ch.9 practice questions

45. The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids

1. Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

47. The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level? 1.Alcoholism 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome

1. The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

37. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Is taking a potassium-retaining diuretic

2. The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

41. The 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 health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? 1.Peas 2.Nuts 3.Cauliflower 4.Processed oat cereals

4. The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.

50. 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.Lung congestion 2.Decreased hematocrit 3.Increased blood pressure 4.Decreased central venous pressure (CVP)

4. A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased 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 (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.

44. The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value? 1.ST depression 2.Inverted T wave 3.Prominent U wave 4.Tall peaked T waves

4. A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

52. The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn

4. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia

48. The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? 1.The skin 2.Urinary output 3.Wound drainage 4.The gastrointestinal tract

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

49. 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 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations

1. A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, are most at risk for fluid volume excess.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value? 1.U waves 2.Absent P waves 3.Elevated T waves 4.Elevated ST segment

1. A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms.

42. 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 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

1. The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. 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 anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

40. 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. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries

2,3,4,6 The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

51. 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 at risk for fluid volume excess? 1.The client taking diuretics 2.The client with kidney disease 3.The client with an ileostomy 4.The client who requires gastrointestinal suctioning

2. Focus on the subject fluid volume excess. Read each option and think about the fluid imbalance that can occur in each. Clients taking diuretics or having ileostomies or gastrointestinal suctioning all lose fluid. The only condition that can cause an excess is the condition noted in the correct option.

46. 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? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3. Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

39. The 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 action is part of the plan for preparation and administration of the potassium? 1.Obtaining an intravenous (IV) infusion pump 2.Monitoring urine output during administration 3.Preparing the medication for bolus administration 4.Ensuring that the medication is diluted in the appropriate amount of normal saline

3. Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. 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, and 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 there is risk of phlebitis. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.

36. 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 signs would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss 2.Flat neck and hand veins 3.An increase in blood pressure 4.Decreased central venous pressure (CVP)

3. A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

43. The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)? 1.Widened T wave 2.Prominent U wave 3.Prolonged QT interval 4.Shortened ST segment

3. The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. 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.