NCLEX PN Fluid and Electrolytes

the nurse checks a clients skin turgor and documents that the client exhibits normal fluid balance. which finding should the nurse have noted? a) the skin when pinched remained elevated when released b) the skin when pinched failed to return to normal when released c) the skin when pinched immediately fell back to normal when released d) the skin when pinched remained tented for several seconds when released

c) the skin when pinched immediately fell back to normal when released rationale turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. in a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. if a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch

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? a) slow pulse rate b) flaccid muscles c) high blood pressure d) abdominal cramping

d) abdominal cramping rationale signs of hyponatremia include rapid, thready pulse; postural blood pressure changes; weakness; abdominal cramping; poor skin turgor; muscle twitching and seizures; mental confusion; and apprehension

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? a) rapid weight loss b) flat hand and neck veins c) a weak and thready pulse d) an increase in blood pressure

d) an increase in blood pressure rationale impaired cardiac or kidney function can result in fluid volume excess. findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, and elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

the nurse is caring for a client with a suspected diagnosis of hypercalcemia. which sign/symptom is an indication of this electrolyte imbalance? a) twitching b) positive Trousseau's sign c) hyperactive bowel sounds d) generalized muscle weakness

d) generalized muscle weakness rationale generalized muscle weakness is seen in clients with hypercalcemia. twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

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? a) gurgling respirations b) increased blood pressure c) decreased hematocrit level d) increased specific gravity of the urine

d) increased specific gravity of the urine rationale clients taking diuretics on a long-term basis are at risk for fluid volume deficit. findings of fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered LOC gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

the nurse is caring for a client whose magnesium level is 4 mg/dL and the client is being treated for the magnesium imbalance. the nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present? a) tetany b) twitches c) muscular excitability d) loss of deep tendon reflexes

d) loss of deep tendon reflexes rationale the normal magnesium level is 1.6 to 2.6 mg/dL. a client with a magnesium of 4 mg/dL is experiencing hypermagnesemia. signs include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, tachycardia and hypotension, and loss of consciousness. tetany, muscle excititability and twitches are seen in a client with hypomagnesemia.

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? a) twitching b) irritability c) hyperactive reflexes d) loss of deep tendon reflexes

d) loss of deep tendon reflexes rationale the normal magnesium level is 1.6 to 2.6 mg/dL. a client with a magnesium level of 3.6 mg/dL is experiencing hypermagnesemia. loss of deep tendon reflexes is characteristic of this condition. twitching, irritability and hyperactive reflexes should be noted in a client with hypomagnesemia.

the nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. which should the nurse observe for on the cardiac monitor as a result of this laboratory value? a) ST elevation b) peaked P waves c) prominent U waves d) narrow, peaked T waves

d) narrow, peaked T waves rationale a serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves

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? a) intense thirst b) slow bounding pulse c) dry mucous membranes d) postural blood pressure changes

d) postural blood pressure changes rationale postural blood pressure changes occur in the client with hyponatremia. intense thirst and dry mucous membranes are seen in clients with hypernatremia. a slow, bounding pulse is not indicative of hyponatremia. in a client with hyponatremia, a rapid, thready pulse is noted.

etidronate (didronel) an antihypercalcemic medication, is prescribed for a client. which information should the nurse reinforce when instructing the client about taking this medication? a) take with milk b) take with meals c) take with an antacid d) take 2 hours before meals

d) take 2 hours before meals rationale etidronate should be taken on an empty stomach 2 hours before meals. it should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron or albumin

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? a) the client with Addison's disease b) the client with metabolic acidosis c) the client with intestinal obstruction d) the client receiving nasogastric suction

d) the client receiving nasogastric suction rationale potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. the client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

the nurse is reviewing the health records of assigned clients. the nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? a) the client with sepsis b) the client with cirrhosis c) the client with kidney failure d) the client with diabetes mellitus

d) the client with diabetes mellitus rationale fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity and pericardial sac. third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age

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 hyperkalemia hyponatremia hypernatremia hypomagnesemia hypermagnesemia

hypokalemia // hyponatremia // hypomagnesemia rationale prolonged gastric suction or gastric surgery can result in electrolyte imbalances. there can be deficits of potassium, sodium, or magnesium blood levels

Calcitriol (racaltrol) 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? a) bran b) milk c) clams d) orange juice

a) bran rationale the client taking an antihypocalcemic medication should be instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption. by contrast, good dietary sources of calcium include milk products; dark green, leafy vegetables; clams; oysters; sardines; and orange juice with added calcium

the nurse is assisting in the care of a group of clients on the nursing unit. the nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid a) major burn b) renal failure c) ischemic stroke d) laennec's cirrhosis

c) ischemic stroke rationale fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. this fluid is physiologically useless because it does not circulate to provide nutrients for the cells. common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac. clients at high risk for third-spacing include older adults and those with liver and kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. the client who suffered a stroke is not at risk for third-spacing

the nurse is assisting in caring for a client who is receiving an IV infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. the nurse is monitoring the client for signs of hyperkalemia. which sign/symptom should be noted in the client if hyperkalemia is present? a) muscle pain b) mental confusion c) muscle weakness d) depressed deep tendon reflexes

c) muscle weakness rationale because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness not muscle pain. mental status changes and confusion are most likely noted in the client experiencing hypocalcemia. depressed deep tendon reflexes are noted in the client with hypermagnesemia.

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 a) tap water b) sterile water c) normal saline d) dextrose solution 5%

c) normal saline rationale a potassium level of 4.5 mEq/L is within normal range. a sodium level of 132 mEq/L is low, indicating hyponatremia. in clients with hyponatremia, normal (isotonic) saline should be used rather than sterile water (hypotonic) for gastrointestinal irrigations. it is not ordinary clinical practice to irrigate with 5% dextrose solution.

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? a) diarrhea b) ulcerative colitis c) severe burn injury d) cushing's syndrome

c) severe burn injury rationale a serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. this electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. the client with cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia.

the nurse is told in a report that the client has hypocalcemia and a postive Chvostek's sign. which signs should the nurse expect to note during the data collection? select all that apply coma tetany diarrhea hypoactive bowel sounds a positive Trousseau's sign

tetany // diarrhea // a positive Trousseau's sign rationale a positive Chvostek's sign is indicative of hypocalcemia. other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, a positive Trousseau's sign, diarrhea, seizures, hyperactive bowel sounds, and a prolonged QT interval

a client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. the client has an indwelling IV catheter. the client's morning lab results show a serum blood sodium level of 130 mEq/L and a serum blood chloride level of 92 mEq/L which IV fluids will provide free water, sodium, and chloride to the client? select all that apply ringers solution 0.9% NaCl in water solution 0.45% NaCl in water solution Dextrose 5% in 0.225% NaCl solution Dextrose 5% in lactated ringers solution

0.45% NaCl in water solution // dextrose 5% in 0.225% NaCl solution rationale the IV fluid 0.45% NaCl in water solution provides free water in addtion to Na+ and Cl- dextrose 5% in 0.225% NaCl solution provides Na+ Cl- and free water. Ringers solution is similar in composition to plasma except that it has excess Cl- no Mg2+ and no HCO3- it does not provide free water or calories. the IV fluid 0.9% NaCl in water solution does not provide free water, calories, or other electrolytes. 5% Dextrose in Lactated ringers (Hartmann's) solution is similar in composition to normal plasma except it does not contain Mg2+ and it does not provide free water.

a client enters the emergency department confused, twitching, and having seizures. his family states he recently was placed on corticosteriods 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 HCP likely prescribe? select all that apply. monitor the vital signs monitor intake and output increase water intake orally monitor electrolyte levels provide a sodium-reduced diet administer sodium replacements

monitor the vital signs // monitor intake and output // increase water intake orally // monitor electrolyte levels // provide a sodium-reduced diet rationale hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. sodium replacement therapy would not be prescribed for a client with hypernatremia.

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 HCP likely prescribe? select all that apply monitor vital signs monitor electrolyte levels increase water intake orally monitor intake and output maintain sodium-reduced diet administer sodium replacements

monitor vital signs // monitor electrolyte levels // increase water intake orally // monitor intake and output // maintain sodium-reduced diet rationale hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. sodium replacement therapy would not be prescribed for a client with hypernatremia.

which of these clients are most likely to develop fluid (circulatory) overload. select all that apply. a premature infant a 101-year-old man a client on renal dialysis a client with heart failure a client with diabetes mellitus a 29-year-old client with pneumonia

a premature infant // a 101-year-old man // a client on renal dialysis // a client with heart failure rationale clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. the risk of fluid (circulatory) overload exists with these clients

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) a client with an ileostomy b) a client with major trauma c) a client with heart failure d) a client with acute kidney injury

a) a client with an ileostomy rationale the client with an ileostomy is at risk for deficient fluid volume because of increased GI tract losses. other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy or colostomy. clients who have heart failure, renal failure, or major trauma are at risk for excess fluid volume.

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? a) monitor the client for dysrhythmias b) instruct the client to consume low-calcium foods c) instruct the client to include a banana in the daily diet d) instruct the client to consume foods low in magnesium

a) monitor the client for dysrhythmias rationale hypomagnesemia is defined as a plasma magnesium level less than 1.6 mg/dL the client should be monitored for dysrhythmias because the client is predisposed particularly to ventricular dysrhythmias. the client also should consume foods high in magnesium. bananas are high in potassium, not magnesium. because hypocalcemia frequently accompanies hypomagnesemia, high-calcium foods should be consumed.

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? a) obtain orthostatic vital signs b) prepare to insert a nasogastric tube feeding c) prepare to insert a parenteral nutrition infusion d) check the client's skin for irritation caused by diarrhea

a) obtain orthostatic vital signs rationale the initial nursing action is to determine the client's level of dehydration. orthostatic vital signs (blood pressures and pulses, lying, sitting, standing) are actions to determine the probability of fluid losses. a drop of more than 10 to 20 mmHg and an increased pulse rate of 10 to 20 beats per minute probably indicate a significant intravascular fluid volume deficit. with a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is facing a life-threatening problem. generally, the fluid levels must be increased quickly with lactated ringers or normal saline IV solutions as prescribed. the last option may be an intervention but it is not an initial action. the other options are not initial measures to treat dyhydration

a client has a serum sodium level of 129 mEq/L because of hypervolemia. the nurse consults with the HCP to determine whether which measure should be instituted? a) restricting fluid intake b) providing a 2-g sodium diet c) providing a 4-g sodium diet d) administering IV hypertonic saline

a) restricting fluid intake rationale hyponatremia is defined as a serum sodium level of less than 135 mEq/L when it is caused by hypervolemia, it may be treated with fluid restriction. the low serum sodium value is a result of hemodilution. IV hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L a 4-g sodium diet is a no-added-salt diet; a 2-g sodium diet does not raise the serum sodium level

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? a) increasing pulse b) decreasing body weight c) decreasing urine output d) increasing central venous pressure

b) decreasing body weight rationale a sign that fluid overload is resolving of body weight. the other options listed indicate that the client is retaining additional fluid. assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, decreased urine output, and a decreased hematocrit. these symptoms must reverse if the fluid overload is to be resolved.

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? a) lung crackles b) flat neck veins c) decreased pulse d) increased blood pressure

b) flat neck veins rationale a client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins. other findings are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. the symptoms noted in the other options indicate fluid volume excess

a normal saline 0.9% IV solution is prescribed for a client. the IV is to run at 100 mL/hr. the nurse prepares the solution, understanding that which is a characteristic of this type of solution? a) affects the plasma osmolarity b) is the same solution as sodium chloride 0.9& c) is hypertonic with the plasma and other body fluids d) is hypotonic with the plasma and other body fluids

b) is the same solution as sodium chloride 0.9% rationale sodium chloride is the same solution as normal saline 0.9%. this solution is isotonic, and isotonic solutions frequently are used for IV infusion because they do not affect the plasma osmolarity

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? a) the client with cirrhosis b) the client with a colostomy c) the client with heart failure d) the client with decreased kidney function

b) the client with a colostomy rationale causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. a client with cirrhosis, HF, or decreased kidney function is at risk for fluid volume excess

the nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L the nurse understands that a potassium value at this level should be noted with which condition? a) diarrhea b) traumatic burn c) Cushing's syndrome d) overuse of laxatives

b) traumatic burn rationale a serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. the client with Cushing's syndrome or diarrhea and the client who has been overuisng laxatives are at risk for hypokalemia

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) a client receiving chemotherapy b) a client with hypoparathyroidism c) a client with a history of alcoholism d) a client admitted with vitamin D intoxication

c) a client with a history of alcoholism rationale the normal serum phosphorus level is 2.7 to 4.5 mg/dL , so a value of 2.0 mg/dL is indicative of hypohosphatemia. causative factors include decreased nutritional intake and malnutrition. a poor nutritional state is associated with alcoholism. hypoparathyroidism, chemotheraphy, and vitamin D intoxication are causative factors of hyperphosphatemia.

the nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL which prescribed medication should the nurse prepare to assist in administering to the client? a) calcium chloride b) calcium gluconate c) calcitonin (miacalcin) d) large doses of vitamin D

c) calcitonin (miacalcin) rationale the normal serum calcium level is 8.6 to 10.0 mg/dL this client is experiencing hypercalcemlia. calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. in hypercalcemia, large doses of vitamin D need to be avoided. calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

the nurse is monitoring the fluid balance of a client with 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? a) moistness of the skin b) skin turgor with tenting c) decreased urine output and hypotension d) precise measurement of vomitus and diarrhea

c) decreased urine output and hypotension rationale with the loss of muscle mass and adipose tissue, the overlying skin loses its support. the usual elasticity of skin becomes a less reliable indicator of body fluid status. vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium. decreased urine output and hypotension more accurately correlate with loss of fluid in this client population.

a client is at risk for developing hypocalcemia. the nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted? a) increased heart rate b) increased blood pressure c) positive trousseau's sign d) hypoactive bowel sounds

c) positive trousseau's sign rationale signs of hypocalcemia include paresthesias, hyperactive reflexes, and a positive trousseau's or chvostek's sign. additional signs of hypocalcemia include a decreased heart rate, hypotension, hyperactive bowel sounds, increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. the other signs are of hypercalcemia

which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L? a) U waves b) flat P waves c) elevated T waves d) prolonged PR interval

a) U waves rationale a serum potassium level less than 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life threatening. cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

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? a) prolonged bed rest b) adrenal insufficiency c) hyperparathroidism d) excessive ingestion of vitamin D

a) prolonged bed rest rationale the normal serum calcium level is 8.6 to 10.0 mg/dL a client with a serum calcium level of 8.0 mg/dL is experiencing hypocalcemia. the excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. although immobilization can initially cause jypercalcemia, the long-term effect of prolonged bedrest is hypocalcemia.

an 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 LPN recalls that the RN is referring to fluid losses occurring through which areas? a) skin and lungs b) wound drain and skin c) nasogastric tube and wound drain d) foley catheter and nasogastric tube

a) skin and lungs rationale insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. they occur on a daily basis without the client's awareness. sensible losses are those that are measurable and include wound drainage, gastrointestinal tract losses, and urine output

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? a) the client with renal failure b) the client with an ileostomy c) the client with a draining abdominal wound d) the client with a nasogastric tube to low suction

a) the client with renal failure rationale the client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. the client with an ileostomy, a draining abdominal wound, or a nasogastric tube attached to suction is at risk for deficient fluid volume.

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) a client with ulcerative colitis b) a client with a new burn injury c) a client with cushing's syndrome d) a client who has a history of long-term laxative abuse

b) a client with a new burn injury rationale hyperkalemia is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction such as in trauma or burns. clients with cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia

the nurse is caring for a client with a diagnosis of hyperparathyroidism. laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. based on this laboratory value, the nurse should take which action? a) document the value in the client's record b) inform the RN of the laboratory value c) place the laboratory result form in the client's record d) reassure the client that the laboratory result is normal

b) inform the RN of the laboratory value rationale the normal serum calcium level ranges from 8.6 to 10.0 mg/dL. the client is experiencing hypercalcemia and the nurse would inform the RN of the laboratory value. because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

the nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. the client is being treated with an IV hypertonic saline. the nurse determines that the treatment measures are effective when the laboratory results reveal which sodium level? a) 120 mEq/L b) 130 mEq/L c) 140 mEq/L d) 150 mEq/L

c) 140 mEq/L rationale hyponatremia is defined as a serum sodium level of less than 135 mEq/L. when it is caused by hypervolemia, it may be treated with fluid restriction. the low serum sodium value is a result of hemodilution. IV hypertonic solution (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L the normal serum sodium level is 135 to 145 mEq/L the first two options identify hyponatremia and the last option indicates hypernatremia.

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? a) the client with watery diarrhea b) the client with diabetes insipidus (DI) c) the client with an inadequate daily water intake d) the client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

d) the client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) rationale hyponatremia is a serum sodium level less than 135 mEq/L. hyponatremia can occur secondary to SIADH. the client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia

the nursing instructor asks the student to describe isotonic dehydration. the student correctly responds by stating which pathophysiological process? a) serum sodium level rises above 150 mEq/L b) the loss of electrolytes is greater than the loss of water c) the loss of water is greater than the loss of electrolytes d) water and electrolytes are lost in approximately the same proportion as they exist in the body

d) water and electrolytes are lost in approximately the same proportion as they exist in the body rationale isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. in this type of dehydration, the serum sodium levels remain normal (1135-145) the second option describes hypotonic dehydration in which the serum sodium level is less than 130. the other options describe hypertonic dehydration

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? a) spinach b) avocado c) fresh pork d) white bread

d) white bread rationale a slice of white bread provides 27mg of potassium. raw spinach (3 1/2 ounces) provides 470 mg of potassium. one avocado provides 1097 mg of potassium and 4 ounces of pork provides 525 mg of potassium

the nurse is assigned to care for a group of clients on the clinical nursing unit. which client is least likely to develop third spacing of fluids? a) major burn b) renal failure c) hypertension d) laennec's cirrhosis

hypertension rationale fluid that shifts into the interstitial spaces and remains there is referred to as "third space fluid" this fluid is physiologically useless because it does not circulate to provide nutrients for the cells. common sites for third spacing include the pleural and peritoneal cavities and the pericardial sac. risk factors include the older client, and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition

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 muscle weakness presence of decreased deep tendon reflexes 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

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 rationale the laboratory result reveals hypocalcemia. tetany, electrocardiogram abnormalities, and tingling can be present in hypocalcemia. to test for tetany, the nurse should check for a positive Chvostek's sign (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) and Trousseau's sign (checking for a carpal spasm induced by inflating a blood pressure cuff over the systolic blood pressure for a few minutes). muscle weakness is commonly associated with potassium abnormalities. decreased deep tendon reflexes are associated with both hypercalcemia and hypermagnesemia

the nurse is calculating a client's 24-hour fluid intake. the client consumed coffee 8 oz water 8 oz orange juice 6 oz soup 4 oz iced tea 8oz milk 10 oz tea 8 oz water 8 oz. water 24 oz how many milliliters of fluid did the client consume in the 24-hour period?

2520 mL rationale the client consumed a total of 84 oz of fluid. because 1 oz is equal to 30 mL, multiply 84 oz by 30 mL/ oz. this yields 2520 mL

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? a) milk b) butter c) spinach d) collard greens

b) butter rationale butter comes from milk fat and does not contain significant amounts of calcium. milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

the nurse is reviewing the health care records of assigned clients. which client is at risk for excess fluid volume? a) the client on diuretics b) the client with renal failure c) the client with an ileostomy d) the client on GI suctioning

b) the client with renal failure rationale the causes of excess fluid volume include decreased kidney function, heart failure, cirrhosis, the use of hypotonic fluids to replace isotonic fluid losses, and the excessive ingestion of table salt. the client with an ileostomy, the client on diuretics, and the client on GI suctioning are at risk for deficient fluid volume

the nurse is reading the 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? a) client with a draining wound b) client with a urinary catheter c) client with a fast respiratory rate d) client with a nasogastric tube to low suction

c) client with a fast respiratory rate rationale sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. insensible losses occur daily through the skin and the lungs

the HCP 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? a) with meals b) just before meals c) two hours after meals d) at bedtime with a snack

c) two hours after meals rationale calcium carbonate is best administered between meals. the other options are incorrect.

the nurse is monitoring a client for hypercalcemia. which sign/symptom would the nurse note in hypercalcemia? a) muscle cramps b) tingling sensations c) hyperactive reflexes d) slight muscle weakness

d) slight muscle weakness rationale hypotonia (slight muscle weakness) is seen in hypercalcemia. signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive trousseau's or chvostek's sign. other signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety.