F&E NCLEX
B. Baked chicken D. Baked potato
. Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L? A. Pretzels B. Baked chicken C. Chicken bouillon D. Baked potato E. Baked ham
C. 2000 mL First, determine how many pounds the client has lost: 180 - 175.6 = 4.4 pounds lost Then, based on the fact that 1 liter of fluid weighs 2.2 pounds, determine how many liters of fluid have been lost. 4.4 / 2.2 = 2 liters lost Then, because the question asks for the answer in milliliters, convert 2 liters into milliliters. 2 x 1000 = 2000 mL TEST-TAKING HINT: The test taker must be able to work basic math problems. This problem has several steps. Sometimes it is helpful to write out what is occurring at each step, such as 4.4 divided by 2.2 kg per pound. This can help the test taker realize if a step has been overlooked.
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A. 500 mL B. 1000 mL C. 2000 mL D. 4400 mL
D. Place on seizure precautions A. (incorrect) The client probably will be placed on fluid restriction. Fluids should not be encouraged for a client with a low sodium level (135-145 mEq/L). B. (incorrect) Hypertonic solutions of saline are 3% to 5%, not 10%, because of the extreme nature of hypertonic solutions. Hypertonic solutions of saline may be used but very cautiously because if the sodium levels are increased too rapidly, a massive fluid shift can occur in the body, resulting in neurological damage and heart failure. C. (incorrect) THe antidiuretic hormone (vasopressin) would cause water retention in the body and increase the problem. D. (correct) Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure. TEST-TAKING HINTS: The test taker must memorize certain common lab values and understand how deviations in the electrolytes affect the body.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.
A. 50-year-old with pneumonia, diaphoresis, and high fevers Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.
The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50-year-old with pneumonia, diaphoresis, and high fevers B. 62-year-old with congestive heart failure taking loop diuretics C. 39-year-old with diarrhea and vomiting D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)
A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L Normal serum magnesium is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.
The nurse evaluates which of the following clients to have hypermagnesemia? A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L
B. Baked chicken D. Baked potato Normal serum sodium is between 135 and 145 mEq/L. A sodium level of 158 mEq/L is elevated and a low sodium diet should be prescribed. A peanut butter sandwich, pretzels, chicken bouillon, and baked ham are all foods high in sodium content. Baked chicken and baked potato are low-sodium food choices.
The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of A. Acute renal failure. B. Malabsorption syndrome. C. Nasogastric drainage. D. Laxative abuse
B. Question the results and redraw the specimen A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.
The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen C. Encourage the client to increase the intake of bananas D. Initiate seizure precautions
B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.
The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? A. Increase intake of dairy products and nuts B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals C. Reduce intake of chocolate, meats, and whole grains D. Avoid calcium supplements
B. Ensure the client is safe from falls and check the most recent potassium level In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.
A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A. Request a physical therapy consult from the physician B. Ensure the client is safe from falls and check the most recent potassium level C. Allow uninterrupted rest periods throughout the day D. Encourage the client to increase intake of dairy products and green leafy vegetables.
C. Positive Chvostek's sign
A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain B. Depressed deep tendon reflexes C. Positive Chvostek's sign D. Nausea
B. Hypocalcemia Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.
A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia
D. Processed oat cereals Rationale: 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. Test-Taking Strategy: First, you must determine that the client has hypernatremia. Next, note the strategic word AVOID in the question. Eliminate options A and B first because these are vegetables. From the remaining options, note the word PROCESSED in option D. Processed foods tend to be higher in sodium content. Review foods high in sodium content if you had difficulty with this question.
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
B. Excess fluid volume related to increased water retention The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.
A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A. Deficient fluid volume related to decreased fluid intake B. Excess fluid volume related to increased water retention C. Deficient fluid volume related to excessive fluid loss D. Risk for injury related to fluid volume loss
D. Milk of magnesia Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.
A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A. Bisacodyl (Dulcolax) suppository B. Fiber supplements C. Docusate sodium D. Milk of magnesia
C. Dehydration. A. (incorrect) Clients who are overhydrated or have fluid volume excess would experience dilutional values of sodium (135-145 mEq/L) and red blood cells (44% to 52%). The levels would be lower than normal, not higher. B. (incorrect) Anemia is a low red blood cell count for a variety of reasons. C. (correct) Dehydration results in concentrated serum that causes lab values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower. D. (incorrect) In renal failure, the kidneys cannot excrete, and this results in too much fluid in the body. TEST-TAKING HINT: The test taker must decide first if the values are high or low and then determine what is happening with body fluids in each process. Overhydration and renal failure result in the same fluid shift, so these two options (A and D) could be excluded.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. B. Anemia. C. Dehydration. D. Renal failure.
D. Hypocalcemia Normal serum calcium is 9 to 11 mg/dl. A client who has hypocalcemia would experience muscle cramps, numbness, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypothyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.
The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following? A. Hypokalemia B. Hypernatremia C. Hypermagnesemia D. Hypocalcemia
B. A client who is alcoholic receiving total parenteral nutrition A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving TPN are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.
The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A. A client with osteoporosis taking vitamin D and calcium supplements B. A client who is alcoholic receiving total parenteral nutrition C. A client with chronic renal failure awaiting the first dialysis run D. A client with hypoparathyroidism secondary to thyroid surgery
C. Prolonged QT interval Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. Test-Taking Strategy: Use knowledge regarding the electrocardiographic changes that occur in a calcium imbalance to answer the question. Remember that hypocalcemia causes a prolonged ST or QT interval. If you had difficulty with this question, review the electrocardiographic changes that occur in these conditions
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
C. On auscultation, crackles and rales in all lung fields are noted. A. (incorrect) The pump is alerting the nurse that there is resistance distal to the pump; this does not require notifying the health care provider. B. (incorrect) The client has an 1800 mL intake and total output of 1500 mL. The body has an insensible loss of approximately 400 mL per day through the skin, respirations, and other body functions. This would not warrant notifying the health care provider. C. (correct) Crackles and rales in all lung fields indicate that the body is not able to process the amounts of fluids being infused. This should be brought to the health care provider's attention. D. (incorrect) Negative pedal edema and an increasing level of consciousness indicate that the client is not experiencing a problem. TEST-TAKING HINT: The question requires the test taker to distinguish nursing problems from client problems. Option A is a nursing problem and options B and D are expected results, so the health care provider does not need to be notified. Only one option, C, contains abnormal or life-threatening information.
The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A. The pump keeps sounding an alarm that the high pressure has been reached. B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL. C. On auscultation, crackles and rales in all lung fields are noted. D. Client has negative pedal edema and an increasing level of consciousness.
B. 0.9 NS at an open rate A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly
A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A. D5.45 NS at 50 ml/hr B. 0.9 NS at an open rate C. D5W at 125 ml/hr D. 0.45 NS at open rate
C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.
A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? A. "The fluid is an adverse reaction to chemotherapy." B. "A decrease in activity has allowed extra fluid to accumulate in the tissues." C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."
A. Acute renal failure. A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndrome, nasogastric drainage, and laxative abuse may result in a low serum potassium level, because output may be greater than input. Diarrhea results in malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L.
A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A. Withhold furosemide (Lasix) B. Notify the physician C. Administer the prescribed potassium supplement D. Instruct the client on foods high in potassium
C. Bowel movements. Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.
A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A. Urine output. B. Blood pressure. C. Bowel movements. D. ECG for tall, peaked T waves.
C. Assess for signs of fluid overload A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.
A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician
D. Check to see if a serum albumin level is available A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.
A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A. Assess for depressed deep tendon reflexes B. Call the physician to report calcium level C. Place an intravenous catheter in anticipation of administering calcium gluconate D. Check to see if a serum albumin level is available
C. Call the physician D. Report the urine output E. Report indications of nausea Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.
A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin B. Encourage the client to increase fluid intake C. Call the physician D. Report the urine output E. Report indications of nausea
D. Magnesium Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.
A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? A. Sodium B. Phosphorus C. Calcium D. Magnesium
D. Decreased central venous pressure (CVP) Rationale: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options A, B, and C are seen in a client with excess fluid volume. Test-Taking Strategy: Use the process of elimination and focus on the subject, deficient fluid volume. Eliminate options A and C first. Lung congestion is noted in excess fluid volume, as is increased blood pressure. From the remaining options, recall that central venous pressure reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore, pressure (volume) would be decreased in a deficient fluid volume. If you had difficulty with this question, review the assessment findings noted in deficient fluid volume.
A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A. Lung congestion B. Decreased hematocrit C. Increased blood pressure D. Decreased central venous pressure (CVP)
A. Twitching Rationale: 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 ansiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Test-Taking Strategy: Use the process of elimination, noting that options B, C, and D are comparative or alike in that they reflect a hypoactivity. The option that is different is option A. Review the assessment signs and symptoms noted in hypocalcemia if you had difficulty with this question.
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
B. The client with renal failure Rationale: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. Test-Taking Strategy: Use the process of elimination and focus on the subject, excess fluid volume. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options A, C, and D lose fluid. The only condition that can cause an excess is the condition noted in option B. If you had difficulty with this question, review the causes of excess fluid volume.
A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A. The client who requires gastrointestinal suctioning B. The client taking diuretics C. The client with renal failure D. The client with an ileostomy
C. Sodium chloride Rationale: 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 chloride (isotonic) should be used rather than water for gastrointestinal irrigations. Test-Taking Strategy: Use the process of elimination. Eliminate options A, B, and D because they are comparative or alike (sterile water, tap water, and distilled water). Also, recalling that the serum sodium level identified in the question indicates hyponatremia will direct you to option C. If you had difficulty with this question, review the care of the client experiencing hyponatremia.
A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations 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
C. Hyperactive bowel sounds Rationale: Hyperactive bowel sounds indicate hyponatremia. Options A, B, and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. Test-Taking Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to option C. If you had difficulty with this question, review the assessment signs associated with hyponatremia and hypernatremia.
A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? A. Dry skin B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine
A. Prolonged bed rest Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. Test-Taking Strategy: Note the strategic words MOST LIKELY. First, you must determine that the client is experiencing hypocalcemia. This should assist in eliminating option D. Next, you must recall the causative factors associated with hypocalcemia to direct you to option A. If you had difficulty with the question, review the causative factors associated with hypocalcemia.
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
D. Preparing the medication for bolus administration Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. Test-Taking Strategy: Use the process of elimination and knowledge regarding the administration of potassium chloride intravenously. Noting the strategic word UNPREPARED in the question and BOLUS in option D will direct you to the correct option. Review the administration of potassium chloride if you had difficulty with this question.
A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? A. Obtaining a controlled IV infusion pump B. Monitoring urine output during administration C. Diluting in appropriate amount of normal saline D. Preparing the medication for bolus administration
A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. E. Monitor intake and output every shift. A. (correct) TPN is a hypertonic solution that has enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion. B. (correct) TPN contains 50% dextrose solution; therefore, the client is monitored to ensure that the pancreas is adapting to the high glucose levels. C. (incorrect) The client is weighed daily, not weekly, to monitor for fluid overload. D. (incorrect) The IV tubing is changed with every bag because the high glucose level can cause bacterial growth. E. (correct) Intake and output are monitored to observe for fluid balance. TEST-TAKING HINT: Options C and E refer to the same factor--namely, fluid level. The test taker should then determine if the time factors are appropriate. Weekly weighing is not appropriate so C can be eliminated.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. C. Weigh the client weekly, first thing in the morning. D. Change the IV tubing every three (3) days. E. Monitor intake and output every shift.
C. Instruct the client on appropriate fluid restrictions. A. (incorrect) An assistant can empty the catheter and measure the amount. B. (incorrect) The assistant can record intake and output on the I & O sheet. C. (correct) The nurse cannot delegate teaching. D. (incorrect) The client has a disease, but all the assistant is being asked to do is take water to the client. TEST-TAKING HINT: This is an example of an "except" question. Frequently questions ask which tasks can be assigned to the assistant, but this question asks which action the nurse should implement. If the test taker does not read carefully, it is easy to jump to the first option for actions that the assistant can perform.
The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform? A. Measure the client's output from the indwelling catheter. B. Record the client's intake and output on the I & O sheet. C. Instruct the client on appropriate fluid restrictions. D. Provide water for a client diagnosed with diabetes insipidus.
A. Baked cod D. Baked potato E. Spinach Normal serum potassium is 3.5 to 5.5 mEq/L. A client who has a potassium of 3.2 mEq/L would benefit from a diet high in potassium. Baked cod, baked potato, and spinach are all food selections high in potassium. A ham and cheese omelet is high in sodium. Fried eggs are high in cholesterol. A whole grain muffin is high in grains.
The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A. Baked cod B. Ham and cheese omelet C. Fried eggs D. Baked potato E. Spinach
D. A client with dehydration and a sodium level of 149 mEq/L Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dl is normal. Normal serum calcium is 9 to 11 mg/dl. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal. Normal serum potassium is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated. Bren Marie: because the mg level stated is still within normal range. A patient who is already dehydrated and has a high sodium level is more likely to have severe acute issues needing to be addressed immediately. Naomi Pitt: I used Maslow's Hierarchy of needs for this one. Water, breathing, and essentials are at the bottom so that's why I chose dehydration.
The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A. A client with osteoporosis and a calcium level of 10.6 mg/dl B. A client with renal failure and a magnesium level of 2.5 mEq/L C. A client with bulimia and a potassium level of 3.6 mEq/L D. A client with dehydration and a sodium level of 149 mEq/L
B. Restrict the client's sodium in the diet. A. (incorrect) The nursing plan of care does not include changing the health care provider's orders. B. (correct) Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume. C. (incorrect) High blood glucose levels result in viscous blood and cause the kidneys to try and fix the problem by excreting the glucose through increasing the urine output, which results in fluid volume deficits. D. (incorrect) If the FVE is the result of renal failure, then hemodialysis may be ordered, but this information was not provided in the stem of the question. TEST-TAKING HINT: Option A is not a nursing prerogative. The test taker should not read into the question.
The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? A. Change the IV fluid from 0.9% NS to D5W. B. Restrict the client's sodium in the diet. C. Monitor blood glucose levels. D. Prepare the client for hemodialysis.
A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience a low chloride level, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dl is elevated. Normal serum phosphate is 2.8 to 4.5 mg/dl. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium is 135 to 145 mEq/L
The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl D. A client with dehydration who has a serum sodium level of 128 mEq/L
A. The client in normal sinus rhythm with a peaked T wave. A. (correct) A client with a peaked wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability. B. (incorrect) Fluctuations in rate are expected in clients diagnosed with atrial fibrillation, and a heart rate of 100 is at the edge of a normal rate. C. (incorrect) Most people experience an occasional premature ventricular contraction (PVC); this would not warrant the nurse assessing this client first. D. (incorrect) A first-degree block is not an immediate problem. TEST-TAKING HINT: The test taker must know the normal data so that the abnormal will be apparent. Normal heart rate is 60-100. The nurse should assess the client who has an abnormal or life-threatening condition.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A. The client in normal sinus rhythm with a peaked T wave. B. The client diagnosed with atrial fibrillation with a rate of 100. C. The client diagnosed with a myocardial infarction who has occasional PVC. D. The client with a first-degree AV block and a rate of 92.
A. Deep tendon reflexes decreasing from +2 to +1 A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.
Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A. Deep tendon reflexes decreasing from +2 to +1 B. Bicarbonate rising from 20 mEq/L to 22 mEq/L C. Urine pH less than 6 D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
C. The lungs speed up to release carbon dioxide and increase the pH. A. (incorrect) Kussmaul's respirations are the lung's attempt to maintain the narrow range of pH that is compatible with human life. The respiratory system reacts rapidly to changes in pH. B. (incorrect) Respiration is the act of moving oxygen and carbon dioxide. Kussmaul's respirations are rapid and deep and allow the client to exhale carbon dioxide. C. (correct) The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid). D. (incorrect) HCO3 (sodium bicarbonate) is an alkaline (base) substance that is a metabolic buffer system, not a respiratory system buffer. The excretion and retention of sodium bicarbonate is regulated by the kidneys; therefore, it is a metabolic buffer system. The excretion and retention of carbon dioxide (CO2) are regulated by the lungs and therefore is a respiratory buffer system. TEST-TAKING HINT: Homeostasis is a delicate balance between acids and bases. The test taker can discard option A by realizing that production of urine does not affect the respirations
Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? A. The kidneys produce excess urine and the lungs try to compensate. B. The respirations increase the amount of carbon dioxide in the bloodstream. C. The lungs speed up to release carbon dioxide and increase the pH. D. The shallow and slow respirations will increase the HCO3 in the serum.
