HESI Fluid & Electrolytes

A client taking lithium for Bipolar

equires serum sodium level monitoring because both sodium and lithium are monovalent positive ions, and one can affect the other.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? 1. Alkalosis 2. Renal failure 3. Hypervolemia 4. Pulmonary edema

4. Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

A 1-month-old infant is fed breast milk exclusively. The parent asks the nurse if fluoride supplementation is required. What is the best response from the nurse? 1. "Fluoride supplementation is needed in hot climates." 2. "Fluoride supplementation may result in dental fluorosis." 3. "There is no need to give fluoride if the child appears fine." 4. "The child may need fluoride supplementation after 3 months of age."

2. "Fluoride supplementation may result in dental fluorosis." Fluoride supplementation before 6 months of age may result in dental fluorosis. Fluoride supplementation is not associated with hot climates. The appearance of the child does not determine the need for fluoride. Fluoride supplementation is necessary only if the breast-feeding mother's water supply does not contain the required amount of fluoridation, and not after 3 months of age.

A client is to have hemodialysis. What must the nurse do before this treatment? 1. Obtain a urine specimen to evaluate kidney function. 2. Weigh the client to establish a baseline for later comparison. 3. Administer medications that are scheduled to be given within the next hour. 4. Explain that the peritoneum serves as a semipermeable membrane to remove wastes.

2. Weigh the client to establish a baseline for later comparison. A baseline weight must be obtained to be able to determine the net fluid loss from dialysis. Obtaining a urine specimen to evaluate kidney function is not necessary; clients with advanced kidney disease may not produce urine. Medications often are delayed until after dialysis to prevent them from being filtered into the dialysate. Explaining that the peritoneum serves as a semipermeable membrane to remove wastes applies to peritoneal dialysis, not hemodialysis.

A nurse is caring for a client who is scheduled for cystoscopy. What should the nurse include in the client's postcystoscopy teaching plan? 1. "Remain flat in bed for the first 24 hours." 2. "Notify the nurse if there is any drainage on the dressing." 3. "Increase fluid intake for 3 to 4 days after the procedure." 4. "Bear down when attempting to void during the first 6 hours."

3. "Increase fluid intake for 3 to 4 days after the procedure." Increasing fluid intake [1] [2] [3] flushes the bladder internally and helps decrease the risk of infection and reduce the burning sensation upon urination. Remaining flat in bed for the first 24 hours is unnecessary after a cystoscopy. A cystoscopy is performed through the urethra; a dressing is not necessary. Bearing down increases pressure in the pelvic and perineal area and should be avoided.

A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the pediatric unit for corrective surgery. What is the primary objective of preoperative care for this infant? 1. Stabilizing vital signs 2. Improving nutritional status 3. Correcting fluid and electrolyte imbalances 4. Documenting the amount and character of vomitus

3. Correcting fluid and electrolyte imbalances Preoperative restoration of fluid and electrolyte balance improves the likelihood of a successful outcome after surgery. Vital signs are stabilized as the fluid and electrolyte balances are corrected. Improving nutritional status is not a preoperative objective; the nutritional status should improve after surgery. The amount and character of vomitus are important, but neither is the primary objective of preoperative nursing care.

A client admitted for uncontrolled hypertension and chest pain was prescribed a low-sodium diet and started on furosemide. The nurse should instruct the client to include which foods in the diet? 1. Liver 2. Apples 3. Cabbage 4. Bananas

4. Bananas Furosemide is a loop diuretic that eliminates potassium by preventing renal absorption. Bananas have a significant amount of potassium. Bananas: 450 mg; cabbage: 243 mg; liver: 73.6 mg; apples: 100-120 mg.

Which diagnostic procedure helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit? 1. Loopogram 2. Cystogram 3. Computed tomography urogram 4. Urethrogram

Loopogram Loopogram helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit. Cystogram helps to visualize the bladder and evaluates vesicoureteral reflux. A computed tomography (CT) urogram provides excellent visualization of kidneys and kidney size can be evaluated. When urethral trauma is suspected, an urethrogram is done before catheterization.

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1. Blood glucose 2. Serum lipase 3. Serum bilirubin level 4. White blood cell count

Serum lipase Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.

a client taking clozapine for schizophrenia

may require monitoring of his or her white blood cell count to check for symptoms of agranulocytosis.

A client taking diazepam for panic disorder

may require respiratory monitoring if he or she has a history of hepatic dysfunction because diazepam may cause respiratory depression.

A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take? 1. Cover the cast with plastic wrap until dry. 2. Assist with weight bearing when the client ambulates. 3. Elevate the affected leg above the level of the heart. 4. Insert a finger inside the edges of the cast to check for skin abrasions.

3. Elevate the affected leg above the level of the heart. Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the primary healthcare provider. Nothing should be inserted under the cast; this can cause tissue injury.

The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect to observe if this occurs? 1. Slowed pulse rate 2. Pleural friction rub 3. Neck vein distention 4. Increasing hypotension

3. Neck vein distention Neck vein distention is caused by hypervolemia and pulmonary hypertension. The pulse is likely to be rapid and bounding. Pleural friction rub is present in pleurisy, not heart failure. Hypertension, not hypotension, will occur because of hypervolemia.

While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure? 1. Child client 2. Pregnant client 3. Older adult client 4. Young adult client

3. Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the postanesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1. A defibrillator 2. An IV infusion pump 3. A tracheostomy tray 4. An electrocardiogram (ECG) monitor

3. A tracheostomy tray The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an ECG monitor are equipment items that should be available to all postoperative clients.

What is the maximum length of time a nurse should allow an intravenous bag of solution to infuse?

24 hours

A client drinks 7.5 oz (225 mL) of orange juice, 6 oz (180 mL) of tea, and 8 oz (240 mL) of eggnog. How many milliliters of fluid should the nurse document that the client has consumed? Record your answer using a whole number. ___ mL

645 mL One ounce (oz) equals approximately 30 mL. The client drank a total of 21.5 oz; multiply 21.5 × 30, which yields 645 mL.

A nurse is caring for a severely dehydrated infant. After adequate kidney function is confirmed, potassium is added to the intravenous rehydration solution. The prescribed infusion rate is 15 mL/kg body weight every 24 hours. The infant weighs 13 lb (5.9 kg). What does the nurse calculate as the infant's intravenous fluid intake per 24-hour period? Record your answer using one decimal place. Do not include units in your answer. ___ mL

88.5 mL (5.9 kg *15 mL/kg/24 hour)

Nasogastric (NG) tube irrigations are prescribed for a client after abdominal surgery. The nurse instills 30 mL of saline solution, and 10 mL is returned. How should the nurse proceed? 1. Record 20 mL as intake 2. Increase the amount of suction 3. Reposition the NG tube 4. Irrigate the NG tube more frequently

Record 20 mL as intake

Which component of the client's nephron acts as a receptor site for the antidiuretic hormone and regulates water balance? 1. Collecting ducts 2. Bowman's capsule 3. Distal convoluted tubule 4. Proximal convoluted tubule

collecting ducts The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. The Bowman's capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption. The proximal convoluted tubule is the site for reabsorption of sodium, chloride, water, and urea.

A client taking Lorazepam for anxiety

does not require monitoring of serum sodium levels

A nurse finds it difficult to obtain intravenous (IV) access to administer electrolytes to a 2-year-old child suffering from severe diarrhea. Which other route of administration should the nurse try? 1. Intrathecal 2. Intrapleural 3. Intraosseous 4. Intraperitoneal

intraosseous route The nurse should use the intraosseous route to administer electrolytes to infants and toddlers. This route is most commonly used in infants and toddlers when an emergency arises and IV access is impossible. This method involves the infusion of medication directly into the bone marrow. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters. Chemotherapeutic agents are the most common medications administered via the intrapleural method. Chemotherapeutic agents, insulin, and antibiotics are administered through the intraperitoneal route.

Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood? 1. "I will report any abdominal distress." 2. "I should use salt substitutes with my food." 3. "The drug must be taken on an empty stomach." 4. "The dosage is correct if my urine output increases."

1. "I will report any abdominal distress." Potassium supplements can cause gastrointestinal ulceration and bleeding. Most salt substitutes contain potassium, and their use with potassium supplements can cause hyperkalemia. Because they can be irritating to the stomach, potassium supplements should not be taken on an empty stomach. An increase in urine output is the therapeutic effect of diuretic therapy, not potassium supplements. An adverse effect of potassium supplements is oliguria.

A nurse notes gentamycin in the prescription of an older adult with osteomyelitis. Which nursing interventions should be conducted before starting therapy? Select all that apply. 1. Assessing renal function 2. Assessing hydration status 3. Checking the erythrocyte count 4. Checking the blood platelet count 5. Assessing serum thyroxin levels

1. Assessing renal function 2. Assessing hydration status Because gentamycin can increase the risk of nephrotoxicity, the nurse should assess a client's renal function before starting therapy. Dehydration can further increase the risk of nephrotoxicity; therefore the client's hydration status should also be checked before starting therapy. Gentamycin generally does not impact erythrocyte and blood platelet counts nor does it affect serum thyroxin levels.

A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. How should the nurse interpret this finding? 1. Edema after the surgery is causing this. 2. Absence of intestinal peristalsis is causing this. 3. Decrease in fluid intake before surgery is causing this. 4. Effective functioning of the nasogastric tube is causing this.

2. Absence of intestinal peristalsis is causing this. Absence of peristalsis is caused by manipulation of abdominal contents and the depressant effects of anesthetics and analgesics. Edema will not interfere with peristalsis; edema may cause peristalsis to be less effective, but some output will result. An absence of fiber has a greater effect on decreasing peristalsis than does decreasing fluids. A nasogastric tube decompresses the stomach; it does not cause cessation of peristalsis.

A nurse assesses a client who had a gastric resection. During the first 24 hours after surgery, what symptom should the nurse expect to identify? 1. Vomiting 2. Gastric distention 3. Intermittent periods of diarrhea 4. Bloody nasogastric drainage

4. Bloody nasogastric drainage Drainage is bright red initially and gradually becomes darker red during the first 24 hours. If the nasogastric tube is functioning correctly, secretions will be removed and vomiting will not occur. If the nasogastric tube is functioning correctly, gastric distention will not occur. Because the bowel was emptied before surgery and the client is now nothing by mouth, intestinal activity is not expected.

While reviewing the laboratory reports of a client, the nurse finds that the client has low sodium levels. Which hormonal imbalance should the nurse suspect in the client? 1. Epinephrine 2. Glucagon 3. Calcitonin 4. Cortisol

4. Cortisol Cortisol is the glucocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Therefore, reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? 1. Hypercalcemia 2. Hypocalcemia 3. Hyperkalemia 4. Hypokalemia

4. Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells, and extracellular fluid and does not result in hyperkalemia.

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss? 1. Viral or bacterial infection 2. Obstructive gastrointestinal anomaly 3. Generalized muscle response to stimulation 4. Imbalance between nutrient intake and fluid loss

4. Imbalance between nutrient intake and fluid loss

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss? 1. Viral or bacterial infection 2. Obstructive gastrointestinal anomaly 3. Generalized muscle response to stimulation 4. Imbalance between nutrient intake and fluid loss

4. Imbalance between nutrient intake and fluid loss The newborn's intake of milk is gradual and small, and at the same time there is loss of extracellular fluid, primarily in the form of stool and urine. A 5% weight loss is not uncommon after birth; other signs more commonly support the presence of a viral or bacterial infection or an obstructive gastrointestinal anomaly. A generalized muscle response to stimulation is not the cause of the weight loss.

Which nursing care should be provided to a client who has undergone unilateral adrenalectomy? 1. Offer a high-sodium diet. 2. Encourage the client to use saliva-inducing agents 3. Instruct the client to wear a medical alert bracelet. 4. Administer temporary glucocorticoid replacement therapy.

Administer temporary glucocorticoid replacement therapy. Temporary glucocorticoid replacement therapy is needed for a client who has undergone a unilateral adrenalectomy. Spironolactone therapy is used when surgery cannot be performed. A client on spironolactone therapy is advised to increase sodium intake to reduce the risk of hyponatremia. Spironolactone therapy can cause a side effect of dry mouth that can be managed by saliva-inducing agents. A client who has undergone bilateral adrenal gland removal will require lifelong replacement of glucocorticoids and should wear a medical alert bracelet as an indication.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply. 1. Pulse quality 2. Pulse pressure 3. Bounding pulse 4. Presence of dependent edema 5. Neck vein distention in the upright position

Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

A nurse advises a client receiving furosemide about potassium intake. Which fruits should the nurse encourage the client to eat? Select all that apply. 1. Apple 2. Orange 3. Banana 4. Pineapple 5. Dried fruit

orange, banana, dried fruit Furosemide is a diuretic that causes the body to lose potassium. Apples and pineapple are low in potassium.

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply. 1. Pallor 2. Polyuria 3. Bradypnea 4. Tachycardia 5. Hypertension

pallor & Tachycardia

The nurse is reviewing the urinalysis reports of four clients with renal disorders. Which client's finding signifies the presence of excessive bilirubin?

yellow-brown to olive-green

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1. Crackles in the lungs 2. Decreased heart rate 3. Decreased blood pressure 4. Cyanosis

1. Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? Select all that apply. 1. Extract peritoneal fluid 2. Improve respiratory status 3. Decrease intrapleural fluid 4. Increase intraabdominal tension 5. Obtain peritoneal fluid for culture

1. Extract peritoneal fluid 2. Improve respiratory status 5. Obtain peritoneal fluid for culture When a client has ascites, a peritoneal tap (paracentesis) may be prescribed to remove fluid for diagnostic purposes and for relief of discomfort. The removal of intraabdominal fluid relieves pressure against the diaphragm, which will improve the client's respiratory status. A culture of peritoneal fluid may provide information about the cause of the ascites. Closed-chest drainage, not a paracentesis, removes fluid from the pleural space. A paracentesis is done to decrease, not increase, intraabdominal pressure.

An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? 1. Monitor for cardiovascular irregularities. 2. Inquire about changes in bowel patterns. 3. Assess for leg muscle twitching or weakness. 4. Assess for signs and symptoms of dehydration.

1. Monitor for cardiovascular irregularities. Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.

A nurse is teaching about the function of the loop of Henle. Which function should the nurse include? 1. Secretion of ammonia in the descending limb 2. Secretion of hydrogen in the descending limb 3. Reabsorption of sodium in the ascending limb 4. Reabsorption of water in the ascending limb

3. Reabsorption of sodium in the ascending limb The reabsorption of sodium takes place in the ascending limb of the loop of Henle to maintain normal blood serum levels of sodium in the body. Ammonia is secreted from the distal tubule. The secretion of hydrogen occurs in the proximal and distal tubules of the nephron. Reabsorption of water is carried out in the descending limb of the loop of Henle.

A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? 1. Observe the client for signs of respiratory distress. 2. Percuss the client's abdomen and listen for dull sounds. 3. Palpate the lower extremities over the tibia and observe for edema. 4. Listen for decreased or absent bowel sounds while auscultating the abdomen.

2. Percuss the client's abdomen and listen for dull sounds. Percussing over the client's abdomen will produce a dull, not tympanic, sound if fluid is present. Respiratory distress occurs with ascites, but it is not an early sign; the client does not have ascites but is at risk for ascites at this time. Palpating the lower extremities assesses for dependent edema, not ascites. Ascites is fluid within the peritoneal cavity. Bowel sounds may be heard with developing ascites; when ascites is extensive, bowel sounds may diminish.

During an 8-hour shift a client has a 6-oz (180 mL) cup of tea and 360 mL of water; the client vomits 100 mL, and the intravenous (IV) fluids instilled equal the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? 1. 240 mL 2. 340 mL 3. 440 mL 4. 540 mL

440 mL is the correct calculation. The client's intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which when subtracted from 540 mL leaves 440 mL. The IV fluid intake and the urinary output are equal; therefore, they do not influence the final fluid balance. The options 240 mL, 340 mL, and 540 mL are incorrect calculations.

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply. 1. Administering the drug on an empty stomach 2. Checking the child's weight every day 3. Calculating the dose of drug as carefully as possible 4. Exposing the child to sunlight for increasing periods 5. Assessing the child regularly to help prevent electrolyte loss

2. Checking the child's weight every day 3. Calculating the dose of drug as carefully as possible 5. Assessing the child regularly to help prevent electrolyte loss The child's weight should be checked and recorded daily to aid in the assessment of therapeutic and adverse effects. Pediatric doses should be calculated carefully to prevent an accidental overdose. Pediatric clients are at greater risk of electrolyte loss; therefore, they require closer and more cautious assessment to help prevent hypertension and stroke. Furosemide may cause stomach upset if it is taken on an empty stomach; the child should be given the drug with food to help prevent gastric upset. A child taking diuretics should not be exposed to sunlight for long periods because this action may precipitate fluid volume loss and heatstroke.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1. Sunken eyes 2. Dry, flaky skin 3. Change in mental status 4. Decreased bowel sounds

3. Change in mental status Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1. Abdominal girth decrease 2. Mucous membranes becoming drier 3. Heart rate increases from 80 to 135 4. Blood pressure rises from 130/70 to 190/80

3. Heart rate increases from 80 to 135 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

The laboratory report of a client reveals increased levels of atrial natriuretic peptide. Which other finding does the nurse anticipate to find in the client? 1. Decreased urine output 2. Increased concentration of urine 3. Increased sodium excretion in urine 4. Decreased glomerular filtration rate

3. Increased sodium excretion in urine Atrial natriuretic peptide is secreted by the myocyte cells in the right atrium. Atrial natriuretic peptide acts on the kidneys and causes an increase in the excretion of sodium by inhibiting aldosterone. Atrial natriuretic peptide increases urine output. Atrial natriuretic peptide causes inhibition of renin and angiotensin II, and therefore the resultant urine produced contains more water and is dilute. Because atrial natriuretic peptide relaxes the afferent arteriole in the nephron, glomerular filtration rate is increased.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. 1. Back of the neck 2. Back of the hand 3. Palm of the hand 4. On the sternal area 5. Back of the fore arm

4. On the sternal area 5. Back of the fore arm

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? 1. Clear breath sounds 2. Positive pedal pulses 3. Normal potassium level 4. Decreased urine specific gravity

Clear breath sounds Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

A nurse is caring for a newly admitted client with anorexia nervosa. What is the priority treatment for the client at this time? 1. Medications to reduce anxiety 2. Family psychotherapy sessions 3. Separation from family members 4. Correction of electrolyte imbalances

Correction of electrolyte imbalances Starvation or inadequate/inappropriate nutrition can lead to electrolyte imbalances, which are life threatening. Medication and therapy will be prescribed later and are not the priority at this time. Client independence, not separation from family members, is supported.

The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. Which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client? 1. Gravity 2. Osmosis 3. Active transport 4. Negative pressure

Negative Pressure The negative pressure of a portable wound drainage system exerts a sucking force that pulls fluid toward the collection chamber. An indwelling urinary catheter uses the principle of gravity to draw fluid from the bladder to the collection bag held below the level of the bladder. Osmosis occurs when a solvent moves from a solution of lesser concentration to one of greater solute concentration when the two solutions are separated by a semipermeable membrane; fluid moving from the interstitial compartment into the intracellular compartment uses osmosis. Active transport occurs when ions move across a cell membrane against a concentration gradient with the assistance of metabolic energy; sodium and potassium ions move into and out of cells via active transport (sodium-potassium pump)

An infant with a diagnosis of failure to thrive has been receiving enteral feedings for 3 days. All feedings have been retained, but the skin and mucous membranes are dry, and the infant has lost weight. What should the nurse do first in light of these findings? 1. Notify the practitioner 2. Document the assessment findings 3. Increase the fluid component in the feeding 4. Increase the calorie component of the feeding

Notify the practitioner Dry mucous membranes and weight loss are classic signs of dehydration. The nurse should calculate the infant's fluid requirements, then obtain a prescription from the practitioner to increase either free water or the amount of the feedings as needed. The findings are not expected; documenting them without notifying the practitioner is unsafe. The nurse may not change the composition of the feeding without a practitioner's prescription.

A client on antidepressant therapy develops hyponatremia. Which drug may be responsible for the client's electrolyte imbalance? 1. Phenelzine 2. Paroxetine 3. Imipramine 4. Amitriptyline

Paroxetine Paroxetine is a selective serotonin reuptake inhibitor; side effects include hyponatremia. Phenelzine is a monoamine oxidase inhibitor; side effects include orthostatic hypotension. Imipramine and amitriptyline are tricyclic antidepressants; side effects associated with these drugs include dry mouth and blurred vision.

A nurse is assessing a client admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? 1. Retention of sodium and water 2. Hypotension and a rapid, thready pulse 3. Increased fatty deposition in the extremities 4. Hypoglycemic episodes in the early morning

Retention of sodium and water Increased levels of steroids and aldosterone cause sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. Hyperglycemia is sustained and not restricted to the morning hours.

A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery? 1. Chest 2. Intestinal 3. Nasogastric 4. Gastrostomy

3. Nasogastric Nasogastric surgery involves the stomach, duodenum, pancreas, and common bile duct; a nasogastric tube removes gastric secretions and prevents distention of the gastrointestinal tract. A chest tube is used to remove air or blood from the chest cavity; the chest is not entered in the Whipple procedure. Intestinal tubes are used for small bowel obstructions; except for the duodenum, the small bowel is not included in the Whipple procedure. A gastrostomy tube is used to deliver nutrients into the stomach of a client who cannot ingest food via the oral route.

Despite receiving 2900 mL intake for 2 days, the client's urine output has progressively diminished. The nurse identifies that the urinary output is less than 40 mL/hr over the past 3 hours. What action will the nurse take? 1. Assess breath sounds and obtain vital signs. 2. Decrease the intravenous flow rate and increase oral fluids. 3. Insert an indwelling catheter to facilitate emptying of the bladder. 4. Check for dependent edema by assessing the lower extremities.

Assess breath sounds and obtain vital signs. The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a healthcare provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed.

An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A nasogastric tube to suction is in place. What should the nurse expect regarding the client's nasogastric tube drainage during the first 24 hours after surgery? 1. Minimal to no drainage 2. Contains some blood and clots 3. Contains large amounts of frank blood 4. Similar to coffee grounds in color and consistency

Contains some blood and clots Containing some blood and clots is an expected response during the first 24 hours after a gastric resection because of oozing of blood and blood coagulation. There will be a moderate amount of drainage, not minimal or no drainage. Green and viscid are normal characteristics of gastric contents, which are unexpected after gastric surgery. Containing large amounts of frank blood indicates hemorrhage, which is unexpected. Coffee ground material results from blood that has been digested by the gastric acid; gastric bleeding with a nasogastric tube in place will be red because gastric acids will not have time to act on the blood.

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? 1. Dyspnea 2. Hyperpnea 3. Kussmaul breathing 4. Cheyne-Stokes breathing

Kussmaul breathing Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that is usually associated with pathology of the respiratory center in the brain.

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? 1. Assess urine specific gravity. 2. Collect a weekly urine specimen. 3. Maintain the prescribed hydration. 4. Empty the drainage bag once a day.

Maintain the prescribed hydration. Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner.

Which assessment findings would cause a nurse to believe that a preschool-age client is not receiving enough vitamin C in the diet? Select all that apply. 1. Headaches 2. Rashes 3. Bleeding gums 4. Muscle weakness 5. Scaling of the skin

Rashes & bleeding gums Rashes and bleeding gums are clinical manifestations associated with a vitamin C deficiency in the diet. Headaches are a clinical manifestation associated with a vitamin A, not C, deficiency. Muscle weakness is a clinical manifestation associated with a vitamin D, not C, deficiency. Scaling of the skin is a clinical manifestation associated with a vitamin A, not C, deficiency.

A client is brought to emergency services after a motor vehicle accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure? 1. Warm and flushed skin 2. Confusion and lethargy 3. Increased pulse pressure 4. Reduced peripheral pulses

Reduced peripheral pulse Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. Confusion and lethargy are late signs of shock. The pulse pressure narrows with decreased cardiac pressure associated with hypovolemic shock.

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? 1. A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. 2. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. 3. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. 4. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. The amount of protein permitted in the diet depends on the extent of kidney function; excess protein causes an increase in urea concentration, excess metabolic waste, and added stress on the kidneys, which should be prevented. Adequate calories are provided to prevent tissue catabolism that also results in an increase in metabolic waste products. In kidney failure the kidneys are unable to eliminate the waste products of a high-protein diet, which is to be avoided. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids