Fundamentals Nursing Test Bank (31-35)

31. A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigation are prescribed to be performed once every shift. The client's serum 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 the nasogastric tube irrigation?a) tap water
b) sterile water
c) sodium chloride
d) distilled water

32. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

a) peas
b) cauliflower
c) low-fat yogurt
d) processed oat cereals

33. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

a) twitching
b) negative Trousseau's sign
c) hypoactive bowel sounds
d) hypoactive deep tendon reflexes

34. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that he client most likely to experience what type of acid-base imbalance?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

35. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

a) sodium level of 145 mEq/L
b) potassium level of 3.0 mEq/L
c) magnesium level of 2.0 mg/dL
d) phosporus level of 4.0 mg/dL





Fundamentals Nursing Test Bank:
ANSWERS AND RATIONALE

31) C

- A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium (isotonic) chloride should be used rather than water for gastrointestinal irrigations.

32) D

- The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.

33) A

- Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

34) C

Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Options A, B, and C are incorrect options.

35) B

- Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options A, C, and D identify normal laboratory values. Option B identifies the presence of hypokalemia.


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