Chapter 24 My Nursing Test Banks

 

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/E
Chapter 24

Question 1

Type: MCMA

The nurse practitioner conducts education for home-health nurses who care for geriatric patients. Many of the patients abuse laxatives, so the nurse practitioner focuses the education on problems that can be caused by chronic laxative use. The nurse practitioner evaluates that learning has occurred when the nurses make which statement(s)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The kidneys and GI tract keep electrolytes in narrow balance, where they must be.

2. Electrolytes carry electricity in the body and must stay in balance.

3. The electrolytes can be replaced by eating the right foods.

4. The most important electrolytes are sodium, potassium, and magnesium.

5. Laxatives can lower the level of potassium, necessary for proper heart function.

Correct Answer: 1,2,3,5

Rationale 1: Small, inorganic molecules possessing a positive or negative charge are called electrolytes. These ions are able to conduct electricity. Chronic use of laxatives can result in fluid imbalance and hypokalemia. Cardiac arrest is a possible consequence of hypokalemia. Levels of electrolytes in body fluids are maintained within very narrow ranges, primarily by the kidneys and GI tract. As electrolytes are lost due to normal excretory functions, they must be replaced by adequate intake, otherwise electrolyte imbalances will result. The most important electrolytes are sodium, potassium, and calcium, not magnesium.

Rationale 2: Small, inorganic molecules possessing a positive or negative charge are called electrolytes. These ions are able to conduct electricity. Chronic use of laxatives can result in fluid imbalance and hypokalemia. Cardiac arrest is a possible consequence of hypokalemia. Levels of electrolytes in body fluids are maintained within very narrow ranges, primarily by the kidneys and GI tract. As electrolytes are lost due to normal excretory functions, they must be replaced by adequate intake, otherwise electrolyte imbalances will result. The most important electrolytes are sodium, potassium, and calcium, not magnesium.

Rationale 3: Small, inorganic molecules possessing a positive or negative charge are called electrolytes. These ions are able to conduct electricity. Chronic use of laxatives can result in fluid imbalance and hypokalemia. Cardiac arrest is a possible consequence of hypokalemia. Levels of electrolytes in body fluids are maintained within very narrow ranges, primarily by the kidneys and GI tract. As electrolytes are lost due to normal excretory functions, they must be replaced by adequate intake, otherwise electrolyte imbalances will result. The most important electrolytes are sodium, potassium, and calcium, not magnesium.

Rationale 4: Small, inorganic molecules possessing a positive or negative charge are called electrolytes. These ions are able to conduct electricity. Chronic use of laxatives can result in fluid imbalance and hypokalemia. Cardiac arrest is a possible consequence of hypokalemia. Levels of electrolytes in body fluids are maintained within very narrow ranges, primarily by the kidneys and GI tract. As electrolytes are lost due to normal excretory functions, they must be replaced by adequate intake, otherwise electrolyte imbalances will result. The most important electrolytes are sodium, potassium, and calcium, not magnesium.

Rationale 5: Small, inorganic molecules possessing a positive or negative charge are called electrolytes. These ions are able to conduct electricity. Chronic use of laxatives can result in fluid imbalance and hypokalemia. Cardiac arrest is a possible consequence of hypokalemia. Levels of electrolytes in body fluids are maintained within very narrow ranges, primarily by the kidneys and GI tract. As electrolytes are lost due to normal excretory functions, they must be replaced by adequate intake, otherwise electrolyte imbalances will result. The most important electrolytes are sodium, potassium, and calcium, not magnesium.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-4

Question 2

Type: MCSA

The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses cyanosis, slow respirations, and irregular pulse. What is the nurses priority action?

1. Increase the rate of the infusion and continue to assess the patient for symptoms of acidosis.

2. Decrease the rate of the infusion and continue to assess the patient for symptoms of alkalosis.

3. Continue the infusion; the patient is still in acidosis.

4. Stop the infusion and notify the physician; the patient is in alkalosis.

Correct Answer: 4

Rationale 1: The patient receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The patients symptoms indicate alkalosis so infusion must be stopped and the physician notified. The patient is not in acidosis, symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid. The patient is not in acidosis, so the infusion must be stopped, not increased. The infusion must be stopped, not decreased, as the patient is in alkalosis.

Rationale 2: The patient receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The patients symptoms indicate alkalosis so infusion must be stopped and the physician notified. The patient is not in acidosis, symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid. The patient is not in acidosis, so the infusion must be stopped, not increased. The infusion must be stopped, not decreased, as the patient is in alkalosis.

Rationale 3: The patient receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The patients symptoms indicate alkalosis so infusion must be stopped and the physician notified. The patient is not in acidosis, symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid. The patient is not in acidosis, so the infusion must be stopped, not increased. The infusion must be stopped, not decreased, as the patient is in alkalosis.

Rationale 4: The patient receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The patients symptoms indicate alkalosis so infusion must be stopped and the physician notified. The patient is not in acidosis, symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid. The patient is not in acidosis, so the infusion must be stopped, not increased. The infusion must be stopped, not decreased, as the patient is in alkalosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-6

Question 3

Type: MCMA

The nurse cares for a patient in the critical care setting who was severely burned. The wife of the patient asks the nurse, Why does he need those intravenous infusions (IVs)? What is (are) the best response(s) by the nurse that indicates the primary reason for intravenous infusions (IVs) with a burned patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. So we have an open line for resuscitation in case his heart stops.

2. So he can receive his antibiotics.

3. So we can keep his blood pressure stable.

4. So we can be sure he keeps enough blood volume.

5. So we can rapidly administer his pain medications.

Correct Answer: 3,4

Rationale 1: Net loss of fluids from the body can result in dehydration and shock. Intravenous (IV) fluid therapy is used to maintain blood volume and support blood pressure. Antibiotic therapy is not a primary reason for intravenous (IV) fluid replacement. Cardiac resuscitation is not a primary reason for intravenous (IV) fluid replacement. Administration of analgesics is not a primary reason for intravenous (IV) fluid replacement.

Rationale 2: Net loss of fluids from the body can result in dehydration and shock. Intravenous (IV) fluid therapy is used to maintain blood volume and support blood pressure. Antibiotic therapy is not a primary reason for intravenous (IV) fluid replacement. Cardiac resuscitation is not a primary reason for intravenous (IV) fluid replacement. Administration of analgesics is not a primary reason for intravenous (IV) fluid replacement.

Rationale 3: Net loss of fluids from the body can result in dehydration and shock. Intravenous (IV) fluid therapy is used to maintain blood volume and support blood pressure. Antibiotic therapy is not a primary reason for intravenous (IV) fluid replacement. Cardiac resuscitation is not a primary reason for intravenous (IV) fluid replacement. Administration of analgesics is not a primary reason for intravenous (IV) fluid replacement.

Rationale 4: Net loss of fluids from the body can result in dehydration and shock. Intravenous (IV) fluid therapy is used to maintain blood volume and support blood pressure. Antibiotic therapy is not a primary reason for intravenous (IV) fluid replacement. Cardiac resuscitation is not a primary reason for intravenous (IV) fluid replacement. Administration of analgesics is not a primary reason for intravenous (IV) fluid replacement.

Rationale 5: Net loss of fluids from the body can result in dehydration and shock. Intravenous (IV) fluid therapy is used to maintain blood volume and support blood pressure. Antibiotic therapy is not a primary reason for intravenous (IV) fluid replacement. Cardiac resuscitation is not a primary reason for intravenous (IV) fluid replacement. Administration of analgesics is not a primary reason for intravenous (IV) fluid replacement.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

Question 4

Type: MCSA

The physician orders a hypertonic crystalloid solution for the patient in critical care who has cerebral edema. The nurse hangs a bag of a hypotonic solution. What will the priority assessment by the nurse include?

1. Headache, irritability, and decreasing level of consciousness

2. Nausea, projectile vomiting, and pinpoint pupils

3. Confusion, hallucinations, and agitation

4. Hypertension, headache, and nausea

Correct Answer: 1

Rationale 1: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema. Confusion, hallucinations, and agitation are not classical signs of cerebral edema. Hypertension and nausea are not classical signs of cerebral edema. Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.

Rationale 2: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema. Confusion, hallucinations, and agitation are not classical signs of cerebral edema. Hypertension and nausea are not classical signs of cerebral edema. Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.

Rationale 3: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema. Confusion, hallucinations, and agitation are not classical signs of cerebral edema. Hypertension and nausea are not classical signs of cerebral edema. Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.

Rationale 4: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema. Confusion, hallucinations, and agitation are not classical signs of cerebral edema. Hypertension and nausea are not classical signs of cerebral edema. Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

Question 5

Type: MCSA

The patient is dehydrated, but has a normal blood pressure. The new medical intern orders normal serum albumin intravenously (IV) for this patient. What is the best evaluation by the nurse regarding this order?

1. It is a correct and valid order.

2. The intern should have ordered 5% dextrose in normal saline.

3. The intern should have ordered 0.45% NaCl.

4. The intern should have ordered 0.9% NaCl.

Correct Answer: 3

Rationale 1: 0.45% NaCl is a hypotonic solution. This will cause fluid to shift from plasma to the tissues and cells in the intravascular compartment. Hypotonic solutions are indicated for patients who are dehydrated with normal blood pressure. Normal serum albumin is a hypertonic solution; the patient requires a hypotonic solution 5% dextrose in normal saline is a hypertonic solution; the patient requires a hypotonic solution. 0.9% NaCl is an isotonic solution, the patient requires a hypotonic solution.

Rationale 2: 0.45% NaCl is a hypotonic solution. This will cause fluid to shift from plasma to the tissues and cells in the intravascular compartment. Hypotonic solutions are indicated for patients who are dehydrated with normal blood pressure. Normal serum albumin is a hypertonic solution; the patient requires a hypotonic solution 5% dextrose in normal saline is a hypertonic solution; the patient requires a hypotonic solution. 0.9% NaCl is an isotonic solution, the patient requires a hypotonic solution.

Rationale 3: 0.45% NaCl is a hypotonic solution. This will cause fluid to shift from plasma to the tissues and cells in the intravascular compartment. Hypotonic solutions are indicated for patients who are dehydrated with normal blood pressure. Normal serum albumin is a hypertonic solution; the patient requires a hypotonic solution 5% dextrose in normal saline is a hypertonic solution; the patient requires a hypotonic solution. 0.9% NaCl is an isotonic solution, the patient requires a hypotonic solution.

Rationale 4: 0.45% NaCl is a hypotonic solution. This will cause fluid to shift from plasma to the tissues and cells in the intravascular compartment. Hypotonic solutions are indicated for patients who are dehydrated with normal blood pressure. Normal serum albumin is a hypertonic solution; the patient requires a hypotonic solution 5% dextrose in normal saline is a hypertonic solution; the patient requires a hypotonic solution. 0.9% NaCl is an isotonic solution, the patient requires a hypotonic solution.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-3

Question 6

Type: MCSA

The patient has been running in a long-distance marathon on a very warm day. The patient complains of dizziness and nausea, and is taken to the hospital where she becomes lethargic. The serum sodium level is 125 mEq/L. What will be the best plan of the nurse?

1. Prepare to encourage the patient to drink fluids.

2. Prepare to administer normal saline intravenous (IV).

3. Prepare to administer 0.45% NaCl.

4. Prepare to provide a diet high in NaCl.

Correct Answer: 2

Rationale 1: Hyponatremia is a serum sodium level less the 135 mEq/L. Hyponatremia caused by sodium loss may be treated with intravenous (IV) fluids containing salt, such as normal saline. 0.45% NaCl is a hypotonic solution and will further lower the serum sodium. The patient requires intravenous (IV) fluids at this point, not oral fluids. The patient requires intravenous (IV) fluids at this point, not foods high in NaCl.

Rationale 2: Hyponatremia is a serum sodium level less the 135 mEq/L. Hyponatremia caused by sodium loss may be treated with intravenous (IV) fluids containing salt, such as normal saline. 0.45% NaCl is a hypotonic solution and will further lower the serum sodium. The patient requires intravenous (IV) fluids at this point, not oral fluids. The patient requires intravenous (IV) fluids at this point, not foods high in NaCl.

Rationale 3: Hyponatremia is a serum sodium level less the 135 mEq/L. Hyponatremia caused by sodium loss may be treated with intravenous (IV) fluids containing salt, such as normal saline. 0.45% NaCl is a hypotonic solution and will further lower the serum sodium. The patient requires intravenous (IV) fluids at this point, not oral fluids. The patient requires intravenous (IV) fluids at this point, not foods high in NaCl.

Rationale 4: Hyponatremia is a serum sodium level less the 135 mEq/L. Hyponatremia caused by sodium loss may be treated with intravenous (IV) fluids containing salt, such as normal saline. 0.45% NaCl is a hypotonic solution and will further lower the serum sodium. The patient requires intravenous (IV) fluids at this point, not oral fluids. The patient requires intravenous (IV) fluids at this point, not foods high in NaCl.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-5

Question 7

Type: MCSA

The patient has a potassium level of 5.9 mEq/L. The nurse is administering glucose and insulin. The patients wife says, He doesnt have diabetes, why is he getting insulin? What is the best response by the nurse?

1. Insulin will cause his extra potassium to go into his cells and lower the blood level.

2. Insulin lowers his blood sugar levels and this is how the extra potassium is excreted.

3. Insulin is safer than giving laxatives such as Kayexalate.

4. Insulin will help his kidneys excrete the extra potassium.

Correct Answer: 1

Rationale 1: Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than giving Kayexalate. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.

Rationale 2: Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than giving Kayexalate. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.

Rationale 3: Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than giving Kayexalate. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.

Rationale 4: Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than giving Kayexalate. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-10

Question 8

Type: MCSA

The physician has ordered ammonium chloride for the patient. What will be a primary assessment of the nurse during administration?

1. The patients level of orientation

2. The patients blood pressure

3. The patients renal status

4. The patients liver status

Correct Answer: 3

Rationale 1: The nurse must closely monitor the patients renal status during the administration of ammonium chloride, because the excretion of this drug depends on normal kidney function. Although important, blood pressure is not a primary assessment for a patient receiving ammonium chloride. Although important, liver status is not a primary assessment for a patient receiving ammonium chloride. Although important, the level of orientation is not a primary assessment for a patient receiving ammonium chloride.

Rationale 2: The nurse must closely monitor the patients renal status during the administration of ammonium chloride, because the excretion of this drug depends on normal kidney function. Although important, blood pressure is not a primary assessment for a patient receiving ammonium chloride. Although important, liver status is not a primary assessment for a patient receiving ammonium chloride. Although important, the level of orientation is not a primary assessment for a patient receiving ammonium chloride.

Rationale 3: The nurse must closely monitor the patients renal status during the administration of ammonium chloride, because the excretion of this drug depends on normal kidney function. Although important, blood pressure is not a primary assessment for a patient receiving ammonium chloride. Although important, liver status is not a primary assessment for a patient receiving ammonium chloride. Although important, the level of orientation is not a primary assessment for a patient receiving ammonium chloride.

Rationale 4: The nurse must closely monitor the patients renal status during the administration of ammonium chloride, because the excretion of this drug depends on normal kidney function. Although important, blood pressure is not a primary assessment for a patient receiving ammonium chloride. Although important, liver status is not a primary assessment for a patient receiving ammonium chloride. Although important, the level of orientation is not a primary assessment for a patient receiving ammonium chloride.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-7

Question 9

Type: MCSA

The patient receives dextran 40 (Gentran 40). The patient experiences tachycardia, dyspnea, and a cough. What is the best evaluation by the nurse?

1. The drug caused an interaction with another drug the patient receives.

2. The patient experienced impending kidney failure.

3. The patient is allergic to the drug.

4. The drug was infused too rapidly.

Correct Answer: 4

Rationale 1: Fluid overload will be caused by a rate of infusion that is too rapid. Signs of fluid overload include tachycardia, peripheral edema, distended neck veins, dyspnea, and cough. An allergy would be manifested by urticaria. There is no information in the question that the patient is receiving another drug. The patients symptoms do not indicate kidney failure.

Rationale 2: Fluid overload will be caused by a rate of infusion that is too rapid. Signs of fluid overload include tachycardia, peripheral edema, distended neck veins, dyspnea, and cough. An allergy would be manifested by urticaria. There is no information in the question that the patient is receiving another drug. The patients symptoms do not indicate kidney failure.

Rationale 3: Fluid overload will be caused by a rate of infusion that is too rapid. Signs of fluid overload include tachycardia, peripheral edema, distended neck veins, dyspnea, and cough. An allergy would be manifested by urticaria. There is no information in the question that the patient is receiving another drug. The patients symptoms do not indicate kidney failure.

Rationale 4: Fluid overload will be caused by a rate of infusion that is too rapid. Signs of fluid overload include tachycardia, peripheral edema, distended neck veins, dyspnea, and cough. An allergy would be manifested by urticaria. There is no information in the question that the patient is receiving another drug. The patients symptoms do not indicate kidney failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-8

Question 10

Type: MCSA

The physician orders potassium chloride (KCL) intravenous (IV) for the patient. The nurse administers this drug intravenous (IV) push. What will be the most likely outcome for this patient?

1. The patient will most likely experience cardiac arrest.

2. The patient will not experience adverse effects if the push was given slowly.

3. The patient will most likely experience tissue necrosis at the injection site.

4. The patient will most likely experience renal failure.

Correct Answer: 1

Rationale 1: Potassium chloride (KCL) must never be administered intravenous (IV) push, as bolus injections can overload the heart and cause cardiac arrest. Potassium chloride must never be administered via intravenous (IV) push, even if slowly, as cardiac arrest may result. Cardiac failure, not renal failure, is the most likely outcome of administering potassium chloride intravenous (IV) push. Although tissue necrosis may occur, this is not the primary concern.

Rationale 2: Potassium chloride (KCL) must never be administered intravenous (IV) push, as bolus injections can overload the heart and cause cardiac arrest. Potassium chloride must never be administered via intravenous (IV) push, even if slowly, as cardiac arrest may result. Cardiac failure, not renal failure, is the most likely outcome of administering potassium chloride intravenous (IV) push. Although tissue necrosis may occur, this is not the primary concern.

Rationale 3: Potassium chloride (KCL) must never be administered intravenous (IV) push, as bolus injections can overload the heart and cause cardiac arrest. Potassium chloride must never be administered via intravenous (IV) push, even if slowly, as cardiac arrest may result. Cardiac failure, not renal failure, is the most likely outcome of administering potassium chloride intravenous (IV) push. Although tissue necrosis may occur, this is not the primary concern.

Rationale 4: Potassium chloride (KCL) must never be administered intravenous (IV) push, as bolus injections can overload the heart and cause cardiac arrest. Potassium chloride must never be administered via intravenous (IV) push, even if slowly, as cardiac arrest may result. Cardiac failure, not renal failure, is the most likely outcome of administering potassium chloride intravenous (IV) push. Although tissue necrosis may occur, this is not the primary concern.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-8

Question 11

Type: MCSA

The physician orders potassium chloride (KCL) for the patient who has a nasogastric (NG) tube. What will the nurse plan to do prior to the administration of this drug?

1. Dilute the drug prior to administration through the nasogastric (NG) tube.

2. Flush the nasogastric (NG) tube with Coca-Cola before and after administration.

3. Flush the nasogastric (NG) tube with normal saline before and after administration.

4. There is no particular preparation prior to administration.

Correct Answer: 1

Rationale 1: Liquid forms of potassium chloride (KCL) must be diluted prior to administration through a nasogastric (NG) tube to decrease gastrointestinal (GI) distress. There is a preparation; the drug must be diluted to decrease gastrointestinal (GI) distress. Flushing the tube with Coca-Cola is an outdated practice, and should not be done. Flushing the tube before and after administration of the drug is important, but the drug must still be diluted to decrease gastrointestinal (GI) distress.

Rationale 2: Liquid forms of potassium chloride (KCL) must be diluted prior to administration through a nasogastric (NG) tube to decrease gastrointestinal (GI) distress. There is a preparation; the drug must be diluted to decrease gastrointestinal (GI) distress. Flushing the tube with Coca-Cola is an outdated practice, and should not be done. Flushing the tube before and after administration of the drug is important, but the drug must still be diluted to decrease gastrointestinal (GI) distress.

Rationale 3: Liquid forms of potassium chloride (KCL) must be diluted prior to administration through a nasogastric (NG) tube to decrease gastrointestinal (GI) distress. There is a preparation; the drug must be diluted to decrease gastrointestinal (GI) distress. Flushing the tube with Coca-Cola is an outdated practice, and should not be done. Flushing the tube before and after administration of the drug is important, but the drug must still be diluted to decrease gastrointestinal (GI) distress.

Rationale 4: Liquid forms of potassium chloride (KCL) must be diluted prior to administration through a nasogastric (NG) tube to decrease gastrointestinal (GI) distress. There is a preparation; the drug must be diluted to decrease gastrointestinal (GI) distress. Flushing the tube with Coca-Cola is an outdated practice, and should not be done. Flushing the tube before and after administration of the drug is important, but the drug must still be diluted to decrease gastrointestinal (GI) distress.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-8

Question 12

Type: MCSA

The patient has overdosed on aspirin. In the emergency department, the physician orders sodium bicarbonate. A family member says to the nurse, I thought that was for stomach ulcers. What is the best response by the nurse?

1. It will prevent excessive bleeding from the stomach.

2. It will change the pH of the blood to neutralize the aspirin.

3. It will change the urine so the kidneys can get rid of the aspirin quickly.

4. It will help the liver break down the aspirin more quickly.

Correct Answer: 3

Rationale 1: Sodium bicarbonate makes the urine more basic, which aids in the renal excretion of acidic drugs such as aspirin. Sodium bicarbonate is not given to prevent bleeding when a patient has overdosed on aspirin. Sodium bicarbonate is not given to neutralize blood pH when a patient has overdosed on aspirin. Sodium bicarbonate is not given to enhance liver enzymes when a patient has overdosed on aspirin.

Rationale 2: Sodium bicarbonate makes the urine more basic, which aids in the renal excretion of acidic drugs such as aspirin. Sodium bicarbonate is not given to prevent bleeding when a patient has overdosed on aspirin. Sodium bicarbonate is not given to neutralize blood pH when a patient has overdosed on aspirin. Sodium bicarbonate is not given to enhance liver enzymes when a patient has overdosed on aspirin.

Rationale 3: Sodium bicarbonate makes the urine more basic, which aids in the renal excretion of acidic drugs such as aspirin. Sodium bicarbonate is not given to prevent bleeding when a patient has overdosed on aspirin. Sodium bicarbonate is not given to neutralize blood pH when a patient has overdosed on aspirin. Sodium bicarbonate is not given to enhance liver enzymes when a patient has overdosed on aspirin.

Rationale 4: Sodium bicarbonate makes the urine more basic, which aids in the renal excretion of acidic drugs such as aspirin. Sodium bicarbonate is not given to prevent bleeding when a patient has overdosed on aspirin. Sodium bicarbonate is not given to neutralize blood pH when a patient has overdosed on aspirin. Sodium bicarbonate is not given to enhance liver enzymes when a patient has overdosed on aspirin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-8

Question 13

Type: MCSA

The patient receives normal serum albumin. What are the priority assessments by the nurse?

1. Blood pressure and urinary output

2. Urinary output and pupil response

3. Blood pressure and level of pain

4. Urinary output and nausea or vomiting

Correct Answer: 1

Rationale 1: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output. Level of pain is not a priority assessment. Pupil response is not a priority assessment. Nausea or vomiting is not the priority assessment.

Rationale 2: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output. Level of pain is not a priority assessment. Pupil response is not a priority assessment. Nausea or vomiting is not the priority assessment.

Rationale 3: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output. Level of pain is not a priority assessment. Pupil response is not a priority assessment. Nausea or vomiting is not the priority assessment.

Rationale 4: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output. Level of pain is not a priority assessment. Pupil response is not a priority assessment. Nausea or vomiting is not the priority assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-9

Question 14

Type: MCSA

What is a priority outcome when a patient receives dextran 40 (Gentran 40)?

1. The patient will immediately report any ototoxicity.

2. The patient will immediately report any diarrhea.

3. The patient will immediately report any hiccoughs.

4. The patient will immediately report any itching or flushing.

Correct Answer: 4

Rationale 1: A small percentage of patients are allergic to dextran 40 (Gentran 40), with urticaria being the most common sign. The most important outcome is for the patient to report any allergic symptoms. Diarrhea is not a sign of an allergic reaction so is not the priority. Ototoxicity is not a sign of an allergic reaction so is not the priority. Hiccoughs are not a sign of an allergic reaction so are not the priority.

Rationale 2: A small percentage of patients are allergic to dextran 40 (Gentran 40), with urticaria being the most common sign. The most important outcome is for the patient to report any allergic symptoms. Diarrhea is not a sign of an allergic reaction so is not the priority. Ototoxicity is not a sign of an allergic reaction so is not the priority. Hiccoughs are not a sign of an allergic reaction so are not the priority.

Rationale 3: A small percentage of patients are allergic to dextran 40 (Gentran 40), with urticaria being the most common sign. The most important outcome is for the patient to report any allergic symptoms. Diarrhea is not a sign of an allergic reaction so is not the priority. Ototoxicity is not a sign of an allergic reaction so is not the priority. Hiccoughs are not a sign of an allergic reaction so are not the priority.

Rationale 4: A small percentage of patients are allergic to dextran 40 (Gentran 40), with urticaria being the most common sign. The most important outcome is for the patient to report any allergic symptoms. Diarrhea is not a sign of an allergic reaction so is not the priority. Ototoxicity is not a sign of an allergic reaction so is not the priority. Hiccoughs are not a sign of an allergic reaction so are not the priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-10

Question 15

Type: MCSA

The nurse provides group education to active adolescents about sodium replacement after exercising outdoors. What is the best information to include?

1. Have extra salt with your breakfast on days you exercise outdoors.

2. It is best to avoid exercising outdoors in the summer.

3. You should take one salt tablet for every 2 hours spent outside.

4. Water is the best fluid replacement after exercising.

Correct Answer: 4

Rationale 1: Heat-related problems can be best avoided by consuming adequate amounts of water. Salt tablets can increase the risk of hypernatremia. There is no need to avoid exercising as long as enough water is consumed to avoid dehydration. Increasing salt intake prior to exercising is not necessary.

Rationale 2: Heat-related problems can be best avoided by consuming adequate amounts of water. Salt tablets can increase the risk of hypernatremia. There is no need to avoid exercising as long as enough water is consumed to avoid dehydration. Increasing salt intake prior to exercising is not necessary.

Rationale 3: Heat-related problems can be best avoided by consuming adequate amounts of water. Salt tablets can increase the risk of hypernatremia. There is no need to avoid exercising as long as enough water is consumed to avoid dehydration. Increasing salt intake prior to exercising is not necessary.

Rationale 4: Heat-related problems can be best avoided by consuming adequate amounts of water. Salt tablets can increase the risk of hypernatremia. There is no need to avoid exercising as long as enough water is consumed to avoid dehydration. Increasing salt intake prior to exercising is not necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-9

Question 16

Type: MCSA

Intravenous therapy would be indicated if

1. hypertension were present.

2. fluid intake were greater than 2500 mL/day.

3. intake and output were deregulated.

4. constipation were present.

Correct Answer: 3

Rationale 1: Hypertension would not require IV therapy.

Rationale 2: Fluid intake of 2500 mL/day is the average intake for adults.

Rationale 3: Intake and output imbalance would require IV therapy to treat dehydration or shock and correct fluid imbalance.

Rationale 4: Constipation might indicate lack of fluid, but would not require IV.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-1

Question 17

Type: MCSA

Osmolality and tonicity are not changed when movement of fluids and solution are

1. hypotonic.

2. hypertonic.

3. isotonic.

4. oncotic.

Correct Answer: 3

Rationale 1: Decreased osmolity, waters moves to fluid and cells, hypotonics.

Rationale 2: Increased osmolity, water moves from cells is hypertonic.

Rationale 3: Isotonic does not net fluid change.

Rationale 4: Oncotic refers to a blood product to treat shock.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

Question 18

Type: MCSA

Electrolytes are essential for many body functions, and require a

1. wide level range.

2. low level range.

3. narrow level range.

4. high level range.

Correct Answer: 3

Rationale 1: Levels of electrolytes are maintained within a very narrow range.

Rationale 2: Levels of electrolytes are maintained within a very narrow range.

Rationale 3: Levels of electrolytes are maintained within a very narrow range.

Rationale 4: Levels of electrolytes are maintained within a very narrow range.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-4

Question 19

Type: MCSA

Hyponatremia is marked by a serum sodium level less than

1. 137 mEq/mL.

2. 140 mEq/mL.

3. 135 mEq/mL.

4. 145 mEq/mL.

Correct Answer: 3

Rationale 1: 137 is normal.

Rationale 2: 140 is normal.

Rationale 3: 135 indicates a hyponatremia state.

Rationale 4: Normal serum sodium range is 135145 mEq/L.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-6

Question 20

Type: MCSA

Which of the following is a sign of hypokalemia?

1. Constipation

2. Hypertension

3. Muscle weakness

4. Weight gain

Correct Answer: 3

Rationale 1: Diarrhea, not constipation, will occur.

Rationale 2: Hypertension is usually not a sign of hypokalemia.

Rationale 3: Muscle weakness can occur, since muscle fibers are very sensitive to changes in potassium.

Rationale 4: Weight gain is usually not a sign of hypokalemia.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-7

Question 21

Type: MCSA

Buffers are chemicals that help maintain normal body Ph. The two primary buffers in the body are

1. sodium and calcium ions.

2. sodium and bicarbonate ions.

3. bicarbonate and phosphate ions.

4. potassium and phosphate ions.

Correct Answer: 3

Rationale 1: Sodium and calcium are not buffers.

Rationale 2: Sodium is not a buffer in maintaining normal body Ph.

Rationale 3: Bicarbonate and phosphate are the two primary buffers of Ph balances.

Rationale 4: Potassium and phosphate are not the two primary buffers.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-8

Question 22

Type: MCSA

Potential causes for respiratory alkalosis include

1. hypotension.

2. hypertension.

3. hypoventilation.

4. hyperventilation.

Correct Answer: 4

Rationale 1: Hypotension is unrelated.

Rationale 2: Hypertension is unrelated.

Rationale 3: Hypoventilation is associated with respiratory acidosis.

Rationale 4: Hyperventilation occurs with respiratory alkalosis.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-10

Question 23

Type: MCMA

The nurse is caring for a group of patients on a medical-surgical unit. For which patients would the nurse anticipate the need for intravenous fluid therapy to correct fluid depletion?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient suffering from constipation

2. A patient exhibiting nausea and vomiting following a surgical procedure

3. A patient with a severe burn

4. A patient with congestive heart failure with edema to the lower extremities and rales

5. A patient with uncontrolled diabetic ketoacidosis

Correct Answer: 2,3,5

Rationale 1: A patient who is suffering from constipation will not need intravenous fluid due to fluid depletion. A patient with diarrhea may require intravenous fluid due to fluid depletion.

Rationale 2: A patient exhibiting nausea and vomiting may require intravenous fluid to avoid dehydration.

Rationale 3: A patient with a severe burn will often require intravenous fluid due to fluid depletion that occurs from fluid shifts.

Rationale 4: A patient with congestive heart failure retains fluid and will be on fluid restrictions.

Rationale 5: A patient with uncontrolled diabetic ketoacidosis often requires intravenous fluid administration for fluid depletion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2

Question 24

Type: FIB

A seasoned nurse is caring for a patient receiving intravenous fluid therapy for dehydration. The nurse knows that the osmolarity or tonicity of a fluid causes water to move to a different compartment. The nurse is caring for a patient who weighs 40 kg. The osmolality of the body fluids for this patient is between 11,000 and _____ milliosmoles.

Standard Text:

Correct Answer: 11,800

Rationale : The normal osmolality of body fluids ranges from 275 to 295 milliosmoles per kilogram (mOsm/kg).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.3

Question 25

Type: MCMA

The nurse is reviewing the tonicity of the different intravenous fluids on the medical-surgical unit in preparation for an in-service presentation. Which fluids are considered to be isotonic and appropriate in the treatment of fluid loss due to a surgical procedure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. 5% dextrose in lactated ringers

2. 0.9% sodium chloride (NS)

3. 0.45% sodium chloride

4. Lactated Ringers

5. 5% dextrose in water

Correct Answer: 2,4,5

Rationale 1: This is a hypertonic solution and is not appropriate for the treatment of fluid loss due to a surgical procedure.

Rationale 2: This is an isotonic solution and is appropriate for the treatment of fluid loss due to a surgical procedure.

Rationale 3: This is a hypotonic solution and is not appropriate in the treatment of fluid loss due to a surgical procedure.

Rationale 4: This is an isotonic solution that is appropriate to treat fluid loss caused by a surgical procedure.

Rationale 5: This is an isotonic solution that is appropriate to treat fluid loss caused by a surgical procedure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4

Question 26

Type: MCMA

The nurse is caring for a patient with severe electrolyte imbalances that have occurred as a result of kidney failure. The nurse knows that this patient is at risk for what disorders as a result of this electrolyte imbalance?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fluid retention

2. Muscle spasms

3. Fractures

4. High cholesterol

5. Depression

Correct Answer: 1,2,3

Rationale 1: Electrolytes are responsible for membrane permeability and water balance. An electrolyte imbalance, especially too much sodium, can result in fluid retention.

Rationale 2: Electrolytes are essential for muscle contractions. An imbalance in electrolytes can result in muscle spasms.

Rationale 3: Electrolytes are essential for bone growth and remodeling and may place a patient at risk for fractures, especially when there is an imbalance of calcium.

Rationale 4: There is no indication that electrolyte imbalances result in high cholesterol.

Rationale 5: There is no indication that electrolyte imbalances result in depression.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24.5

Question 27

Type: MCMA

The nurse is caring for a patient with a pH of 7.32. Which medications would be appropriate to administer to a patient with this condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Oral bicarbonate

2. Sodium chloride

3. Citrate salts

4. Potassium chloride

5. Ammonium chloride

Correct Answer: 1,3

Rationale 1: Oral bicarbonate is an agent used to treat acidosis.

Rationale 2: Sodium chloride is an agent used to treat alkalosis.

Rationale 3: Citrate salts are an agent used to treat acidosis.

Rationale 4: Potassium chloride is an agent used to treat alkalosis.

Rationale 5: Potassium chloride is an agent used to treat alkalosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.7

Question 28

Type: MCMA

The nurse is preparing to administer normal serum albumin (Plasbumin) to a patient with an albumin level of 3.2 g/dL.The nurse knows that Plasbumin is classified as

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. a blood product.

2. a colloid.

3. a crystalloid.

4. a vitamin.

5. an electrolyte.

Correct Answer: 1,2

Rationale 1: Plasbumin is an albumin product. Albumin is considered a blood product.

Rationale 2: Plasbumin is an albumin product. Albumin is considered a colloid.

Rationale 3: Plasbumin is an albumin product. Albumin is not considered a crystalloid.

Rationale 4: Plasbumin is an albumin product. Albumin is not considered a vitamin.

Rationale 5: Plasbumin is an albumin product. Albumin is not considered an electrolyte.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24.9

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/E

Copyright 2014 by Pearson Education, Inc.

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