NCLEX REVIEW

A client is admitted with prolonged nausea and vomiting. The client's admission sodium is 149 mEq/L. What action by the nurse would be most appropriate at this time?

1. Administer 3% normal saline at 150 mL/hr 2. Perform neurological assessment. 3. Increase oral intake of sodium. 4. Decrease fluid intake. Answer: 2

The nurse is preparing a teaching plan for a client newly diagnosed w/ fluid retention and heart failure. What should the nurse advise the client to avoid?

1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwichs Answer: 2, 4, 5

A client was admitted with reports of prolonged diarrhea. The clients admission potassium level was 3.3 mEq/L and is receiving an IV of D5 1/2 NS with 20 mEq KCL at 125 ml/hr. The UAP reports an 8 hour urinary output of 200 mL.The previous 8 hour urinary output was 250 mL. What should be the nurses priority action?

1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO Answer: 3.

A client is admitted following a severe burn. What changes related to fluid status with the nurse anticipate?

1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increase the urine specific gravity Answer: 2, 3, 5, 6

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client?

1. Fluid volume excess. 2. Cellular edema. 3. Severe hypotension. 4. Decreasing CVP. Answer: 1

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesium. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse document?

1. Liver function. 2. Respiratory rate. 3. Calcium levels. 4. Deep tendon reflexes. (DTRs) 5. Urinary output. Answer: 2, 4, 5

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client?

1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low, urine specific gravity Answer: 4

A client is admitted with hypocalcemia. Which treatment with the nurse anticipate for this client?

1. PO calcium 2. Rapid IV. Push calcium. 3. Vitamin D. 4. Sevelamer hydrochloride 5. Phosphate supplements Answer: 1, 3, 4

A client is admitted to the cardiac floor in heart failure. The lung sounds review crackles bilaterally and the blood pressure is 160/98. The client has been on diuretics at home and the potassium level is 3.3. Which diuretics with the nurse anticipate being prescribed for this client to minimize potassium loss?

1. Spirolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide Answer: 1

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching?

1. The increase level of ADH will cause my potassium level to be too high. 2. I will be retaining sodium and water due to increased amount of aldosterone. 3. I will be losing lots of fluid due to the hormonal imbalance I have. 4. I will feel jittery and nervous due to the elevated the thyroxine levels. Answer: 2

Concentration makes the #s go ____ and Dilute makes the #s go ____ in reference to what labs?

1. UP 2. DOWN 3. Urine specific gravity, Sodium, & Hematocrit

As fluid volume decreases, what happens to BP and CVP?

BOTH DECREASE

What is the action of a hypertonic solution?

Draws fluid from the cell into the vascular space causing volume to build up in the vascular space.

What type of solution is Albumin?

HYPERTONIC

What should you always monitor before and during IV potassium?

Monitor urinary output

What organ doesn't like it when sodium is messed up?

THE BRAIN!!!! Look for neuro changes when Na is not WNL

What is potassium excreted by?

The kidneys

What clients would the nurse anticipate use of a hypertonic solution?

Third spacing Severe edema Ascites

Having too much aldosterone puts the patient at risk for what imbalance?

fluid volume excess, due to retention of both sodium and water.

What's happens to urine output when fluid volume becomes depleted?

Urine output will decrease in an effort to hold onto fluid **urine specific gravity will be concentrated