NCLEX Fluids and Electrolytes Chapter 9

51. Nurse reviews client's serum phosphorus level and notes that level is 2.0 mg/dL. Nurse understands that which condition causes this serum phosphorus level?

1. Alcoholism Normal 2.7 to 4.5 Hypohosphatemia Causative factors relate to decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism.

49. Nurse is instructing a client on how to decrease the intake of potassium in the diet. The nurse tells the client that which food contains the least amount of potassium?

1. Lettuce Lettuce contains less than 100 mg of potassium. (potatoes, apricots, and avocados are potassium-containing food and s/be avoided by client on a potassium-restricted diet.)

38. Nurse is reading physician's progress notes in client's record and sees that physician has documented "insensible fluid loss of approximately 800mL daily." Nurse understands that this type of fluid loss can occur through:

1. The skin Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

47. Nurse is instructing a client on how to decrease intake of calcium in diet. Nurse tells the client that which food item contains the least amount of calcium?

2. Butter Butter comes from milk fat and does not contain significant amounts of calcium. (Milk, spinach, and collard greens are calcium-containing foods and s/be avoided by client on a calcium-restricted diet.

44. Nurse is caring for client w/diagnosisof hyperparathyroidism. Lab studies are performed, and serum calcium level is 12.0 mg/dL. On basis of this lab value, nurse takes which action?

2. Informs RN of lab value. The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is experiencing hypercalcemia, and the nurse w/inform the RN of the lab value.

52. A nurse is instructing a client regarding how to decrease the intake of phosphorus in the diet. The nurse tells the client that which food item contains the least amount of phosphorus?

2. Oranges Foods high in phosphorus include fish, pork, beef, chicken, organ meats, nuts, whole-grain breads, and cereals.

45. Nurse reviews client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition w/cause this serum calcium level?

2. Prolonged bedrest The normal serum calcium level is 8.6 to 10.0 mg/dL. A client w/a serum calcium level of 8.0 mgdL is experiencing hypocalcemia. Long term effect of prolonged bedrest is hypocalcemia. (The excessive ingestion of vit. D, renal disease, and hyperparathyroidism are causative factors assoc. w/hypercalcemia.

53. Nurse is told in report that client has a positive Chvostek's sign. What data would the nurse expect to note during the data collection?

2. Tetany 3. Diarrhea 4. Possible seizure activity 6. A positive Trousseau's sign

40. A nurse is reviewing health records of assigned clients. Nurse plans care knowing that which client is at risk for fluid volume deficit?

2. The client with a colostomy. Causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fisulas, ileostomy, and colostomy.

36. Nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. Nurse understands that potassium value at this level w/be noted w/which condition?

2. Traumatic burn A serum potassium level that exceeds 5.1 mEq/L is inidcative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in early stages of massive cell destruction (trauma, burns, sepsis, metabolic or respiratory acidosis), are at risk for hyperkalemia. (The client w/Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.)

48. Nurse is caring for a client w/hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication w/the nurse prepare to administer as prescribed to the client?

3. Calcitonin (Miacalcin) Normal - 8.6 to 10.0 mg/dL This patient is hypercalcemic; Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

34. Nurse caring for client w/cirrhosis. Nurse notes client is dyspneic and crackles heard on auscultation of lungs; fluid volume excess suspected. What additional signs w/nurse expect to note in this client if fluid volume excess is present?

4. An increase in blood pressure. Findings assoc. w/fluid volume excess include: Dyspnea Crackles tachypnea tachycardia elevated blood pressure bounding pulse elevated central venous pressure weight gain edema neck and hand vein distention altered level of consciousness/confusion decreased hematocit level

46. A nurse is caring for a client w/a suspected diagnosis of hypercalcemia. Which of the following signs w/be an indication of this diagnosis?

4. Generalized muscle weakness.

41. Nurse is caring for client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in client w/this condition?

4. Increased specific gravity of the urine. Finding in a client w/a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. (Gurgling respirations, increased BP, decreased hematocrit level are seen in fluid volume excess)

50. Nurse is caring for client w/renal failure. Lab results reveal a magnesium level of 3.6 mg/dL. Which of the following signs w/the nurse expect to note in the client based on this magnesium level?

4. Loss of deep tendon reflexes Normal 1.6 to 2.6 This patient is experiencing hypermagnesemia.

37.Nurse reviews a client's electrolyte results and notes that potassium level is 5.4 mEq/L. Which of following w/nurse note on cardiac monitor as a result of this lab value?

4. Narrow, peaked T waves. A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave, a prolonged PR interval; a widened QRS complex; narrow, peaked T-waves; and a depressed ST segment.

35. Nurse is reviewing health records of assigned clients. Nurse plans care knowing that which client is at risk for potassium deficit?

4. The client receiving nasogastric suction Potassium-rich GI fluids are lost through GI suction, which places client at risk for hypokalemia. (The client w/renal disease, Addison's disease and metabolic acidosis is at risk for hyperkalemia)

42. Nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. Nurse understands that this sodium level w/be noted in a client wi/which condition?

4. The client w/the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. (The client w/an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.)

39. Nurse reviewing health records of assigned clients. Nurse plans care knowing that which client is at lowest risk for development of third-spacing?

4. The client with diabetes mellitus. Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless, because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

43. Nurse is caring for a client w/leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs w/the nurse expect to note in this client if hyponatremia is present?

4. Postural blood pressure changes. Postural blood pressure changes occur in the client w/hyponatremia. (Dry mucous membranes and intense thirst are seen in clients w/hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client w/hyponatremia, a rapid thready pulse is noted.) S/s of hyponatremia: Rapid, thready pulse Postural blood pressure changes Weakness Abdominal cramping Poor skin turgor Muscle twitching and seizures Apprehension