NCLEX Evolve electrolytes

A child who has a history of a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonephritis. How can the nurse obtain the most accurate information on the status of the child's edema? 1. Weighing daily 2. Observing body changes 3. Measuring intake and output 4. Monitoring electrolyte values

1

The nurse is educating a client about managing hypoglycemia unawareness. Which information would the nurse provide? 1. Refrain from alternative testing sites. 2. Use any available meter to monitor levels. 3. Initiate continuous blood glucose monitoring. 4. Calibrate the meter before managing hypoglycemia.

1

Which age-related change to the endocrine system affects fluid balance in the body? 1. Adrenal atrophy 2. Insulin resistance 3. Increased secretion of aldosterone 4. Decreased secretion of antidiuretic hormone

1

Which change in patient assessment over 2 days reflects that the administered diuretic is effective? 1. Weight decrease from 168 lb to 162 lb 2. Respiratory rate decrease from 24 breaths/min to 20 breaths/min 3. Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr 4. Blood pressure decrease from 138/88 mmHg to 126/78 mm Hg

1

Which diuretic is preferred for patients with hypokalemia? 1. Amiloride 2. Furosemide 3. Bumetanide 4. Chlorothiazide

1

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

1 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.

Which body substance will the nurse include in the documentation for a patient's measurable output? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected 1. Feces 2. Urine 3. Emesis 4. Perspiration 5. Chest tube drainage

1, 2, 3, 5

Which electrolyte imbalance would the nurse anticipate for a patient who is admitted with fluid volume overload? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected 1. Hypokalemia 2. Hyponatremia 3. Hypercalcemia 4. Hypochloremia 5. Hypermagnesemia

1, 2, 4

An older-adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. Which medication would the nurse expect to administer? Select all that apply. One, some, or all responses may be correct. 1. Diuretics 2. 0.9% saline 3. Antipsychotics 4. Calcium channel blockers 5. 5% dextrose in 0.45% sodium chloride

1, 2, 5

Which factor would the nurse consider when assessing a patient's fluid balance? Select all that apply. One, some, or all responses may be correct. 1. Age 2. Height 3. Sex 4. Body fat 5. Cholesterol

1, 3, 4

Which situation causes insensible water loss? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected 1. Fever 2. Nausea 3. Diarrhea 4. Dry, hot weather 5. Mechanical ventilation 6. Increased respiratory rate

1, 3, 4, 5, 6

The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? 1. Hypokalemia and hyponatremia 2. Hyperkalemia and hyponatremia 3. Hypokalemia and hypernatremia 4. Hyperkalemia and hypernatremia

2

Which aspect of the patient's history is a likely cause of hyperkalemia? 1. Cirrhosis 2. Kidney failure 3. Heart failure 4. Hyperaldosteronism

2

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? 1. Rapid, thready pulse 2. Distended jugular veins 3. Elevated hematocrit level 4. Increased serum sodium level

2

Which factor would the nurse recognize as the cause when a client's intravenous (IV) infusion infiltrates? 1. Excessive height of the IV bag 2. Failure to secure the catheter adequately 3. Contamination during the catheter insertion 4. Infusion of a chemically irritating medication

2

Which fluid volume is the expected insensible water loss for a healthy adult each day? 1. 250 to 500 mL 2. 500 to 1000 mL 3. 1000 to 1250 mL 4. 1250 to 1750 mL

2

Which information would the nurse include when teaching a patient about maintaining fluid balance? 1. "If you increase your intake of salt, you are at a greater risk for dehydration." 2. "Your intake and output have the most influence on your body's fluid balance." 3. "If you decrease your intake of potassium, you are at greater risk for dehydration." 4. "Your prescribed medications have the largest impact on fluid balance in the body."

2

Which statement regarding calcitonin is correct? 1. It is secreted by follicular cells. 2. Its actions are opposite to that of parathyroid hormone. 3. It decreases phosphorous levels by increasing bone resorption. 4. It works along with thyroid hormone to maintain normal calcium levels in blood.

2

Which treatment would the nurse anticipate for a patient admitted to the ICU with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH)? Select all that apply. One, some, or all responses may be correct. 1. Digitalis 2. Furosemide 3. Tolvaptan 4. Conivaptan 5. Vasopressin 6. Norepinephrine

2, 3, 4

Which assessment would the nurse perform to evaluate the effectiveness of rehydration therapy for a patient who was dehydrated? Select all that apply. One, some, or all responses may be correct. 1. Temperature 2. Urinary output 3. Bowel sounds 4. Pulse rate and quality 5. Level of consciousness

2, 4

A 2-year-old child is admitted with gastroenteritis and dehydration. Intravenous fluids are prescribed. Which is the most appropriate site for the first intravenous insertion? 1. Scalp vein near the fontanel 2. Venous arch on top of the foot 3. Dorsal metacarpals of the hand 4. Basilic vein at the antecubital fossa

3

A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. Which item would the nurse keep at the bedside in case of magnesium sulfate toxicity? 1. Oxygen 2. Naloxone 3. Calcium gluconate 4. Suction equipment

3

The nurse is providing care to a patient who is diagnosed with dehydration. Which laboratory finding supports the current diagnosis? 1. Hypokalemia 2. Hypercalcemia 3. Hypernatremia 4. Hypomagnesemia

3

Which condition commonly occurs in patients who are on long-term furosemide therapy? 1. Hypocalcemia 2. Hypercalcemia 3. Hyponatremia 4. Hypernatremia

3

Which hormone is secreted in response to an elevated blood pressure? 1. Insulin 2. Aldosterone 3. Natriuretic peptides (NPs) 4. Antidiuretic hormone (ADH)

3

Which laboratory test would demonstrate effectiveness of diuretic therapy for a patient admitted with fluid overload from heart failure? 1. Serum osmolality 2. Serum creatinine 3. Natriuretic peptide 4. Serum magnesium

3

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected 1. Pulse quality 2. Pulse pressure 3. Bounding pulse 4. Presence of dependent edema 5. Neck vein distention in the upright position

3, 4, 5

Which clinical finding would the nurse associate with hypokalemia? 1. Edema 2. Muscle spasms 3. Kussmaul respirations 4. Muscle weakness

4

Which factor increases when a patient has tachypnea? 1. Heart rate 2. Urine output 3. Blood volume 4. Insensible water loss

4

Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? 1. 32-year-old man consuming alcoholic beverages 2. 28-year-old woman with type 1 diabetes mellitus 3. 68-year-old man frequently wiping sweat from his forehead 4. 72-year-old woman who is 20 lb overweight

4

Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tissue colloid osmotic pressure 4. Decrease in plasma colloid oncotic pressure

4

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? 1. Prevent constipation 2. Prevent dehydration 3. Prevent vomiting 4. Prevent electrolyte imbalance

4

Which type of medication may affect the assessment of a patient's fluid balance? 1. Anticoagulant once daily 2. Cardiac glycoside once daily 3. Antibiotic every 6 hours 4. Angiotensin-converting enzyme (ACE) inhibitor twice daily

4