HCC 2: Fluids/Electrolytes Assessment

A nurse is assessing a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

-Decreased deep tendon reflexes

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?

-2 mL/kg/hr

A nurse is caring for a client who has a 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 assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

-Oliguria

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.

Very right box

A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis?

-Tachycardia

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that client is experiencing fluid overload?

-The client has a 5 lb weight gain since yesterday.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

-The client who has a nasogastric (NG) tube to suction.

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 providing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is being treated with tolvaptan 30 mg PO twice daily. The nurse is evaluating the client's response to the medication prescribed. Which of the following findings indicates an expected outcome?

-The client's mucous membranes are moist.

A nurse is caring for a client who had 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

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication?

-Urine specific gravity 1.015

A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

-Urine specific gravity 1.015

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

-Urine specific gravity 1.020

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse should expect which of the following findings?

-Urine specific gravity 1.035

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

-Verify the most recent calcium level.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

-Weak pulse

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 nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration?

-A client who has a temperature of 39 C (102F)

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?

-A decrease in urine output.

A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification?

-"Adding pecans will be a change I can readily make."

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

-0.45% sodium chloride

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?

-125

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

-13% weight loss

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

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

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 preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number.)

-28

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

-300 mL

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

-35 mg/dL

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

-Abnormally prominent U wave.

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

-Administering sodium polystyrene sulfonate.

A nurse is teaching a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium?

-Baked potato

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

-Bananas

A nurse is caring for a client admitted who reports increased urination and thirst. Complete the following sentence by using the lists of options.

-Blood pressure -Sodium level

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

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

-Bounding pulse -Pitting edema -Crackles upon auscultation

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 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 in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor for which of the following complications?

-Cardiac dysrhythmias

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?

-Check urine specific gravity.

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

-Chvostek's sign

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

-Client has an NG tube to gastric suction.

A nurse is providing teaching to a client who has renal failure and an elevated phosphorus level. The provider instructed the client to take aluminum hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client?

-Constipation

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

-Dark-colored urine

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

-Decrease in kidney function

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?

-Dehydration

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

-Dehydration

A nurse is planning care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?

-Dextrose 5% in water

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

-Dyspnea

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

-Eat foods that contain plenty of potassium

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate?

-Evaluate urine for amount and for specific gravity.

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

-Fatigue

A nurse is the emergency department is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

-Fluid volume deficit -vomiting and diarrhea

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer?

-Furosemide

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 caring for a client. Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again.

-T 38 C (100.4F), oral -HR 99/min -BP 106/60 mm Hg, supine

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 test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

-Hyperkalemia

A nurse is caring for a client in the emergency department (ED). Drag words from the choices below to fill in each blank in the following sentence.

-Hypernatremia -Confusion

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

-Hyperuricemia

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 nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

-Hypokalemia

A nurse is providing teaching to a group of adult athletes about prevention the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching?

-Impaired motor control

A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

-Increase the client's fluid intake.

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

-Increased BUN

A nurse is assessing a client who has fluid 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 in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?

-Irritability

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 collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH?

-Lung cancer

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 diarrhea. Which of the following findings is a manifestation of hypokalemia?

-Muscle weakness

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 caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

-Obtain a 12-lead ECG

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following intervention should the nurse include in the plan of care?

-Offer the client 240 mL (8 oz) of oral fluids every 4 hr.

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 heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

-Potassium

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

-Potassium 2.9 mEq/L.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?

-Restrict fluid intake to 1,000 mL per day.

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?

-Shallow respirations

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 reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?

-Sodium 126 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 providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

-Spironolactone