fluid and electrolytes.

A nurse is caring for an older adult client who has confusion and weakness. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the client's plan of care? (Select all that apply) -restrict the client's fluid intake -monitor the client's intake and output -weigh the client daily -instruct the client to sit on the side of the bed for a few minutes before standing -check the client's orientation to person, place and time regularly

-monitor the client's intake and output -weigh the client daily -instruct the client to sit on the side of the bed for a few minutes before standing -check the client's orientation to person, place, and time regularly

A nurse is caring for a client who is receiving IV dextrose 5% in 0.9% sodium chloride at 75mL/hr. When the nurse checks the client's IV bag at 0700, 300mL remain in the bag. At what time should the nurse hang a new bag of IV fluid? (Use the military format, four-digit number to enter the time). 0700+4hr= 1100

1100

A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess? -116 mEq/L -136 mEq/L -142 mEq/L -167 mEq/L

116 mEq/L

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumed 1 cup of coffee, 4oz of orange juice, 3oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3oz of water. The nurse should record how many mL of intake on the client's record? 240+120+90+240+240+150+90=1170mL

1170mL

A nurse is caring for a client who has percutaneous endoscopic gastrostomy (PEG) tube and a prescription to receive 25mL of fluid replacement every 4hr for each 100mL output. The client's output over the last 4hr was 500mL. How much water should the nurse administer to the client? 500/100=5mL 5mLx25mL= 125mL

125mL

A nurse is calculating a client's fluid intake over the past 8hr. The client had one 8oz cup of coffee, 30z of juice, and 12oz of soda. The client's water pitcher had 800mL and 200mL remain. The client also had IV fluids infusing at 40mL/hr via an IV pump. How many mL should the nurse document as the client's total intake for the shift?

1610

A nurse is calculating the fluid intake for an infant at the end of an 8hr shift. For oral intake, the infant had 10mL of medication, 3oz of formula, and 2oz of juice. In addition, the infant had IV fluid infusing at 20mL/hr via an IV pump. The nurse should record how many mL of intake on the client's record? 10+90+60+20x8=10+90+60+160=320mL

320mL

A nurse is calculating the total fluid intake for a client during an 8hr period. The client had an IV bolus of 150mL and consumed 4oz of juice, 6oz of hot tea, 100mL of water, and 8oz of clear broth. The nurse should record how many mL of intake on the client's record? 150+120+180+100+240=790mL

790mL

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 ml/24hr. During the first 4hr of the shift the client had a total fluid intake of 300mL. How many mL of fluids can the client have over the next 16hr? 1,200-300mL= 900 mL

900 mL

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor? -Brudzinski's sign -Chvostek's sign -Cullen's sign -Kernig's sign

Chvostek's sign

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? -a client who has NPO status since midnight for an endoscopy -a client who has heart failure and is receiving diuretic therapy -a client who has end-stage kidney disease who will undergo dialysis -a client who has gastroenteritis and is receiving oral fluids

a client who has gastroenteritis and is receiving oral fluids

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia -an NG tube to suction -an indwelling urinary catheter to gravity drainage -a chest tube to water-sealed drainage -a nephrostomy tube to a drainage bag

an NG tube to suction

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? -neck vein distention -blood pressure -body weight -abdominal girth

body weight

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect to the client's hypokalemia? -cardiac dysrhythmias -hypoglycemia -hyperreflexia -increased appetite

cardiac dysrhythmias

During a change-0f-shirt report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900mL of fluid left in it. The nurse makes rounds of 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take? -elevate the head of the bed to high Fowler's request NPO status for the client -check the client's respiratory rate and lung sounds -measure the client's temperature

check the client's respiratory rate and lung sounds

A nurse is reviewing a client's admission laboratory findings that indicate the client has hypoantremia. Which of the following laboratory findings should the nurse also expect to be below the expected reference range? -magnesium -calcium -chloride -potassium

chloride

A nurse is reviewing data for a client who has chronic kidney disease. Which of the following data should the nurse identify as the best indicator of fluid volume status? -daily weight -serum sodium -skin turgor -I&O

daily weight

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia? -decreased deep-tendon reflexes -restlessness -hyperactive bowel sounds -bounding peripheral pulses

decreased deep-tendon reflexes

A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find? -cool, clammy skin -decreased level of consciousness -muscle flaccidity -circumoral numbness and tingling

decreased level of consciousness

A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500mL in the past 6hr. The nurse should monitor the client for which of the following electrolyte imbalance? -elevated sodium level -decreased potassium level -elevated magnesium level -decreased calcium level

decreased potassium level

A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis? -diarrhea -vomiting -hyperventilation -salicylate intoxication

diarrhea

A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit? -tenting -protruding eyeballs -elevated blood pressure -dry mucous membranes

dry mucous membranes

A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? -flushing -dyspnea -bradycardia -vomiting

dyspnea

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take? -collect a urine specimen for culture and sensitivity -continue routine care because the results are within the expected reference range -decrease the IV fluid infusion rate and limit oral fluid intake -evaluate urine output for amount and urine for specific gravity

evaluate urine output for amount and urine for specific gravity

A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia? -meloxicam 5mg PO once daily -furosemide 80mg PO daily -acyclovir 400mg PO twice daily -cimetidine 300mg PO four times per day

furosemide 80mg PO daily

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? -cool, clammy skin -hyperventilation -increased blood pressure -bradycardia

hyperventilation

A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance? -intake 2,500 mL, output 500mL -intake 2,400mL, output 2,500mL -intake 1,200mL, output 700mL -intake 800mL, output 2,100mL

intake 2,400mL, output 2,500mL

A nurse is reinforcing teaching about foods that contain water by weight to a client who has a prescription for increased fluid intake. Which of the following foods should the nurse recommend that contains the most water by weight? -carrots -milk -lettuce -honey

lettuce

A nurse is caring for a client who has acute kidney injury. The client's ABGs are: pH: 7.26 PaCO2: 30mm Hg HCO3: 14 mEq/L Which of the following acid-imbalances should the nurse identify the client is experiencing? -metabolic alkalosis -respiratory alkalosis -respiratory acidosis -metabolic acidosis

metabolic acidosis

A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- 18 mEq/L and a PaCO2 of 28mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalance? -metabolic acidosis -respiratory acidosis -metabolic alkalosis -respiratory alkalosis

metabolic acidosis

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are: pH: 7.6 PaCO2: 40mm Hg HCO3: 32 mEq/L Which of the following acid base conditions should the nurse identify the client is experiencing? -metabolic acidosis -respiratory acidosis -metabolic alkalosis -respiratory alkalosis

metabolic alkalosis

A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect? -pH 7.31 -pH 7.39 -pH 7.48 -pH 7.50

pH 7.31

A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child? -broth -cherry gelatin -apple juice -pedialyte

pedialyte

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia? -reports of numbness in the feet -reports of fatigue -increased bowel sounds -postitive Trousseau's sign

reports of fatigue

A nurse is caring for a client whose arterial blood gas results show the following results: pH: 7.2 PaCO2: 50mm Hg HCO3: 24 mEq/L The nurse should identify the client is experiencing which of the following acid-base conditions? -metabolic acidosis -metabolic alkalosis -respiratory acidosis -respiratory alkalosis

respiratory acidosis

A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 OF 53, and an HCO3- of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances? -metabolic acidosis -respiratory alkalosis respiratory acidosis -metabolic alkalosis

respiratory acidosis

A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid-base imbalances should the nurse suspect? -respiratory acidosis -respiratory alkalosis -metabolic acidosis -metabolic alkalosis

respiratory acidosis

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2: 68mm Hg Base excess -2 PaO2: 78mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? -metabolic acidosis -respiratory acidosis -metabolic alkalosis -respiratory alkalosis

respiratory acidosis

A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances? -metabolic acidosis -metabolic alkalosis -respiratory acidosis -respiratory alkalosis

respiratory alkalosis

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply) -shallow respirations -cardiac dysrhythmias -flushing -hyperactive reflexes -abdominal pain

shallow respiration cardiac dysrhythmias hyperactive reflexes

A nurse is reviewing the medical record of a client who has a fluid volume deficit. The nurse should expect which of the following findings? -BUN 12mg/dL -urine output 15mL/hr -Hct 43% -urine specific gravity 1.020

urine output 15mL/hr

A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement. Which of the following findings should the nurse identify as effectiveness of the treatment? -peripheral pulse +1 -urine specific gravity 1.04 -urine output 200mL/4hr -heart rate 104/min

urine output 200mL/4hr

A nurse is caring for a client who has acute dehydration is receiving IV fluids. Which of the following laboratory values indicates to the nurse that the current treatment regimen is effective? -sodium 165 mEq/L -potassium 3.2 mEq/L -urine specific gravity 1.020 -hematocrit 62%

urine specific gravity 1.020

A nurse is reinforcing teaching about fluid replacement to a group of junior high athletes. Which of the following liquids should the nurse include as a priority to provide adequate hydration? -water -vegetable juice -milk -energy drinks

water

A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect? -weak pulse -bradycardia -hypertension -distended neck veins

weak pulse

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? -hyperactive reflexes extreme thirst -weal, irregular pulse -hyperactive bowel sounds

weak, irregular pulse

At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120mL/hr. How many mL of IV fluid should infuse by 0600? 300mL

300mL

A nurse is reviewing the laboratory results of a client who was hyperventilating during a panic attack. Which of the following arterial blood gas values should the nurse expect? -pH 7.32 and PaCO2 50mm Hg -pH 7.30 and HCO3 19mm Hg -pH 7.47 and Paco2 31MM Hg -pH 7.50 and HCO3 31mm Hg

pH 7.47 and PaCO2 31mm Hg

A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89%. ABG result are: pH 7.31, PaO2 93mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse? -switch oxygen to a nonrebreather mask -increase oxygen to 70% -place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing -position the client prone and have the respiratory therapist perform postural drainage

place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing

A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect? -decreased deep-tendon reflexes -skeletal muscle weakness -hypoactive bowel sounds -tingling of the lips

tingling of the lips