NCLEX Review Fundamentals

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological process?

"Water and electrolytes are lost in approximately the same proportion as they exist in the body."

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline. The nurse determines that the treatment measures are effective when the laboratory results reveal which sodium level?

140 mEq/L

The nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse should monitor this client for which symptoms of this electrolyte imbalance?

Abdominal cramping

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

2520mL

Etidronate (Didronel), an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before meals.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Butter

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance?

Flat neck veins

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL?

A client with a history of alcoholism

The nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?

A client with a new burn injury

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which client is at risk for this fluid imbalance?

A client with an ileostomy

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L?

U waves

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.2 mEq/L

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client?

An increase in blood pressure

Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia. The nurse instructs the client to avoid excessive amounts of which food item that interfere with calcium absorption?

Bran

The nurse is monitoring the fluid balance of a client with human immunodeficiency disease (HIV). Because loss of subcutaneous adipose tissue and muscle atrophy occur in such clients, the nurse understands that which will provide a reliable indicator of fluid balance?

Decreased urine output and hypotension

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained by the nurse?

Decreasing body weight

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on aspirin (acetylsalicylic acid) 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea

A client is 3 days postoperative from gastric surgery and still has a nasogastric tube in place. The client is at risk to develop which electrolyte imbalances? Select all that apply.

Hypokalemia Hyponatremia Hypomagnesemia

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Increased specific gravity of the urine

The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations observed

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes

A client has had a set of arterial blood gases drawn. The results are pH 7.34, Paco2 of 37, Pao2 of 79, HCO3- of 19. The nurse interprets that the client is experiencing which acid-base imbalance?

Metabolic acidosis

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. Which is the most appropriate nursing intervention?

Monitor the client for dysrhythmias.

The nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis

The nurse is caring for a client who is nervous and is hyperventilating. The nurse should monitor the client for signs of which acid-base imbalance?

Respiratory alkalosis

The nurse is told that the blood gas results indicate a pH of 7.50 and a PCo2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbance?

Respiratory alkalosis

The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? Select all that apply.

Tetany Diarrhea A positive Trousseau's sign

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

The client with a colostomy

Which arterial blood gas (ABG) result should the nurse anticipate in the client with profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO3- 30

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mm Hg, and a PCo2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down breathing.

A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down his breathing.

A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?

Hypokalemia

A 3-year-old child is hospitalized because of persistent vomiting. Which condition should the nurse expect to occur in this child?

Metabolic alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

Monitor the vital signs. Monitor intake and output. Increase water intake orally. Monitor the electrolyte levels. Provide a sodium-reduced diet.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

Monitor vital signs. Monitor electrolyte levels. Increase water intake orally. Monitor intake and output. Maintain sodium-reduced diet.

The nurse is caring for a client with a nasogastric tube who has prescriptions to have the tube irrigated once every 8 hours. The nurse ensures that which solution is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L?

Normal saline

The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?

Obtain a 3-mL syringe from the medication supply area.

A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?

Positive Trousseau's sign

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values should the nurse expect to note in this client?

Potassium 5.4 mEq/L

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

Presence of Chvostek's sign Presence of electrocardiogram abnormalities Presence of tingling in the fingertips and around the mouth Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?

Prolonged bed rest

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Pulling up and releasing the skin on the sternal area

The nurse is monitoring a client for hypercalcemia. Which sign/symptom would the nurse note in hypercalcemia?

Slight muscle weakness

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?

The client with renal failure

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

A health care provider has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given at which time?

Two hours after meals

The nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-retaining diuretic. The nurse should be sure to include which food on a list of foods that have low potassium content?

White bread

A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN records that the client's insensible fluid loss is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to fluid losses occurring through which areas?

Skin and lungs

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?

Metabolic acidosis

The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

Hypokalemia

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs.

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse should determine that this is an expected finding if the client had which health problem?

Severe burn injury

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

Client with a fast respiratory rate

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Metabolic acidosis