ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 19 Questions
Question 1 of 5
The nurse is caring for a patient who is receiving iso-osmolar continuous tube feedings who has developed nausea, vomiting, and tachycardia. Which of the following laboratory results is most important for the nurse to report to the health care provider?
Correct Answer: B
Rationale: The elevated sodium level is consistent with the patient's symptoms and is an indication of hypernatremia, which should be reported to the provider for further management to prevent complications such as seizures or coma.
Question 2 of 5
The nurse is caring for a postoperative patient who is receiving nasogastric suction and is anxious with incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
Question 3 of 5
The nurse is caring for a patient who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3 mmol/L. Of the following medications that the patient has been taking at home, which of the following would be of most concern to the nurse?
Correct Answer: A
Rationale: Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.
Question 4 of 5
The nurse is caring for an alert and oriented older-adult patient with a history of dehydration. Which of the following information should the home health nurse teach the patient as to when to increase fluid intake?
Correct Answer: B
Rationale: An alert, elderly 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 LOC occur.
Question 5 of 5
The nurse obtains the following data when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulphate. Which of the following findings is most important to report to the health care provider immediately?
Correct Answer: B
Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are adverse effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.