The vein in the middle of the scalp
Which actions related to intravenous (IV) fluid administration are the responsibility of the registered nurse?	Verify that the fluid is appropriate for the patient. Evaluate the effectiveness of IV therapy. Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration.
Which complications would a nurse need to monitor for when caring for a patient receiving a hypertonic intravenous (IV) fluid?	Cellular dehydration Circulatory overload Air embolism
Which intravenous (IV) solution would a nurse use to prime the IV tubing when preparing to administer a blood product?	0.9% normal saline
Which procedural step failure would a nurse recognize as the most common cause of adverse blood transfusion events?	Inappropriate identification prior to blood administration
During which time period would the nurse ensure extra vigilance when administering a blood product?	As the transfusion is started and within the first 15 minutes
Which signs or symptoms of an adverse reaction would a nurse monitor for in a patient who is receiving a unit of blood?	Itching Hypotension Dyspnea Fever
Which statements made by the nursing student regarding an isotonic fluid deficit demonstrate an understanding of the condition?	-Water and sodium are lost together equally. -Serum osmolality does not change.
Which postoperative factors increase the risk for fluid volume deficit (FVD)?	-A draining wound. -Dressing changes for severe burns. -Nausea and vomiting.
Which category on the dehydration severity scale would a nurse use to describe a patient whose weight has decreased from 160 lb to 152 lb since admission?	Moderate dehydration.
Which features of fluid volume excess (FVE) would a nurse expect when caring for a patient with severe oliguric kidney disease?	Increased shortness of breath because of pulmonary edema Equal gain of water and sodium
Which unique features of fluid volume excess (FVE) would a nurse expect when caring for a patient with severe FVE caused by syndrome of inappropriate antidiuretic hormone (SIADH)?	Water gain in excess of sodium Decreased serum osmolality Signs of cerebral edema
Which feature is common to both hypotonic and isotonic fluid volume excess (FVE)?	Increased circulating volume
Which explanation would a nurse include in the response to a patient diagnosed with high blood pressure who asks, “Why do I have to monitor my salt intake?”	“Sodium has an effect on your blood pressure. Since your blood pressure is high, you should decrease your salt intake.”
Which electrolyte supplement is most important for the nurse to include in a teaching session for a patient who is recovering from a broken bone?	Calcium
Which supplements would a nurse include when asked by patient with osteoporosis, “Is there anything I can take over-the-counter to manage my condition?”	Calcium Magnesium
Which primary functions would the nurse include when teaching the patient about electrolytes within the body?	Transmitting nerve impulses Regulating acid-base balance Altering the action potential of nerve fibers Maintaining fluid osmolality
A patient has developed a clot in a coronary artery, and the heart muscle cells did not make enough adenosine triphosphate (ATP). Which explanation would the nurse give a nursing student about the effect of poor ATP supply on electrolyte movement?	Active transport will be impaired, so the sodium-potassium pumps will not work normally.
Which statement regarding electrolyte movement from one compartment to another would the nursing student include in a class presentation?	“The movement of electrolytes is necessary to preserve their distribution.”
Which statements regarding the sodium-potassium pump are true?	Adenosine triphosphate (ATP) is required for the sodium-potassium pump to move sodium and potassium ions. This pump moves sodium out of the cell and potassium into the cell. This pump moves three sodium ions for every two potassium ions.
The nursing student is presenting information about the movement of electrolytes to fellow classmates. Which process would the nursing student describe as the movement of electrolytes across a membrane using a carrier?	Facilitated diffusion
The nurse is educating a patient regarding the normal levels of potassium within the blood. Which response by the patient indicates a correct understanding of the information presented?	“The normal range for potassium is 3.5 to 5 mEq/L.”
The nurse is providing care to a patient with decreased levels of serum potassium caused by excessive hormone action that shifts potassium into cells. Which hormone would the nurse expect to be elevated in the laboratory report?	Insulin
Which data would the nurse report to the primary health care provider as abnormal when monitoring serum electrolyte levels for a patient admitted with dehydration?	Serum Na+ of 150 mEq/L Serum K+ of 5.2 mEq/L Serum PO43- of 2.9 mEq/L
Which factors would a nurse assess for when admitting a patient with an alteration in total body water (TBW)?	Age Gender Body weight Overall health
An intravascular fluid sample is to be collected from a patient. Based on the location of this type of fluid, the nurse would inform the patient that the sample will come from which source?	Blood
Which information regarding solutes would a nurse include when preparing a continuing education class on body fluid components?	Colloids do not fully dissolve in a solvent.
Which type of problem would a nurse expect when caring for a patient with a blood disease that has significantly reduced the number of red blood cells?	Oxygenation.
Which type of blood would a nurse anticipate transfusing to a patient who tests positive for Rhesus (Rh) factor and no ABO antigen in the blood?	Type O+ blood
Which components of donated blood would a nurse at a community blood drive explain can be separated for individual use?	Plasma Albumin Cryoprecipitate Red blood cells
Which patient factors controlling hydrostatic pressure would a nurse consider when caring for a patient with heart disease?	The strength of the heart muscle contraction Heart rate Blood pressure
Which effect on oncotic pressure would a nurse expect when caring for a patient with a kidney disorder causing low levels of plasma protein?	Decreased oncotic pressure, which decreases the amount of water shifting into the blood.
Which information would a student nurse include when explaining the process of filtration to another student?	Filtration is the movement of water and solutes from an area of higher net pressure to lower net pressure.
Which alteration in body water homeostasis would a nurse expect in a patient whose posterior pituitary gland no longer releases antidiuretic hormone (ADH)?	Body water will be lost in large volumes.
Which rationale would the nurse associate with thirst in a frail, confused older patient with dehydration secondary to severe vomiting who is continuously calling for water even though he is nauseated?	Increased plasma osmolality and decreased plasma volume
Which information regarding the renin-angiotensin-aldosterone system would be included by a student nurse making flashcards for an exam focusing on body fluid homeostasis?	-Renin converts angiotensinogen into angiotensin I. -The renin-angiotensin system regulates fluid balance through vasoconstriction and excretion of sodium and water.
Which information would a nurse include when teaching about Rhesus (Rh) factor?	-Rh antibodies can develop during a blood transfusion. -If Rh antibodies have developed, a life-threatening reaction can occur.
Which statements are important for a nurse to know about the filtration process?	-It is the movement of water and solutes together. -Arterial blood pressure affects hydrostatic pressure.
Which processes would a nurse include when teaching about the regulation of blood pressure and fluid balance by the renin-angiotensin-aldosterone system?	-Vasoconstriction. -Release of aldosterone. -Reabsorption of sodium.
If a patient had to have part of the colon (large intestine) removed, which of the following may result?	The patient could experience an acid-base imbalance.
A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment:	- the patient is an elderly woman - the patient takes opioids for chronic back pain - the patient takes daily iron and calcium supplements
A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding?	The ascending colon would be found in the right side of the patient s abdomen.
An increase in venous pressure caused by liver disease can result in the development of:	Hemorrhoids.
The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect?	Impaction
The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe?	A decrease in heart rate.
An adult patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare:	1000 mL or less of tap water.
The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction?	The nurse squeezes and releases the bottle several times until all of the solution has entered the patient.
An adult patient complains of cramping during the administration of an enema. What could be a possible cause?	The solution was instilled too rapidly. The enema solution was too cold.
Which of the following is the best example of documentation of enema administration?	0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended. Patient states "I’m glad that’s over."
The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP, would require correction?	The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it.
A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do?	Administer a third enema.
An infant is to have an enema. Which solution would the nurse anticipate using?	Normal saline.
A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucus. What is your best response?	"The distal stoma may secrete mucus and that would be normal."
A patient has been admitted for surgery for a colostomy. The patient states, "I can’t believe this has happened to me." What is the nurse’s best response?	"It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?"
A patient is scheduled to have an ileostomy. The patient asks, "Will I always have to wear a pouch?" What is the nurse’s best response?	"Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times."
The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect?	The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to one-quarter inch larger than the stoma.
When is the best time to change the skin barrier pouch?	Several hours after breakfast. Several hours after lunch.
Identify the equipment needed to pouch an enterostomy by using a precut system.	Basin with warm tap water. Gauze pads or washcloth. Towel or disposable waterproof barrier. Pouch closure device, such as a clamp. Clean disposable gloves. clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece
Identify interventions for irritation around the stoma.	good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided. the patient’s skin is reacting to adhesive removal. Consult the ostomy care nurse. a different type of pouching system is needed to prevent leakage.
Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause?	A lack of circulation to the stoma.
The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates further instruction is needed?	“I should clean the peristomal skin with soap and warm water.”
From the following, choose the four primary functions of the colon. (Select all that apply.)	Secretion oProtection oAbsorption oElimination
From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared Fleet enema.	Water-soluble lubricant oWaterproof bed pad oCommercially prepared enema productoClean disposable gloves oToilet paper and/or basin with warm water, washcloth, and towel
The nurse listens for bowel sounds before administering an enema. The patient asks, “Why are you listening to my abdomen?” The nurse’s accurate response is:	“To determine the presence of bowel sounds, which indicates the intestines are working.”
To which of the following patients would it be considered acceptable to administer an enema without the nurse needing to question the order?	A patient who is going to have abdominal surgery.
A nurse is preparing to administer an enema. Which of the following actions indicates correct understanding?	The nurse holds the tubing in the patient’s rectum constantly until the end of the fluid instillation
The nurse is reviewing enema administration with nursing assistive personnel(NAP). Which of the following statements by the NAP indicates further instruction is necessary?	“The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of an adolescent.”
Which of the following would be considered a normal finding after the administration and evacuation of an enema?	Abdominal distention is absent
The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse?	Lower the height of the enema container or clamp the tubing.
Which of the following is considered a sterile procedure and therefore requires sterile gloves?	None of the above
The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficulty with this change in body?	The patient continues to rely on the nurse to change the ostomy pouch.
How often should an ostomy pouch be changed	Every 3 to 7 day
pouching a new ostomy. The patient asks why the nurse always measures the size of the stoma, stating, “Don’t you remember how large to cut the opening?” Which of the following would be an inaccurate response by the nurse and would require correction	The stoma typically increases in size with the passage of time.
Which of the following would be inappropriate to delegate to NAP?	Pouching a newly established ostomy.
The NAP tells the nurse she doesn’t want to care for a certain patient becauseshe is afraid of contracting C. difficile. Which is the best response by the nurse?	Good hand hygiene with soap and water is your best defense against C. difficile.”
The nurse instructs the patient that the health care provider has ordered an enema. The patient states, An enema! I’m not constipated. What are other possible reasons for the order?	Preparation for surgery oPreparation for a diagnostic procedure oTo administer a medication
The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a client who has had discomfort when walking to the bathroom. statement made by the NAP requires the nurse’s follow-up?	“If I can get someone to help, I’ll walk her to the bathroom.”
A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the client’s safety?	Obtain help to place the client on the bedpan.
A dependent, confused client is being given a bedpan. How can the nurse best ensure the client’s safety?	Raise the side rails on the bed before leaving the room.
The nurse is assisting with a bedpan for a client who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the client uses the bedpan?	Elevate the head of the bed to between 30 and 60 degrees.
After assisting with a bedpan, the nurse notes that the client’s stool is streaked with bright-red blood. What would the nurse do first?	Ask if the client has a history of hemorrhoids.
A client with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping the client to a standing position?	Determine his risk for orthostatic hypotension
he nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which client?	Client with complete left-sided paralysis caused by a stroke
Why would the nurse assess a client’s abdomen before helping with the use of a urinal?	To assess for bladder distention
The nurse is assisting a patient with the placement of a urinal. The client tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?	“Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.”
Which action promotes infection control when assisting a client with a urinal?	Applying gloves before emptying and cleaning the urinal
Which acid-base imbalance would the nurse anticipate in a patient after a motor vehicle accident in which the steering wheel hit the patient’s chest and trapped the patient in the car until rescue workers arrived?	Respiratory acidosis
fell and is receiving treatment for a fractured arm. The nurse reviews the patient’s laboratory results, which indicate an elevated pH and a decreased PaCO2. Which condition is the patient experiencing based on the current data?	Respiratory alkalosis
Which patients would the nurse identify as being at risk for respiratory acidosis secondary to impaired gas exchange?	A patient experiencing an asthma attack A patient diagnosed with Guillain-Barré syndrome A patient who is 2 hours postoperative for thoracic surgery
Which conditions in the medical history would the nurse identify as a risk factor for metabolic acidosis?	Type I diabetes Sepsis
patient who is awake, but lethargic, and taking rapid, deep breaths would the nurse suspect as the cause of the following laboratory values: pH 7.31, PaO2 59.2 mm Hg, PaCO2 38.6 mm Hg, HCO3– 17.5 mEq/L, and oxygen saturation 88%?	Diabetes mellitus
Which ABG data would the nurse identify as supporting the diagnosis of metabolic alkalosis in a patient admitted with dehydration and lethargy?	Increased pH Increased bicarbonate
Which change in respiratory pattern observed in a type I diabetic patient with metabolic acidosis indicates to the nurse that compensation is occurring?	Kussmaul respirations
Which hypotheses would the nurse consider when handed over a patient with an acid-base imbalance who has Kussmaul respirations and is reported to be hypotensive and dysrhythmic?	Excess acid production
Which additional cues would the nurse expect when caring for a patient with Acute Confusion associated with respiratory alkalosis?	Muscle cramping Restlessness Tachypnea
Match each hypothesis with the acid-base imbalance.	Impaired Gas Exchange Respiratory acidosis Hyperventilation Respiratory alkalosis Excess acid production Metabolic acidosis Excess serum bicarbonate Metabolic alkalosis
dyspnea and impaired gas exchange secondary to chest injury causing respiratory acidosis. in the plan of care to specifically monitor a goal of returning blood pressure to baseline or within normal limits within 24 hours of admission?	Vital signs
Which solutions are appropriate for a nurse to include in the plan of care for a diabetic patient with metabolic acidosis?	Decrease blood sugar Replace fluid loss Correct electrolyte imbalances
history of tobacco use reports fatigue, decreased energy, and difficulty breathing. The hypothesis includes Impaired Gas Exchange with respiratory acidosis. Which goal statement specific for fatigue would the nurse include in the plan of care?	Patient will verbalize feelings of increased energy within 24 hours of admission.
Which conclusion would the nurse make when the ABG results for a patient suspected of having an acid-base imbalance reveal a decreased pH, increased PaCO2, and normal HCO3–?	Respiratory acidosis
Which actions would the nurse perform when analyzing ABG values for a patient suspected of having an acid-base imbalance?	Examining oxygenation status Evaluating the pH Assessing PaCO2 and HCO3– Determining compensation
Which acid-base imbalance would the nurse suspect when providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3– 20 mEq/L?	Metabolic acidosis
Which assessments would the nurse perform in all patients experiencing an acid-base imbalance?	ABG analysis Vital signs
Which cardiovascular findings would the nurse anticipate in a patient with respiratory acidosis?	Tachycardia Dysrhythmia
Which clinical manifestation would the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis?	Tachypnea
Which assessment finding would cause the nurse to suspect that a patient is experiencing metabolic acidosis?	Kussmaul respirations
Which acid-base imbalance would the nurse suspect in a patient presenting with muscle twitching and tetany who experiences a seizure 10 minutes after hospital admission?	Metabolic alkalosis
Which intervention would the nurse include in the plan of care for a patient experiencing respiratory alkalosis?	Having the patient breathe into a paper bag
Which members of the health care team would the nurse include when planning a collaborative care conference about the acute phase of any acid-base imbalance?	Health care provider Respiratory therapist
Which interventions would the nurse independently implement for a patient experiencing respiratory acidosis?	Encouraging deep breathing exercises Monitoring breath sounds Providing emotional support
Which interventions would the nurse anticipate when caring for a patient experiencing metabolic alkalosis?	Administering potassium Implementing seizure precautions
The nurse is caring for a patient admitted with metabolic alkalosis. Which intervention would the nurse anticipate when providing care to this patient?	Implementing seizure precautions
Which intervention would the nurse anticipate when caring for a patient experiencing metabolic acidosis?	Providing mechanical ventilation
Which statement by a student nurse would the nurse consider accurate regarding a patient who exercises in excess, leading to acidosis?	“Anaerobic respiration is causing lactic acid to form, leading to acidosis.”
Which patient response about the purpose of bicarbonate in the blood indicates correct understanding?	“It is a weak base that plays a crucial role in acid-base balance.”
Which venous pH values would the nurse report to the primary health care provider as within expected limits?	7.35 7.40
Which statement would the nursing student include in a presentation regarding the mechanism by which the body excretes excess hydrogen ions?	“Kidneys excrete hydrogen ions in the urine.”
Which response would the nurse expect for a patient whose arterial pH level is 8.0?	The body systems would shut down.
Which actions in the body would the nurse anticipate as compensatory mechanisms to regulate pH when providing care to a patient whose pH is less than 7.35?	The respiratory system eliminates excess carbon dioxide. The chemical buffering system releases bicarbonate acid.

Created by: iobraztsov

"Know" box contains:
Time elapsed:
Retries: