A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained.
Based
on the laboratory findings, which of the following conditions should the nurse expect?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ANS - D. CORRECT: Excessive vomiting causes a loss of gastric acids
and an accumulation of bicarbonate in
the blood, resulting in metabolic alkalosis.
\A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment,
the client
has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations
24/min, skin
cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a
high specific
gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that
apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - ANS - A. CORRECT: Decreased skin turgor is a clinical manifestation present
with fluid volume deficit. Skin
turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit.
The
urine is concentrated due to urinary output being decreased.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit.
Low-grade fever
is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the
body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.
\A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight
gain
of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a
temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via
nasal
, cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are
indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness - ANS - A. CORRECT: Dyspnea is a clinical manifestation present with fluid
volume excess. Dyspnea is due to
an excess of fluids within the body and lungs, and the client is struggling to breath to obtain
oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due
to the
excess of fluid within the body. Weight gain can be a result of edema.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood
pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness
is due
to the excess fluid that is retained, which depletes energy and increases the workload for the
body.
\A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the
nurse use
to perform this test?
A. Apply a blood pressure cuff to the client's arm.
B. Place the stethoscope bell over the client's carotid artery.
C. Tap lightly on the client's cheek.
D. Ask the client to lower his chin to his chest. - ANS - C. CORRECT: The nurse taps the client's
cheek over the facial nerve just below and anterior to the ear
to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching
on this side of his face.
\A nurse is assessing a client who has hyperkalemia. Which of the following conditions is
associated with
this electrolyte imbalance?
A. Diabetic ketoacidosis
B. Heart failure
C. Cushing's syndrome
D. Thyroidectomy - ANS - A. CORRECT: Hyperkalemia, an increase in serum potassium, is a
laboratory finding associated with
diabetic ketoacidosis.
\A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic
acidosis.
Which of the following is an expected finding? (Select all that apply.)
A. Tachycardia
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