Exam 1 F & E Practice
A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline
3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.
What is the osmolarity of blood?
300 mOsmol/L
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Administer IV fluids evenly over 24hr B. Provide the client with a salt substitute C. Assess for pitting edema D. Encourage the client to rise slowly when standing up E. Weigh the client every 8hr
A D E
Lactated Ringer's Solution
A sterile crystalloid isotonic IV solution of specified amounts of calcium chloride, potassium chloride, sodium chloride, and sodium lactate in water.
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? 1. risk of dehydration 2. risk of kidney damage 3. risk of stroke 4. risk of bleeding
Answer: 1 Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality. Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.
The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing? 1. intracellular fluid deficit 2. intracellular fluid overload 3. extracellular fluid deficit 4. interstitial fluid deficit
Answer: 1 Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate? 1. Risk for Imbalanced Fluid Volume 2. Excess Fluid Volume 3. Imbalanced Nutrition 4. Ineffective Tissue Perfusion
Answer: 1 Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium. Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition does not apply. Rationale 4: Ineffective Tissue Perfusion does not apply
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? 1. hyperkalemia 2. hypokalemia 3. hypercalcemia 4. hypocalcemia
Answer: 1 Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes. Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics. Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.
A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt? 1. Digoxin toxicity may occur. 2. A higher dose of digoxin (Lanoxin) may be needed. 3. A diuretic may be needed. 4. Fluid volume deficit may occur.
Answer: 1 Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure. Rationale 2: More digoxin is not needed. Rationale 3: A diuretic may cause further fluid loss. Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.
The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure? 1. The pt breathes rapidly to eliminate carbon dioxide. 2. The pt will retain bicarbonate in excess of normal. 3. The pH will decrease from the present value. 4. The pt's oxygen saturation level will improve.
Answer: 1 Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis. Rationale 2: Because compensation must be performed by the system other than the affected system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value. Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? 1. seizure 2. infection 3. neutropenic 4. high-risk fall
Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included. Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia. Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia. Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? 1. The kidneys retain bicarbonate. 2. The kidneys excrete bicarbonate. 3. The lungs will retain carbon dioxide. 4. The lungs will excrete carbon dioxide.
Answer: 1 Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis
An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? 1. hypernatremia 2. hyponatremia 3. fluid volume excess 4. hyperkalemia
Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia. Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level. Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit. Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.
A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is 1. to sustain respiratory function. 2. to help regulate acid-base balance. 3. to keep a vein open. 4. to encourage urine output.
Answer: 2 Rationale 1: Potassium does not sustain respiratory function. Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity. Rationale 3: Intravenous fluids are used to keep venous access not potassium. Rationale 4: Urinary output is impacted by fluid intake not potassium.
A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances? 1. hypokalemia 2. hypernatremia 3. carbon dioxide 4. magnesium
Answer: 2 Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels. Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt. Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt? 1. poor skin turgor 2. decreased urine output 3. distended neck veins 4. concentrated hemoglobin & hematocrit levels
Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit. Rationale 2: Decreased urine output is associated with fluid volume deficit. Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema. Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.
A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing? 1. pulmonary edema 2. atrial dysrhythmias 3. cerebral bleeding 4. stress fractures
Answer: 3 Rationale 1: Pulmonary edema is not associated with dehydration. Rationale 2: Atrial dysrhythmias are not a factor for this pt. Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding. Rationale 4: There have been no activities to support the development or occurrence of stress fractures.
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? A. BUN 26 mg/dL B. Serum sodium 138 mEq/L C. Hct 56% D. Urine specific gravity 1.035
B
A patient with hypovolemic hyponatremia is started on IV fluids. Which of the following fluids do you expect the patient to be started on? A. 0.45% Saline B. 3% Saline C. D5W D. 0.33% Saline
B: 3% Saline Patients with hypovolemic hyponatremia are started on a hypertonic solution (the circulatory system is dehydrated & and the cells are swollen...so a hypertonic solution will shrink the cells and increase fluid volume) and 3% Saline is the only hypertonic solutions. The other options are either hypotonic or isotonic.
When administering a hypertonic solution the nurse should closely watch for?
B: Pulmonary Edema
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A. Urine output of 30 mL/hr B. Blood glucose of 180 mg/dL C. Serum potassium 3.0 mEq/L D. BUN 18 mg/dL
C. Serum potassium 3.0 mEq/L
A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances? A. fluid volume deficit and acidosis B. fluid volume excess and alkalosis C. fluid volume deficit and alkalosis D. fluid volume excess and acidosis
D. fluid volume excess and acidosis
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Blood pressure, heart rate, and rhythm b) Intake and output, urine volume, and color c) Strength testing for muscle wasting d) Skin assessment for edema and turgor e) Nutritional status and diet a) Blood pressure, heart rate, and rhythm, b) Intake and output, urine volume, and color, d) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess. A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypocalcemia b) Hypokalemia c) Hyponatremia d) Hypomagnesium
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Blood pressure, heart rate, and rhythm b) Intake and output, urine volume, and color c) Strength testing for muscle wasting d) Skin assessment for edema and turgor e) Nutritional status and diet a) Blood pressure, heart rate, and rhythm, b) Intake and output, urine volume, and color, d) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess. A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypocalcemia b) Hypokalemia c) Hyponatremia d) Hypomagnesium b) Hypokalemia Explanation: Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.
2. Which of the following is not a symptom of hyperkalemia? A. Positive Chvostek's sign B. Decreased blood pressure C. Muscle twitches/cramps D. Weak and slow heart rate
a
6. A patient with nasogastric suctioning is experiencing diarrhea. The patient is ordered a morning dose of Lasix 20mg IV. Patient's potassium level is 3.0. What is your next nursing intervention? A. Hold the dose of Lasix and notify the doctor for further orders B. Administered the Lasix and notify the doctor for further orders C. Turn off the nasogastric suctioning and administered a laxative D. No intervention is need the potassium level is within normal range
a
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. Hypotension B. Peripheral edema C. Facial flushing D. Hyperreflexia
a
A patient has a potassium level of 9.0. Which nursing intervention is priority? A. Prepare the patient for dialysis and place the patient on a cardiac monitor B. Administer Spironolactone C. Place patient on a potassium restrictive diet D. Administer a laxative
a
Which patient is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? A. a 4-month-old infant B. a 45-year-old woman C. an 86-year-old man D. a 17-year-old adolescent
a
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 155 mEq/L b) 135 mEq/L c) 125 mEq/L d) 145 mEq/L
a The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Intake and output, urine volume, and color b) Blood pressure, heart rate, and rhythm c) Strength testing for muscle wasting d) Nutritional status and diet e) Skin assessment for edema and turgor
a b e
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) 0.45% NaCl b) Lactated Ringer's solution c) 0.9% NaCl d) 5% NaCl
a) 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer's solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? A. Decreased muscle strength B. Decreased gastric motility C. Increased heart rate D. Increased blood pressure
a. decreased muscle strength
9. A patient has a potassium level of 2.0. What would you expect to be ordered for this patient? A. Potassium 30 meq IV push B. Infusion of Potassium intravenously C. An oral supplement of potassium D. Intramuscular injection of Potassium
b
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 -26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis A. Respiratory acidosis A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? A. Sodium polystyrene sulfonate 30 g/day B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr C. Bumetanide 8 mg/day D. 100 mL of dextrose 10% in water with 10 units of insulin
b
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A. Hyperactive deep-tendon reflexes B. Orthostatic hypotension C. Rapid, deep respirations D. Strong, bounding pulse
b
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A. Administer a hypertonic solution B. Repeat the potassium level C. Withhold the medication D. Monitor for paresthesia C. Withhold the medication A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate
b
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) Lactated Ringer's solution b) 0.45% NaCl c) 5% NaCl d) 0.9% NaCl
b
Arterial blood gases reveal that a patient's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? A. increased excretion of bicarbonate ions by the kidneys B. increased respiratory rate C. hypoventilation D. renal retention of H+ ions
b
Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of? A. an infiltration B. phlebitis C. rapid fluid administration D. a systemic blood infection
b
When assessing a patient who is about to receive an albumin infusion, the nurse knows that a contraindication for albumin would be a. acute liver failure. b. heart failure. c. severe burns. d. fluid-volume deficit.
b
The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Increase the rate of the IV lactated Ringer's solution. b) Discontinue the IV lactated Ringer's solution. c) Change the lactated Ringer's solution to 3% saline. d) Change the lactated Ringer's solution to 2.5% dextrose.
b The lactated Ringer's IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer's contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer's also contains potassium, which would worsen the hyperkalemia.
The nurse is administering an IV solution that contains potassium chloride to a patient in the critical care unit who has a severely decreased serum potassium level. Which action(s) by the nurse are appropriate? (Select all that apply.) a. Administer the potassium by slow IV bolus. b. Administer the potassium at a rate no faster than 20 mEq/hr. c. Monitor the patient's cardiac rhythm with a heart monitor. d. Use an infusion pump for the administration of IV potassium chloride. e. Administer the potassium IV push.
b c d
The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Respiratory acidosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory alkalosis
b) Metabolic acidosis The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
(Select all that apply) Which of the following are hypertonic solutions? A. NS B. LR C. D5 0.45% NS D. D5 0.9% NS E. 0.45% NS C. D5 0.45% NS D. D5 0.9% NS What are the total electrolytes in hypotonic solution? A. 300 mEq/L B. >375 mEq/L C. 250 mEq/L D. 310 mEq/L
c
4. Which patient is at risk for hyperkalemia? A. Patient with Parathyroid cancer B. Patient with Cushing's Syndrome C. Patient with Addison's Disease D. Patient with breast cancer
c
7. A patient is presenting with an orthostatic blood pressure of 80/40 when she stands up, thready and weak pulse of 58, and shallow respirations. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? A. Potassium level of 7.0 B. Potassium level of 3.5 C. Potassium level of 2.4 D. None of the options are correct
c
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A. Administer a hypertonic solution B. Repeat the potassium level C. Withhold the medication D. Monitor for paresthesia
c
Albumin is ____% of the plasma proteins. A. 20% B. 40% C. 50% D. 60%
c
when preparing IV solution that contains potassium, the nurse knows that a contraindication to the potassium infusion would be a. diarrhea. b. serum sodium level of 145 mEq/L. c. serum potassium level of 5.6 mEq/L. d. dehydration.
c
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Hallucinations b) Nausea c) Confusion d) Headache
c Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Mild confusion c) Irregular heart rate d) Weight loss of 4 lb
c) Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.
13. A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline
d
3. Tall peaked T-waves, flat P-waves, prolonged PR intervals and widened QRS complexes can present in which of the following conditions? A. Hypocalemia B. Hypercalemia C. Hypokalemia D. Hyperkalemia
d
4. The nurse is preparing an infusion for a patient who has a deficiency in clotting factors. Which type of infusion is most appropriate? a. Albumin 5% b. Packed RBCs c. Whole blood d. Fresh frozen plasma
d
9. Which of the following is indicative of an EKG change in a case of hypokalemia? A. Widened QRS complex and prolonged PR interval B. Prolonged ST interval and Widened T-wave C. Tall T-waves and depressed ST segment D. ST depression and inverted T-wave
d
A nurse is reviewing the laboratory data on four clients. Which of the following serum laboratory values should the nurse expect off for the client who is experiencing 2+ pitting ankle edema? A. Sodium 138 mEq/L B. Hematocrit 34% C. BUN 22 mg/dL D. Protein 9 g/L B. Hematocrit 34% A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering? A. 1,000 mL 0.9% sodium chloride B. 1,000 mL dextrose 5% in water C. 1,000 mL dextrose 10% in water D. 1,000 mL 0.225% sodium chloride
d
What is the order of the acid-base regulators? A. Respiratory, chemical, renal B. Chemical, renal, respiratory C. Renal, respiratory, chemical D. Chemical, respiratory, renal
d
While monitoring a patient who is receiving an infusion of a crystalloid solution, the nurse will monitor for which potential problem? a. Bradycardia b. Hypotension c. Decreased skin turgor d. Fluid overload
d
True/False Hypertonic solutions cause cells to swell.
false
while monitoring a patient whose given an infusion of crystalloid solution, the nurse should monitor for which potential problem?
fluid overload
Which action by the nurse is most appropriate for the patient receiving an infusion or packed red blood cells? a. Flush the IV line with normal saline before the blood is added to the infusion. b. Flush the IV line with dextrose before the blood is added to the infusion. c. Check the patient's vital signs once the infusion is completed. d. Anticipate that flushed skin and fever are expected reactions to a blood transfusion.
flush the IV line with normal saline before the blood is added to the infusion
6. when assessing a patient receiving albumin, the nurse knows which is the contraindication for albumin
heart failure
When administering sodium polystyrene sulfonate orally the nurse would monitor for which adverse effect?
hypokalemia
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A. Skin turgor B. Urine output C. Weight D. Mental status
mental status
When administering potassium chloride intravenously the nurse would monitor the patient for which of the following?
phlebitis
what decreases oncotic pressure
sodium chloride
Which drug has the greatest associated risk of fluid overload?
sodium chloride its given in larger quantities
True/False When a patient is in an acidotic state, their potassium levels increase.
true
