Unit 4 Study Guide Rev Questions Edit PDF

A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the pa...

A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a\. Normal in the older adult b\. A need for the patient to be evaluated for cognitive impairment c\. A side effect of anti-hypertensive medication d\. Pathologic impairment of sensory responses ANS: D This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a\. "This will help us to identify your baby's risk for ear infections the first year of life." b\. "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." c\. "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." d\. "Imitation of sounds is the first step in language development, and it is important to identify alterations early." ANS: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby's response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response? a\. "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." b\. "Notify your doctor immediately, because this is a concerning reaction to the medication." c\. "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." d\. "You should see an improvement in the next week or so. Call if this continues." ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? a\. "I will make sure that Dad always wears warm socks." b\. "Dad needs to wear his glasses so he can delay the onset of macular degeneration." c\. "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." d\. "We will give him only warm foods, so that he doesn't burn his mouth." ANS: C Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one's own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase? a\. Place the television to the left or right of patient's visual field. b\. Encourage the patient to learn braille. c\. Suggest use of talking books. d\. Provide headphones for listening to music. ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action? a\. Notify the physician. b\. Document the finding in the records. c\. Recheck the reflex after several hours. d\. Monitor the eye movements and pupil reactions closely. ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a\. "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." b\. "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." c\. "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" d\. "I see now why when my child has a cold, he complains about everything tasting blah!" ANS: B Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a\. Tympanoplasty b\. Irrigation of the ear c\. Pure tone test d\. Otoscopic exam by a specialist ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present. Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a\. Use of oral opioids for pain control b\. Administration of corticosteroid drops c\. Importance of coughing and deep breathing exercises d\. Need for bed rest for the first 1 to 2 days after the surgery ANS: B Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery. In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a\. visual acuity. c\. color perception. b\. pupil reaction. d\. peripheral vision. ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma. A 72-yr-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a\. "I will use drops to keep my pupils dilated until my appointment." b\. "I will need to use brighter lights to read for at least the next week." c\. "I will not use facial lotions near my eyes during the recovery period." d\. "I will cover up with long-sleeved shirts and pants for the next 5 days." ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a\. questioning the patient about blurred vision. b\. noting any changes in the patient's visual field. c\. asking the patient to rate the pain using a 0 to 10 scale. d\. assessing the patient's depth perception when climbing stairs. ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a\. "Those symptoms may indicate a need for a change in dosage of the eye drops." b\. "The drops are uncomfortable, but it is important to use them to retain your vision." c\. "These are normal side effects of the drug, which should be less noticeable with time.\" d\. "Notify your health care provider so that different eye drops can be prescribed for you." ANS: B Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change. The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medication should the nurse question? a\. Morphine sulfate 4 mg IV b\. Diazepam (Valium) 5 mg IV c\. Betaxolol (Betoptic) 0.25% eyedrops d\. Scopolamine patch (Transderm Scop) 1.5 mg ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate at this time? a\. Grieving related to current loss of functional vision b\. Ineffective health management related to inability to see c\. Anxiety related to the possibility of permanent vision loss d\. Situational low self-esteem related to loss of visual function ANS: C The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time. To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? a\. Perform tympanometry. b\. Schedule otoscopic examinations. c\. Administer influenza immunizations. d\. Discuss exposure to amplified music. ANS: D The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients. A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a\. "I will apply the eardrops to the cotton wick in the ear canal." b\. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c\. "I will clean the ear canal daily with a cotton-tipped applicator." d\. "I can use warm compresses to the outside of the ear for comfort." ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful. The nurse will instruct a patient who has undergone a left tympanoplasty to a\. remain on bed rest. c\. avoid blowing the nose. b\. keep the head elevated. d\. irrigate the left ear canal. ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation. The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a\. The patient has a temperature of 100.6° F. b\. The patient complains of "popping" in the ear. c\. Clear fluid is visible through the tympanic membrane. d\. The patient frequently asks the nurse to repeat information. ANS: A The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment. 20\. A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a\. Dim the lights in the patient's room. b\. Encourage increased oral fluid intake. c\. Change the patient's position every 2 hours. d\. Keep the head of the bed elevated 45 degrees. ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort. Which statement by the patient to the home health nurse indicates a need for more teaching about selfadministering eardrops? a\. "I will leave the ear wick in place while administering the drops." b\. "I will hold the tip of the dropper above the ear to administer the drops." c\. "I will refrigerate the medication until I am ready to administer the drops." d\. "I should lie down before and for 5 minutes after administering the drops." ANS: C Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate. An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a\. Increase the speaking volume. b\. Overenunciate while speaking. c\. Speak normally but more slowly. d\. Use more facial expressions when talking. ANS: C Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend. A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a\. Keep the volume low on the hearing aids for the first week. b\. Experiment with volume and hearing in a quiet environment. c\. Add the second hearing aid after making adjustments to the first hearing aid. d\. Begin wearing the hearing aids for an hour a day, gradually increasing the use. ANS: B Initially the patient should use the hearing aids in a quiet environment such as the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used. Which information will the nurse include for a patient contemplating a cochlear implant? a\. Cochlear implants are not useful for patients with congenital deafness. b\. Cochlear implants are most helpful as an early intervention for presbycusis. c\. Cochlear implants improve hearing in patients with conductive hearing loss. d\. Cochlear implants require extensive training in order to reach the full benefit. ANS: D Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness. Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a\. "I will wash my hands often during the day." b\. "I will remove my contact lenses at bedtime." c\. "I will not share towels with my friends or family." d\. "I will monitor my family for eye redness or drainage." ANS: B Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact. Which information will the nurse include when teaching a patient with herpes simplex type 1 keratitis? a\. Use of natamycin (Natacyn) antifungal eyedrops b\. Application of corticosteroid ophthalmic ointment c\. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d\. Completion of the prescribed series of oral acyclovir (Zovirax) ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex type 1 is viral, not parasitic or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis. The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider at this time? a\. The patient has had blurred vision for 3 years. b\. The patient has not eaten anything for 8 hours. c\. The patient takes 2 antihypertensive medications. d\. The patient gets nauseated with general anesthesia. ANS: C Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia. During the preoperative assessment of a patient scheduled for a right cataract extraction and intraocular lens implantation, it is important for the nurse to assess a\. the visual acuity of the patient's left eye. b\. how long the patient has had the cataract. c\. for presence of a white pupil in the right eye. d\. for a history of reactions to general anesthetics. ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics. Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? a\. UAP raise the side rails on the bed. b\. UAP turn on the patient's television. c\. UAP place an emesis basin at the bedside. d\. UAP helps the patient turn to the right side. ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack. The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a\. The patient requests a prescription refill for next week. b\. The patient feels uncomfortable wearing an eye patch. c\. The patient complains that the vision has not improved. d\. The patient reports eye pain rated 5 (on a 0 to 10 scale). ANS: D Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring. The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a\. The nurse leaves the eye shield in place. b\. The nurse encourages the patient to cough. c\. The nurse elevates the patient's head to 45 degrees. d\. The nurse applies corticosteroid drops to the right eye. ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery. Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a\. Instilling antiviral drops for a patient with a corneal ulcer b\. Application of a warm compress to a patient's hordeolum c\. Instruction about hand washing for a patient with herpes keratitis d\. Looking for eye irritation in a patient with possible conjunctivitis ANS: B Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN. A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a\. Assess cranial nerve functions. b\. Administer the prescribed analgesic. c\. Check the patient's oxygen saturation. d\. Examine the eye for evidence of trauma. ANS: C The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take. Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a\. Morphine sulfate 4 mg IV b\. Mannitol (Osmitrol) 100 mg IV c\. Betaxolol (Betoptic) 1 drop in each eye d\. Acetazolamide (Diamox) 250 mg orally ANS: B The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered. 39\. The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a\. risk for falls related to episodic dizziness. b\. impaired verbal communication related to tinnitus. c\. self-care deficit (bathing and dressing) related to vertigo. d\. imbalanced nutrition: less than body requirements related to nausea. ANS: A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness. 40\. Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a\. Oral temperature is 100.8° F (38.1° C). b\. The patient complains of ear "fullness." c\. Small amount of dried drainage on dressing. d\. The patient reports that hearing has gotten worse. ANS: A An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery 41\. A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a\. Discuss the increased risk for falls that is associated with impaired vision. b\. Ask the patient about what type of vision problems are being experienced. c\. Explain that there are many ways to compensate for decreases in visual acuity. d\. Suggest ways of improving the patient's safety, such as using brighter lighting. ANS: B The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment. 43\. Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a\. Assist the patient to a supine position for the irrigation. b\. Fill the irrigation syringe with body-temperature solution. c\. Use a sterile applicator to clean the ear canal before irrigating. d\. Occlude the ear canal completely with the syringe while irrigating. ANS: B Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cottontipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a\. Teach the patient about use of medications to reduce symptoms. b\. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c\. Teach the patient that canalith repositioning may be used to reduce dizziness. d\. Speak with a low-pitched voice so that the patient is able to hear instructions. ANS: C The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Ménière's disease, but are not necessary for BPPV. There is no hearing loss with BPPV. When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a\. applying sunscreen. c\. decreasing dietary sodium. b\. preventing fall injuries. d\. chemotherapy side effects. ANS: B Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy. Distortion of sound and problems in discrimination are characteristic of which type of hearing loss? a\. Conductive c\. Mixed conductive-sensorineural b\. Sensorineural d\. Central auditory imperceptive ANS: B Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or the auditory nerve. It results in distortion of sounds and problems in discrimination. Conductive hearing loss involves mainly interference with loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination of both sensorineural and conductive loss. The central auditory imperceptive category includes all hearing losses that do not demonstrate defects in the conduction or sensory structures. The most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called: a\. Conductive. c\. Mixed conductive-sensorineural. b\. Sensorineural. d\. Central auditory imperceptive. ANS: A Conductive or middle-ear hearing loss is the most common type. It results from interference of transmission of sound to the middle ear, most often from recurrent otitis media. Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less common types of hearing loss. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. The most appropriate nursing action is to: a\. Ignore the sound. b\. Ask him to reverse the hearing aids in his ears. c\. Suggest that he reinsert the hearing aid. d\. Suggest that he raise the volume of the hearing aid. ANS: C The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure that no hair is caught between the ear mold and the ear canal. Ignoring the sound and suggesting that he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear. An implanted ear prosthesis for children with sensorineural hearing loss is a(n): a\. Hearing aid. c\. Auditory implant. b\. Cochlear implant. d\. Amplification device. ANS: B Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids are external devices for enhancing hearing. An auditory implant does not exist. An amplification device is an external device for enhancing hearing. A nurse is preparing a teaching session for parents on prevention of childhood hearing loss. The nurse should include that the most common cause of hearing impairment in children is: a\. Auditory nerve damage. c\. Congenital rubella. b\. Congenital ear defects. d\. Chronic otitis media. ANS: D Chronic otitis media is the most common cause of hearing impairment in children. It is essential that appropriate measures be instituted to treat existing infections and prevent recurrences. Auditory nerve damage, congenital ear defects, and congenital rubella are rarer causes of hearing impairment. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a\. "The patient is angry about the dementia diagnosis." b\. "The patient is losing sphincter control due to the dementia." c\. "The patient forgets where the bathroom is located due to the dementia." d\. "The patient wants to leave the hospital." ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient\'s elimination status. What is the nurse's best action? a\. Speak with the patient\'s family about food choices. b\. Establish a bowel and bladder program for the patient. c\. Speak with the patient about past elimination habits. d\. Establish a bedtime ritual for the patient. ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a\. Large intestine b\. Stomach c\. Small intestine d\. Pancreas ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a\. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." b\. "Some people have a slower bowel than others, and this is nothing to be concerned about." c\. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." d\. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day." ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel. What is a primary prevention tool used for colon cancer screening? a\. Abdominal x-rays b\. Blood, urea, and nitrogen (BUN) testing c\. Serum electrolytes d\. Occult blood testing ANS: D Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a\. Increase fiber intake. b\. Increase water consumption. c\. Decrease physical exercise. d\. Refrain from alcohol. e. Refrain from smoking. ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements. When conducting a health history assessment, the nurse would want to know what most important information about the patient\'s elimination status? (Select all that apply.) a\. Recent changes in elimination patterns b\. Changes in color, consistency, or odor of stool or urine c\. Time of day patient defecates d\. Discomfort or pain with elimination e\. List of medications taken by patient f. Patient\'s preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect. A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a\. Poor skin turgor c\. Elevated urine ketones b\. Recent weight gain d\. Decreased blood pressure ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome. A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a\. Give ketorolac 10 mg PO PRN for pain. b\. Infuse 5% dextrose in normal saline at 75 mL/hr. c\. Order regular diet after patient is awake and alert. d\. Draw blood urea nitrogen (BUN) and creatinine in 2 hours. ANS: A The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change. A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a\. Urinary urgency c\. Intermittent hematuria b\. Left-sided flank pain d\. Burning with urination ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection. A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)? a\. Milk b\. Liver c\. Spinach d\. Chicken e\. Cabbage f\. Chocolate ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a\. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b\. Furosemide (Lasix) 20 mg PO now c\. Oxygen via face mask at 8 L/min d\. KCl 20 mEq PO two times per day ANS: A A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess. The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician? a\. Swollen ankles in patient with compensated heart failure b\. Positive Chvostek's sign in patient with acute pancreatitis c\. Dry mucous membranes in patient taking a new diuretic d\. Constipation in patient who has advanced breast cancer ANS: B Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign. The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a\. Weight gain of 2 pounds since last week b\. Dry mucous membranes and skin tenting c\. Urine output 8 mL/hr d\. Blood pressure 98/58 ANS: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a\. Vomiting all day and not replacing any fluid b\. Tumor that secretes excessive antidiuretic hormone (ADH) c\. Tumor that secretes excessive aldosterone d\. Tumor that destroyed the posterior pituitary gland ANS: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a\. Development of ankle or sacral edema b\. Increased skin tenting and dry mouth c\. Postural hypotension and tachycardia d\. Decreased level of consciousness ANS: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit. 6\. The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a\. Severe hemorrhage b\. Diabetes insipidus c\. Oliguric renal disease d\. Adrenal insufficiency ANS: C When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake. The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a\. Raise bed side rails due to potential decreased level of consciousness and confusion. b\. Examine sacral area and patient's heels for skin breakdown due to potential edema. c\. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d\. Institute fall precautions due to potential postural hypotension and weak leg muscles. ANS: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a\. Bilateral ankle edema b\. Weaker leg muscles than usual c\. Postural blood pressure and heart rate d\. Positive Trousseau's sign e\. Flat neck veins when upright f\. Decreased patellar reflexes ANS: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a\. Test for skin tenting. b\. Measure rate and character of pulse. c\. Measure postural blood pressure and heart rate. d\. Check Trousseau's sign. e\. Observe for flatness of neck veins when upright. f\. Observe for flatness of neck veins when supine. ANS: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a\. Urine output is 30 mL/hr. b\. Blood pressure is 90/40 mm Hg. c\. Oral fluid intake is 100 mL for the past 8 hours. d\. There is prolonged skin tenting over the sternum. ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a\. Serum hematocrit of 42% b\. Serum sodium level of 120 mg/dL c\. Reported weight gain of 2.2 lb (1 kg) d\. Urinary output of 280 mL during past 8 hours ANS: B Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a\. Skin turgor c\. Urine output b\. Daily weight d\. Edema presence ANS: B Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? a\. "Drink more fluids in the late evening." b\. "Increase fluids if your mouth feels dry." c\. "More fluids are needed if you feel thirsty." d\. "If you feel confused, you need more to drink." ANS: B An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? a\. Assess for facial muscle spasms. b\. Ask the patient about loose stools. c\. Recommend the patient avoid drinking orange juice with meals. d\. Suggest that the health care provider order a basic metabolic panel. ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a\. "I will try to drink at least 8 glasses of water every day." b\. "I will use a salt substitute to decrease my sodium intake." c\. "I will increase my intake of potassium-containing foods." d\. "I will drink apple juice instead of orange juice for breakfast." ANS: D Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium. A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action? a\. Assign the patient to a semi-private room. b\. Assign the patient to a room near the nurse's station. c\. Place the patient in a room nearest to the water fountain. d\. Place the patient on telemetry to monitor for peaked T waves.. ANS: B The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a\. Administer the KCl as a rapid IV bolus. b\. Infuse the KCl at a rate of 10 mEq/hour. c\. Only give the KCl through a central venous line. d\. Discontinue cardiac monitoring during the infusion. ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a\. Infuse 5% dextrose in water at 125 mL/hr. b\. Administer 3% saline at 50 mL/hr for a total of 200 mL. c\. Administer IV morphine sulfate 4 mg every 2 hours PRN. d\. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. ANS: A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a\. Metabolic acidosis c\. Respiratory acidosis b\. Metabolic alkalosis d\. Respiratory alkalosis ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3 An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a\. Pallor c\. Confusion b\. Edema d\. Restlessness ANS: B The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a\. Lung sounds c\. Peripheral pulses b\. Urinary output d\. Peripheral edema ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a\. Hematocrit 28% c\. Decreased peripheral edema b\. Absence of skin tenting d\. Blood pressure 110/72 mm Hg ANS: C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a\. Metabolic acidosis c\. Respiratory acidosis b\. Metabolic alkalosis d\. Respiratory alkalosis ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a\. Digoxin (Lanoxin) 0.25 mg/day b\. Metoprolol (Lopressor) 12.5 mg/day c\. Ibuprofen (Motrin) 400 mg every 6 hours d\. Lantus insulin 24 U subcutaneously every evening ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a\. Maintain the patient on bed rest. b\. Auscultate lung sounds every 4 hours. c\. Monitor for Trousseau's and Chvostek's signs. d\. Encourage fluid intake up to 4000 mL every day. ANS: D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate? a\. "The prescribed infusion can be given more rapidly when the patient has a central line." b\. "The hypertonic solution will be more rapidly diluted when given through a central line." c\. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d\. "The required blood glucose monitoring is based on samples obtained from a central line." ANS: B The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a\. K+ 3.4 mEq/L (3.4 mmol/L) c\. Na+ 154 mEq/L (154 mmol/L) b\. Ca+2 7.8 mg/dL (1.95 mmol/L) d\. PO4-3 4.8 mg/dL (1.55 mmol/L) ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a\. Oral temperature of 100.1°F b\. Serum sodium level of 138 mEq/L (138 mmol/L) c\. Gradually decreasing level of consciousness (LOC) d\. Weight gain of 2 pounds (1 kg) over the admission weight ANS: C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a\. Skin turgor c\. Mental status b\. Heart sounds d\. Capillary refill ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a\. Arterial blood pH is 7.32. b\. Serum calcium is 18 mg/dL. c\. Serum potassium is 5.1 mEq/L. d\. Arterial oxygen saturation is 91%. ANS: B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening. A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first? a\. Obtain the baseline weight. b\. Check the patient's blood pressure. c\. Draw blood for serum electrolyte levels. d\. Ask about extremity numbness or tingling. ANS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status. Nurses must be alert for increased fluid requirements when a child has: a\. Fever. c\. Congestive heart failure. b\. Mechanical ventilation. d\. Increased intracranial pressure (ICP). ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children. Which type of dehydration results from water loss in excess of electrolyte loss? a\. Isotonic dehydration c\. Hypotonic dehydration b\. Isosmotic dehydration d\. Hypertonic dehydration ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of: a\. Overhydration. c\. Sodium excess. b\. Dehydration. d\. Calcium excess. ANS: B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching. Acute diarrhea is often caused by: a\. Hirschsprung's disease. c\. Hypothyroidism. b\. Antibiotic therapy. d\. Meconium ileus. ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprung's disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea A child has a nasogastric (NG) tube to continuous low intermittent suction. The physician's prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the previous 4 hours totaled 50 mL. What milliliter/hour rate should the nurse administer to replace with a normal saline piggyback? \_\_\_\_\_ Record your answer as a whole number. ANS: 25