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The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client’s potassium level is too low?

Case Study Question #4 The nurse cares for a 72-year-old female admitted to the medical unit with dehydration and secondary diagnosis of mid-stage Alzheimer’s disease.  Phase Sheet   Name Theresa Peters Gender F Age 72 Weight (lbs/kg) 122 lb (55 kg) Allergies NKA Nurses’ Notes   DAY 1 1800:  Client admitted from ED to medical unit for dehydration after several days of poor PO intake where she appeared to briefly lose consciousness this am after breakfast. Retired for several years as seamstress and husband passed away last year. Now lives with daughter/family due to recent diagnosis of middle stage Alzheimer’s disease, history of mild hypertension & gastroesophageal reflux.  Daughter notes appetite has diminished in past 2-3 weeks and it is hard to get her to drink enough fluids even in the warmer weather.  She has been more “down in the dumps” the past few weeks. Client has been unsteady on her feet due to dizziness and increasingly weak. P: 104 and B/P 102/62 (sitting) & 94/55 (standing). Skin & mucous membranes dry; tenting noted. Admission BUN & creatinine elevated.  Foley inserted and draining concentrated amber urine. Provider notified; ordered fluid challenge of 500 ml normal saline. Alert/oriented to name only, answers questions, pleasant, cooperative, asking for daughter.  2200:  B/P and P improved after saline bolus. U/O clear yellow and increased to 240 ml in past 4 hrs. Resting quietly, cooperative and no report of dizziness, etc. DAY 2 0800: IV normal saline running at 75 ml/hr. B/P improved to 124/74 and negative for orthostatic changes. Lisinopril dose held this am. Am labs improved—BUN/creatinine WNL. 1200:  VS stable. Not interested in lunch despite reminders to eat. IV normal saline @ 50 ml/hr. Foley draining adequate amts clear yellow urine. Seems more disoriented, anxious and inattentive. 1500: Client calling out from room, anxious and agitated, asking about needing to use bathroom and pulling at Foley catheter and IV.  Seems easily distracted and suddenly hyperalert. States she “needs to leave so can get ready to go to work”; states she sees her boss outside waiting. Provider notified. Vital Signs   Time 1800 2200 0800 1200 1500 T ◦F/ ◦C 97.8 F /36.5 C 98 F / 36.6 C 97.8 F/36.5 C 98.2/36.7 C 97.8 F/36.5 C P 104 94 86 84 98 RR 20 18 16 18 26 B/P 102/62 110/68 120/72 130/76 138/78 Pulse oximeter 97 97 96 97 95 Oxygen Room air Room air Room air Room air Room air Laboratory Report   Lab Results @ 1400 (ED) Reference Range Sodium 145 135 to 145 mEq/L Potassium 5.0 3.5 to 5.0 mEq/L Glucose (fasting) 72 Normal

A nurse is caring for an elderly client that has been vomiting all weekend. What expected findings are associated with excessive vomiting the nurse might discover when performing assessment of this client? Select All that Apply

Case Study Question #3 The nurse cares for a 72-year-old female admitted to the medical unit with dehydration and secondary diagnosis of mid-stage Alzheimer’s disease.  Phase Sheet   Name Theresa Peters Gender F Age 72 Weight (lbs/kg) 122 lb (55 kg) Allergies NKA Nurses’ Notes   DAY 1 1800:  Client admitted from ED to medical unit for dehydration after several days of poor PO intake where she appeared to briefly lose consciousness this am after breakfast. Retired for several years as seamstress and husband passed away last year. Now lives with daughter/family due to recent diagnosis of middle stage Alzheimer’s disease, history of mild hypertension & gastroesophageal reflux.  Daughter notes appetite has diminished in past 2-3 weeks and it is hard to get her to drink enough fluids even in the warmer weather.  She has been more “down in the dumps” the past few weeks. Client has been unsteady on her feet due to dizziness and increasingly weak. P: 104 and B/P 102/62 (sitting) & 94/55 (standing). Skin & mucous membranes dry; tenting noted. Admission BUN & creatinine elevated. Foley inserted and draining concentrated amber urine. Provider notified; ordered fluid challenge of 500 ml normal saline. Alert/oriented to name only, answers questions, pleasant, cooperative, asking for daughter.  2200:  B/P and P improved after saline bolus. U/O clear yellow and increased to 240 ml in past 4 hrs. Resting quietly, cooperative and no report of dizziness, etc. DAY 2 0800: IV normal saline running at 75 ml/hr. B/P improved to 124/74 and negative for orthostatic changes. Lisinopril dose held this am. Am labs improved—BUN/creatinine WNL. 1200:  VS stable. Not interested in lunch despite reminders to eat. IV normal saline @ 50 ml/hr. Foley draining adequate amts clear yellow urine. Seems more disoriented, anxious and inattentive. Vital Signs   Time 1800 2200 0800 1200   T ◦F/ ◦C 97.8 F /36.5 C 98 F / 36.6 C 97.8 F/36.5 C 98.2/36.7 C   P 104 94 86 84   RR 20 18 16 18   B/P 102/62 110/68 120/72 130/76   Pulse oximeter 97 97 96 97   Oxygen Room air Room air Room air Room air   Laboratory Report   Lab Results @ 1400 (ED) Reference Range Sodium 145 135 to 145 mEq/L Potassium 5.0 3.5 to 5.0 mEq/L Glucose (fasting) 72 Normal

A nurse is caring for a client who has experienced significant blood loss following a traumatic injury. The client is tachycardic, pale, and has an SpO₂ of 89% on room air. Which of the following best explains the client’s impaired gas exchange?

A nurse is assessing a patient admitted with pneumonia.  Which clinical manifestations would the nurse expect to find.  (Select all that apply).

The concentration of oxygen at room air is:

A client who has a history of chronic lung disease is admitted to the hospital with possible pneumonia. Respirations are shallow and breath sounds are diminished. Blood gases reveal: pH – 7.25, PCO2 – 70, HCO3- 24.  What acid-base imbalance is this client experiencing?

Place these nursing actions in order of proper sequence for preparing an IV solution and tubing when initiating an intravenous infusion.  When recording your answer below, enter the number only, that corresponds to your choice.  1. Clamp tubing, uncap spike, and insert spike into entry site on the solution bag as directed by the manufacturer 2. Verify the primary care providers orders, gather all supplies and wash your hands, identify the patient 3. Label tubing with date of initiation, due date to replace tubing, and name. 4. Maintain aseptic technique when opening sterile packages and IV solutions 5. Prime the tubing eliminate all air, by releasing the clamp that allows fluid to move through the tubing prior to initiating the infusion 6. Squeeze the drip chamber and allow it to fill one-half full or as indicated by the manufacturer and open the IV tubing clamp.

A nurse in the pediatric unit is caring for a 4-month-old infant with bronchiolitis. Which of the following findings would indicate that the infant is experiencing respiratory distress (Select all that apply).