Biophysical: Fluid/Electrolytes + Acid Base (HESI Concept)

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? a. Peripherally inserted central catheter (PICC) line b. #20 angiocatheter in either antecubital area c. Large-gauge butterfly needle in hand d. Femoral line

a. Peripherally inserted central catheter (PICC) line Rationale Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

A 1-month-old infant is fed breast milk exclusively. The parent asks the nurse if fluoride supplementation is required. What is the best response from the nurse? a. "Fluoride supplementation is needed in hot climates." b. "Fluoride supplementation may result in dental fluorosis." c. "There is no need to give fluoride if the child appears fine." d. "The child may need fluoride supplementation after 3 months of age."

b. "Fluoride supplementation may result in dental fluorosis." Rational Fluoride supplementation before 6 months of age may result in dental fluorosis. Fluoride supplementation is not associated with hot climates. The appearance of the child does not determine the need for fluoride. Fluoride supplementation is necessary only if the breast-feeding mother's water supply does not contain the required amount of fluoridation, and not after 3 months of age.

Which action should the nurse take first when a client's gravity flow IV rate is too slow? a. Reposition the client's arm. b. Adjust the flow clamp to deliver the correct rate. c. Evaluate the appearance of the catheter insertion site. d. Determine the amount of fluid that should have been absorbed.

c. Evaluate the appearance of the catheter insertion site. Rationale If infiltration or phlebitis is responsible for the decreased flow rate, the IV catheter must be removed and restarted in a new site. Repositioning the client's arm will do nothing if the catheter is not in a vein; this is not the priority. If the catheter is not in a vein, adjusting the flow clamp will be unsafe because fluid will enter interstitial tissues. Although determining the amount of fluid that should have been absorbed eventually will be done, this intervention will not resolve the cause of the problem; this is not the priority.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? a. Abdominal girth decrease b. Mucous membranes becoming drier c. Heart rate increases from 80 to 135 d. Blood pressure rises from 130/70 to 190/80

c. Heart rate increases from 80 to 135 Rationale Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? a. 150 to 250 mL b. 250 to 350 mL c. 300 to 500 mL d. 500 to 750 mL

d. 500 to 750 mL Rationale In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. a. Acidosis b. Lethargy c. Fractures d. Osteomalacia e. Eye calcium deposits

c. Fractures d. Osteomalacia e. Eye calcium deposits Rationale Because of calcium loss from the bone, fractures, osteomalacia, and eye calcium deposits occur. Acidosis decreases calcium that binds to albumin, resulting in more ionized calcium (free calcium) in the blood. Lethargy and weakness are associated with hypercalcemia.

A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure? a. Anemia b. Weight loss c. Uremic frost d. Hyperkalemia

d. Hyperkalemia Rational Decreased glomerular filtration leads to hyperkalemia, which may cause lethal dysrhythmias such as cardiac arrest. Anemia may occur but is not the most serious complication and should be treated in relation to the client's clinical manifestation; erythropoietin and iron supplements usually are used. Weight loss alone is not life threatening. Uremic frost, a layer of urea crystals on the skin, causes itching but it is not the most serious complication.

An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. _______ gtts/min

38 Rationale The total volume to be infused is 50 mL. The total infusion time is 20 minutes. The drop factor of the tubing is 15 gtts/mL. Use the following formula to determine the IV flow rate in gtt/min.

The laboratory reports of a client reveal that the serum creatinine value is 7 mg/dL (618.8 mmol/L) and the blood urea nitrogen (BUN) value is 240 mg/dL (85.68 mmol/L). Which integumentary manifestations can be noticed in this client? Select all that apply. a. Pruritus b. Clubbing c. Cyanosis d. Ecchymosis e. Uremic frost

a. Pruritus d. Ecchymosis e. Uremic frost Rational Elevated serum creatinine and BUN levels indicate chronic kidney disease, the integumentary manifestations of which include pruritus, ecchymosis, uremic frost, decreased skin turgor, yellow-gray pallor, dry skin, purpura, and soft-tissue calcifications. Clubbing is the integumentary manifestation of heart and lung diseases from chronic hypoxia. Cyanosis is the manifestation of decreased peripheral circulation and deoxygenated blood.

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply. a. Thirst b. Anorexia c. Leg cramps d. Rapid, thready pulse e. Dry mucous membranes

b. Anorexia c. Leg cramps Rationale The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased Peristalsis. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst is associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia. Dry mucous membranes are associated with hypernatremia.

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. a. Polyuria b. Lethargy c. Hypotension d. Muscle twitching e. Respiratory acidosis

b. Lethargy d. Muscle twitching Rationale Lethargy results from anemia, buildup of urea, and vitamin deficiencies. Muscle twitching results from excess nitrogenous wastes. Extensive nephron damage causes oliguria, not polyuria. Hypotension does not occur; the blood pressure is within the expected range or elevated as a result of increased total body fluid. Metabolic, not respiratory, acidosis occurs because of the kidneys' inability to excrete hydrogen and regulate sodium and bicarbonate levels.

After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea? a. Administer the prescribed antiemetic drug. b. Provide some dry crackers for the client to eat. c. Explain that this is expected following surgery d. Teach how to breathe deeply until the nausea subsides.

a. Administer the prescribed antiemetic drug. Rationale An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Providing some dry crackers for the client to eat, explaining that this is expected following surgery, and teaching how to breathe deeply until the nausea subsides. are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required.

What clinical finding indicates to the nurse that a client may have hypokalemia? a. Edema b. Muscle spasms c. Kussmaul breathing d. Abdominal distention

d. Abdominal distention Rationale Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

A nurse notes gentamycin in the prescription of an older adult with osteomyelitis. Which nursing interventions should be conducted before starting therapy? Select all that apply. a. Assessing renal function b. Assessing hydration status c. Checking the erythrocyte count d. Checking the blood platelet count e. Assessing serum thyroxin levels

a. Assessing renal function b. Assessing hydration status Rationale Because gentamycin can increase the risk of nephrotoxicity, the nurse should assess a client's renal function before starting therapy. Dehydration can further increase the risk of nephrotoxicity; therefore the client's hydration status should also be checked before starting therapy. Gentamycin generally does not impact erythrocyte and blood platelet counts nor does it affect serum thyroxin levels.

A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report? a. Feeling bloated after eating b. Tingling in the upper extremities c. Needing to use three pillows at night to sleep d. Swelling of the ankles that is more apparent in the morning

c. Needing to use three pillows at night to sleep Rationale Heart failure causes a fluid volume excess that results in pulmonary edema and dyspnea in the supine position, requiring pillows to sleep. Feeling bloated after eating and tingling in the upper extremities are unrelated to the cardiopulmonary system. Dependent edema usually occurs after standing or walking; swelling of the ankles is more evident in the evening.

To manage heart failure a client has been taking several medications, including furosemide 40 mg by mouth twice a day. The client develops severe muscle cramps and fatigue, and laboratory tests confirm the presence of hypokalemia. Potassium chloride intravenously (IV) and ECG monitoring have been prescribed. Which ECG change associated with hypokalemia should the nurse expect to observe? a. Inverted P waves b. Flattened T waves c. Absence of U waves d. Elevated ST segment

b. Flattened T waves Rationale A flattened T wave is associated with hypokalemia. A depressed T wave indicates a problem with ventricular repolarization, a process involved in muscle contraction. Adequate potassium levels are needed for efficient muscle contraction. P waves may peak in hypokalemia. In hypokalemia, U waves appear. ST segment is depressed in hypokalemia.

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing? a. Left ventricular failure b. Right ventricular failure c. Restrictive pulmonary disease d. Obstructive pulmonary disease

b. Right ventricular failure Rationale The failing right ventricle fails to contract effectively, which causes a backup of blood into the right atrium and venous circulation, causing peripheral edema and hepatomegaly. Left-sided heart failure results from left ventricular dysfunction, which prevents normal forward blood flow and causes blood to back up into the left atrium and pulmonary veins, causing pulmonary congestion. Although dyspnea on exertion is associated with obstructive and restrictive pulmonary disease, hypertension and pedal edema are related to cardiac, not respiratory, problems.

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? a. Elevate the IV site. b. Discontinue the infusion. c. Attempt to flush the tubing. d. Apply a warm, moist compress.

b. Discontinue the infusion. Rationale When an IV infusion infiltrates, it should be removed to prevent edema and pain. Elevation does not change the position of the IV cannula; the infusion must be discontinued. Flushing the tubing will add to the infiltration of fluid. Soaks may be applied, if prescribed, after the IV cannula is removed.

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning? a. White blood cell (WBC) cell count b. Renal ultrasound c. Serum creatinine level d. 24-hour urinary output

c. Serum creatinine level Rationale Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a nitrogenous product of protein breakdown, is increased with renal insufficiency. WBC count does not measure kidney function; white blood cells usually are depressed because of immunosuppressive therapy to prevent rejection. WBC count is more valuable for assessing structure than function. Although 24-hour urinary output should be considered, it is not as definitive as the serum creatinine level.

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client? a. Intravascular to interstitial as a result of glycosuria b. Extracellular to interstitial as a result of hypoproteinemia c. Intracellular to intravascular as a result of hyperosmolarity d. Intercellular to intravascular as a result of increased hydrostatic pressure

c. Intracellular to intravascular as a result of hyperosmolarity Rationale The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.

The nurse observes that an infant has lost 5% of body weight a few days after birth. Which reason does the nurse attribute to this weight loss? a. Immaturity of the renal structures b. Decreasing glomerular filtration rate c. Dehydration and electrolyte imbalance d. Extracellular fluid (ECF) compartment contraction

d. Extracellular fluid (ECF) compartment contraction Rationale ECF compartment contraction causes a loss of 5% to 10% of body weight in a newborn infant during the first 5 days of life. The amount of ECF decreases as the percentage of body water decreases in the infant's body, resulting in weight loss. Dehydration and electrolyte imbalance result from the immaturity of the renal structures. The increasing glomerular filtration rate causes weight loss in infants.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? a. Weigh the client daily. b. Restrict the client's oral fluid intake. c. Measure the client's urine specific gravity. d. Observe the client for increasing confusion.

d. Observe the client for increasing confusion. Rationale An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

A client requires intravenous fluids postoperatively. The healthcare provider has prescribed D 5W to infuse at 125 mL/hr. To deliver the solution at the correct drip rate, what must the nurse calculate first? a.Total fluid volume in the bag b.Diameter of the tubing being used c.Size of the needle or catheter in the vein d.Drops per milliliter delivered by the infusion set

d.Drops per milliliter delivered by the infusion set Rationale Knowing the number of drops per milliliter delivered by the infusion set is necessary to calculate the drip rate of an intravenous infusion. The total fluid volume in the bag does not determine the drip rate. The diameter of the tubing being used does not determine the drip rate, only the size of the drop. The size of the needle or catheter in the vein does not determine the drip rate. Different infusion sets deliver different, preset numbers of drops per milliliter.

The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply. a. "I should assess for low blood pressure." b. "I should assess for increased digitalis toxicity." c. "I should assess for a decreased rate of ventilation in respiratory alkalosis." d. "I should assess for an increased depth of ventilation in respiratory alkalosis." e. "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."

a. "I should assess for low blood pressure." b. "I should assess for increased digitalis toxicity." c. "I should assess for a decreased rate of ventilation in respiratory alkalosis." Rationale The nurse should assess for low blood pressure and increased digitalis toxicity as cardiovascular manifestations of alkalosis, not respiratory manifestation. The nurse should assess for increased rate of ventilation in respiratory alkalosis. The nurse should assess for increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.

A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? a. "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." b. "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." c. "It decreases the need for immobility, because it clears toxins in short and intermittent periods." d. "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."

d. "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." Rationale Diffusion moves particles from an area of greater concentration to an area of lesser concentration; osmosis moves fluid from an area of lesser to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane to indirectly cleanse the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.

The nurse is teaching a nursing student about caring for a client who is undergoing blood studies for antidiuretic hormone stimulation. Which statements made by the nursing student indicate effective instruction? Select all that apply. a. "I will assess the pulse rate after rehydrating the client." b. "I will perform the test if the serum sodium level is high." c. "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." d. "I will hydrate the client with oral fluids before performing the test." e. "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)."

a. "I will assess the pulse rate after rehydrating the client." c. "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." e. "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)." Rational The client's pulse rate and blood pressure should be assessed after rehydration for orthostatic hypertension after the procedure to ensure adequate fluid volume. The test should be performed if the serum osmolarity is less than 300 mOsm (mmol)/kg to avoid severe dehydration in clients who have central or nephrogenic diabetes insipidus. The test should be discontinued if the client's weight loss is greater than 2 kg. The test should not be performed if the serum sodium levels are high because severe dehydration may develop in central or nephrogenic diabetes insipidus clients. The client should have nothing by mouth before the test. Oral fluids are given to the client to rehydrate if the client is experiencing dehydration during the test.

Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching? a. "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." b. "Any reconstituted solution must be discarded in 1 week." c. "I can continue driving my car as long as I have the stamina." d. "While taking this medicine I should be able to continue my usual activity."

a. "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." Rationale Adequate fluid intake helps to flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution may be stored in the refrigerator for 1 month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flulike symptoms are common with this drug.

The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? a. Crackles in lungs b. Supple skin turgor c. Urine output of 240 mL over 8 hours d. Increase in blood pressure from 110/76 to 124/68 mm Hg

a. Crackles in lungs Rationale Crackles in the lungs indicate the client is overloaded with fluids. The nurse should notify the primary healthcare provider to slow or discontinue the IV fluid. Supple skin turgor is a normal finding indicating that the IV fluid is working. A urine output of 240 mL in 8 hours is adequate. Therefore simply having a urine output of 30 mL/hr is not an indication that the IV fluid should be decreased or discontinued; it demonstrates that the kidneys are adequately perfused. An increase in blood pressure is to be expected with administration of fluid.

A nurse is caring for a client admitted to the hospital with primary hyperparathyroidism. Which action should be included in this client's plan of care? a. Ensuring a large fluid intake b. Providing a high-calcium diet c. Instituting seizure precautions d. Encouraging complete bed rest

a. Ensuring a large fluid intake Rationale Fluids help prevent the formation of renal calculi associated with high levels of serum calcium. Additional calcium intake may increase the already high levels of serum calcium. Seizures are associated with low, not high, levels of serum calcium. Bed rest is contraindicated because it accelerates bone destruction.

What is the action of the vasopressin hormone released from the client's posterior pituitary? a. Helps produce concentrated urine b. Causes tubular secretion of sodium c. Promotes potassium secretion in the collecting duct d. Enhances sodium reabsorption in the distal convoluted tubule

a. Helps produce concentrated urine Rationale The action of the hormone vasopressin released from the posterior pituitary is to make the distal convoluted tubule and collecting duct permeable to water so as to maximize reabsorption and produce concentrated urine. The natriuretic hormones produced from cardiac ventricles cause tubular secretion of sodium. Aldosterone released from the adrenal cortex promotes potassium secretion and sodium reabsorption in the distal convoluted tubules and collecting duct.

The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia

a. Hypokalemia Rationale In case of hypokalemia, the nurse should assess the respiratory status of the client every 2 hours. In case of hyperkalemia, the nurse should notify the healthcare team if the heart rate falls below 60 beats per minute or T waves become spiked. In case of hyponatremia, the nurse should be aware of muscle weakness in the client and immediately check respiratory effectiveness. In case of hypernatremia, the nurse should assess the client hourly for excessive losses of fluid, sodium, or potassium.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings? a. Hypokalemia b. Hyponatremia c. Hyperglycemia d. Hypercalcemia

a. Hypokalemia Rationale These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Clinical manifestations of hyponatremia include nausea, malaise, and changes in mental status. Clinical manifestations of hyperglycemia include weakness, dry skin, flushing, polyuria, and thirst. Clinical manifestations of hypercalcemia include lethargy, nausea, vomiting, paresthesias, and personality changes.

What instructions should a nurse give an adolescent who is taking benzoyl peroxide for acne? a. "Avoid frequent hair shampooing." b. "Comb your hair to cover your forehead. " c. "Apply the gel 20 to 30 minutes after washing your face." d. "Use light-colored towels and bed sheets while on benzoyl peroxide treatment." e. "Increase the frequency of the application gradually to prevent the drying effect."

d. "Use light-colored towels and bed sheets while on benzoyl peroxide treatment." e. "Increase the frequency of the application gradually to prevent the drying effect." Rationale Benzoyl peroxide may have a drying effect on the skin; the client can adjust to this effect by gradually increasing the frequency of application. Benzoyl peroxide causes a bleaching effect on clothes. Therefore, the adolescent should be instructed to use light-colored towels and bed sheets. Frequent shampooing reduces sebum secretion and thus acne. Brushing the hair away from forehead helps to reduce acne on the forehead due to dandruff. Tretinoin gel should be applied at least 20 to 30 minutes after face washing to reduce the burning sensation.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. a. Back of the neck b. Back of the hand c. Palm of the hand d. On the sternal area e. Back of the fore arm

d. On the sternal area e. Back of the fore arm Rationale Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

A child is admitted to the hospital with diarrhea and is prescribed antidiarrheal medications. Which nursing actions indicate that the nurse is skilled in safe drug administration to pediatric clients? Select all that apply. a. The nurse calculates the drug dose according to the weight. b. The nurse recommends long-term use of the medication. c. The nurse promotes fluid and electrolyte balance. d. The nurse assesses the child for the presence of any eating disorders. e. The nurse assesses the severity of diarrhea by counting the number of stools every 48 hours.

a. The nurse calculates the drug dose according to the weight. c. The nurse promotes fluid and electrolyte balance. d. The nurse assesses the child for the presence of any eating disorders. Rationale The nurse should calculate the dose according to the weight of the child to ensure accurate dosing. Diarrhea causes rapid loss of fluid volume and electrolytes through the stools; therefore, the nurse should promote fluid and electrolyte balance by ensuring the appropriate intake of fluids. The nurse should assess the child for the presence of eating disorders such as bulimia and anorexia to check for the abuse of laxatives. The nurse should not recommend the long-term use of antidiarrheal medications because they cause toxic effects. The nurse should measure the amount of diarrhea by the number of stools every 24 hours and not for 48 hours.

A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? a. Use normal saline to irrigate the tube. b. Employ sterile technique when irrigating the tube. c. Withdraw the tube quickly when decompression is terminated. d. Allow the client to have small sips of ice water unless nauseated.

a. Use normal saline to irrigate the tube. Rationale Patency of the tube should be maintained to ensure continued suction. Use of normal saline minimizes fluid and electrolyte disturbances during irrigation. The stomach is not considered a sterile body cavity, so medical asepsis is indicated. Care must be taken to avoid traumatizing the mucosa. Ice chips and water represent fluid intake, which must be approved by the healthcare provider; being hypotonic in nature, such intake may lower the level of serum electrolytes.

The nurse is explaining the physiologic reasons for taking vitamin D and calcium supplements to a client with renal failure. Which statement made by the nurse is appropriate? a. "There will be a decrease in the inactive forms of vitamin D in your body." b. "There will be a decrease in the active metabolite of vitamin D in your body." c. "There will be an increase in the conversion of skin cholesterol into vitamin D." d. "There will be an increase in the vitamin D associated intestinal absorption of calcium."

b. "There will be a decrease in the active metabolite of vitamin D in your body." Rationale Renal failure results in decrease in the active metabolite of vitamin D because inactive vitamin D gets activated in the liver followed by the kidneys. Food sources of vitamin D and sunlight contribute to an inactive form of the hormone in the body. Inactive vitamin D will decrease if foods rich in vitamin D are not consumed or exposure to sunlight is reduced. Conversion of skin cholesterol to vitamin D depends on the exposure to sunlight and not renal impairment. In renal failure, there is less active vitamin D and therefore less intestinal absorption of calcium.

After abdominal surgery, a client is transferred to the post anesthesia care unit (PACU) with a nasogastric tube in place and attached to low intermittent wall suction. Which action should the nurse take initially when the client vomits 90 mL of bile-colored fluid? a. Elevate the head of the bed. b. Check the patency of the tube. c. Administer the prescribed antiemetic. d. Encourage the client to take several deep breaths.

b. Check the patency of the tube. Rational A nasogastric tube attached to suction removes gastric secretions and prevents vomiting. However, if it becomes obstructed, secretions accumulate, leading to distention, nausea, and vomiting. The client initially should be turned on the side to prevent aspiration. An antiemetic may be administered after tube patency is verified. Deep breathing will not prevent vomiting if a nasogastric tube is not patent.

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first? a. Irrigate the IV tubing b. Discontinue the infusion c. Slow the rate of the infusion d. Obtain a prescription for an analgesic

b. Discontinue the infusion Rationale The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion do not address the underlying problem and may further irritate the vein and precipitate a thrombophlebitis. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client? a. Sodium: 143 mEq/L b. Potassium: 2.9 mEq/L c. Bicarbonate: 25 mEq/L d. Total calcium: 10 mg/dL

b. Potassium: 2.9 mEq/L Rationale The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is below the normal level. Therefore, it may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL. Thus, the laboratory values of sodium (143 mEq/L), bicarbonate (25 mEq/L), and total calcium (10 mg/dL) lie in the normal range, which does not indicate hyperfunction of the adrenal gland in the client.

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication? a. Constipation b. Dehydration c. Electrolyte imbalance d. Nausea and vomiting

c. Electrolyte imbalance Rationale When clients do not receive nutrients or fluids by mouth and have loss of electrolytes through the removal of gastric secretions via an NG tube, then electrolyte imbalance is a primary concern. Constipation is usually not a concern in this type of situation. Although dehydration is a possible effect of an NG tube removing gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action should the nurse take next? a. Hold the client's morning diuretic dose b. Notify the healthcare provider that the potassium level is above normal c. Notify the healthcare provider that the potassium level is below normal d. No action is required because the potassium level is within normal limits

c. Notify the healthcare provider that the potassium level is below normal Rationale The healthcare provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5 mmol/L to 5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because supplemental potassium may be needed.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? a. Skeletal and nervous b. Circulatory and urinary c. Respiratory and urinary d. Muscular and endocrine

c. Respiratory and urinary Rationale Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first? a. Alert the cardiac arrest team. b. Call the laboratory to repeat the test. c. Take vital signs and notify the primary healthcare provider d. Obtain an electrocardiogram (ECG) strip and obtain an antiarrhythmic medication.

c. Take vital signs and notify the primary healthcare provider Rationale Vital signs monitor the cardiopulmonary status; the primary healthcare provider must treat this hyperkalemia to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Although obtaining an ECG strip is appropriate, obtaining an antiarrhythmic is premature; vital signs and medical attention is needed first.

After radioactive iodine therapy, a female client becomes hypothyroid and levothyroxine is prescribed. The client asks the nurse whether the hormone replacement therapy will interfere with the ability to become pregnant. What is the nurse's best response? a. "Do you think you won't be able to get pregnant?" b. "I recommend that you discuss this with your healthcare provider." c. "While taking this medication, you should avoid becoming pregnant." d. "If your thyroid function is controlled, the medicine should not interfere with your ability to become pregnant."

d. "If your thyroid function is controlled, the medicine should not interfere with your ability to become pregnant." Rationale Hormone replacement should stabilize the metabolic rate and should not interfere with the client's becoming pregnant. The response "Do you think you won't be able to get pregnant?" may elicit feelings but does not answer the client's question. The response "I recommend that you discuss this with your healthcare provider" ignores the client's request for information and abdicates the nurse's teaching responsibility. If thyroid function remains controlled, there is no reason why the client should not become pregnant.

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? a. Hemorrhage with subsequent anemia b. Diminished resistance to bacterial insult c. Malnutrition of cells, especially hepatic cells d. Reduction of colloidal osmotic pressure in the blood

d. Reduction of colloidal osmotic pressure in the blood Rationale Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.

An infant who has had diarrhea for 3 days is admitted in a lethargic state and is found to be breathing rapidly. The parent states that the baby has been taking formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent? a. Cellular metabolism is unstable in young children. b. Renal function is immature in children until they reach school age. c. The proportion of water in the body is less in infants than that in adults. d. The extracellular fluid requirement per unit of body weight is greater in infants than in adults.

d. The extracellular fluid requirement per unit of body weight is greater in infants than in adults. Rationale Extracellular body fluid represents 45% of the body at birth, 25% at 2 years of age, and 20% at maturity. Another measurement is fluid's percentage of total body weight, which is 80% at birth, 63% at 3 years, and approximately 60% at 12 years. Cellular metabolism in children is stable, but its rate is higher than that in adults. The proportion of total body water in children (up to 2 years) is greater than it is in adults. Renal function is immature through the second year of life, not until school age, which makes it more difficult to maintain fluid balance.

A client receiving calcitonin therapy reports a stinging sensation in the hands and feet. The primary healthcare provider analyzes the client's laboratory results and finds the client is experiencing a side effect of calcitonin therapy. Which finding will the nurse observe to support this conclusion? a. Serum sodium of 139 mEq/L (mmol/L) b. Serum creatinine of 0.4 mg/dL (35.36 µmol/L) c. Blood urea nitrogen of 17 mg/dL (6.07 mmol/L) d. Total serum calcium of 8 mg/dL (2 mmol/L)

d. Total serum calcium of 8 mg/dL (2 mmol/L) Rationale Calcitonin therapy is associated with the risk of hypocalcemia, which is manifested by tingling or numbness in the muscles. Normal levels of total calcium lie between 9.0-10.5 mg/dL (2.25 and 2.75 mmol/L). Because the client's total serum calcium concentration is 8 mg/dL (2 mmol/L), the nurse would conclude that the client has hypocalcemia. All the other values are normal. The normal range of sodium in the serum ranges from 135 to 145 mEq/L (135-145 mmol/L). The normal level of serum creatinine ranges from 0.6 to 1.2 mg/dL (53.04-106.08 µmol/L); while 0.4 mg/dL (35.36 µmol/L) is low, it will not cause stinging sensation in the hands and feet. The normal range of blood urea nitrogen lies between 7 and 20 mg/dL (2.5-7.14 mmol/L), and 17 mg/dL (6.07 mmol/L) is considered normal.

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record your answer using a whole number. ______ mL/hr

167 Rational The volume to be infused is 2000 mL. The total time of infusion is 12 hours.

The primary healthcare provider has prescribed an intravenous piggyback (IVPB) to be administered every 4 hours. The prescription is 1200 mg vancomycin, which must be added to 50 mL D5W after being diluted according the pharmacy's instructions. After the nurse dilutes the powdered medication with the correct amount of saline, the resulting solution contains 1 gram of drug per 3 mL. How much antibiotic solution should be added to the 50 mL of D5W? Record your answer using one decimal place. ______ mL

3.6 Rationale The prescribed dose is 1200 mg. The available concentration of drug is 1 g/3 mL. The prescribed dose should first be converted to the available concentration. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be added to 50 mL D 5W.

A client with a hemoglobin level of 6.2 g/dL (62 mmol/L) is receiving packed red blood cells. Twenty minutes after the infusion starts, the client complains of chest pain, difficulty breathing, and feeling cold. What is the first action the nurse should take? a. Stop the transfusion. b. Notify the healthcare provider. c. Provide several warm blankets. d. Slow down the rate of infusion.

a. Stop the transfusion. Rationale The client is experiencing an anaphylactic reaction, and the infusion should be stopped to prevent further problems. The healthcare provider should be notified after the transfusion is stopped. The blood transfusion should be stopped before implementing actions that address the client's anaphylactic reaction. Slowing the infusion will permit more of the incompatible blood to infuse, worsening the response.

A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client? a. Infection b. Vomiting c. Osteomyelitis d. Bronchospasm

b. Vomiting Rationale Vomiting may result in aspiration of vomitus, because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? a. Increased blood urea nitrogen (BUN) and hypotension b. Hyperkalemia and poor skin turgor c. Hyponatremia and decreased urine output d. Polyuria and increased specific gravity of urine

c. Hyponatremia and decreased urine output Rationale Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

The nurse is caring for a client who has been diagnosed with glomerulonephritis. Which initial urinary finding supports this diagnosis? a. Anuria b. Dysuria c. Polyuria d. Proteinuria

d. Proteinuria Rationale Protein in the urine (proteinuria) and hematuria (blood in the urine) are classic manifestations of the onset of glomerulonephritis because of the increased permeability of the vascular bed in the kidneys. Suppression of urine formation (anuria) is not an initial manifestation of glomerulonephritis; oliguria may be present. Pain or burning on urination (dysuria) is indicative of cystitis, not glomerulonephritis. Excessive urination (polyuria) does not occur as an initial change with glomerulonephritis; polyuria and nocturia may occur later with chronic glomerulonephritis, when the renal structures are destroyed.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? a. 4+ b. 3+ c. 2+ d. 1+

b. 3+ Rationale The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

A nurse concludes that clients who receive intravenous (IV) fluids rather than total parenteral nutrition for gastrointestinal problems lose weight for what reason? a. Lack of bulk in the diet b. Deficient carbohydrate intake c. Insufficient intake of water-soluble vitamins d. Increasing concentrations of electrolytes in the cells

b. Deficient carbohydrate intake Rationale Intravenous fluids supply minimal calories; a client receiving only intravenous fluids will lose weight and become malnourished. Lack of bulk in the diet is not related to weight; lack of bulk in the diet results in constipation. Vitamins are not related to weight loss. Intracellular electrolytes are not related to weight loss.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? a. Hypernatremia b. Hyponatremia c. Hyperkalemia d. Hypokalemia

b. Hyponatremia Rationale The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

Which statement regarding calcitonin is correct? a. It is secreted by follicular cells. b. Its actions are opposite to that of parathyroid hormone. c. It decreases phosphorous levels by increasing bone resorption. d. It works along with thyroid hormone to maintain normal calcium levels in blood.

b. Its actions are opposite to that of parathyroid hormone. Rationale Calcitonin reduces serum calcium levels, whereas parathyroid hormone increases serum calcium levels. Therefore, the actions of calcitonin are opposite to that of parathyroid hormone. Calcitonin is secreted by parafollicular cells of the thyroid gland. Calcitonin decreases calcium and phosphorus levels by decreasing bone resorption. Calcitonin works along with parathyroid hormone to maintain calcium levels in blood.

Which nutrient deficiency in the pregnant adolescent may result in decreased birth weight as a consequence of low bone mineral density in the fetus? a. Zinc b. Iron c. Calcium d. Folic acid

c. Calcium Rationale Calcium and vitamin deficiency may result in decreased birth weight as a consequence of low bone mineral density. Zinc deficiency may not lead to a decrease in bone mineral density. Iron deficiency may lead to anemia. Folic acid deficiency may result in neural tube defects.

The nurse cares for a client with bipolar disorder who is receiving drug therapy. The laboratory report reveals that the client's serum sodium level is 132 mEq/L (132 mmol/L). Which drug might have led to this condition? a. Lithium b. Bupropion c. Fluoxetine d. Nortriptyline

c. Fluoxetine Rationale A serum sodium level of 132mEq/L (132 mmol/L) indicates hyponatremia. Fluoxetine is a serotonin reuptake inhibitor that may lead to hyponatremia. Lithium is a mood stabilizer used to treat bipolar disorder; it does not lead to hyponatremia. Bupropion is an atypical antidepressant that does not cause hyponatremia. Nortriptyline is a tricyclic antidepressant used to treat bipolar disorder that does not lead to hyponatremia.

A nurse administers sodium polystyrene sulfonate to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? a. Frequent loose stools b. Improved mental status c. Sodium increases to 137 mEq/L (137 mmol/L) d. Potassium decreases to 4.2 mEq/L (4.2 mmol/L)

d. Potassium decreases to 4.2 mEq/L (4.2 mmol/L) Rationale This resin exchanges sodium ions for potassium in the large intestine to lower the serum potassium level; 4.2 mEq/L (4.2 mmol/L) is in the expected range for potassium. Constipation is a more common side effect. Mental status improvement is not a therapeutic effect of the drug. Sodium retention is an adverse effect; 137 mEq/L (137 mmol/L) is in the expected range for sodium.

The 1-day urine sample results of a client reveal that the calcium level is 800 mg/24 hr. What does the finding indicate? a. The client has nephritis. b. The client has nephrosis. c. The client has hypocalcemia. d. The client has hyperparathyroidism.

d. The client has hyperparathyroidism. Rationale In hyperparathyroidism the levels of parathormone in the body are increased and there is decalcification of bones and excretion of high-levels of calcium in the urine. Therefore a urine calcium level of 800 mg/24 hr, which is double the normal range of 100 to 400 mg/24 hr (2.50-7.50 mmol/kg/24 hr), indicates hyperparathyroidism. In nephritis, nephrosis, and hypocalcemia, the urine calcium level is decreased and the level is less than 100 mg/24 hr (2.50 mmol/kg/24 hr).