Hematological; Fluids &Electrolytes

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

1. Daily weight

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply.

1. 10% dextrose in water 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 6. 5% dextrose in lactated Ringer's solution

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply.

1. Blood transfusions 3. Bleeding or hemorrhage 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

1. Dehydration

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.

1. Dehydration 3. Physiological stress 4. Decreased blood volume

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply.

1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.

1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 5. Prevent complications during potassium administration.

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

1. Heparin

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

1. Hypotension

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

1. Monitor the client for dysrhythmias.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

1. Pour the aspirate into the NG tube through a syringe with the plunger removed.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

1. Prolonged bed rest

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take?

1. Take no action.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.

1. Tetany 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

Which clients are most likely to be at risk for the development of third spacing? Select all that apply.

1. The client with cirrhosis 2. The client with liver failure 5. The client with chronic kidney disease

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply.

1. " I may continue to use an electric shaver" 2. " I will not blow my nose if I get a cold" 5. " I should use a soft-bristled toothbrush to avoid mouth trauma"

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

1. " I need to increase my fluid intake"

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

1. A client with an ileostomy

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

1. Bounding pulse 2. Difficulty breathing 4. Presence of dependent edema 5. Neck vein distention in the upright position

The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client?

1. Initiate an intravenous (IV) line for the administration of fluids.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

1. Malnutrition

The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply.

1. Pallor 2. Fever 3. Joint swelling 5. Abdominal pain

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

1. Peas 2. Nuts 4. Cauliflower

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

1. The client who is taking diuretics

prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply.

1. Transfusions 2. Splenectomy 4. Corticosteriod medication 5. Immunosuppressive agents

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

1. Twitching

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

1. U waves 3. Inverted T waves 4. Depressed ST segment

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

1. Weight loss and poor skin turgor

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

2. Asks the athletes to take a salt tablet before football practice

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

2. Client with an ischemic stroke

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

2. Contact the health care provider (HCP).

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

2. Muscle weakness

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

2. A urine specific gravity of 1.043

When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about?

2. Dietary intake of iron

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

2. Raisins 3. Potatoes 4. Cantaloupe 5. Strawberries

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

2. Resume full activity level

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

4. Th client who has sustained a traumatic burn

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

4. The client with kidney disease and a 12-year history of diabetes mellitus

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?

3. 0.9% sodium chloride

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?

3. A client admitted 6 hours ago with a 40% burn injury

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?

3. Areflexia

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

3. Client with diabetes insipidus

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level?

3. Depressed ST segment

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

3. Changes in mental status

The nurse is caring for a client with 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 a client with hyponatremia?

3. Hyperactive bowel sounds

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

3. Integumentary output

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?

3. Respiratory depression

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

3. Tall peaked T waves 5. Widened QRS complexes

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.

30mL

The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored?

4. Hyperkalemia

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

4. Loss of deep tendon reflexes

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures.

4. Pulling up and releasing the skin on the sternal area

The 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 result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?

4. Sodium chloride

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do?

4. Stop administering the enemas until the health care provider (HCP) is notified.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

4. Urine specific gravity of 1.032

The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures?

4. "I need to avoid situations that may lead to an infection"

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia?

4. Decreased production of erythropoietin is causing anemia.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition?

4. Disseminated intravascular coagulopathy (DIC)

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply.

4. Prolonged QT interval 5. Prolonged ST segment

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client?

4. Red tongue that is smooth and sore

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia?

4. Shortness of breath with activity

A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action?

4. Sit the client down, ask the client to lean forward slightly and apply pressure to the nose for 5 to 10 minutes

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?

Check skin turgor over the client's sternum.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L (3.0 mmol/L)

potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction