practice question for fluid and electrolytes
A nurse is caring for a client who has a serum potassium of 5.4 mEq/L. The nurse should assess for which of the following manifestations? A ECG changes B Constipation C Polyuria D Parasthesia
a. ECG changes
The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about... A daily alcohol intake. B intake of dietary protein. C multivitamin/mineral use. D use of over-the-counter (OTC) laxatives.
daily alcohol intake
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A Hypercalcemia B Hyponatermia C Hyperphosphatemia D Hyperkalemia
hyponatremia
When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is... A skin turgor. B daily weight. C presence of edema. D hourly urine output.
daily weight
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patients radial pulse is 105 beats/minute. b. There is sediment and blood in the patients urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.
there are crackles audible throughout both lung fields
In a patient with sodium imbalances, the primary clinical manifestations are related to alterations in what body system? A Kidneys B Cardiovascular system C Musculoskeletal system D CNS
CNS
The nurse is reviewing a patient's morning laboratory results. Which result is of greatest concern? A Serum Na of 150 mEq/L B Serum Mg of 1.9 mEq/L C Serum K of 4.5 mg/dL D Serum Ca2 (total) of 8.6 mg/dL
a. serum NA of 150
A nurse is caring for a client who has a serum sodium level of 133 mEq/L and serum potassium level of 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A Three tap water enemas B 0.9% sodium chloride solution IV at 50 mL/hr C 5% dextrose with 0.45% sodium chloride D Antibiotic therapy
a. three tap water enemas
A nurse is assessing a client for Trousseau's sign. Which of the following techniques should the nurse use to perform this test? A Apply a blood pressure cuff to the patient's arm. B Place the stethoscope bell over the client's carotid artery. C Tap lightly on the client's cheek. D Ask the client to lower her chin to her chest.
apply a blood pressure cuff to the pt's arm
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.
ask the health care provider to order a basic metabolic panel
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurses station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet
assign the pt to a room bear the nurses station
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.
blood pressure is 90/40 (indicate hypovolemic shock)
In a patient with a positive Chvostek's sign, the nurse would anticipate the IV administration of which medication? A Calcitonin B Vitamin D C Loop diuretics D Calcium gluconate
calcium glutonate
In a patient with a potassium imbalance, the primary clinical alterations will be altered in which body system? A Nervous system B Cardiovascular system C GI system D Musculoskeletal system
cardiovascular system
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patients blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.
check pt BP (history suggests hypovolemia)
A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives
daily alcohol intake
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine outpu
daily weight
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) A Decreased skin turgor B Concentrated urine C Bradycardia D Low-grade fever
decreased skin turgor, concentrated urine
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ bilateral edema of the lower extremities. The client has a temperature of 37.2 C, pulse of 96 beats per min, 26 respirations per minute, oxygen saturation of 94% on 3 L via nasal cannula, and blood pressure of 152/96. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) A Dyspnea B Edema C Bradycardia D Hypertension E Weakness
dyspnea, edema, hypertension, weakness
A common collaborative problem related to both hyperkalemia and hypokalemia is which potential complication? A Seizures B Paralysis C Dysrhythmias D Acute kidney injury
dysrhythmias
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseaus and Chvosteks signs. d. Encourage fluid intake up to 4000 mL every day.
encourage fluid intake up to 4000mL everyday
Fluid volume deficit is the same as dehydration. A True B False
false
The nursing care for a patient with hyponatremia and fluid volume excess includes A fluid restriction. B administration of hypotonic IV fluids. C administration of a cation-exchange resin. D placement of an indwelling urinary catheter.
fluid restriction
Which patient is most at risk for hypernatremia? A. Has a deficiency of aldosterone B Has prolonged vomiting and diarrhea C Receives excessive IV 5% dextrose solution D Has impaired consciousness and decreased thirst sensitivity
has impaired consciousness and decreased thirst sensitivity
While caring for an 84-year-old patient, the nurse monitors the patient's fluid and electrolyte imbalance, recognizing what as a normal change of aging? A Hyperkalemia B Hyponatremia C Decreased insensible fluid loss D Increased plasma oncotic pressures
hyponatremia
A patient is taking diuretic drugs. Which fluid or electrolyte imbalance can occur in this patient? (Select all that apply) A Hyperkalemia B Hyponatremia C Hypocalcemia D Hypercalcemia
hyponatremia, hypocalcemia
When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake... A in the late evening hours. B if the oral mucosa feels dry. C when the patient feels thirsty. D as soon as changes in level of consciousness (LOC) occur.
if the oral mucosa feels dry
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. Increase fluids if your mouth feels dry. b. More fluids are needed if you feel thirsty. c. Drink more fluids in the late evening hours. d. If you feel lethargic or confused, you need more to drink.
increase fluids if your mouth feels dry
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.
infuse the KCL at a rate of 10 mEq/hr
The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify for early changes in the patient's post-op fluid volume? (Select all that apply) A Intake and output B Skin turgor C Lung sounds D Respiratory rate E Level of consciousness
intake/ output, skin turgor, lung sounds, respiratory rate, LOC
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00AM. What is the priority nursing intervention? A Notify the physician and complete an incident report. B Slow the rate to keep vein open until next bag is due at noon. C Obtain a new bag of IV solution to maintain patency of the site. D Listen to the patient's lung sounds and assess respiratory status.
listen to patients lung sounds and assess respiratory status
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema
lung sounds
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast
milk carton
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.
monitor ionzied calcium levels
Which body system will most exhibit symptoms of a calcium imbalance? A Nervous system B Cardiovascular system C GI system D Musculoskeletal system
musculoskeletal system
After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
patient with magnesium level of 1.1 who has tremors and hyperactive deep tendon reflexes
Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately? a. Presence of the Chvosteks sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patients dressing
presence of Chvosteks sign (symptoms indicate possible hypocalcemia)
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.
serum calcium is 18
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours
serum sodium level of 120
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? A Moist skin B Distended neck veins C Increased urinary output D Tachycardia
tachycardia
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patients bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.
the patient is experiencing laryngeal stridor
Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L (below normal) is most important for the nurse to report to the health care provider? A The patient is experiencing laryngeal stridor. B The patient complains of generalized fatigue. C The patients bowels have not moved for 4 days. D The patient has numbness and tingling of the lips.
the pt is experiencing laryngeal stridor
The nurse should be alert for which manifestations in a patient receiving a loop diuretic? A Restlessness and agitation B Paresthesias and irritability C Weak, irregular pulse and poor muscle tone D Increased blood pressure and muscle spasms
weak, irregular pulse and poor muscle tone
