Download The physician`s order reads flush NG tube with 30 to 50 ml saline

Practice Questions, Answers and Rationales
The physician’s order reads flush NG tube with 30 to 50 ml saline solution
for irrigation q2h prn. The nurse knows that saline solution is used instead
of water because:
a. water is irritating to the gastric mucosa.
b. saline is better in maintaining tube patency.
c. flushing with water can deplete electrolytes in the stomach.
d. the sterility of the stomach is maintained with saline solution.
RATIONALE: SALINE IS PREFERRED TO MINIMIZE THE RISK OF ELECTROLYTE
DEPLETION. The highlighted section of the question is not important to what’s being
asked in this question. This question wants to know why is saline better than water.
The nurse checks the results of lab tests and notes that the potassium level
is 2.8 mEq/L. After reporting this finding to the physician, the nurse
assesses the client for:
a. hypertension.
b. a bounding pulse.
c. a weak, irregular pulse.
d. increased bowel sounds.
RATIONALE: APATIENT WITH A LOW POTASSIUM LEVEL WILL HAVE A WEAK &
IRREGULAR PULSE. BOWEL SOUNDS WOULD BE DECREASED. OPTIONS A&B
ARE INCORRECT AND DOES NOT APPLY TO HYPOKALEMIA.
Which statement is correct regarding sodium? Sodium . . .
a. regulation is controlled only by the kidneys.
b. is regulated by the amount of daily oral intake.
c. is found in the intracellular fluid to help maintain water balance.
d. is found in the extracellular fluid to help maintain water balance.
RATIONALE: SODIUM IS FOUND PRIMARILY IN THE EXTRACELLULAR FLUID
AND HELPS TO MAINTAIN WATER BALANCES IN THE BODY. AVOID ALL
INCLUSIVE OR EXCLUSIVE ANSWER CHOICES. THE KIDNEYS IS NOT THE ONLY
PLACE OF SODIUM REGULATION WHICH MAKES OPTION A INCORRECT.
A patient has experienced vomiting and diarrhea for several days. The
nurse understands that the nursing interventions should include safety
precautions because hypovolemia can lead to:
a. twitching and weak muscles.
b. abdominal distention and rapid pulse.
c. shortness of breath and pedal pitting edema.
d. decreased cerebral circulation and postural hypotension.
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RATIONALE: LOSS OF FLUID VOLUME CAN CAUSE A DECREASE IN CEREBRAL
PERFUSION AND THE PATIENT CAN HAVE A SUDDEN DROP IN BLOOD
PRESSURE (POSTURAL/ORTHOSTATIC HYPOTENSION) WHEN MOVING FROM A
SITTING TO STANDING POISITION. PATIENTS CAN BECOME SYNCOPAL (DIZZY)
AND FALL. SAFETY PRECAUTIONS SHOULD BE IN PLACE BECAUSE OF THIS.
A patient was weak and complained of extreme fatigue at admission. Lab
tests showed hypokalemia and hyponatremia. After 2 days of IV therapy
and electrolyte replacement, the patient tells the nurse that she feels much
better. The BEST way to evaluate electrolyte balance in a client is to:
a. review lab results from admission to the most recent values.
b. review the nurse's document indicating improved skin turgor and mucous
membranes.
c. compare the client’s vital sign readings, especially the pulse, to those taken on
admission.
d. assess the client’s level of orientation and ability to respond appropriately to
simple questions.
RATIONALE: THIS NURSING INTERVENTION WILL PROVIDE THE NURSE WITH
THE BEST DATA TO EVALUATE RESTORED ELECTROLYTE BALANCE.
ALTHOUGH OPTION C IS A WAY TO EVALUATE BALANCE
THE QUESTION IS ASKING FOR THE BEST WAY.
The nurse is conducting dietary teaching with a patient being treated for
hypocalcemia. The nurse encourages the patient to increase intake of which
of the following foods?
a. apples
b. cheese
c. cooked pasta
d. chicken breast
RATIONALE: PRODUCTS THAT ARE NATURALLYY HIGH IN CALCIUM ARE DAIRY
PRODUCTS THAT HAVE GREATER THAN 100 MG OF CALCIUM PER SERVING.
PRODUCTS INCLUDE: MILK, CHEESE, ICE CREAM AND YOGURT. THE OTHER
FOODS LISTED ARE LOW IN CALCIUM.
A patient in the emergency department has complaints of numbness and
tingling in their fingers. Physical assessment reveals positive Trousseau
and Chvostek’s signs. The nurse suspects that patient may have which of the
following electrolyte imbalances?
a. hyponatremia
b. hyperkalemia
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c. hypocalcemia
d. hypermagnesemia
RATIONALE: TROUSSEAU AND CHVOSTEK’S SIGNS ARE POSITIVE IN PATIENTS
WHO HAVE HYPOCALCEMIA AND HYPOMAGNESEMIA.
A patient is brought to the emergency department with complaints of
diarrhea and vomiting for the past two days. The patient has a history of
hypertension and is taking a potassium wasting diuretic daily. The
physician orders a basic metabolic panel. What changes would you expect
to see in this patient?
a. decrease sodium levels
b. increased potassium levels
c. decreased potassium levels
d. increased sodium levels
RATIONALE: THE PATIENT SEEMS TO BE HYPOKALEMIC AS EVIDENCE BY
DIARRHEA, VOMITTING AND IS ON A POTASSIUM WASTING DIURECTIC. THE
NURSE SHOULD EXPECT TO SEE DECREASED POTASSIUM LEVELS.
The nurse educates a patient being treated for hypokalemia about foods
high in potassium that should be included in the daily diet. The nurse
determines that the patient understands the food sources of potassium if
the patient states that the food lowest in potassium is:
a. Spinach
b. Carrots
c. Avocado
d. Apples
RATIONALE: SPINACH CARROTS AND AVOCADOS ARE HIGH IN POTASSIUM.
APPLES HAVE LOW LEVELS OF POTASSIUM.
A nurse is caring for a patient with a nasogastric tube. Nasogastric tube
irrigations are prescribed to be performed once every shift. The patient’s
electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium
level of 132 mEq/L. Based on these laboratory findings, the nurse selects
which solution to use for nasogastric tube irrigation?
a. Tap water
b. Distilled water
c. Sterile water
d. Normal saline
RATIONALE: NORMAL SALINE SHOULD BE USED BECAUSE IT WILL MINIMIZE
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THE RISK OF ELECTROLYTE DEPLETION. ELIMINATE OPTIONS A, B, C BECAUSE
THEY ARE ALL SIMILAR.
The nurse is assessing a client with a diagnosis of hypocalcemia. Which of
the following clinical symptoms are not associated with this diagnosis?
a. Hypoactive bowel sounds
b. Paresthesias
c. Hyperactive deep tendon reflexes
d. Positive Trousseau’s sign
RATIONALE: HYPOACTIVE BOWEL SOUNDS IS A SYMPTOM OF
HYPERCALCEMIA. SYMPTOMS OF HYPOPCALCEMIA ARE LISTED IN OPTIONS B,
C, D.
The nurse reviews the serum magnesium level and notes that the patient’s
level is 1.1 mEq/L. Which condition is most likely caused this?
a. Alcoholism
b. Osteoporosis
c. Renal failure
d. Pancreatitis
RATIONALE: THE PATIENT’S MAGNESIUM LEVEL INDICATES HYPOMAGESEMIA
WHICH CAN BE CAUSED BY ALCOHOLISM. THE OTHER OPTIONS ARE NOT
ASSOCIATED WITH DECREASED MAGNESIUM LEVELS.
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