Fundamentals Quiz 6

1. A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.)

"I feel a little short of breath." "I feel as though my heart is racing." "The nurse technician told me that my blood pressure was 150 over 90."

A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:

0.45% normal saline (NS)

A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:

0.45% normal saline (NS) · Explanation: The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid.

What is an example of an isotonic solution?

0.9 wt % NaCl solution (regular saline)

The three steps of oxygenation:

1- Ventilation 2- Perfusion 3- Diffusion

. If parenteral nutrition (PN) must be discontinued suddenly, hang___________ in water at the same infusion rate to prevent hypoglycemia

5% dextrose Explanation: The 5% dextrose solution will maintain the fluid and electrolyte balance of the patient until the PN therapy may be either restarted or gradually withdrawn.

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

A client who has nasogastric suctioning

Which of the following foods will have the greatest impact on the water balance of the person consuming it?

A pickle Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food

A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

Move fluid into the cells · Explanation: Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge.

When preparing an infant for an enema, the nurse understands that which solution is the safest?

Physiological normal saline · Explanation: Physiological normal saline is the safest solution. Infants and children can only tolerate this type of solution because of their predisposition to fluid imbalance.

A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Postural hypotension

1. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL

Potassium 5.4 mg/dL

A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by the nurse is appropriate?

Push the catheter in until resistance is felt or the patient coughs.

Pregnancy affects a woman's oxygenation needs primarily because of:

The increased metabolic demands required to support the fetus

The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor:

Urine output Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved

Which assessment should a nurse expect to see for a patient receiving parenteral nutrition (PN)?

Weight gain of 1 to 2 pounds per week

Which of the following clients is most at risk for fluid volume deficit? 25-year-old male near-drowning victim 56-year-old woman with salicylate poisoning 45-year-old woman with second-degree burns over 20% of her body 13-year-old boy with an oral temperature of 103.4 F

45-year-old woman with second-degree burns over 20% of her body

The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is appropriate?

Applying suction for 15 seconds or less

What type of patient should have their weight taken daily?

Cardiac

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

Evaluate electrolytes Explanation: Assess the client's electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances.

Symptoms: Distended neck veins, increased blood pressure, tachycardia , shortness of breath, crackles in the lungs, edema Treatment: Stop the infusion, raise the head of the bed, measure vital signs and oxygen saturation, adjust the rate after correcting fluid overload, admin diuretics

Fluid overload

The main function is to help with the transport of gases, nutrients, and other molecules. Also important for intracellular communication and cell signaling.

Intracellular fluid

A solution that has the same salt concentration as cells and blood

Isotonic solution

Although the provider might prescribe other mild cleansing agents, _____________ remain the preferred cleansing agents.

Isotonic solutions

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching?

"Report diarrhea while taking this medication."

Which of the following foods will have the greatest impact on the hearts conductivity of the person consuming it?

A banana Explanation: Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food.

Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?

A milkshake Calcium is necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction.

Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?

A spinach salad Magnesium is essential for enzyme activities, neurochemical activities, and cardiac and skeletal muscle excitability

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping The client has hyponatremia, manifestations include abdominal cramping, weakness, headache, and nausea.

When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: An elevated hematocrit level Engorged peripheral veins A bounding pulse Rales

An elevated hematocrit level

In reviewing the results of the clients blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is: Magnesium 2.1 mEq/L Potassium 3.5 mEq/L Sodium 140 mEq/L Calcium 3.9 mEq/L

Calcium 3.9 mEq/L A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L

A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:

Cardiac dysrhythmias Lasix is a nonpotassium-sparing diuretic. Without a potassium supplement the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias.

A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction

A mineral naturally found in various foods, but our main dietary source is sodium chloride, otherwise known as table salt. Chloride carries an electric charge and therefore is classified as an electrolyte, along with sodium and potassium.

Chloride

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?

Crohn's disease

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate Explanation: Fluid volume deficit causes tachycardia

Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics?

Decreased bowel sounds Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse.

When observing a patient for symptoms of dehydration, the nurse should observe which assessment?

Decreased capillary filling

A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced:

Diarrhea A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting

Which symptom is the patient with fluid overload likely to exhibit?

Distended neck veins · Explanation: Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins.

Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.) Dry, hot skin Memory lapses Dry, cracked lips Weak, slow pulse Physical weakness Decreased urination

Dry, hot skin Memory lapses Dry, cracked lips Physical weakness Decreased urination

Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?

Dry, sticky tongue

The nurse is caring for a patient receiving parenteral nutrition (PN). In planning the patient's care for the day, which nursing assessment is most essential?

Electrolyte levels Explanation: Since the need for parenteral nutrition (PN) is usually associated with conditions that result in electrolyte instability, maintaining electrolyte balance during therapy is crucial. Monitor the patient's electrolyte levels (potassium, magnesium, and phosphorus) for low serum levels which may indicate a risk for arrhythmias and muscle weakness, Patients at risk may require having electrolyte panels done several times a day.

The client is taking medications to promote defecation. Which of the following instructions should be included by the nurse in the teaching plan for this client?

Emollient solutions may increase the amount of water secreted into the bowel.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Explanation: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath. Auscultate lung sounds Explanation: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

Body fluid that is not contained in cells. It is found in blood, in lymph, in body cavities lined with serous (moisture-exuding) membrane, in the cavities and channels of the brain and spinal cord, and in muscular and other body tissues.

Extracellular fluid

A term used to describe the balance of input and output of fluids in the body, to allow metabolic processes to function properly. The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in. Fluid imbalance causes: hypovolemia, normo-volemia with maldistribution of fluid, and hypervolemia, blood loss from due to trauma, dehydration Inadequate fluid intake or excessive fluid loss can lead to dehydration, which in turn can affect cardiac and renal function and electrolyte management. Inadequate urine production can lead to volume overload, renal failure and electrolyte toxicity.

Fluid balance

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) a. Hct 55% b. Blood osmolarity 260 mOsm/kg c. Blood sodium 150 mEq/L d. Urine specific gravity 1.035 e. Blood creatinine 0.6 mg/dL

Hct 55% b. Blood osmolarity 260 mOsm/kg Blood sodium 150 mEq/L Urine specific gravity 1.035

A solution that contains more dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood.

Hypertonic solution

_____________ pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.

Hypertonic solutions

A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of:

Hypokalemia Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics.

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

Hyponatremia

The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?

Hypotonic or isotonic solutions · Explanation: Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss.

A solution that contains fewer dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood. Commonly used to give fluids intravenously to hospitalized patients in order to treat or avoid dehydration.

Hypotonic solution

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) a. Increase protein intake to increase muscle mass. b. Decrease fluid intake to prevent urinary incontinence. c. Increase calcium intake to prevent osteoporosis. d. Limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation.

Increase protein intake to increase muscle mass. Increase calcium intake to prevent osteoporosis. Limit sodium intake to prevent edema. Increase fiber intake to prevent constipation.

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

Infuse hypotonic IV fluids

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

Infuse hypotonic IV fluids.

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions?

Initiating continuous cardiac monitoring

Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as________ fluids.

Isotonic · Explanation: Isotonic fluids have the same osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic the body's fluid loss in the absence of an electrolyte imbalance.

The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is:

Lactated Ringers · Explanation: Lactated Ringers is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringers are both hypertonic solutions.

The nurse is reviewing lab results for a patient with hypoxemia. The nurse is aware that which of the following results may worsen the patient's hypoxemia? (Select all that apply.)

Low hemoglobin levels Increased blood pH

Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?

Monitor vital signs every 15 minutes. Explanation: Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure).

Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia?

Nausea and vomiting

When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

Neurological

The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are run to assess the level of which component in the patient's blood?

Potassium (K) When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk.

A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider? a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L d.) Loose stools

Potassium 5.5 mEq/L

A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

Pull fluid from the cells · Explanation: A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink.

The nurse is discussing dietary intake with a client who is human immunodeficiency virus (HIV) positive. The nurse informs the client that the diet will include a:

Reduction in fat with smaller, more frequent meals HIV-infected clients typically experience body wasting and severe weight loss. Restorative care for these clients focuses upon maximizing kilocalories and nutrients. Low-fat diets and small, frequent, nutrient-dense meals may be better tolerated.

The client is to receive a Kayexalate enema. The nurse recognizes that this is used to:

Remove excess potassium from the system Kayexalate is a type of medicated enema used to treat clients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent constipation, and Kayexalate is not a diarrheal medication

The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:

Replace the oxygen and allow rest in between suctioning passes

The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include:

Replacement of fluid and electrolytes · Explanation: The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance

An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from:

Respiratory acidosis

The nurse in the intensive care unit (ICU) is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.)

Respiratory arrest/Medications/Heart damage/Electrolyte disturbances · Explanation: Causes of dysrhythmia may include electrolyte disturbances (potassium, magnesium, calcium), heart damage, and certain prescribed or recreational medications. Early intervention for a respiratory arrest usually prevents a cardiac arrest.

The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the clients assessment?

Serum potassium Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.

A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.)

Sodium and water shift that out of the vessels because of increased permeability Plasma that leaves the intravascular space and becomes trapped in blisters Plasma and interstitial fluids that are lost as burn exudate Water vapor that is lost through the skin that is burned Blood leakage via damaged capillaries in the dermis

The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload?

Tap water · Explanation: A tap-water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop.

A 64-year-old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the clients having an autologous infusion, but there are some drawbacks as well. Which of the following would be considered a drawback to an autologous infusion?

The client may have a decreased hemoglobin and hematocrit level on the day of surgery.

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

An appropriate technique for the nurse to implement when obtaining an arterial blood gas (ABG) specimen is to:

insert the needle at a 45-degree angle

The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse's first action should be to:

reduce the infusion rate.