Exam (elaborations)
LCCC Nurs172 Exam 3- F&E correctly answered 100%
- Course
- Hondros Nursing 172
- Institution
- Hondros College School Of Nursing
LCCC Nurs172 Exam 3- F&E correctly answered 100%
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LCCC Nurs172 Exam 3- F&EWhile caring for a patient with metastatic bone cancer, which clinical manifestations would alert the
nurse to the possibility of hypercalcemia in this patient (select all that apply)?
A. Weakness
B. Paresthesia
C. Facial Spasms
D. Muscle Tremors
E. Depressed Reflexes - correct answer ✔✔A. Weakness
E. Depressed Reflexes
Parestesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.
You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In
analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be
caused by which factors in this patient (select all that apply)?
A. The potassium level may be increased if the patient has nephropathy.
B. The patient has been eating excessive amounts of foods that increase potassium levels.
C. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition.
D. There may be excess potassium being released into the blood as a result of massive blood transfusion.
E. The potassium level may be increased because of dehydration that accompanies high blood glucose
levels. - correct answer ✔✔A. The potassium level may be increased if the patient has nephropathy.
D. There may be excess potassium being released into the blood as a result of massive blood transfusion.
E. The potassium level may be increased because of dehydration that accompanies high blood glucose
levels.
A patient was admitted for a paracentesis to remove ascites Fluid. Five liters of fluid was removed. Which
IV solution may be used to pull fluid into the intravascular space after paracentesis?
,A. 0.9% Sodium Chloride
B. 25% Albumin Solution
C. Lactated Ringers
D. 5% Dextrose in 0.45% Saline - correct answer ✔✔B. 25% Albumin Solution
NaCl and LR are isotonic. D5 in 1/2 NS is hypotonic. Need hypertonic Albumin to pull fluid into
intravascular space.
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20
mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV
order change?
a. Sodium 136 mEq/L, potassium 3.6 mEq/L
b. Sodium 145 mEq/L, potassium 4.8 mEq/L
c. Sodium 135 mEq/L, potassium 4.5 mEq/L
d. Sodium 144 mEq/L, potassium 3.7 mEq/L - correct answer ✔✔C. Sodium 135 mEq/L, potassium 4.5
mEq/L
The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to
5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of
sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and
the sodium level near the low end of their respective ranges.
While performing patient teaching regarding hypercalcemia, which statements are appropriate?
A. Have patient restrict fluid intake to less that 2000mL/day.
B. Renal calculi may occur as a complication of hypercalcemia.
C. Weight bearing exercises can help keep calcium in the bones.
D. The patient should increase daily fluid intake to 3000 to 4000 mL.
E. Any heart burn can be managed with an as needed calcium containing antacid. - correct answer ✔✔B.
Renal calculi may occur as a complication of hypercalcemia.
C. Weight bearing exercises can help keep calcium in the bones.
, D. The patient should increase daily fluid intake to 3000 to 4000 mL.
Calcium levels are inversely related to? - correct answer ✔✔Phosphorus levels
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 am
assessment of this patient you note that the IV solution, which was ordered to infuse at 125 mL/hr, has
infused 950 mL since it was hung at 4:00 am. What is the priority nursing intervention?
A. Slow the rate to KVO until the next bag is due at noon.
B. Notify the healthcare provider and complete an incidence report.
C. Listen to the patient's lung sounds and assess respiratory status.
D. Assess the patient's cardiovascular status by checking pulse and blood pressure. - correct answer
✔✔C. Listen to the patient's lung sounds and assess respiratory status.
Which action is most important for the nurse to take when caring for a patient with a subclavian triple
lumen catheter?
A. Change the injection cap after the administration of IV medications.
B. Use a 5 mL syringe to flush the catheter between medications and after use.
C. During removal of the catheter, have the patient perform the Valsalva maneuver.
D. If resistance is met when flushing, use the push-pause technique to dislodge the clot. - correct answer
✔✔C. During removal of the catheter, have the patient perform the Valsalva maneuver.
The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an
air embolism. Injection caps should be changed at regular intervals but not routinely after medications.
Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If
resistance is encountered during flushing, force should not be applied. The push-pause method is
preferred for flushing catheters but not used if resistance is encountered during flushing.
Which nursing intervention is most appropriate when caring for a patient with dehydration?
A. Monitor skin turgor every shift.
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