NCLEX Questions F&E

5. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? Administer the KCl as a rapid IV bolus. Infuse the KCl at a rate of 10 mEq/hour. Only give the KCl through a central venous line. Discontinue cardiac monitoring during the infusion.

Infuse the KCl at a rate of 10 mEq/hour.

A patient had the following during the previous shift: emesis 75 mL, urine output 725 mL, water 240 mL, IV fluids 650 mL, and IV medication 100 mL. Which intake and output values should the nurse document for this patient? ANSWER Intake 990 mL, output 800 mL Intake 950 mL, output 840 mL Intake 890 mL, output 900 mL Intake 940 mL, output 850 mL

Intake 990 mL, output 800 mL

A patient had the following during the previous shift: emesis 75 mL, urine output 725 mL, water 240 mL, IV fluids 650 mL, and IV medication 100 mL. Which intake and output values should the nurse document for this patient? Intake 990 mL, output 800 mL Intake 950 mL, output 840 mL Intake 890 mL, output 900 mL Intake 940 mL, output 850 mL

Intake 990 mL, output 800 mL Output consists of urine and emesis and this totals 800 mL for this patient. IV fluids, IV medication, and water are counted as intake and this totals 990 mL for this patient. Accurate intake and output is important to determine if the amount of intake is proportional to the amount of output, because this is objective and can be measured. This must be considered when looking at insensible fluid losses, as well.

Laboratory results for a patient show a serum potassium level of 2.2 mEq/L. Which of the following nursing actions is of highest priority for this patient? A. Keep the patient on bed rest. B. Initiate cardiac monitoring. C. Start oxygen at 2 L/min. D. Initiate seizure precautions.

initiate cardiac monitoring

A nurse is unable to secure an intravenous access site due to severe dehydration. Which prescription should the nurse expect to replace this patient's fluid deficit? "Administer fluids via hypodermoclysis." "Administer sodium supplements." "Administer oral fluid replacement." "Administer diuretics."

"Administer fluids via hypodermoclysis."

A nurse is unable to secure an intravenous access site due to severe dehydration. Which prescription should the nurse expect to replace this patient's fluid deficit? "Administer fluids via hypodermoclysis." "Administer sodium supplements." "Administer oral fluid replacement." "Administer diuretics."

"Administer fluids via hypodermoclysis." When IV access is problematic, fluids can be administered subcutaneously, using a method called hypodermoclysis. Diuretics are used to treat fluid volume excess, not dehydration. Oral fluid replacement is ordered for mild dehydration, not severe dehydration. Fluid replacement, not sodium supplements, would be anticipated.

The nurse is teaching older adult patients how to prevent fluid volume deficit. Which information should the nurse include? ANSWER "Avoid extreme temperatures." "Decrease fluid intake." "Increase sodium in the diet." "Take diuretics daily."

"Avoid extreme temperatures."

The nurse is teaching older adult patients how to prevent fluid volume deficit. Which information should the nurse include? "Avoid extreme temperatures." "Decrease fluid intake." "Increase sodium in the diet." "Take diuretics daily."

"Avoid extreme temperatures." Exposure to extreme temperatures such as heat can cause the patient to sweat and experience insensible fluid loss. Decreasing the amount of fluid intake and taking diuretics will cause fluid loss. Increasing sodium in the diet will cause fluid volume excess.

The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte imbalances, which statement or question is the most important for the nurse to ask? ANSWER "Describe what you eat and drink on a typical day." "Are you currently being treated for joint problems?" "Have you recently had a cold?" "Describe your anxiety level on a typical day."

"Describe what you eat and drink on a typical day."

The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte imbalances, which statement or question is the most important for the nurse to ask? "Describe what you eat and drink on a typical day." "Are you currently being treated for joint problems?" "Have you recently had a cold?" "Describe your anxiety level on a typical day."

"Describe what you eat and drink on a typical day." It is important for the nurse to consider socioeconomic factors affecting food and fluid intake when assessing a patient's risk for fluid and electrolyte imbalances, especially with a vulnerable population such as the homeless. Asking a patient to describe a typical day's food and fluid intake will help the nurse determine if a patient's oral intake is adequate. Joint problems and minor respiratory infections are not primary risk factors for fluid and electrolyte imbalances. It would be more important for the nurse to ask about kidney or thyroid disease, diabetes, or hypertension and acute conditions that cause fluid loss, such as gastroenteritis. Asking about anxiety is too general when assessing a patient's fluid and electrolyte status, because some anxiety is to be expected in a homeless patient.

The nurse is providing discharge instructions to the parent of a baby who has been treated for dehydration. Which statement by the parent should the nurse identify as indicative of a need for further instructions? ANSWER "I need to bring my baby back to the clinic if the number of wet diapers increases." "I need to return to the clinic if my baby's urine appears dark with crystals." "I should return to the clinic if my baby's fontanels are sunken." "I need to return to the clinic if my baby does not have tears when he cries."

"I need to bring my baby back to the clinic if the number of wet diapers increases."

The nurse is teaching a patient about maintenance of fluid and electrolyte balance. Which patient statement indicates an understanding of the modifiable risk factor with the most direct effect on calcium balance? ANSWER "I should exercise to help me to maintain an appropriate calcium balance." "I need to manage my stress level to help keep a good calcium level." "I should maintain adequate fluid intake for better calcium balance." "I need to take my diuretic medication as directed to maintain the appropriate calcium level."

"I should exercise to help me to maintain an appropriate calcium balance."

The nurse is teaching a patient taking a loop diuretic about prevention of fluid volume excess. Which should the nurse include in this teaching session? "You should perform daily weights." "You will need to increase the dose of the medication." "You can eat a banana each day." "You should decrease fluid intake."

"You should perform daily weights." Daily weights are the best indicator of fluid imbalance. The patient should not increase the amount of diuretic medication because that can cause fluid volume deficit. Bananas provide a source of potassium for the patient and bear no impact on fluid balance. Decreasing fluid intake could promote a fluid volume deficit and would be incorrect advice.

A patient with fluid volume excess has hypokalemia. Which collaborative therapy should the nurse expect to implement for this patient? Diuretic Oral fluid solution Isotonic electrolyte solution Heparin

Diuretic

The nurse is teaching a patient about maintenance of fluid and electrolyte balance. Which patient statement indicates an understanding of the modifiable risk factor with the most direct effect on calcium balance? "I should exercise to help me to maintain an appropriate calcium balance." "I need to manage my stress level to help keep a good calcium level." "I should maintain adequate fluid intake for better calcium balance." "I need to take my diuretic medication as directed to maintain the appropriate calcium level."

"I should exercise to help me to maintain an appropriate calcium balance." Regular weight-bearing exercise helps maintain calcium balance. Stress, fluid intake, and diuretics can all affect fluid and electrolyte balance in a general way, but they do not specifically target calcium.

4. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? "I will try to drink at least 8 glasses of water every day." "I will use a salt substitute to decrease my sodium intake." "I will increase my intake of potassium-containing foods." "I will drink apple juice instead of orange juice for breakfast."

"I will drink apple juice instead of orange juice for breakfast."

The nurse is teaching parents about fluid replacement in an infant who has been vomiting. Which statement made by the parents should indicate to the nurse that further teaching is required? ANSWER "I will withhold oral fluids until the vomiting stops." "Oral fluid replacement is the preferred method of fluid replacement." "When fluid loss is minimal, water may be sufficient to use for replacement." "With fluid loss due to diarrhea or vomiting, a rehydrating solution with electrolytes may be needed."

"I will withhold oral fluids until the vomiting stops."

The nurse is teaching parents about fluid replacement in an infant who has been vomiting. Which statement made by the parents should indicate to the nurse that further teaching is required? "I will withhold oral fluids until the vomiting stops." "Oral fluid replacement is the preferred method of fluid replacement." "When fluid loss is minimal, water may be sufficient to use for replacement." "With fluid loss due to diarrhea or vomiting, a rehydrating solution with electrolytes may be needed."

"I will withhold oral fluids until the vomiting stops." Oral fluid replacement is preferred when treating fluid volume deficit. Water may be acceptable, a rehydrating solution may be necessary, and oral fluid replacement is preferred.

A patient with severe heat exhaustion asks what type of fluid is in the intravenous infusion. Which response should the nurse provide? ANSWER "I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." "I'm giving you a solution that is a lot like your blood. It will replace the fluid you lost." "I'm giving you a solution that has proteins in it. It will help replace the fluid you lost." "I'm giving you a solution with a drug that will keep you from losing water."

"I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost."

A patient with severe heat exhaustion asks what type of fluid is in the intravenous infusion. Which response should the nurse provide? "I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." "I'm giving you a solution that is a lot like your blood. It will replace the fluid you lost." "I'm giving you a solution that has proteins in it. It will help replace the fluid you lost." "I'm giving you a solution with a drug that will keep you from losing water."

"I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." Crystalloid solutions are given intravenously to patients like this who have lost fluids from excessive sweating, inadequate intake, or insensible water loss. Crystalloid solutions mimic the body's extracellular fluid and replace lost fluids. Colloid solutions resemble blood more closely, because they contain proteins and other large molecules, and are given in cases of excessive blood loss. Crystalloid solutions do not contain a drug that causes a person to retain water.

2. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? "Increase fluids if your mouth feels dry. "More fluids are needed if you feel thirsty." "Drink more fluids in the late evening hours." "If you feel lethargic or confused, you need more to drink."

"Increase fluids if your mouth feels dry.

A parent asks how a 4-month-old infant with frequent vomiting can become dehydrated. Which response by the nurse is the best response to this query? ANSWER "Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a smaller body water percentage than adults, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a low body surface area, so they lose fluid more easily than adults and it is easy for them to get dehydrated." "Infants have a smaller percentage of their body water outside their cells than adults, so it is easy for them to get dehydrated."

"Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated."

A parent asks how a 4-month-old infant with frequent vomiting can become dehydrated. Which response by the nurse is the best response to this query? "Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a smaller body water percentage than adults, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a low body surface area, so they lose fluid more easily than adults and it is easy for them to get dehydrated." "Infants have a smaller percentage of their body water outside their cells than adults, so it is easy for them to get dehydrated."

"Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." Infants have a proportionally higher body water percentage, higher fluid requirements, higher body surface area, and lower intracellular fluid volume than adults, all of which make them more prone to dehydration. If the infant is unable to adequately take in enough fluids due to vomiting, dehydration can happen rapidly.

The nurse is teaching a patient taking a loop diuretic about prevention of fluid volume excess. Which should the nurse include in this teaching session? ANSWER "You should perform daily weights." "You will need to increase the dose of the medication." "You can eat a banana each day." "You should decrease fluid intake."

"You should perform daily weights."

The nurse discusses how active transport differs from other transport processes with colleagues. Which statement should the nurse include? "Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike diffusion, active transport moves solutes from a solution with a higher concentration of solutes to a less concentrated solution." "Unlike osmosis, active transport moves water from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike osmosis, active transport moves water from a solution with a higher concentration of solutes to a less concentrated solution."

"Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution."

The nurse discusses how active transport differs from other transport processes with colleagues. Which statement should the nurse include? "Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike diffusion, active transport moves solutes from a solution with a higher concentration of solutes to a less concentrated solution." "Unlike osmosis, active transport moves water from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike osmosis, active transport moves water from a solution with a higher concentration of solutes to a less concentrated solution."

"Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." Unlike diffusion, active transport moves solutes against their concentration gradients from a solution with a lower concentration to a more concentrated solution. Active transport does not move water, only solutes. Osmosis is the movement of water from a solution with a lower concentration of solutes to a more concentrated solution.

A patient has a low serum sodium level. Which intervention should the nurse expect to be prescribed for this patient? ANSWER 0.9% saline IV infusion Heparin injection Oral furosemide IV vasopressin

0.9% saline IV infusion

A patient has a low serum sodium level. Which intervention should the nurse expect to be prescribed for this patient? 0.9% saline IV infusion Heparin injection Oral furosemide IV vasopressin

0.9% saline IV infusion Normal saline, or 0.9% saline, solution contains the sodium chloride necessary to treat the hyponatremia. Heparin is an anticoagulant and has a potential side effect of hyponatremia. Furosemide blocks sodium and water reabsorption, possibly causing further hyponatremia. Vasopressin is a vasoconstrictor that can cause fluid retention, which could exacerbate hyponatremia as dilutional hyponatremia.

9. The order for a child reads, "Give furosemide (Lasix) 2 mg/kg IV STAT." The child weighs 33 pounds. How many milligrams will the child receive for this dose?

15 kg x 2 = 30 mg

A patient is prescribed daily weights. Which information should the nurse recall as the purpose of daily weights to evaluate fluid balance? ANSWER A gain or loss of 5-8% of body weight can represent fluid imbalance. Daily weights will not reflect fluid imbalance unless greater than 20% of body weight is affected. Though blood pressure is always a better indicator of fluid imbalance, daily weight is a good adjunct measure. Daily weights are only required for patients taking cardiac medications.

A gain or loss of 5-8% of body weight can represent fluid imbalance.

A patient is prescribed daily weights. Which information should the nurse recall as the purpose of daily weights to evaluate fluid balance? A gain or loss of 5-8% of body weight can represent fluid imbalance. Daily weights will not reflect fluid imbalance unless greater than 20% of body weight is affected. Though blood pressure is always a better indicator of fluid imbalance, daily weight is a good adjunct measure. Daily weights are only required for patients taking cardiac medications.

A gain or loss of 5-8% of body weight can represent fluid imbalance. A change in weight of 5-8% (gain or loss) can represent fluid imbalance. A change in body weight greater than 20% would be problematic and more serious than fluid imbalance. Blood pressure can represent alterations in fluid imbalance, but it is not always the best indicator of changes in fluid status. Daily weights are required in many patients, regardless of the medications taken.

6. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? Infuse 5% dextrose in water at 125 mL/hr. Administer IV morphine sulfate 4 mg every 2 hours PRN. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

The patient diagnosed with diabetes insipidus weighted 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds One liter of fluid weight approximately 2.2 pounds. How much fluid has the patient lost?

Answer: 2000 mL has been lost. 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 nurse is reviewing the medication record of a patient admitted with dehydration. Which medication type should cause the nurse concern? ANSWER Antipsychotic Selective serotonin reuptake inhibitor Nonsteroidal anti-inflammatory drug Antibiotic

Antipsychotic

The nurse is reviewing the medication record of a patient admitted with dehydration. Which medication type should cause the nurse concern? Antipsychotic Selective serotonin reuptake inhibitor Nonsteroidal anti-inflammatory drug Antibiotic

Antipsychotic Patients with dehydration are likely to develop electrolyte imbalances as the body attempts to compensate for the lost fluid. Individuals taking antipsychotic agents are often at risk for alterations in fluid intake due to the effect on thirst mechanisms. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics are not associated with fluid or electrolyte imbalances and do not affect fluid balance.

3. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? Assess for facial muscle spasms. Ask the patient about loose stools. Suggest that the patient avoid orange juice with meals. Ask the health care provider to order a basic metabolic panel

Ask the health care provider to order a basic metabolic panel

The nurse is assessing a patient with a fluid volume deficit. Which finding should the nurse expect in this patient? ANSWER BP 92/56 mmHg, P 134 beats/min, R 22 breaths/min BP 124/63 mmHg, P 56 beats/min, R 16 breaths/min BP 90/54 mmHg, P 68 beats/min, R 18 breaths/min BP 155/100 mmHg, P 144 beats/min, R 24 breaths/min

BP 92/56 mmHg, P 134 beats/min, R 22 breaths/min

The nurse is assessing a patient with a fluid volume deficit. Which finding should the nurse expect in this patient? BP 92/56 mmHg, P 134 beats/min, R 22 breaths/min BP 124/63 mmHg, P 56 beats/min, R 16 breaths/min BP 90/54 mmHg, P 68 beats/min, R 18 breaths/min BP 155/100 mmHg, P 144 beats/min, R 24 breaths/min

BP 92/56 mmHg, P 134 beats/min, R 22 breaths/min When a patient experiences a deficiency in fluid volume, the body's vital signs will try to compensate for the decreased volume to maintain perfusion. Typical changes that are seen with fluid volume deficit include decreased blood pressure, increased heart rate, and increased respiration, along with decreased urine output. Vital signs of BP 92/56 mmHg, P 134 beats/min, and R 22 breaths/min would be consistent with these typical changes.

The patient is admitted to a nursing unit from a LTC facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings? A) Overhydration B) Anemia C) Dehydration D) Renal Failure

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 nurse is teaching a patient about oral fluid volume replacement. Which fluid should the patient be advised to avoid? ANSWER Coffee Water Milk Juice

Coffee

The nurse is teaching a patient about oral fluid volume replacement. Which fluid should the patient be advised to avoid? Coffee Water Milk Juice

Coffee Coffee contains caffeine, which exerts a diuretic effect. Water, milk, and juice are acceptable forms of oral fluid replacement and will not exert a diuretic effect.

A patient is experiencing a fluid imbalance caused by excessive blood loss. Which fluid should the nurse expect to be prescribed for this patient? ANSWER Colloid Crystalloid Electrolytes Oral fluids

Colloid

A patient is experiencing a fluid imbalance caused by excessive blood loss. Which fluid should the nurse expect to be prescribed for this patient? Colloid Crystalloid Electrolytes Oral fluids

Colloid Fluids are replaced in an attempt to put back what is lost, so blood loss is replaced with blood transfusions, albumins, or other large-molecule protein solutions (colloids). Fluids lost secondary to excessive diuresis, perspiration, inadequate intake, or insensible water losses are replaced by using crystalloids.

A patient has a severe fluid deficit caused by hypovolemia. Which fluid should the nurse expect to be prescribed for this patient? ANSWER Crystalloid Colloid Oral water Ice chips

Crystalloid

A patient has a severe fluid deficit caused by hypovolemia. Which fluid should the nurse expect to be prescribed for this patient? Crystalloid Colloid Oral water Ice chips

Crystalloid Fluids are replaced in an attempt to put back what is lost, so blood loss is replaced with blood transfusions, albumins, or other large-molecule protein solutions (colloids). Fluids lost secondary to excessive diuresis, perspiration, inadequate intake, or insensible water losses are replaced by using crystalloids.

1. A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? Skin turgor Daily weight Presence of edema Hourly urine output

Daily weight

A patient with fluid volume excess has hypokalemia. Which collaborative therapy should the nurse expect to implement for this patient? Diuretic Oral fluid solution Isotonic electrolyte solution Heparin

Diuretic Diuretics are used to remove excess fluid. A specific diuretic that does not remove potassium will be prescribed. Oral fluids, isotonic electrolyte solutions, and heparin are not appropriate for this patient's health problem.

The nurse is performing an assessment on a patient who has had nothing by mouth since the previous evening. Which manifestation related to the patient's fluid restriction should be of concern to the nurse? ANSWER Dry mucous membranes Edema Increased blood pressure Bounding pulse

Dry mucous membranes

The nurse is performing an assessment on a patient who has had nothing by mouth since the previous evening. Which manifestation related to the patient's fluid restriction should be of concern to the nurse? Dry mucous membranes Edema Increased blood pressure Bounding pulse

Dry mucous membranes Oral fluid restriction can cause dehydration. The nurse should monitor for manifestations of dehydration such as dry mucous membranes, increased hematocrit, and tenting skin. Edema, increased blood pressure, and bounding pulse are manifestations of fluid volume excess, not deficit.

9. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? Maintain the patient on bed rest. Auscultate lung sounds every 4 hours. Monitor for Trousseau's and Chvostek's signs. Encourage fluid intake up to 4000 mL every day.

Encourage fluid intake up to 4000 mL every day.

The patient is admitted to a nursing unit from a LTC facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. What is a priority N.D.? A) Knowledge deficit B) Risk for Injury C) Fluid Volume Excess D) Activity Intolerance

HCT is high (Male= 39-50%) Sodium is high (135-145) Pt is dehydrated if sodium is high so it can not be fluid excess

the nurse prepares to assess patients arriving at the clinic for routine prenatal care. Which factor should the nurse identify that contributes to fluid and electrolyte imbalances in pregnant patients? ANSWER Hyperemesis gravidarum Increased vascular volume Decreased kidney function Decreased thirst mechanism

Hyperemesis gravidarum

The nurse prepares to assess patients arriving at the clinic for routine prenatal care. Which factor should the nurse identify that contributes to fluid and electrolyte imbalances in pregnant patients? Hyperemesis gravidarum Increased vascular volume Decreased kidney function Decreased thirst mechanism

Hyperemesis gravidarum Hyperemesis gravidarum can cause fluid and electrolyte imbalances. It is a disorder that involves an extreme amount of vomiting during pregnancy. Increased intravascular volume is expected during pregnancy. Decreased kidney function and decreased thirst mechanism are not causes of fluid imbalance in pregnant women.

The nurse is providing discharge instructions to the parent of a baby who has been treated for dehydration. Which statement by the parent should the nurse identify as indicative of a need for further instructions? I need to bring my baby back to the clinic if the number of wet diapers increases." "I need to return to the clinic if my baby's urine appears dark with crystals." "I should return to the clinic if my baby's fontanels are sunken." "I need to return to the clinic if my baby does not have tears when he cries."

I need to bring my baby back to the clinic if the number of wet diapers increases." Dehydrated infants tend to have a decrease in the number of wet diapers. So, an increase in wet diapers would indicate the infant is recovering from dehydration. The other statements by the parent show clear understanding of signs of dehydration in an infant. Infants have a proportionally higher body water percentage, higher fluid requirements, higher body surface area, and lower intracellular fluid volume than adults, all of which make them more prone to dehydration.

10. A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which equipment will the nurse need to obtain? Urinary catheter Cleaning towelettes Large container for urine Sterile urine specimen cup

Large container for urine

The nurse is documenting a patient's fluid output. Which fluid should the nurse include in this calculation? Liquid feces Parenteral fluids Irrigants Tube feeding

Liquid feces

The nurse is documenting a patient's fluid output. Which fluid should the nurse include in this calculation? Liquid feces Parenteral fluids Irrigants Tube feeding

Liquid feces Liquid feces is considered output. Parenteral fluids, irrigants, and tube feedings are considered input.

7. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? Lung sounds Urinary output Peripheral pulses Peripheral edema

Lung sounds

16. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? Increased calories are needed because glucose is lost during hemodialysis. Unlimited fluids are allowed because retained fluid is removed during dialysis. More protein is allowed because urea and creatinine are removed by dialysis. Dietary potassium is not restricted because the level is normalized by dialysis.

More protein is allowed because urea and creatinine are removed by dialysis.

8. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? Oral digoxin (Lanoxin) 0.25 mg daily Ibuprofen (Motrin) 400 mg every 6 hours Metoprolol (Lopressor) 12.5 mg orally daily Lantus insulin 24 U subcutaneously every evening

Oral digoxin (Lanoxin) 0.25 mg daily

When assessing a patient with fluid volume deficit, what would the nurse expect to find? A. increased pulse rate and blood pressure B. dyspnea and respiratory crackles C. headache and muscle cramps D. orthostatic hypotension and flat neck veins

Orthostatic hypotension and flat neck veins

13. When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? Patient who is scheduled for a renal biopsy after a recent kidney transplant Patient who will need monitoring for several hours after a renal arteriogram Patient who requires teaching about possible post-cystoscopy complications Patient who will have catheterization to check for residual urine after voiding

Patient who will have catheterization to check for residual urine after voiding

15. Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? Blood pressure Phosphate level Neurologic status CBC status

Phosphate level

A nurse is assessing a patient with fluid volume overload. Which mechanism should the nurse understand assists in the regulation of body fluids? Renin-angiotensin-aldosterone pathway Release of cortisol from the adrenal gland Suppression of epinephrine from the adrenal gland Erythropoietin release from the kidney

Renin-angiotensin-aldosterone pathway

A nurse is assessing a patient with fluid volume overload. Which mechanism should the nurse understand assists in the regulation of body fluids? Renin-angiotensin-aldosterone pathway Release of cortisol from the adrenal gland Suppression of epinephrine from the adrenal gland Erythropoietin release from the kidney

Renin-angiotensin-aldosterone pathway The renin-angiotensin-aldosterone pathway is one of the mechanisms used to maintain fluid balance in the body. Cortisol and epinephrine are stress hormones that are not related to the maintenance of body fluids. Erythropoiesis is the process to stimulate red blood cell production. This process would be stimulated to increase oxygenation but not to maintain the balance of body fluids.

14. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? Teach the patient about normal AVG function. Remind the patient to take a daily low-dose aspirin tablet. Report the patient's symptoms to the health care provider. Elevate the patient's arm on pillows to above the heart level.

Report the patient's symptoms to the health care provider.

The nurse prepares an educational program for colleagues about intracellular and extracellular fluid compartments. Which solutes or electrolytes that are predominantly found within the intracellular and extracellular fluids, should the nurse explain help with transmitting nerve impulses and contracting muscles? ANSWER Sodium and potassium Albumin and magnesium Chloride and phosphate Calcium and bicarbonate

Sodium and potassium

The nurse prepares an educational program for colleagues about intracellular and extracellular fluid compartments. Which solutes or electrolytes that are predominantly found within the intracellular and extracellular fluids, should the nurse explain help with transmitting nerve impulses and contracting muscles? Sodium and potassium Albumin and magnesium Chloride and phosphate Calcium and bicarbonate

Sodium and potassium Sodium and potassium are found in both intracellular and extracellular fluid and are involved in transmitting nerve impulses and contracting muscles. Albumin is a protein found in cellular fluid but plays no role in transmitting nerve impulses or contracting muscles. Magnesium is involved with relaxing muscle contractions. Calcium and phosphate are involved in teeth and bone formation. Phosphate is involved with nerve function but does not transmit nerve impulses. Chloride and bicarbonate are involved with acid-base balance.

Which should the nurse expect the patient to experience in response to this drop in volume? Stimulation of the thirst center Increasing kidney function Decreasing secretion of insulin Stimulation of thyroid function

Stimulation of the thirst center

A patient is experiencing signs of a decrease in extravascular volume. Which should the nurse expect the patient to experience in response to this drop in volume? Stimulation of the thirst center Increasing kidney function Decreasing secretion of insulin Stimulation of thyroid function

Stimulation of the thirst center In order to temporarily respond to decreased extracellular volume, the hypothalamus will be stimulated to initiate thirst. Increasing kidney function would cause more fluid volume loss. Decreased secretion of insulin and stimulation of thyroid function would not decrease extracellular fluid volume.

The nurse is caring for a patient who exhibits manifestations of fluid volume overload. Which body mechanism should the nurse anticipate will be activated to assist in the regulation of body fluids? ANSWER Suppression of antidiuretic hormone from the posterior pituitary gland Secretion of thyroxine from the thyroid gland Suppression of norepinephrine from the adrenal gland Secretion of growth hormone from the anterior pituitary gland

Suppression of antidiuretic hormone from the posterior pituitary gland

The nurse is caring for a patient who exhibits manifestations of fluid volume overload. Which body mechanism should the nurse anticipate will be activated to assist in the regulation of body fluids? Suppression of antidiuretic hormone from the posterior pituitary gland Secretion of thyroxine from the thyroid gland Suppression of norepinephrine from the adrenal gland Secretion of growth hormone from the anterior pituitary gland

Suppression of antidiuretic hormone from the posterior pituitary gland Antidiuretic hormone (ADH) regulates water excretion from the kidneys. With fluid volume overload, decreased blood osmolality leads to suppression of ADH, causing distal tubules to become less permeable to water. This leads to decreased reabsorption of water into blood and an increase in urine output as serum osmolality returns to normal.

A patient reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which manifestation should the nurse expect to find during assessment? ANSWER Tachycardia Ascites Dyspnea Warm, flushed skin

Tachycardia

A patient reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which manifestation should the nurse expect to find during assessment? Tachycardia Ascites Dyspnea Warm, flushed skin

Tachycardia When a patient experiences a deficiency in fluid volume, the heart rate will increase (tachycardia) in an attempt to improve circulation. Ascites and dyspnea are frequently noted with fluid volume excess. Warm, flushed skin is typically seen with a fever.

A patient's urine specific gravity is elevated at 1.045. Which explanation should the nurse identify as the reason for this value? ANSWER The concentration of solute in the urine is elevated and could indicate fluid volume deficit. The concentration of the solute in the urine is decreased and could indicate fluid volume deficit. The concentration of the solute in the urine is increased and could indicate fluid volume excess. The concentration of the solute in the urine is decreased and could indicate fluid volume excess.

The concentration of solute in the urine is elevated and could indicate fluid volume deficit.

A patient's urine specific gravity is elevated at 1.045. Which explanation should the nurse identify as the reason for this value? The concentration of solute in the urine is elevated and could indicate fluid volume deficit. The concentration of the solute in the urine is decreased and could indicate fluid volume deficit. The concentration of the solute in the urine is increased and could indicate fluid volume excess. The concentration of the solute in the urine is decreased and could indicate fluid volume excess.

The concentration of solute in the urine is elevated and could indicate fluid volume deficit. Specific gravity is an indicator of urine concentration that can be performed quickly and easily by nursing personnel. Normal specific gravity ranges from 1.005 to 1.030 (usually 1.015-1.024). When the concentration of solutes in the urine is high, the specific gravity rises; in very dilute urine with few solutes, it is abnormally low.

17. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? The patient has an outflow volume of 1800 mL. The patient's peritoneal effluent appears cloudy. The patient has abdominal pain during the inflow phase. The patient's abdomen appears bloated after the inflow.

The patient's peritoneal effluent appears cloudy.

The nurse recalls that sodium and potassium are major electrolyte components in the intracellular and extracellular fluid. Which function should the nurse identify that these electrolytes share? ANSWER Transmitting electrical impulses and muscle contraction Forming bones and teeth Regulating acid-base balance Maintaining blood volume

Transmitting electrical impulses and muscle contraction

The nurse recalls that sodium and potassium are major electrolyte components in the intracellular and extracellular fluid. Which function should the nurse identify that these electrolytes share? Transmitting electrical impulses and muscle contraction Forming bones and teeth Regulating acid-base balance Maintaining blood volume

Transmitting electrical impulses and muscle contraction Sodium and potassium are involved in the transmission of electrical impulses and muscle contraction. Calcium and phosphate are involved in the formation of bones and teeth. Potassium, along with chloride and bicarbonate, is involved in regulating acid-base balances, but sodium is not. Sodium, along with chloride, maintains blood volume, but potassium does not.

The nurse is reviewing laboratory values for a patient with hyperthyroidism. Which component of the urinalysis should the nurse use to help determine the patient's fluid status? ANSWER Urine specific gravity Ketones Nitrites Glucose

Urine specific gravity

The nurse is reviewing laboratory values for a patient with hyperthyroidism. Which component of the urinalysis should the nurse use to help determine the patient's fluid status? Urine specific gravity Ketones Nitrites Glucose

Urine specific gravity Specific gravity is an indicator of urine concentration that can be performed quickly and easily by nursing personnel. Normal specific gravity ranges from 1.005 to 1.030 (usually 1.015-1.024). When the concentration of solutes in the urine is high, the specific gravity rises. In very dilute urine with few solutes, it is abnormally low. Ketones are found in the urine when the body is breaking down fats to have an alternate form of energy. Nitrites found in the urine are usually related to an infection. Glucose found in the urine can indicate elevated blood sugar.

The nurse caring for a patient with acute hypernatremia includes which of the following in the plan of care? Select all that apply. A. Conduct frequent neurologic checks. B. Restrict fluids to 1500 mL per day. C. Orient to time, place, and person frequently. D. Maintain IV access. E. Administer 0.9% Normal Saline via IV

a) Conduct frequent neurologic checks. c) Orient to time, place, and person frequently. e) Maintain intravenous access. Frequent neurological checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function (including orientation to time, place, and person), as can rapid correction of hypernatremia. Fluid replacement is the primary treatment for hypernatremia. Maintaining intravenous access is necessary for administration of fluids and possible emergency medications. There is no reason to limit visit length.

11. Which medication taken at home by a 47-year-old patient with decreased renal function will be of most concern to the nurse? ibuprofen (Motrin) warfarin (Coumadin) folic acid (vitamin B9) penicillin (Bicillin LA) .

ibuprofen (Motrin)

8. A patient experiencing hyperkalemia related to end stage renal disease is being given Sodium Polystyrene Sulfonate for treatment. A main teaching point to include for this patient would be: a. This medication works by increasing the elimination of potassium in the intestines b. This medication works by increasing the elimination of potassium in the kidneys c. This medication works by shifting potassium from extracellular to intracellular d. This medication works by increasing the elimination of potassium in the urine

a. This medication works by increasing the elimination of potassium in the intestines

7. A patient experiencing hyperphosphatemia related to end stage renal disease is being placed on Sevelamer. A main teaching point to include for this patient would be: a. Prior to taking medication, crush the tablet for easier swallowing b. Take the medication with meals c. Take the medication on an empty d. Take regardless of food intake

b. Take the medication with meals

10. A patient experiencing hypokalemia related to diuretic therapy is being given Potassium Chloride (KCL) intravenous ((V) for treatment. Key points in administering KCL intravenously include: (SELECT ALL THAT APPLY) a. May be given IV undiluted b. When giving IV dilute c. IV solutions must not exceed 10 mEq/hr in adults d. IV solutions must not exceed 40 mEq/hr in adults e. Sodium polystyrene sulfonate can be given to decrease toxic levels

b. When giving IV dilute c. IV solutions must not exceed 10 mEq/hr in adults

3. When a patient is receiving diuretic therapy, which of these assessment measures would best reflect the patient' fluid volume status? a. Blood pressure and pulse b. Serum potassium and sodium levels c. Intake, output, and daily weight d. Measurements of abdominal girth and calf circumference

c. Intake, output, and daily weight

6. A patient experiencing anemia related to end stage renal disease is being placed on epoetin. A main teaching point to include for this patient would be: a. Take the medication first thing in AM with a full glass of water. b. Carefully monitor blood glucose levels c. Carefully monitor blood white blood count d. Teach subcutaneous injection technique

d. Teach subcutaneous injection technique

2. Furosemide is prescribed for a patient who is about to be discharge, and the nurse provides instructions to the patient about the medication. Which statement by the nurse is correct? a. "take this medication in the evening." b. "Avoid foods high in potassium, such as bananas, oranges, fresh vegetables, and dates." c. "If you experience weight gain, such as 5 pounds or more per week, be sure to tell your physician during your next routine visit." d. "Be sure to change positions slowly and rise slowly after sitting or lying so as to prevent dizziness and possible fainting because of blood pressure changes."

d. "Be sure to change positions slowly and rise slowly after sitting or lying so as to prevent dizziness and possible fainting because of blood pressure changes."

4. A patient on diuretic therapy calls the clinic because he has had the flu, with "terrible vomiting and diarrhea, "and he has not kept anything down for 2 days. He feels weak and extremely tired. Which statement by the nurse is correct? a. "It's important to try to stay on your prescribed medication. Try to take it with sips of water." b. "Stop taking the diuretic for a few days, and then restart it when you feel better." c. "You will need an increased dosage of the diuretic because of your illness. Let me speak to the physician." d. "Please come into the clinic for an evaluation to make sure there are no complications."

d. "Please come into the clinic for an evaluation to make sure there are no complications."

5. When assessing a patient, who is receiving a loop diuretic, the nurse looks for the manifestations of potassium deficiency, which would include what symptoms? (SELECT ALL THAT APPLY) a. Dyspnea b. Constipation c. Tinnitus d. Muscle weakness e. Anorexia f. Lethargy

d. Muscle weakness e. Anorexia f. Lethargy

1. The nurse will monitor a patient for signs and symptoms of hyperkalemia if the patient is taking which of these diuretics? a. Hydrochlorothiazide b. Furosemide c. Acetazolamide d. Spironolactone

d. Spironolactone

A patient is admitted to the emergency department with hypovolemia. Which IV solution would the nurse anticipate administering? A. Lactated Ringer's solution B. 10% dextrose in water C. 3.3% sodium chloride D. 0.45% sodium chloride

lactated Ringer's solution (isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance)

12. A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.