Fluid and eletrolye test

The nurse is reviewing lab values for a group of clients and notes a potassium level of 7 mEq/L in a client. Which of the following clients is most at risk for developing this potassium imbalance?

A client with chronic kidney failure

The nurse is caring for a group of clients. Which client is at highest risk for developing respiratory acidosis?

A client with chronic obstructive pulmonary disease (COPD)

The nurse reviews the effects of epinephrine on the body with a colleague. Which statement indicates a need for further teaching?

Epinephrine causes decreased blood pressure

The nurse is caring for a client admitted for cardiogenic shock. Which statement by the family should most concern the nurse immediately? Select all that apply.

"His lips look a little bluish." "He has a very wet cough today."

A client presents to the emergency room with multiple stab wounds to the abdomen. The client is severely hypotensive, tachycardic, and pale with diaphoretic skin. The nurse estimates how much fluid loss has occurred?

. 40%

The nurse is reviewing arterial blood gas (ABG) results for a client. Which pH value would the nurse expect to find in a client with acidosis

. 7.23

A client in cardiogenic shock has a weak, thready radial pulse. What is the minimal systolic blood pressure (SBP) the nurse should expect?

. 80 mm Hg

he nurse is caring for a group of clients. Which client is at highest risk for developing hypercalcemia?

. A client with metastatic lung cancer

The nurse is caring for a client prescribed several intravenous (IV) medications. The nurse notes a pressure ulcer on the left posterior aspect of the foot. The nurse understands which medication increases risk for pressure-related injuries? Select all that apply.

. IV norepinephrine IV vasopressin

The nurse is caring for a 174-pound client diagnosed with septic shock. A bolus is ordered by the provider at 30 mL/kg. The nurse should expect to administer how many milliliters of fluid? Round to the nearest whole number. Enter the numeral only.

2,373 mL

A client with dehydration is prescribed intravenous (IV) fluid of 0.9% normal saline solution. The order is for 1 L to run over 4 hrs. At what rate should the nurse set the infusion pump? Enter the numeral only.

250

The nurse is assisting in triage of clients in the emergency department. Which client should the nurse expect to be seen first?

47-year-old client receiving chemotherapy with a temperature of 101.4° F (38.6° C)

The nurse is reviewing arterial blood gas (ABG) results for a client admitted with hypokalemia. What can the nurse expect for a pH result?

7.55

The nurse is teaching a client about options for food high in calcium. Which food choices made by the client indicate an understanding of the teaching? Select all that apply.

8 ounces of plain yogurt 1 cup of low-fat milk

The nurse is screening clients at risk for sepsis. Which client has a higher risk for sepsis? Select all that apply.

82-year-old client diagnosed with urinary tract infection (UTI) and confusion 42-year-old client receiving chemotherapy admitted for pneumonia 6-month-old infant admitted with severe burns on hands 21-year-old HIV-positive client admitted with an opportunistic infection

A client weighed 140 pounds yesterday. Today the client weighs 138 pounds. 1 pint of fluid (473 mL) weighs 1 pound. How many milliliters of fluid did the client lose? Enter the numeral only.

946

The nurse is assigned to the following clients. Which client should the nurse see first?

A client that fell off a ladder with a blood pressure of 84/55, pulse of 54 beats/min, and respirations of 14 breaths per minute.

The nurse is caring for a group of clients. Which of the following clients is at high risk for developing hyponatremia? Select all that apply

A client who experienced a near-drowning in freshwater A client taking diuretics A client who is nothing by mouth (NPO)

The nurse is caring for a group of clients. Which of the following clients is at highest risk for fluid volume excess?

A client who has received six liters of intravenous (IV) fluid

A client develops dry mucous membrane, skin tenting, and a decrease in urine output. Which of the following orders from the health-care provider should the nurse expect to implement?

Administer 0.9% normal saline intravenously

The nurse is reviewing lab values for a client and notes a magnesium level of 1.0 mEq/L. Which of the following interventions should the nurse expect to implement?

Administer magnesium sulfate intravenously (IV) per order

The nurse is caring for a client with a calcium level of 6 mg/dL. The nurse would expect the client to exhibit which clinical manifestation?

Altered heart rhythm

Fluid volume excess use

Calcium gluconate

The nurse is reviewing forms of shock. Which of the following are not forms of distributive shock?

Cardiogenic shock

The nurse is assisting the RN in administering an intravenous (IV) piggyback medication. Which action is essential for the nurse to take?

Check compatibility of the medication with the IV infusion

The nurse is reviewing lab results for a client with fluid volume deficit and notes a sodium level of 118 mEq/L. The nurse will expect the client to exhibit which of the following clinical manifestations? Select all that apply.

Confusion changes in mental status

The nurse is caring for a client with dehydration. Which of the following clinical manifestations will the nurse expect the client to exhibit? Select all that apply.

Constipation Poor skin turgor Dark urine

The nurse is caring for a client presenting with obstructive shock. Which nursing diagnoses are priority? Select all that apply.

Decreased cardiac output Ineffective tissue perfusion

The nurse is caring for a client returning from a computed tomography (CT) scan with contrast. Which symptom should concern the nurse?

Diffuse wheezing in lungs

The nurse is caring for a client with fluid volume excess who has begun to feel short of breath. Which of the following interventions should the nurse implement?

Elevate the head of the bed

The nurse is caring for a client receiving multiple liters of intravenous (IV) fluid following surgery. For which complication should the nurse assess?

Fluid volume excess

he nurse is caring for a client with fluid volume excess. Which of the following medications can the nurse expect to administer?

Furosemide

The nurse is taking a medication history on a client admitted with hypokalemia. Which of the following medications would be of most concern to the nurse?

Fursoemide

The nurse is caring for a client in the compensated stage of shock. Which finding should the nurse expect?

Heart rate 112 beats/min

A client admitted with hypovolemia asks the nurse the cause of this condition. The nurse identifies which of the following as risk factors for hypovolemia? Select all that apply.

Hemorrhage Vomiting Liver cirrhosis Burns

The nurse is caring for a client admitted with kidney failure waiting to receive dialysis. Which of the following electrolyte imbalances should the nurse expect to see?

Hyperkalemia

The nurse is caring for a client who has developed hyperthermia from working in extremely high temperatures. Which of the following electrolyte imbalances will the nurse expect the client to develop?

Hyponatremia

The nurse is caring for a hypotensive client with neurogenic shock who is unresponsive to intravenous (IV) crystalloid fluids. Which order should the nurse anticipate the health-care provider to prescribe next?

IV norepinephrine infusion

The nurse is caring for a client diagnosed with cardiogenic shock. Which nursing diagnosis is a priority?

Ineffective tissue perfusion

the nurse is explaining shock to an elderly client admitted to the unit. Which intervention should be included in the teaching? Select all that apply.

Involve family members/caregiver in instruction Provide larger print material Allow time for questions

The nurse is assisting in blood draws for a client diagnosed with septic shock. The nurse should expect which acid/base disorder?

Metabolic acidosis

The nurse is caring for a client who has developed fluid volume deficit. Which of the following interventions should the nurse expect to implement?

Monitor weight daily

The nurse is confused about a client's IV medication. Which of these is the best action the nurse should take?

Notify the RN

The nurse is caring for a client who has new-onset confusion and has been diagnosed with a thoracic tumor. Vital signs are pulse 141 beats/min, blood pressure 74/51 mmHg, SpO2 93% on room air, and respirations 28 breaths/min. Which type of shock should the nurse expect the health-care provider to diagnose?

Obstructive shock

he nurse is assessing a client presenting after a motor vehicle collision (MVC). Which assessment should the nurse consider top priority?

POX

The nurse is caring for a client in the emergency department with a stab wound to the left lower leg. The wound is actively bleeding, and vital signs are: heart rate 110 beats/min, blood pressure 94/61 mm Hg, and SpO2 98% on room air. Which intervention should the nurse perform first?

Place pressure dressing on wound

The nurse is caring for a client on a continuous electrocardiogram (ECG). The ECG shows a potential dysrhythmia, and the client reports increased shortness of breath and crushing chest pain. Vitals remain stable. Which action should the nurse anticipate the health-care provider will do next?

Prepare for potential coronary angioplasty

the nurse is caring for a client diagnosed with septic shock. The client's vitals are: blood pressure 84/64, heart rate 134, respiratory rate 20, and temperature 97.4° F (36.3° C). The nurse should understand the client is in which phase of shock?

Progressive

The nurse is caring for a client admitted to the unit for myocarditis that has progressed to cardiogenic shock. Which symptom would the nurse expect to see in cardiogenic shock?

Pulmonary edema

The nurse is caring for a client diagnosed with distributive shock secondary to severe burns. The client's urinary output has decreased to 10 mL/hr. The nurse understands that this is a result of which physiological response?

Renin-angiotensin-aldosterone system

The nurse is reviewing arterial blood gas (ABG) results for a client with chronic obstructive pulmonary disease (COPD) and notes a pH of 7.23. Which of the following imbalances is the client experiencing?

Respiratory acidosis

The nurse is caring for a client with a diagnosis of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care?

Restrict sodium in the diet

The nurse is deciding whether to work at a facility that allows LPNs/LVNs to administer intravenous (IV) fluids. Which essential action should the nurse take to identify legal, safe standards of practice?

Review the state's Nurse Practice Act

The nurse is caring for a client diagnosed with cardiogenic shock. The nurse notes new-onset crackles in the lower lungs and distended jugular veins. Which of these actions should the nurse anticipate the health-care provider to order next? Select all that appl

Slow intravenous fluid infusion. Chest x-ray Obtain new set of vital signs Obtain electrocardiogram

The nurse is reviewing lab values for a group of clients. Which lab value would be of most concern to the nurse?

Sodium 120 mEq/L

The nurse is reviewing the physiological response to shock. The nurse determines that the response to shock results from which mechanism?

Sympathetic nervous system stimulation

Which type of fluid is found in synovial fluid in the joints?

Transcellular

he nurse is caring for a client in obstructive shock. Vital signs are blood pressure 77/46 mm Hg, pulse 166 beats/min, SpO2 96% on room air, respirations 22 breaths/min, and urinary output 20 mL/hr. Of the following objective findings, which indicates adequate perfusion?

Urinary output 30 mL/hr

he nurse expects a client to lose up to 2500 mL of sensible and insensible fluid each day. Which of the following is an example of sensible water loss?

Urination

The nurse is assessing a client who is being treated for fluid volume excess. Which of the following situations warrants notifying the health-care provider (HCP)?

Urine output 10 mL/hr

A client has a saline lock. Which technique is used when checking patency?

Use gentle pressure to insert fluid

The nurse is caring for a client diagnosed with cardiogenic shock. Which finding indicates an improvement in client condition? Select all that apply.

Venous lactic acid level >2.2 mmol/L

A client asks the nurse what causes fluid volume excess. What is the nurse's best response?

You were diagnosed with heart failure last year, which can cause you to retain fluid."

The nurse is caring for a group of clients. Which of the following clients is at high risk for developing hyponatremia? Select all that apply.

client who experienced a near-drowning in fresh water A client with a bowel obstruction connected to high intermittent suction A client taking diuretics A client who is nothing by mouth

The nurse is caring for a client reporting shortness of breath after a bee sting. Which medication is used to dilate the bronchioles during a severe allergic reaction?

epinephrine

The nurse is caring for four clients. Which client has the highest risk of septic shock?

67-year-old client with a urinary tract infection (UTI) that tested positive for Escherichia coli

he nurse is caring for a client with a potassium level of 2.4 mEq/L. Which statement made by the client warrants a telephone call to the health-care provider (HCP)?

I feel like my heart is skipping a beat."

he nurse in the emergency room is observing a 6-year-old client after a bee sting. Which symptom should concern the nurse for anaphylaxis?

Angioedema

The nurse is caring for a client admitted for septic shock. Vital signs are pulse 131 beats/min, blood pressure 110/72 mm Hg, respirations 18 breaths/min, and lactate 4.4 mmol/L. Which of these options should the nurse anticipate the health-care provider to order? Select all that apply.

Continuous urinary output monitoring Crystalloid fluid bolus 30 mL/kg Intravenous (IV) broad-spectrum antibiotics within 3 hr of diagnosis Two sets of blood cultures prior to intravenous (IV) antibiotics

The nurse is caring for a client diagnosed with cardiogenic shock. The nurse understands that which of the following are potential complications of shock? Select all that apply.

Disseminated intravascular coagulation (DIC) Multiple organ dysfunction syndrome (MODS) Paralytic ileus Acute respiratory distress syndrome (ARDS)

The nurse is caring for a client in the emergency department reporting severe chest pain. Which additional finding would indicate the client is in cardiogenic shock? Select all that apply.

Distended jugular veins Pulse 126 beats/min Coarse crackles in lower lobes of lungs

The nurse is reviewing the pathophysiology of shock with a colleague. The nurse understands that altered body fluid distribution without blood loss is a cause for which type of shock?

Distributive shock

The nurse is preparing to discharge a client prescribed an epinephrine autoinjector. What statement by the client indicates that teaching has been successful? Select all that apply.

I should go to the hospital after using my autoinjector." "I should always carry my autoinjector with me." "The epinephrine will open my airways if I'm having a reaction."

The nurse is reinforcing education for a client being discharged on potassium supplements. Which statement made by the client indicates a need for further education?

I will take my potassium on an empty stomach

The nurse is reviewing laboratory values for a client and notes a calcium level of 13 mg/dL. The nurse can expect to see which of the following clinical manifestations? Select all that apply.

Increased heart rate Muscle weakness

The nurse is caring for a client with severe fluid volume excess. What clinical manifestations should the nurse expect to find on assessment? Select all that apply.

Increased respirations Pitting edema in the feet Weight gain Crackles in the lungs

The nurse is caring for a client presenting with a penetrating wound to the left chest. The client is currently unconscious, and the nurse hears no breath sounds on the left lung. Vitals are blood pressure 69/29, pulse 155 beats/min, and SpO2 86% on room air. Which type of shock does the nurse expect the health-care provider to diagnose?

Obstructive shock

The nurse is caring for a hypotensive client diagnosed with septic shock. Which orders by the health-care provider should the nurse consider priority? Select all that apply.

Obtain two sets of blood cultures Administer ordered broad-spectrum antibiotics Administer ordered crystalloid fluid bolus at 30 mL/kg

The nurse is caring for a 75-year-old client admitted with dehydration. The nurse knows that the following statements are true regarding dehydration and older adults. Select all that apply.

Older adults require 30 mL/kg/day of fluids to prevent dehydration Older adults need to be encouraged to drink fluids often An older adult has a decrease in total body water from 60% to 50%

The nurse is assisting in the care of a client suffering from septic shock. Which order should the nurse question?

Place the client in the Trendelenburg position

The nurse is caring for a client admitted with vomiting and diarrhea for 3 days. Which lab test should the nurse monitor?

Potassium

the nurse is caring for a client diagnosed with septic shock. Which set of vital signs indicates treatment is successful?

Pulse 88 beats per minute, blood pressure 110/77 mm Hg, spO2 94% on 4 L per nasal cannula

The nurse is preparing to administer intravenous (IV) norepinephrine to a client in septic shock. Which goal should the nurse expect the client to reach if treatment is effective? Select all that apply.

Systolic blood pressure above 100 mm Hg Tachycardia Decrease in white blood cell count

The nurse is caring for a client receiving furosemide. Which of the following clinical manifestations would be of most concern to the nurse?

Weak, irregular pulse and decreased muscle tone

The nurse is preparing to administer a beta-adrenergic agent to a client in cardiogenic shock. Which medication is a beta-adrenergic agent often used for cardiogenic shock?

dobutamine

The nurse is caring for a client who is in metabolic alkalosis. The client asks the nurse about the cause of the diagnosis. The nurse describes which of the following as a cause of metabolic alkalosis? Select all that apply.

Vomiting Hypovolemia Hypokalemia

. The nurse is caring for a group of clients. Which clients does the nurse recognize as being at risk for hypomagnesemia? Select all that apply.

client with kidney disease A client with Crohn's disease A client with chronic alcoholism A client with anorexia

Which intravenous fluid should be maintained for a client who is receiving blood?

0.9% sodium chloride

The nurse is caring for a client who is prescribed furosemide. The nurse instructs the client on food choices for a diet high in potassium and low in sodium. Which food selection made by the client indicates an understanding of the teaching?

1 plain baked potato

The nurse is teaching a client with hypernatremia about food options low in sodium. Which food choices indicate an understanding of the teaching? Select all that apply.

1 small fresh orange 2 ounces of fresh carrots 1 cup of brown rice

The nurse is monitoring intake and output for a client with fluid volume excess. The client consumed 240 mL of orange juice, 1.5 L of water, 1 L of 0.9% normal saline, and 480 mL of chicken broth. How many milliliters will the nurse document for the client's intake?

3220mL

The nurse is caring for a client diagnosed with septic shock. Which assessment finding warrants immediate intervention by the nurse?

Hypotension

The nurse is caring for a client diagnosed with hypovolemic shock after a fall. The client reports taking a stool-softener, a beta-blocker, and an 81-mg aspirin daily. Which abnormal assessment finding should the nurse expect in this client? Select all that apply.

Hypotension Thready peripheral pulses Flat, nondistended peripheral veins

The nurse is caring for a client who has returned from a magnetic resonance imaging (MRI) scan with contrast. Which of the following findings would indicate an anaphylactic reaction to the intravenous (IV) contrast? Select all that apply.

Hypotension Urticaria Pruritus

A client has arrived at the emergency room after sustaining a fractured pelvis and fractured right femur from a motor vehicle accident. Vitals are pulse 144 beats/min, blood pressure 74/39 mm Hg, SpO2 93% on 2 L oxygen, temperature 99.0° F (37.2° C). The nurse understands that this client is most likely suffering from which type of shock?

Hypovolemic shock

The nurse assists with care of a client suffering from heat stroke. The nurse notes pallor, clammy skin, and sinus tachycardia on the monitor. Which is the most likely cause?

Hypovolemic shock

A client presents to the hospital reporting diarrhea and vomiting for 3 days. The nurse notes the client also has a fever and tachycardia. The nurse suspects the client is experiencing which of the following?

hyponatremia

The nurse is caring for a 68-pound client diagnosed with septic shock. The provider orders a crystalloid fluid bolus for the client at 30 mL/kg. Which size bag should the nurse retrieve?

1000 mL

A client with hypokalemia is prescribed a second order for 1 L of 0.9% normal saline with 40 mEq of potassium per liter. The fluid is ordered to run for 8 hrs. At what rate will the nurse set the infusion pump? Enter the numeral only.

125

A client with dehydration has been prescribed 500 mL of 0.9% normal saline to run over 3 hrs using a microdrip set with a drip factor of 60 gtt/mL. Calculate the drip rate for the solution. Record your answer as a whole number. Enter the numeral only.

167

The nurse is caring for a client reporting urticaria, pruritus, wheezing, and apprehension. Which order from the provider should the nurse question? Select all that apply.

Dobutamine drip Crystalloid fluid bolus