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Ch 13 - Test bank questions with accurate/correct answers already graded A+ 2024/25 latest Medical Surgical 1 (Southeastern University)
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A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
Ans: D
Feedback:
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank pain
Ans: A
Feedback:
To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
Ans: D
Feedback:
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO 3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
Ans: C
Feedback:
Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70.
Ans: C
Feedback:
Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when selecting a site.
C) Have the patient briefly hold his arm over his head before insertion.
D) Leave the tourniquet on for at least 3 minutes.
Ans: B
Feedback:
Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport
Ans: B
Feedback:
The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O 2 and CO 2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.
A) Hypercalcemia
B) Metabolic acidosis
C) Metabolic alkalosis
D) Respiratory acidosis
Ans: C
Feedback:
Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status.
A) Leave one hand ungloved to assess the site.
B) Cleanse the skin with normal saline.
C) Ask the patient about allergies to latex or iodine.
D) Remove excessive hair from the selected site.
Ans: C
Feedback:
Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Metabolic acidosis
Ans: A
Feedback:
The pH is below 7.40, PaCO 2 is greater than 40, and the HCO 3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO 3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7. indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO 3 of 24 is within the normal range, ruling out metabolic acidosis.
A) Help distinguish hyponatremia from hypernatremia
B) Help evaluate pituitary gland function
C) Help distinguish reduced renal blood flow from decreased renal function
D) Help provide an effective treatment for hypertension-induced oliguria
Ans: C
Feedback:
If a patient is not excreting enough urine, the health care provider needs to determine whether the
D) The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Ans: D
Feedback:
Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.
A) Leave the hair intact.
B) Shave the area.
C) Clip the hair in the area.
D) Remove the hair with a depilatory.
Ans: C
Feedback:
Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.
A) Increased serum sodium
B) Decreased serum potassium
C) Decreased hemoglobin
D) Increased platelets
Ans: A
Feedback:
Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.
A) The patients calcium will rise dramatically due to pituitary stimulation.
B) Oxygen will increase the patients intracranial pressure and create confusion.
C) Oxygen may cause the patient to hyperventilate and become acidotic.
D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Ans: D
Feedback:
When PaCO 2 chronically exceeds 50 mm Hg, it creates insensitivity to CO 2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.
A) Diffusion
B) Osmosis
C) Active transport
D) Filtration
Ans: A
Ans: D
Feedback:
Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.
A) Substantially reduced renal function
B) Acute kidney injury
C) Decreased cardiac output
D) Alterations in ratio of body fluids to muscle mass
Ans: A
Feedback:
Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acidbase disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.
A) Extravasation of the medication
B) Discomfort to the patient
C) Blanching at the site
D) Hypersensitivity reaction to the medication
Ans: A
Feedback:
Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.
A) Diarrhea
B) Dilute urine
C) Increased muscle tone
D) Joint pain
Ans: B
Feedback:
Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.
A) Hypernatremia
B) Hypomagnesemia
C) Hypophosphatemia
D) Hypercalcemia
Ans: C
Feedback:
Respiratory acidosis is always due to inadequate excretion of CO 2 with inadequate ventilation, resulting in elevated plasma CO 2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO 2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barr syndrome. The other listed diagnoses are not associated with respiratory acidosis.
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Mixed acidbase disorder
Ans: D
Feedback:
Patients can simultaneously experience two or more independent acidbase disorders. A normal pH in the presence of changes in the PaCO 2 and plasma HCO 3 concentration immediately suggests a mixed disorder, making the other options incorrect.
A) Never, because it rapidly enters red blood cells, causing them to rupture.
B) When the patient is severely dehydrated resulting in neurologic signs and symptoms
C) When the patient is in excess of calcium and/or magnesium ions
D) When a patients fluid volume deficit is due to acute or chronic renal failure
Ans: A
Feedback:
IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte- free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture.
A) Decreased kidney mass
B) Increased conservation of sodium
C) Increased total body water
D) Decreased renal blood flow
E) Decreased excretion of potassium
Ans: A, D, E
Feedback:
Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.
A) Hypocalcemia
B) Hyponatremia
C) Hyperchloremia
D) Hypophosphatemia
Ans: C
Feedback:
break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.
A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate
Ans: B
Feedback:
The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.
A) Milk
B) Beef
C) Poultry
D) Green vegetables
E) Liver
Ans: A, C, E
Feedback:
If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.
A) Hypertension
B) Kussmaul respirations
C) Increased DTRs
D) Shallow respirations
Ans: D
Feedback:
If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.
A) Apples
B) Asparagus
C) Carrots
D) Bananas
Ans: D
Feedback:
Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.