Question

A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse suspect?

Answer 1

Correct Answers:

Respiratory acidosis

Rationale :

🔷 Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airflow obstruction and CO₂ retention.

🔷 Hypoventilation leads to CO₂ accumulation (hypercapnia), increasing carbonic acid levels and causing respiratory acidosis.

🔷 Arterial blood gas (ABG) values typically show ↓ pH (<7.35) and ↑ PaCO₂ (>45 mm Hg).

🔷 Dyspnea with minimal exertion indicates worsening gas exchange and CO₂ retention.

🔷 Chronic cases may also show renal compensation with increased HCO₃⁻, but the primary imbalance remains respiratory acidosis.

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Answer 2

Correct Answers:

Hypocalcemia

Rationale :

🔷 A positive Trousseau’s sign (carpal spasm when a blood pressure cuff is inflated) is a classic indicator of neuromuscular irritability caused by low calcium levels.

🔷 Bone pain is also associated with hypocalcemia because low serum calcium may result from bone demineralization or underlying bone disorders.

🔷 Hypocalcemia commonly presents with tetany, muscle cramps, paresthesias, and hyperreflexia due to increased neuromuscular excitability.

🔷 Electrolyte imbalances such as hyperkalemia or hyponatremia do not cause a positive Trousseau’s sign.

🔷 Early recognition and treatment of hypocalcemia are critical to prevent life-threatening complications like laryngeal spasm or cardiac arrhythmias.

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Answer 3

Correct Answers:

Educate client regarding high-potassium food sources.
Cardiac monitoring during infusion.
Repeat blood serum potassium.
Ensure that the client's urine output is at least 1 mL/kg/hour.

Rationale :

Educate client regarding high-potassium food sources

🟢 Client education promotes long-term potassium balance and helps prevent recurrent hypokalemia.

🟢 Foods rich in potassium (bananas, oranges, spinach, and potatoes) should be encouraged once oral intake is appropriate.

🟢 Teaching enhances self-care and dietary adherence after discharge.

Cardiac monitoring during infusion

🟢 Hypokalemia and rapid potassium replacement can lead to serious cardiac dysrhythmias.

🟢 Continuous ECG monitoring allows for early detection of arrhythmias or conduction disturbances.

🟢 Monitoring is especially critical when potassium levels are severely low (<3.0 mEq/L).

Repeat blood serum potassium

🟢 Frequent monitoring ensures safe correction of hypokalemia and helps prevent rebound hyperkalemia.

🟢 Serum potassium levels should be checked regularly, especially during IV replacement therapy.

🟢 Adjusting dosage depends on lab value trends and clinical response.

Ensure that the client's urine output is at least 1 mL/kg/hour

🟢 Adequate urine output confirms normal renal function, reducing the risk of potassium accumulation and hyperkalemia.

🟢 Potassium should never be administered to clients with renal failure or oliguria until renal function is verified.

🟢 This precaution prevents life-threatening hyperkalemia.

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Answer 4

Correct Answers:

Rales in lung fields
Dyspnea

Rationale :

Rales in lung fields

🟢 A BNP level of 1200 pg/mL is significantly elevated, indicating heart failure and fluid overload.

🟢 Excess fluid backs up into the pulmonary circulation, causing pulmonary congestion and crackles (rales) heard on auscultation.

🟢 Rales are a classic sign of left-sided heart failure due to pulmonary edema.

Dyspnea

🟢 Pulmonary congestion leads to impaired gas exchange, causing shortness of breath (dyspnea), especially on exertion or when lying flat (orthopnea).

🟢 Dyspnea is a key symptom of fluid overload and decreased cardiac output.

🟢 Elevated BNP correlates with the severity of heart failure symptoms, including dyspnea.

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Answer 5

Correct Answers:

Baked turkey and salad

Rationale :

🔷 After a myocardial infarction (MI), the recommended diet is heart-healthy, low in saturated fats, cholesterol, and sodium to reduce cardiovascular strain.

🔷 Baked turkey is a lean protein source, providing essential nutrients without excess unhealthy fats.

🔷 A fresh salad is rich in fiber, vitamins, and antioxidants, which promote cardiovascular health and help reduce cholesterol levels.

🔷 Fried, barbecued, or heavily processed foods (like ribs, sausage gravy, or fried fish) are high in saturated fats and sodium, which can worsen atherosclerosis and hypertension.

🔷 Adopting a heart-healthy diet is essential for secondary prevention of cardiac events.

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Answer 6

Correct Answers:

Vitamin K

Rationale :

🔷 Warfarin is an anticoagulant that works by inhibiting vitamin K–dependent clotting factors, which prolongs PT/INR.

🔷 An elevated PT/INR indicates an increased risk of bleeding, and Vitamin K is the specific antidote used to reverse warfarin’s effects.

🔷 Administering vitamin K promotes the synthesis of clotting factors, thereby reducing bleeding risk.

🔷 Protamine is used for heparin overdose, naloxone is an opioid antagonist, and disulfiram is used for alcohol dependence, making them inappropriate for warfarin reversal.

🔷 Careful monitoring of PT/INR levels is required after administration to prevent rebound clotting.

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Answer 7

Correct Answers:

Monitor platelet levels

Rationale :

🔷 Clients with DVT are commonly treated with anticoagulants such as heparin or low-molecular-weight heparin, which carry a risk of heparin-induced thrombocytopenia (HIT).

🔷 Monitoring platelet levels is crucial to detect this serious complication early and prevent further thrombotic events or bleeding risks.

🔷 Restricting fluids is inappropriate because maintaining adequate hydration helps prevent further clot formation.

🔷 Vasodilating medications are not standard treatment for DVT; anticoagulants are the primary therapy.

🔷 Ice application is avoided as it causes vasoconstriction, which can worsen venous stasis; instead, warm compresses and leg elevation are recommended.

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Answer 8

Correct Answers:

Plan to have potassium blood levels checked when taking a thiazide diuretics.

Rationale :

🔷 Thiazide diuretics can cause potassium loss (hypokalemia), so regular monitoring of serum potassium levels is essential.

🔷 Hypokalemia can lead to muscle weakness, arrhythmias, and worsening hypertension if not corrected.

🔷 Clients with hypertension should also follow other lifestyle modifications, such as reducing sodium to <2,300 mg/day, limiting alcohol (≤2 drinks/day for men and ≤1 for women), and achieving a goal weight close to ideal body weight, not 25% above it.

🔷 Proper medication and electrolyte monitoring help prevent complications from both hypertension and medication therapy.

🔷 Reinforcing this teaching promotes medication adherence and early detection of side effects.

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Answer 9

Correct Answers:

Respiratory acidosis

Rationale :

🔷 Low pH (7.22) → Indicates acidemia.

🔷 High PaCO₂ (68 mm Hg) → Indicates CO₂ retention, which is the primary cause of the acid-base imbalance.

🔷 Bicarbonate (HCO₃⁻ = 28 mEq/L) → Slightly elevated, suggesting renal compensation, which occurs in chronic or partially compensated respiratory acidosis.

🔷 Respiratory rate of 7/min → Hypoventilation leads to CO₂ accumulation (hypercapnia), consistent with respiratory acidosis.

🔷 Oxygen saturation (80%) and PaO₂ (78 mm Hg) → Indicate hypoxemia, which can further worsen CO₂ retention.

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Answer 10

Correct Answers:

Obtain a 12-lead ECG.

Rationale :

🔷 Spironolactone is a potassium-sparing diuretic, and a potassium level of 6.8 mEq/L indicates severe hyperkalemia, which is a medical emergency.

🔷 Hyperkalemia can cause life-threatening cardiac dysrhythmias such as ventricular fibrillation or asystole.

🔷 A 12-lead ECG is the immediate priority to detect ECG changes (peaked T waves, widened QRS complexes, prolonged PR interval) caused by high potassium.

🔷 After ECG evaluation, further treatments such as calcium gluconate, insulin with glucose, or sodium polystyrene sulfonate may be initiated.

🔷 Potassium administration or fluid restriction is contraindicated; hyperkalemia requires urgent management to prevent cardiac arrest.

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Custom~162 Unit V Mental Health Exam-PN

No.

1 :
A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse suspect?

2 :
A nurse is caring for a client who has a positive Trousseau's sign and bone pain. Which of the following electrolyte imbalances should the nurse suspect to find with this client?

3 :
A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select All that Apply.)

4 :
A nurse is caring for a client who has a serum brain natriuretic peptide (BNP) of 1200 pg/mL 100pg/mL). Which of the following findings should the nurse anticipate with this client? (Select all that apply.)

5 :
The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who is taking warfarin and has an elevated PT/INR. Which of the following medications should the nurse anticipate administering?

7 :
A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

10 :
A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

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Custom~162 Unit V Mental Health Exam-PN

No.

1 : A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse suspect?

2 : A nurse is caring for a client who has a positive Trousseau's sign and bone pain. Which of the following electrolyte imbalances should the nurse suspect to find with this client?

3 : A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select All that Apply.)

4 : A nurse is caring for a client who has a serum brain natriuretic peptide (BNP) of 1200 pg/mL 100pg/mL). Which of the following findings should the nurse anticipate with this client? (Select all that apply.)

5 : The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?

6 : A nurse is collecting data from a client who is taking warfarin and has an elevated PT/INR. Which of the following medications should the nurse anticipate administering?

7 : A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

8 : A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

10 : A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

1 :
A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse suspect?

2 :
A nurse is caring for a client who has a positive Trousseau's sign and bone pain. Which of the following electrolyte imbalances should the nurse suspect to find with this client?

3 :
A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select All that Apply.)

4 :
A nurse is caring for a client who has a serum brain natriuretic peptide (BNP) of 1200 pg/mL 100pg/mL). Which of the following findings should the nurse anticipate with this client? (Select all that apply.)

5 :
The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who is taking warfarin and has an elevated PT/INR. Which of the following medications should the nurse anticipate administering?

7 :
A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

10 :
A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?