NURS 320 Exam 1 - Questions, Answers and Rationales

NURS 320 Exam 1 - Questions, Answers and Rationales On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his we ...

NURS 320 Exam 1 - Questions, Answers and Rationales On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect? A)Third spacing B)This is normal and expected after a burn and it is benign C)Document this finding as non-pitting abdominal edema D)Intravascular compartment syndrome You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values. Which patient is at more risk for an electrolyte imbalance? A)An 8 month old with a fever of 102.3 'F and diarrhea B)A 55 year old diabetic with nausea and vomiting C)A 5 year old with RSV D)A healthy 87 year old with intermittent episodes of gout The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance. A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient? A)Restrict fluid intake and monitor daily weights B)Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output C)Administer hypotonic IV fluid and administer sodium tablets. D)No interventions are expected The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells. After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A)Potassium level of 2.2 B)Potassium level of 5.6 C)Magnesium level of 2.3 D)Phoshorus level of 2.0 Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings. Which patient below would have a potassium level of 5.5? A)A 76 year old who reports taking lasix four times a day B)A patient with Addison's disease C)A 55 year old woman who have been vomiting for 3 days consistently D)A patient with liver failure A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease. You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true? A)This is known as Trousseau's Sign and is present in patients with hypocalemia B)This is known as Trousseau's Sign and is present in patients with HYPERcalemia C)This is known as Chvostek's Sign D)The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure The correct answer is "this is known as Trousseau's Sign and is present in patients with hypocalemia". Patient's with hypokalemia may present with a positive Trousseau's and Chvostek sign. Which patient is at most risk for hypomagnesemia? A)A 55 year old chronic alcoholic B)A 57 year old with hyperthroidism C)A patient reporting overuse of anatacids and laxatives D)A 25 year old suffering from hypoglycemia The correct answer is a 55 year old who is a chronic alcoholic. Patients who suffer from alcoholism have an increased secretion of magnesium and usually do not eat a proper diet, therefore, they are at risk for lower magnesium levels. In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority? A)Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions B)Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate C)Set-up bedside suction D)None of the above are correct As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level. Which patient is at most risk for fluid volume deficient? A)A patient who has been vomiting and having diarrhea for 2 days. B)A patient with continous nasogastric suction. C)A patient with an abdominal wound vac at intermittent suction. D)All of the above are correct. As the nursing administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level. A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment? A)Flat neck and hand veins B)Furrowed dry tongue C)Increased blood pressure and crackles throughout the lungs D)Bradycardia and pitting edema in lower extremities The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia. A patient has a potassium level of 9.0. Which nursing intervention is priority? A. Prepare the patient for dialysis and place the patient on a cardiac monitor B. Administer Spironolactone C. Place patient on a potassium restrictive diet D. Administer a laxative Which of the following is not a symptom of hyperkalemia? A. Positive Chvostek's sign B. Decreased blood pressure C. Muscle twitches/cramps D. Weak and slow heart rate Tall peaked T-waves, flat P-waves, prolonged PR intervals and widened QRS complexes can present in which of the following conditions? A. Hypocalemia B. Hypercalemia C. Hypokalemia D. Hyperkalemia Which patient is at risk for hyperkalemia? A. Patient with Parathyroid cancer B. Patient with Cushing's Syndrome C. Patient with Addison's Disease D. Patient with breast cancer A patient's potassium level is 3.0. Which foods would you encourage the patient to consume? A. Cheese, collard greens, and fish B. Avocados, strawberries, and potatoes C. Tofu, oatmeal, and peas D. Peanuts, bread, and corn A patient with nasogastric suctioning is experiencing diarrhea. The patient is ordered a morning dose of Lasix 20mg IV. Patient's potassium level is 3.0. What is your next nursing intervention? A. Hold the dose of Lasix and notify the doctor for further orders B. Administered the Lasix and notify the doctor for further orders C. Turn off the nasogastric suctioning and administered a laxative D. No intervention is need the potassium level is within normal range A patient is presenting with an orthostatic blood pressure of 80/40 when she stands up, thready and weak pulse of 58, and shallow respirations. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? A. Potassium level of 7.0 B. Potassium level of 3.5 C. Potassium level of 2.4 D. None of the options are correct Which patient is at a potential risk for Digoxin toxicity? A. A patient with Cushing's syndrome taking Laxis 20 mg IV twice a day B. A patient with a calcium level of 8.9 C. A patient with a potassium level of 3.8 D. A patient presenting with painful muscle spasms and positive Trousseau's sign Which of the following is indicative of an EKG change in a case of hypokalemia? A. Widened QRS complex and prolonged PR interval B. Prolonged ST interval and Widened T-wave C. Tall T-waves and depressed ST segment D. ST depression and inverted T-wave A patient has a potassium level of 2.0. What would you expect to be ordered for this patient? A. Potassium 30 meq IV push B. Infusion of Potassium intravenously C. An oral supplement of potassium D. Intramuscular injection of Potassium A patient with a potassium level of 2.1 has been taking Lasix daily. What medication will the patient most likely be switched to? A. Spironolactone B. None the patient will likely stay on the Lasix C. Hydrochlorothiazide D. Demadex Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?