Test 2
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
The client who has gastroenteritis and is febrile.
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?
pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
The majority of the body's water is contained in which of the following fluid compartments?
intracellular
Which of the following are symptoms of hypovolemia?
oliguria
A patient has been admitted with a potassium of 5.8 mEq/L; the nurse anticipates which of the following action?
Administration of glucose / insulin / diuretics IV.
A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Body weight
Which of the following diets contain the most sodium?
Bologna sandwich with pickles and potato chips
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first?
Initiate high-flow oxygen therapy.
An example of an isotonic solution is:
Normal Saline
The plasma oncotic pressure does which of the following?
Pulls fluid back into the vascular space at the venous side of the capillary
The major cation regulating extracellular osmolality is:
Sodium
Which of the following statements best describes electrolytes in extracellular and intracellular fluid?
There is a greater concentration of sodium in extracellular fluid and a greater concentration of potassium in intracellular fluid.
A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
Tingling of the extremities
The active process by which sodium moves out of the cell and potassium moves into the cell is called:
active transport.
Which of the following interventions would be the best choice to monitor fluid and electrolyte balance?
assess daily weight
A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates a need for further teaching?
"I will monitor my husband for tilting his head forward when he swallows."
A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?
"I will add broccoli and kale to my diet."
A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the clients partner indicated the need for further teaching?
"I will monitor my husband for titling his head forward when he swallows."
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?
"I will use the incentive spirometer every hour."
A 15-year-old girl, the unrestrained passenger, in the front seat of a pickup truck was thrown from the vehicle when it hit a guard rail. She is admitted to the ER where she is evaluated by the ER physician. STAT lab work has been ordered and a student nurse asks why the doctor wants to have electrolytes done, "She's so young, and besides what abnormal labs could she have this early?" The best response would be:
"It is very possible that she will have an elevated potassium."
A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?
"When I sit down to watch television, I'll be sure to put my feet up."
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
-Administer IV fluids to the client evenly over 24 hr -Encourage the client to rise slowly when standing up -Weigh the client every 8 hr
A nurse is assessing a client who has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)
-Increased heart rate -Increased blood pressure -Increased respiratory rate
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)
-Poor Skin Turgor -Hypotension -Flat Neck Veins
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?
0.45% sodium chloride
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer?
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following food should the nurse recommend as containing the greatest amount of potassium?
1 cup plain yogurt
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?
1 large hard-boiled egg
Which of the following are symptoms of hypocalcemia (low calicum)?
1) Positive Chvostek's and Trousseau signs and seizures 2) Prolonged QT interval 3) Numbness and tingling of the hands and muscle cramps
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?
1370 mL
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400mL at 1100 and 350mL at 1430. The closed chest drainage system was previously marked at 155mL and is now at 175mL. The NG tube has 575mL in drainage container, and 25mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?
1370mL
A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment had corrected the fluid imbalance?
2 mL/kg/hr
A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525 mL
A nurse is calculating the intake of a client during the past 9 hrs. The client's intake includes lactated Ringer's IV at 150mL/hr, cefazolin 2g IV intermittent bolus in 100mL of 0.9% sodium chloride, two units of packed RBCs of 275mL and 250mL; two IV bolus infusions of 250mL of 0.9% sodium chloride, ranitidine 50mg IV intermittent bolus in 50mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525mL
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
260 mL
A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance?
2mL/kg/hr
A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?
A client who weighs 28% above ideal body weight
For the patient in hemorrhagic (hypovolemic) shock, the most important nursing action is to:
Administer adequate fluid / blood volume IV.
Which of the following is responsible for the oncotic pressure in the blood stream?
Albumin
A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first?
Auscultate the client's lungs.
A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?
Bounding peripheral pulses
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.3 mEq/L. Which of the following actions should the nurse take?
Call the prescribing physician and inform her of the client's serum potassium level results.
A nurse is caring for a client who has a prescription for potassium chloride (KCl) 20mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
Call the prescribing physician and inform her of the client's serum potassium level results.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?
Cardiac rhythm
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?
Confusion
During the administration of IV fluids, which of the following findings should prompt further action?
Crackles heard during pulmonary assessment.
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?
Decreased muscle strength
A nurse is caring for a client who has a postoperative ileum and an NG tube that has drained 2,500mL in the past 6 hrs. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level
A nurse is caring for a client who has postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level
A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instruction should the nurse include?
Encourage the client to take small bites
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
Encourage the client to take small bites.
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?
Furrows in the tongue
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
Give the ordered KCL as prescribed.
A nurse is preparing to administer potassium chloride (KCl) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
Give the ordered KCl as prescribed
A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?
Hematocrit 34%
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?
Hyperactive deep-tendon reflexes
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
Hypokalemia
A patient developed a bowel obstruction after surgery and a nasogastric tube was inserted. The most common electrolyte imbalances secondary to gastric suctioning is what?
Hyponatremia / hypokalemia
An elderly patient has been ill with fever, muscle cramps, nausea and vomiting. His daughter calls the physician's office and asks what she should do. The nurse knows that these symptoms mostly likely represent what?
Hypovolemia
While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take?
Implement seizure precautions.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
Increased heart rate, increased blood pressure, increased respiratory rate
When evaluating the effectiveness of IV fluid re-hydration for severe dehydration, which of the following is the best indicator?
Increased urinary output
A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?
Instructing the client to tilt head forward when swallowing.
Which of the following laboratory results places the patient at greatest risk for dysrhythmias?
K+ 6.6 mEq/L
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
Lethargy
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?
Muscle tremors
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?
Nausea and vomiting
A nurse is assessing a client who has a sodium level of 116mEq/L. Which of the following findings should the nurse expect?
Nausea and vomiting
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?
Orthostatic hypotension
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis?
PaCO2
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Poor skin turgor, hypotension, flat neck veins
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding?
Potassium 6.1 mEq/L
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take?
Provide calming interventions.
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmHg, PaCO2 56 mmHg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances?
Respiratory acidosis
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?
Serum potassium 3.0 mEq/L
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective?
Serum sodium 138 mEq/L
A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
Skin tenting present
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?
Slow peripheral pulses
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?
Sodium 126mEq/L
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider?
Sodium 128 mEq/L
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?
Sodium polystyrene
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8mEq/L. Which of the following medications should the nurse plan to administer?
Sodium polystyrene
A nurse is caring for a client who is experiencing dysphagia. The nurse should recommend a referral to which of the following members of the health care team?
Speech therapist
A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provide. Which of the following nutritional therapies will likely be prescribed?
Supplements via nasogastric tube
A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
Supplements via nasogastric tube
Which of the following statements about IV fluid replacement therapy for an infant with dehydration is true?
The infusion rate may be higher during the first 1-3 hours
A patient is being discharged following an acute myocardial infarction and subsequent heart failure. His discharge medications include: Lasix 40 mg daily, Lanoxin 0.25 mg daily, and the ACE inhibitor, Capoten (captopril) 50 mg TID. Prior to sending him home, the nurse should call the physician regarding:
The lack of a potassium supplement order.
Which of the following actions is important to observe when giving potassium chloride (KCl) 100 mEq intravenously (IV) to a client with severe hypokalemia?
Use an IV pump to ensure safe delivery.
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?
Withhold the medication.
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis?
pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L
A client is hyponatremic and the cause is thought to be fluid overload. When this is the etiology, what would be the intervention of choice?
restrict oral fluids
A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?
Irritability
A nurse is assessing a preschooler who has a calcium level of 8.0mg/dL. Which of the following findings should the nurse expect?
Muscle tremors
The IV fluid should be used to prime tubing for administration of blood is:
NS
Aldosterone promotes which of the following?
Reabsorption of sodium.
Which of the following meals is highest in calcium?
Salmon sandwich with spinach and a glass of milk.
Which of the following is the normal level of potassium in the blood?
3.5 - 5.0
Two-thirds of total body fluid is located in which compartment?
Intracellular
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
Mental status
The preferred route for potassium replacement is:
Oral
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Weak, irregular pulse
A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms?
Weak, irregular pulse, cardiac arrhythmias, and muscle weakness
A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?
25 mg/dL