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.)
Decreased skin turgor
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 nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?
Distended neck veins
Increased urinary output
A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client’s temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Initiate fluid restrictions to limit intake.
Observe for signs of hypertension.
Encourage the client to ambulate to promote oxygenation.
Monitor respirations for shortness of breath.
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings?
Three tap water enemas
0.9% sodium chloride solution IV at 50 mL/hr
5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
Administration of glucocorticoids
A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations?
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
A nurse is assessing a client for Chovstek’s sign. Which of the following techniques should the nurse use to perform this test?
Apply a blood pressure cuff to the client’s arm.
Place the stethoscope bell over the client’s carotid artery.
Tap lightly on the client’s cheek.
Ask the client to lower his chin to his chest.
A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance?
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?
pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 24 mEq/L
pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3 - 23 mEq/L
pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L
pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 29 mEq/L
A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?
pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3 - 24 mEq/L
pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3 - 23 mEq/L
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 nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective?
“Metabolic acidosis can occur due to diabetic ketoacidosis.”
“Metabolic acidosis can occur in a client who has myasthenia gravis.”
“Metabolic acidosis can occur in a client who has asthma.”
“Metabolic acidosis can occur due to cancer.”
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.)