Which syndrome would the nurse suspect when a patient has a potassium level of 6.2 mEq/dl

A client is experiencing respiratory distress asa result of acute pulmonary edema. What should the nurse do first?

A:Place the client in high-Fowlers’

R:According to the airway, breathing, circulation priority setting framework, theleast invasive action is to place the client in high-Fowler’s position to allowfor greater lung expansion and ease of breathing.

Which of the following assessment findings should a nurse expect when caring for a client who has a serum potassium level of 3.0 mEq/L?

A:Orthostatic hypotension

R:Orthostatic hypotension is an expected finding with hypokalemia

A nurse is performing a neurological assessment on a client who has dehydration. The nurse notes that the client’s mental status has changed, and she now appears confused and lethargic. What of the priority nursing action?

A:Report this finding to the client’s primary care provider

R:According to the safety and risk reduction priority setting framework, thegreatest risk to the client is worsening dehydration. The priority nursingaction is to contact the primary care provider to obtain further orders.

A nurse notes that a client’s serum sodium 155 mEq/L. The primary care provider prescribes IV fluids. The nurse should question which of the following orders? A) 1,000 mL 0.9% saline B) 1,000 mL 5%dextrose with water C) 1,000 mL 3% saline D) 1,000 mL 5% dextrose and 0.45%saline

A:C) 1,000 mL 3% saline

R:This hypertonic solution will increase serum sodium

A nurse is caring for a client on continuous cardiac monitoring and identifies a prolonged PR interval and a widended QRS complex. What laboratory value would support this finding?

A:Increased potassium

R:Hyperkalemia may cause prolonged PR interval and widened QRS complex

A nurse is planning dietary teaching for a client who has hypermagnesemia. Which food choice should the nurse plan to instruct the client to avoid?

A:Spinach or other foods high in

magnesium

R:Spinach contains 88 mg of magnesium per serving

A nurse is caring for a client who as experienced excessive fluid loss. The nurse should include what in the plan of care?

A:Administer prescribed IV fluids (a client with excessive fluid loss will mostlikely receive replacement fluids by IV), encourage client to drink fluid, encourage client to rise slowlywhen standing up (encouraging the client to rise slowly when standing up helpsprevent orthostatic hypotension), weigh the client each morning (weighing theclient each morning will provide information regarding fluid balance)

A client is admitted with status asthmaticus. An ABG analysis show pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 26 mEq/L. The nurse interprets these lab values as…

A nurse is caring for a client who has insulin-dependent diabetes mellitus and is experiencing DKA. The client is receiving IV insulin therapy, and laboratory values are being monitored. What lab values should the nurse anticipate reporting to the primary care provider?

A:Decreased serum potassium

R:Decreased serum potassium levels need to be addressed immediately by theprimary care provided

A client diagnosed with dehydration is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following as a sign of fluid overload?

A:Bounding peripheral pulses

R:Fluid overload results in increased vascular volume and places a greaterworkload on the heart. Thus, an expected finding is bounding peripheral pulses.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. The nurse evaluates that the teaching has been effective or ineffective when the client states, "When I sit down to watch television, I’ll be sure to put my feet up".

A:Effective

R:Venous insufficiency makes it difficult for blood to return to the heart, andelevating the feet will increase the return

A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. The nurse evaluates the teaching has been effective or ineffective when the client states, "I will use the incentive spirometer every hour”.

A: Effective

R:Use of an incentive spirometer postoperatively will promote adequate gas exchange and decrease the risk of respiratory acidosis.

Which of the following is the priority assessment a nurse should make when caring for a client who has a calcium level of 8.1 mg/dL

A:Cardiac rhythm

R:According to the airway, breathing, circulation priority-setting framework, thegreates risk to the client is cardiac dysrhythmias, making this the priority assessment

Q:Which action should a nurse consider to take for a client with a serum calcium level of 8.4 mg/dL

A:Implement seizure precautions

R:The client is at risk for seizures due to the lowered excitation threshold.Seizure precautions should be implemented to prevent injury to the client

A nurse is caring for a client who has heart failure and is receiving furosemide (Lasix). The client is experiencing general muscle weakness and decreased bowel sounds. Which action should the nurse anticipate taking?

A:Recommend a potassium-sparring diuretic

R:The findings indicate hypokalemia likely caused by furosemide. The nurse should anticipate a prescription for a potassium-sparing diuretic.

This nurse evaluates the following laboratory values and determines the patient is experiencing what acid-base imbalance pH 7.26, PaO2 84 mmHg, PaCO2, 38 mmHg, HCO3- 20 mEq/L

A:Metabolic acidosis

R: A decrease in pH and HCO3- with a normal PaCO2indicates metabolic acidosis

What is an expected finding of hyperkalemia?

A:Decreased muscle strength

R:Muscle weakness may result from hyperkalemia

A nurse is caring for a client who is receiving nasogastric suctioning and the nurse reviews the patient’s following laboratoryv alues: pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3 31 mEq/L. Which acid base imbalance does the patient have?

A:Metabolic alkalosis

R:An elevated pH and HCO3 with a PaCO2 within the expected reference rangeindicates metabolic alkalosis

Q:A client diagnosed with acute heart failure is prescribed furosemide (Lasix) daily. During the client’s morning assessment, he tells the nurse that he is “feeling weak in the legs”. What action should the nurse take first?

A:Review the daily lab results

R:The nurse needs to collect more data before taking any action; therefore, the first action the nurse should take is to review the daily laboratory results.

Q:A nurse is caring for a client with a serum potassium of 6.2 mEq/L. The client is on potassium chloride (K-Dur), furosemide (Lasix), and has IV fluid infusion. What actions should the nurse anticipate implementing?

A:Administer D50W and regular insulin IV

R:An IV solution with a high dextrose concentration and Regular Insulin willcause the potassium to move from the blood into the cells and decrease theserum potassium level

Q:What is an expected finding of hypomagnesemia

A: Hyperactive deep tendon reflexes

A client with heart failure is admitted following 3 days of vomiting. He is currently taking 40 mg furosemide (Lasix) and 0.125 mg digoxin (Lanoxin) daily. The nurse suspects hypokalemia. What should the nurse anticipate administering

A:Normal saline with 40 mEq/L K+ at 100 mL/hr

R:This IV solution will provide adequate fluid and potassium replacement to offset the losses related to vomiting

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse expect to be abnormal if the client is experiencing respiratory alkalosis?

A:PaCO2

R:With respiratory alkalosis, the PaCO2 level is decreased

Q:A client is admitted with isotonic dehydration following 2 days of vomiting and diarrhea. What laboratory result should indicate to the nurse that the client has responded to fluid therapy?

A:Serum sodium 138 mEq/L

R:Osotonic dehydration causes loss of water only. A serum sodium of 138 mEq/Lindicates that the fluids are being replace and that the client has respondedto fluid therapy

A nurse enters the room of a client receiving PCA following a thoracotomy. The client is short of breath, appears restless,and has respirations of 28/min. What action should to nurse anticipate taking?

Providecalming interventions

R:The client is likely hyperventilating and needs to be calmed down to allow forcarbon dioxide to build up

Q:A nurse is caring for a client who has Guilliain-Barre Syndrome. A pH of 7.30 indicates…

A:Acidosis

R:An arterial pH of 7.30 indicates acidosis

A nurse is preparing to administer oral potassium. The client’s potassium level is 5.5 mEq/L. Which of the following actions should the nurse take?

A:Withheld the mediation because lab result is high

R:The client’s potassium level is high; therefore, the nurse should withhold themedication and notify the provider.

Which intravenous solution would the nurse use for a patient who presents with severe hyperkalemia?

Which medication would the nurse associate to the treatment of a patient with hyponatremia secondary to heart failure and liver cirrhosis?

Which clinical manifestation would the nurse expect to see when assessing a client with hypocalcemia?

Which medication would the nurse administer to counter the signs of toxicity when infusing magnesium sulphate IV to a patient with preeclampsia?