Exam 1: fluid/electrolytes 1215

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A. Increased serum sodium B. Decreased serum potassium C. Decreased hemoglobin D. Increased platelets

A

What does the nurse understand is the primary method by which fluid volume is regulated? A. Urine excretion B. Breathing C. Bowel elimination D. Perspiration

A

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? A. Irregular heart rate B. Weight loss of 4 lb C. Mild confusion D. Blood pressure 96/53 mm Hg

A

A nurse is evaluating a client's laboratory results. What laboratory findings does the nurse determine are consistent with hypovolemia in a female client? Select all that apply. A. hematocrit level of greater than 47% B. BUN: serum creatinine ratio of greater than 12.1 C. urine specific gravity of 1.027 D. urine osmolality of 850 mOsm/kg E. urine positive for blood

A, C, D

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. A. Extravasation B. Infection C. Hematoma D. Phlebitis E. Air embolism

A, C, D

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.) A. Assessing for symptoms of nausea and malaise B. Encouraging the intake of low-sodium liquids C. Monitoring neurologic status D. Restricting tap water intake E. Encouraging the use of salt substitute instead of salt

A, C, D

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? A. Lactated Ringer solution B. 0.45% NaCl C. 0.9% NaCl D. 5% NaCl

B

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? A. "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." B. "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." C. "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D. "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. "

B

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? A. Abnormal potassium level B. Elevated hematocrit level C. Low white blood count D. Low urine specific gravity

B

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? A. Give medications that promote fluid retention. B. Limit sodium and water intake. C. Assess for dehydration. D. Teach client behaviors that decrease urination.

B

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should the nurse document this complication related to IV therapy? A. Air emboli B. Phlebitis C. Infiltration D. Fluid overload

C

A client's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? A. Apples B. Fish C. Rice D. Bananas

D

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. A. Cool area around the insertion site B. Reddened area along the path of the vein C. Tender area around the insertion site D. Ecchymosis at the insertion site E. Rapid, shallow respirations

B, C