Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess?
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Solution
Tented skin turgor and thirst
Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.
Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
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Solution
Positive Trousseau’s sign
In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.
Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake.
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Solution
2,470
The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.
Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?
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Solution
Encouraging slow, deep breaths
The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.
Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?
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Solution
Orange juice and bananas
The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.
A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?
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Solution
Administering I.V. and oral fluids
The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.
Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?
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Solution
Correct handwashing technique
Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.
Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?
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Solution
Attempting to rule out complications before administering pain medication
When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.
Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?
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Solution
Keeping the linens dry and wrinkle free
Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.
Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?
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Solution
Turn the client to the right side for 2 hours
Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.