Module 6 - Fluid and Electrolytes

The nurse is concerned that an older adult client is at risk for developing acute kidney injury (AKI). Which data in the client's history supports the nurse's concern? Select all that apply. A) Diagnosed with hypotension B) Recent aortic valve replacement surgery C) Prescribed high doses of intravenous antibiotics D) Total hip replacement surgery 5 years ago E) Taking medication for type 2 diabetes mellitus

A) Diagnosed with hypotension B) Recent aortic valve replacement surgery C) Prescribed high doses of intravenous antibiotics

The community nurse visits the home of a young child who is home from school because of sudden onset of nausea, vomiting, and lethargy. The nurse suspects acute kidney injury (AKI). Which clinical manifestations support the nurse's suspicions? Select all that apply. A) Elevated blood pressure B) Postural hypotension C) Wheezing D) Edema E) Hematuria

A) Elevated blood pressure D) Edema E) Hematuria

An older adult client is brought to the emergency department. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis should the nurse most anticipate for this client? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging

B) Dehydration

The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply. A) Drink diet soda. B) Drink more fluids during hot weather. C) Drink flat caffeine-free cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea. E) Exercise between the hours of 10 a.m. and 2 p.m.

B) Drink more fluids during hot weather. C) Drink flat caffeine-free cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea.

A client diagnosed with acute kidney injury (AKI) has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on this data, which nursing diagnosis is most appropriate? A) Ineffective Renal Tissue Perfusion B) Excess Fluid Volume C) Risk for Decreased Cardiac Tissue Perfusion D) Risk for Infection

B) Excess Fluid Volume

During an assessment, the nurse becomes concerned that an older adult client is at risk for dehydration. Which of the following assessment findings would cause the nurse to come to this conclusion? A) The client has poor skin turgor. B) The client reports ingesting two glasses of water each day. C) The client's blood pressure is 140/98 mmHg. D) The client's body mass index is 20.5.

B) The client reports ingesting two glasses of water each day.

The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the session? A) "It is important for my child to wear dark clothing while exercising in the heat." B) "Water is the drink of choice to replenish fluids that are lost during exercise." C) "My child only needs to hydrate at the end of an exercise session." D) "I will have my child stop every 15 to 20 minutes during physical activity to drink fluids."

D) "I will have my child stop every 15 to 20 minutes during physical activity to drink fluids."

The nurse is caring for an older adult client diagnosed with chronic kidney disease (CKD). The client reports no bowel movements in the past 2 days. Based on this data, which condition is the client at risk for developing? A) Metabolic acidosis B) Hypercalcemia C) Increased serum creatinine levels D) Hyperkalemia

D) Hyperkalemia

A client agrees to receive long-term hemodialysis to treat acute kidney injury (AKI). Based on this information, the nurse should prepare the client for which surgical procedure? A) Insertion of a double-lumen catheter into the subclavian artery B) Placement of a peritoneal catheter C) Insertion of a subarachnoid-peritoneal shunt D) Placement of an arteriovenous fistula

D) Placement of an arteriovenous fistula

Which of the following electrolytes would be classified as a cation? A) Chloride B) Bicarbonate C) Phosphate D) Potassium

D) Potassium

The nurse is planning care for a client admitted with a diagnosis of heart failure. Based on this diagnosis, which type of kidney failure is the client at an increased risk for experiencing? A) Prerenal hypovolemia B) Intrarenal glomerular injury C) Intrarenal acute tubular necrosis D) Prerenal low cardiac output

D) Prerenal low cardiac output

Which stage of chronic kidney disease is characterized by hypertension, anemia, malnutrition, altered bone metabolism, metabolic acidosis, and a severely decreased glomerular filtration rate? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

D) Stage 4

Rejection of a donor kidney that begins months to years after transplant surgery and does not respond to increased immunosuppression would be categorized as which type of rejection? A) Acute rejection B) Chronic rejection C) Delayed rejection D) Nonimmune rejection

B) Chronic rejection

The nurse is planning a seminar to instruct community members on ways to reduce the development of chronic kidney disease (CKD). Which topics should the nurse include in the seminar? Select all that apply. A) Avoid eating red meat. B) Control blood glucose levels in diabetes mellitus. C) Adhere to medication regimen to control hypertension. D) Participate in regular exercise. E) Avoid smoking.

B) Control blood glucose levels in diabetes mellitus. C) Adhere to medication regimen to control hypertension. D) Participate in regular exercise. E) Avoid smoking.

A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The healthcare provider has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. Which urinary output would indicate that efforts to rehydrate this client have been successful? A) 40 mL per hour B) 20 mL per hour C) 25 mL per hour D) 30 mL per hour

A) 40 mL per hour

Which of the following total serum calcium levels would be considered normal in an adult client? A) 9.88 mg/dL B) 2.21 mg/dL C) 4.87 mg/dL D) 7.03 mg/dL

A) 9.88 mg/dL

The nurse is caring for a client diagnosed with heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which drug on the client's medication administration record may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin

B) Cortisol

The nurse is caring for a client diagnosed with acute kidney injury (AKI). When reviewing the client's laboratory data, which findings should indicate to the nurse that the client has met the expected outcomes? Select all that apply. A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN) C) Decreasing neutrophil count D) Decreasing lymphocyte count E) Decreasing erythrocyte count

A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN)

A client diagnosed with frequent urinary tract infections is seen in the urology clinic. The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury. Which items in the client's history support this conclusion? Select all that apply. A) Dehydration B) Renal calculi C) Ineffective wound healing D) Low serum albumin E) Hypertension

A) Dehydration B) Renal calculi E) Hypertension

The nurse is instructing a client diagnosed with heart failure about a prescribed sodium-restricted diet. Which client statement indicates that additional teaching is required? A) "I can use as much salt substitute as I want." B) "I have to read the labels on foods to find out the sodium content." C) "I have to limit the intake of food with baking soda or baking powder." D) "I can use spices and lemon juice to add flavor to food when cooking."

A) "I can use as much salt substitute as I want."

A client diagnosed with acute kidney injury (AKI) will be discharged to home in the next few days. When conducting dietary instruction, the nurse should teach the client to choose proteins that are high in biological value. Which client statement indicates that this teaching has been effective? A) "I will be sure to include eggs in my diet." B) "I should include vegetables at every meal." C) "Legumes should be included in my diet, because they are complete proteins." D) "I will eat nuts daily because they are high in protein."

A) "I will be sure to include eggs in my diet."

The nurse is preparing to discharge a client diagnosed with chronic kidney disease (CKD). The nurse is teaching the client and family about administering calcium acetate tablets by mouth with each meal at home. Which explanation about this medication is most appropriate for the nurse to include? A) "The calcium acetate will lower your serum phosphate levels." B) "The calcium acetate helps neutralize your gastric acids." C) "The calcium acetate will help stimulate your appetite." D) "The calcium acetate will decrease your serum creatinine levels."

A) "The calcium acetate will lower your serum phosphate levels."

A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Based on this information, which response by the nurse is most appropriate? A) "You should bring the infant in to be seen by the doctor." B) "Give your baby at least 2 ounces of juice every 2 hours." C) "Give your baby 50 mL of glucose water every hour." D) "Measure your baby's urine output for 24 hours and call back tomorrow."

A) "You should bring the infant in to be seen by the doctor."

Which of the following lab values is indicative of hypokalemia? A) Serum potassium of 3.25 mEq/L B) Serum potassium of 5.45 mEq/L C) Serum sodium of 125 mEq/L D) Serum sodium of 155 mEq/L

A) Serum potassium of 3.25 mEq/L

During an assessment, the nurse learns that a client who is seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The current air temperature outside is 88 degrees, and the client reports drinking water several times throughout the day because of heavy sweating. Based on this data, which instruction is most appropriate for the nurse to give the client? A) "Eat something sweet when drinking water." B) "Eat something salty when drinking water." C) "Double the amount of water you are drinking." D) "Drink juices and carbonated sodas instead of water."

B) "Eat something salty when drinking water."

Which of the following terms refers to severe, generalized edema, which may occur as a result of fluid volume excess? A) Ascites B) Anasarca C) Hypervolemia D) Orthopnea

B) Anasarca

The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. Which response by the nurse is the most appropriate? A) "Fluid volume excess commonly occurs due to new onset liver failure caused by the surgery." B) "Fluid volume excess is frequently caused by the administration of intravenous fluids." C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D) "Fluid volume excess is frequently caused by inactivity."

C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."

A client with a history of hypertension is diagnosed with chronic kidney disease (CKD). When the client asks the nurse how this disease developed, which response by the nurse is the most appropriate? A) "Thickening of the kidney structures and gradual death of nephrons has led to this diagnosis." B) "Cysts have compressed your renal tissue and destroyed your kidneys, causing this diagnosis." C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis." D) "Immune complexes have formed in your kidney tissue, causing inflammation that has led to this diagnosis."

C) "High blood pressure has reduced your renal blood flow, harming the kidney tissue and causing this diagnosis."

What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance? A) Antidiuretic hormone B) Parathyroid hormone C) Aldosterone D) Progesterone

C) Aldosterone

The nurse is caring for a client from another country who was admitted to the hospital with a diagnosis of hypertension and chronic kidney disease. The client is receiving hemodialysis three times a week. When the nurse inquires about diet, the client reports the use of salt substitutes. Why should the nurse teach the client to avoid these products? A) They will increase the risk of AV fistula infection. B) They will cause the client to retain fluid. C) They will interact with the client's antihypertensive medications. D) They can contribute to hyperkalemia.

D) They can contribute to hyperkalemia.

Which symptom suggests that a client is entering the maintenance phase of acute kidney injury (AKI)? A) Onset of metabolic acidosis B) Onset of diuresis C) Increase in glomerular filtration rate D) Decrease in serum potassium levels

A) Onset of metabolic acidosis

The nurse is caring for a client admitted with a diagnosis of acute kidney injury (AKI). The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? A) "No, don't think that. You're going to be fine." B) "In most cases, your condition can be reversed with prompt treatment and usually will not destroy the kidneys." C) "Kidney transplantation is highly likely, so it would be a good idea to start talking to your family members about organ donation." D) "When the doctor comes to see you, we can talk about whether you will need a transplant."

B) "In most cases, your condition can be reversed with prompt treatment and usually will not destroy the kidneys."

The nurse receives a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client should the nurse plan to assess first based on an increased risk for dehydration? A) A 4-year-old child with a broken leg B) A 15-month-old child with tachypnea C) A 16-year-old child with migraine headaches D) A 10-year-old child with cellulitis of the left leg

B) A 15-month-old child with tachypnea

A client in the emergency department is being admitted with a diagnosis of fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal

C) Gastrointestinal

The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse? A) Serum osmolality 230 mOsm/kg B) Hematocrit 30% C) Hematocrit 53% D) Serum potassium 3.8 mEq/L

C) Hematocrit 53%

The nurse is planning care for a client admitted to the unit with a diagnosis of dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines that Risk for Electrolyte Imbalance is an appropriate nursing diagnosis. Which medical condition supports this nursing diagnosis? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure

C) Hypotonic dehydration

The nurse reviewing lab results on one of her adult clients notices the client's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this client? Select all that apply. A) Monitor heart rate and rhythm. B) Elevate the head of the bed. C) Instruct on a low-sodium diet. D) Administer diuretics as prescribed. E) Administer potassium supplement as prescribed.

C) Instruct on a low-sodium diet. D) Administer diuretics as prescribed.

A client diagnosed with recurrent urinary tract calculi would be at elevated risk for which of the following types of acute kidney injury (AKI)? A) Prerenal AKI B) Intrinsic AKI C) Postrenal AKI D) Intrarenal AKI

C) Postrenal AKI

The nurse is planning care for a client diagnosed with chronic kidney disease (CKD) and osteoporosis. Based on this information, which should be the nurse's priority diagnosis for this client? A) Anxiety B) Disturbed Body Image C) Risk for Injury D) Risk for Bleeding

C) Risk for Injury

The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lb and had a 24-hour intake of 2000 mL and urine output of 1200 mL. Based on this data, which conclusion by the nurse is the most appropriate? A) Treatment needs to include a diuretic. B) Treatment has not been effective. C) Treatment is effective and should continue. D) Treatment has been effective and should end.

C) Treatment is effective and should continue.

The nurse instructs a client diagnosed with chronic kidney disease (CKD) regarding the prescribed medication furosemide (Lasix). Which client statement indicates that the teaching has been effective? A) "I will take this medication to keep my calcium balance normal." B) "This medication will make sure I have enough red blood cells in my body." C) "I will take this pill to keep my protein level in my body stable." D) "This pill will reduce the swelling in my body and get rid of the extra potassium."

D) "This pill will reduce the swelling in my body and get rid of the extra potassium."

A client with a diagnosis of chronic kidney disease (CKD) is experiencing manifestations of anemia. Based on this data, which treatment should the nurse anticipate for this client? A) Begin fluid restriction. B) Administer intravenous glucose and insulin. C) Begin a low-sodium diet. D) Administer epoetin injections.

D) Administer epoetin injections.

While caring for a client diagnosed with end-stage renal disease (ESRD), the nurse tracks the client's serum albumin level. For which nursing diagnosis is this action most indicated? A) Excess Fluid Volume B) Imbalanced Nutrition: Less than Body Requirements C) Risk for Ineffective Perfusion D) Risk for Infection

B) Imbalanced Nutrition: Less than Body Requirements

The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare provider prescribes both glucose and insulin for the client. The client's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate? A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood." B) "Insulin is safer than other medications that can lower potassium levels." C) "The insulin lowers his blood sugar levels and causes the extra potassium to be excreted." D) "The insulin will help his kidneys excrete the extra potassium."

A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood."

Which of the following statements is correct with regard to hypercalcemia? A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. B) Hypercalcemia is often a result of hyperparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. C) Hypercalcemia is often a result of hypoparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. D) Hypercalcemia is often a result of hypoparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.

A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.

The nurse is preparing to administer a hemodialysis treatment for a client diagnosed with chronic kidney disease (CKD). Which laboratory values should the nurse anticipate prior to the client's treatment? Select all that apply. A) Increased blood urea nitrogen (BUN) B) Decreased potassium C) Decreased phosphorus D) Increased urine osmolality E) Increased creatinine

A) Increased blood urea nitrogen (BUN) E) Increased creatinine

The nurse is providing care to a client who is exhibiting clinical manifestations of a severe fluid and electrolyte imbalance. Based on this data, which of the following orders should the nurse anticipate from the healthcare provider? Select all that apply. A) Initiate intravenous therapy. B) Initiate hypodermoclysis. C) Administer antibiotics. D) Administer diuretics. E) Administer red blood cells.

A) Initiate intravenous therapy. B) Initiate hypodermoclysis. D) Administer diuretics.

Why is development of Kussmaul respirations problematic in a client with chronic kidney disease (CKD)? A) It suggests the client is experiencing metabolic acidosis. B) It suggests the client is dehydrated. C) It suggests the client is hypotensive. D) It suggests the client is experiencing proteinuria.

A) It suggests the client is experiencing metabolic acidosis.

The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit. In the assessment, the nurse documents that the client is experiencing tachycardia, decreased urine output, and pale, cool skin. Based on this information, which should the nurse anticipate as the cause of the client's current symptoms? A) Natural compensatory mechanisms B) Cardiac failure C) Pharmacological effects of a diuretic D) Rapidly infused intravenous fluids

A) Natural compensatory mechanisms

The nurse is planning care for a client diagnosed with acute kidney injury (AKI). The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? A) Pitting edema in the lower extremities B) Bowel sounds positive in four quadrants C) Wheezing in the lungs D) Generalized weakness

A) Pitting edema in the lower extremities

During a home visit, the nurse is concerned that an older adult client is developing chronic kidney disease (CKD). The client has no history of cardiovascular disease. Which data in the client's assessment caused the nurse to have this concern? Select all that apply. A) Progressive edema B) Complaints of hip joint pain C) New onset of hypertension D) Recent increase in hunger and thirst E) Warm moist skin

A) Progressive edema C) New onset of hypertension

The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is currently 2.0 mg/dL. Based on this data, which nursing intervention is most appropriate for the nurse to implement? A) Enforce contact precautions. B) Encourage consumption of a high-calorie carbohydrate diet. C) Strain all urine. D) Encourage consumption of milk and yogurt.

D) Encourage consumption of milk and yogurt.

The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before the surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? A) Measure the client's vital signs every 8 hours. B) Assist the client in ambulating around the room at least three times daily. C) Irrigate the client's Foley catheter daily. D) Help the client turn, cough, and deep breathe every 2 hours.

B) Assist the client in ambulating around the room at least three times daily.

Which laboratory finding is suggestive of chronic kidney disease? A) Increase in creatinine clearance B) Decrease in serum sodium C) Increase in hematocrit D) Decrease in BUN

B) Decrease in serum sodium

An older adult client is admitted to the hospital after a fall. The client is intermittently confused. Based on age and current data, which of the following conditions is the client most at risk for developing? A) Kidney damage B) Dehydration C) Stroke D) Bleeding

B) Dehydration

A client with acute kidney failure is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? A) Provide mouth care before meals. B) Administer an antiemetic as prescribed. C) Restrict fluids. D) Encourage the intake of protein, salt, and potassium.

A) Provide mouth care before meals.

________ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure. A) Osmosis B) Filtration C) Active transport D) Diffusion

B) Filtration

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate? A) Speed shock B) Fluid volume excess C) Pulmonary embolism D) An allergic reaction

B) Fluid volume excess

What is the most frequent complication during hemodialysis? A) Hemorrhage B) Hypotension C) Localized infection D) Hypertension

B) Hypotension

The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. Which information about the purpose of this medication should the nurse explain to the client? A) It is vital in regulating muscle contraction and relaxation. B) It is needed to maintain skeletal, cardiac, and neuromuscular activity. C) It controls and regulates water balance in the body. D) It is used to synthesize protein and DNA within the body's cells.

B) It is needed to maintain skeletal, cardiac, and neuromuscular activity.

The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply. A) Skin turgor 20 seconds B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time E) Bowel sounds sluggish in all four quadrants

B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time

Which laboratory finding suggests that a client is experiencing acute kidney injury (AKI) as a result of glomerular damage? A) Hyperkalemia B) Proteinuria C) Urine specific gravity of 1.010 D) Moderate anemia

B) Proteinuria

A client diagnosed with acute kidney injury (AKI) is receiving peritoneal dialysis. The nurse is explaining the dialysis process to the client and family. Which statement should the nurse include in this discussion? A) "The peritoneum is more permeable because of the presence of excess metabolites." B) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration." C) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." D) "The solutes in the dialysate will enter the bloodstream through the peritoneum."

C) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis."

The nurse is caring for a client diagnosed with chronic kidney disease (CKD) who is pale and experiencing fatigue. The nurse attributes these symptoms to anemia secondary to CKD. The client's spouse asks why the client is anemic. Which response by the nurse is the most appropriate? A) "Your spouse has a genetic tendency for the development of anemia." B) "The increased metabolic waste products in your spouse's body depress the bone marrow and cause anemia." C) "Your spouse's kidneys are producing reduced amounts of the hormone erythropoietin, and this is the cause of the anemia." D) "Your spouse is not eating enough iron-rich foods, and this has led to anemia."

C) "Your spouse's kidneys are producing reduced amounts of the hormone erythropoietin, and this is the cause of the anemia."

The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client diagnosed with heart failure. Which assessment finding supports the use of this diagnosis for the client? A) Shortness of breath with ambulation B) Productive cough C) +3 pitting edema both feet D) Heart rate 104 and regular

C) +3 pitting edema both feet

A home health nurse is providing care for a client diagnosed with heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Based on this data, which food should the nurse encourage the client to consume? A) Baked fish B) Iced tea C) Banana D) Peas

C) Banana

The nurse is administering peritoneal dialysis to a client with a diagnosis of chronic kidney disease (CKD). The nurse notes the presence of a cloudy dialysate return. After notifying the healthcare provider, which action by the nurse is the most appropriate and of highest priority? A) Measure the client's abdominal girth. B) Document the cloudy dialysate. C) Culture the dialysate return. D) Increase dialysate instillation.

C) Culture the dialysate return.

An increase in blood hydrostatic pressure would result in which fluid volume disturbance? A) Fluid volume excess, because the pressure would force fluid out through the lymphatic system and into the interstitial compartment. B) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the lymphatic system. C) Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment. D) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the capillaries.

C) Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment.

A young school-age client is in the hospital with an acute kidney injury diagnosis following a streptococcus infection. The client's parents primarily speak Spanish but have a limited ability to understand English. Through an interpreter, the parents ask the nurse what mistake they made that caused their child to be so sick. Which response by the nurse is the most appropriate? A) "Your child does not eat enough dietary protein." B) "Your child has a congenital defect that led to renal failure." C) "Your child's renal failure has been caused by a low calcium level." D) "Your child's recent infection may have caused the renal failure."

D) "Your child's recent infection may have caused the renal failure."

Which statement is true? A) A dehydrated client would be considered to be in a hypotonic state because the client would have a lower concentration of solutes in the body in relation to water. B) A dehydrated client would be considered to be in a hypertonic state because the client would have a lower concentration of solutes in the body in relation to water. C) A dehydrated client would be considered to be in a hypotonic state because the client would have a higher concentration of solutes in the body in relation to water. D) A dehydrated client would be considered to be in a hypertonic state because the client would have a higher concentration of solutes in the body in relation to water.

D) A dehydrated client would be considered to be in a hypertonic state because the client would have a higher concentration of solutes in the body in relation to water.

A nurse is evaluating whether the drug sodium polystyrene sulfonate (Kayexalate) is exerting the desired therapeutic effect for a client diagnosed with chronic kidney disease (CKD). Which therapeutic effect should the nurse anticipate from this medication? A) Increased serum sodium B) Increased stool excretion C) Decreased urine specific gravity D) Decreased serum potassium

D) Decreased serum potassium

Which medication is used to increase renal blood flow in clients with acute kidney injury? A) Furosemide (Lasix) B) Mannitol (Osmitrol) C) Bumetanide (Bumex) D) Dopamine (Intropin)

D) Dopamine (Intropin)