Term
| A client with atrial fibrilation and a serum potassium level of 3.0 mEq/L takes Digoxin (Lanoxin) and Warfarin (Coumadin) daily. The client reports visual disturbances. Which medication places the client at greatest risk? |
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Definition
| Hypokalemia increase sensitivity tof the heart to digoxin. The client is complaining of visual disturbances which are characteristics of digoxin toxicity. |
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Term
| A client who ingests calcium 600 mg daily with vitamin D for an electrolyte imbalance is experiencing chronic constipation. What should the nurse include when instructing the client about the side effects of calcium? |
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Definition
| "Oral administraiotn of calcium can cause constipation". |
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Term
| A nurse is caring for a client whose sodium level is 118 mEq/L. Which nursing daignosis is a priority for this client? |
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Definition
| Risk for Injury. THe clients sodium level is critically low. The clinet might develop personality changes, lethargy, muscle twitching, trmeors and seizures. |
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Term
| A client with cancer is experiencing an electrolyte imbalance, which is manifested by muscle spasm and numbness in the left hand. The nurst determines that these signs/symptoms represent which electrolyte imbalance? |
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Definition
| Muscle spasms and numbness along with positive Trousseau's and chvostek's signs are characteristics of hypocalcemia. |
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Term
| An 80 year old client with a history of renal insufficiency is receiving intravenous fluids at 100 ml/hr. Which interventions should the nurst include in the plan of care. |
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Definition
1. Monitor oral and intravenous intake and output.
2. Monitor serum creatinine and electrolytes.
3. Assess breath and heart sounds |
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Term
| A client is receiving D5NS, which is infusing at 75 ml/hr to treat dehydration. Because of the nody's response to the infusion of this type of solution, what is the most appropriate nursing action? |
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Definition
| Monitor heart rate and quality at well as urinary output. |
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Term
| The oxygen saturation of a 72-year old client with dementia decreased from 97% to 89%. The client is receiving D5LR at 75 ml/hr. After auscultating crackles, the nurse should perform what? |
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Definition
| Perform a head to toe assessment to select and implement nursing interventions. |
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Term
| A client with intractable nausea and vomiting has a serum blood urea notrogen (BUN) of 46 mg/dl and a uring specific gravity of 1.031. The client's neck veins are flat, and the vital signs are BP 90/60, pulse 104m temp 98.4 and respirations 18. What is the most approprate nursing daignosis? |
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Definition
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Term
| The arterial blood gases (ABG's) of a client with tupe 1 daibetes mellitus include a H of 7.24, a CO2 of 52.6 mm Hg, and a HCO3 of 23.6 MEq/L. The urst monitors for which of the following signs/symptoms? |
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Definition
| Pale dry skin and sallow rapid respirations which would indicate respiratory acidosis. |
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Term
| A client receiving 2mg of bumetanide (Bumex) itravenously to treat congestive heart failure-indused fluid imbalance has a serum potassium of 3.1 mEq/L. The nurse should suspend the administration of which of the following medications? |
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Definition
| Because digoxin increases contractility, it is the drug of choice for the traetment of congestive heart failure, |
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Term
| A health care provider has instructed a client with a potassium level of 3.3 mEq/L to consume a high-potassium diet. What food choices shoudl the nurst include in the teaching plan for the client. |
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Definition
Cantaloupe
Bananas
Avocado
Orange Juice |
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Term
| A client with Alzheimer's disease has arterial blood gases that include pH 7.42, CO2 49 mm Hg, and HCO3 38 mEq/L. How should the nurse interprest the arterial blood gas results. |
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Definition
| Compensated metabolic alkalosis |
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Term
| The nurst teaches a client about the safety precautions associated with management of dehydration. Select all precautions that should be included in the teaching plan. |
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Definition
1. The ise of assistive devices to help corrdinate movement and balance.
2. Moving from one position to another in stages, to ensure safety |
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Term
| Which nursing diagnosis is most approprate for a client with hyperkalemia? |
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Definition
| Decreased cardiac putput, risk for r/t dysrhythmias. The patient with significant elevated potassium could develop fatal heart rhythms. |
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Term
| A serum calcium value greater than 10.0 mg/dL. |
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Definition
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Term
| A serum potassium greater than 5 mEq/L. |
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Definition
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Term
| A serum magnesium level in excess of 2.1 mEq/L. |
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Definition
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Term
| A serum sodium concentration in excess of 148 mEq/L. |
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Definition
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Term
| A serum phosphate level greater than 4.5 mg/dL |
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Definition
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Term
| Excess intravascular fluid |
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Definition
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Term
| A total serum calcium level less than 8.8 mg/dl. |
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Definition
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Term
| A serum potassium less than 3.5 mEq/L |
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Definition
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Term
| A magnesium level of less than 1.3 mEq/L |
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Definition
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Term
| A serum sodium level of less than 136 mEq/L |
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Definition
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Term
| A serum phosphorus level of less than 2.5 mg/dl |
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Definition
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Term
| Decreased circulating blood volume |
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Definition
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Term
| A deficit of bicarbonate in relation to the amount of acid in the body; may result from bicarbonate loss or excess acid production. |
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Definition
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Term
| An excess of bicarbonate in relation to the amount of acid in the body; may result from excess bicarbonate intake or loss of hydrogen ion. |
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Definition
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Term
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Definition
| Acidosis caused by excess dissolved carbon dioxide; characterized by a Paco2 greater than 45 mm Hg and serum pH less than 7.35 |
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Term
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Definition
| A carbon dioxide deficity characterized by a Paco2 below 35mm Hg, and pH greater than 7.45 |
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Term
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Definition
| The concetration ions in the blood, reflects the renal or metabolic regulation of acid-base balance. |
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Term
| Which of the following hospitalized clients would the nurse be most concerned is at risk for developing an |
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Definition
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Term
| While assisting a new client from a wheelchair to a bed in the emergency room, the client complains of being dizzy. Which intervention by the nurse would be the best in this situation: |
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Definition
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Term
| A client is brought to the emergency room following a motor vehicle accident. There is a moderate amount of blood loss. The physician has ordered 1000 ml of intravenous fluids to infuse over 4 hours. Which type of solution would be appropriate? Select all that apply. |
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Definition
0.9% sodium chloride
0.45% sodium chloride |
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Term
| While orienting a new nurse to work in the surgical intensive care unit, the charge nurse quizzes the new nurse as to which of the following postoperative clients would be at highest risk for problems related to excess fluids? Select all that apply. |
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Definition
Client with heart failure
Client with liver cirrhosis |
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Term
| The nurse is preparing to administer the discharge teaching instructions to a client with heart failure. Which measure will be included that the client will need to monitor on their own related to their recent hospitalization: _________________ . |
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Definition
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Term
| The nurse is evaluating the medication list of a newly-admitted client with hypokalemia. The client has been experiencing dysrhythmias and is on a cardiac monitor. Which medication from the list would alert the nurse to pursue a discussion with the physician? |
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Definition
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Term
| A client is admitted to the hospital for dehydration related to a gastrointestinal viral illness. The client is also on an alcohol withdrawal protocol. They complain of their lips and mouth feeling numb and tingling. When the nurse observes the lab results from the morning, which result would provide an insight into this client’s complaint: |
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Definition
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Term
| The client with a history of chronic obstructive pulmonary disease has 10 liters of oxygen per nasal cannula applied by the student nurse for complaints of shortness of breath. The nursing instructor reduces this to 2 liters after reading the student’s documentation. What is the rationale for this intervention? |
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Definition
| The client’s history prohibits the use of high levels of supplemental oxygen. |
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Term
| The ambulance arrives with a client who presents with Kussmaul’s respirations. The client has a history of diabetes. The nurse does a fingerstick blood sugar test immediately. The nurse is anticipating results that will lead to the diagnosis of which acid-base imbalance: |
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Definition
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Term
| Most common cause of fluid volume deficit is: |
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Definition
| Loss of GI fluids from vomiting,diarrhea,gastrointestinal suctioning , intestinal fistulas and intestinal drainage |
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Term
| What is fluid volume deficit? |
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Definition
| A decrease in intravascular, interstitial, and or intracellular fluid in the body. |
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Term
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Definition
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Term
Of the following which can be replaced immediately intravascularly?
Plasma, Urine, Synovial Fluid, perspiration |
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Definition
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Term
| Identify the primary process that controls body fluid movement between the intracellular fluid and extracellular fluid? |
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Definition
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Term
| A poor indicator of fluid volume deficit in the older adult is monitoring which of the following? |
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Definition
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Term
| Your client is dagnosed with a fluid volume deficit due to a severe brain injury. Which laboratory finding is incorrect? |
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Definition
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Term
| Your client is diagnosed to undergo a fluid challenge. The nurst knows to administer the chalange at what volume and rate? |
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Definition
| Initial IV fluid volume of 200mL to 300mL over 5-10 minutes |
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Term
Which of the following is not an appropriate nursing action when caring for a client with fluid volume excess?
Assess for lower extremity edema, provide oral care every 2 hours, teach about sodium resctricted diets, or obtain weights at various times throughout the day |
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Definition
| Obtain weights are various times throughout the day |
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Term
| What is an initial manifestation of hypernatremia? |
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Definition
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Term
| What is an early manifestation of hyperkalemia? |
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Definition
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Term
| A buffer prevents major changes in pH be releasing: |
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Definition
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Term
| Your client is experiencing meabolic acidosis. You will document their respirations as: |
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Definition
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Definition
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Definition
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Definition
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Definition
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Definition
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Term
| Mild, Moderate and Sever Hypokalemia |
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Definition
| (3.0-3.5) - (2.5-3.0) - (Less than 2.5) |
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