Exam3 Study Questions

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? -Increased urine specific gravity -Hypoactive bowel sounds -Bounding peripheral pulses -Decreased respiratory rate

Bounding peripheral pulses The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses.

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?SELECT ALL THAT APPLY. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. Assess for orthostatic hypotension E. Initiate cardiac monitoring.

A. Place the client on bed rest. B. Evaluate the electrolyte levels. D. Assess for orthostatic hypotension E. Initiate cardiac monitoring. RATIONALE:Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? Initiating an IV potassium infusion. Encouraging the client to eat bananas. Administering sodium polystyrene sulfonate. Administering a potassium-sparing diuretic.

Administering sodium polystyrene sulfonate. Rationale: The nurse should expect to administer sodium polystyrene sulfonate, which absorbs excessive potassium and excretes it through the stool. Other treatments include hemodialysis and IV glucose and insulin.

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? A. "Be careful not to overload them with too many oral fluids." B. "Offer fluids that they prefer frequently and on a regular schedule." C. "Restrict their fluids if they are incontinent." D. "Wake them every 2 hours during the night with a drink.

B. "Offer fluids that they prefer frequently and on a regular schedule." RATIONALE:The long-term care nurse teaches the UAPs to frequently offer older adults fluids that they prefer and on a regular basis. Because of the decreased thirst mechanism, older adults can become dehydrated and must be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer.Risk of overhydration, especially with oral fluids, is minimal. Fluids would never be restricted even if the client is incontinent. Restricting fluids to incontinent clients is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids. However, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A. Assesses for dry oral mucous membranes B. Checks for orthostatic blood pressure changes C. Notes pulse rate is 72 beats/min and bounding D. Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

B. Checks for orthostatic blood pressure changes RATIONALE:When caring an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure. Blood pressure measured with the client lying, then sitting, and finally standing is done to detect orthostatic or postural changes. During low blood volume states, especially when standing, insufficient blood flow to the brain may cause hypotension and tachycardia upon arising. This may cause light-headedness and dizziness, which increases the risk for falls, especially in older adults.Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does ensure safety for ambulation nor assess for fall risk.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? Contract the pelvic muscles. Take a sip of water. Exhale slowly. Bear down.

Bear down. Rationale: Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. A. Strength testing for muscle wasting B. Nutritional status and diet C. Skin assessment for edema and turgor D. Blood pressure, heart rate, and rhythmE. Intake and output, urine volume, and color

C. Skin assessment for edema and turgor D. Blood pressure, heart rate, and rhythm E. Intake and output, urine volume, and color To assess for FVE the nurse measures blood pressure, heart rate and rhythm, and breath sounds; inspects the skin to look for edema and turgor; and inspects neck veins. Intake and output, daily weight, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L). B. The client's heart rate is 101 beats per minute. C. The client is free from adventitious breath sounds. D. The client has experienced a weight gain of 1 pound (0.5 kg).

C. The client is free from adventitious breath sounds. RATIONALE:The nurse recognizes that Furosemide is effective when the client is free from adventitious breath sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight loss with resolution of edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels such as hypokalemia are side effects of furosemide, not therapeutic effects. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly indicate the medication has been effective. Weight loss, rather than weight gain, is often the effect of Furosemide, caused by the diuresis.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Assessing oral mucosa for dryness B. Choosing appropriate oral fluids C. Monitoring skin turgor for tenting D. Offering fluids to drink every hour

D. Offering fluids to drink every hour RATIONALE:Offering oral fluids every hour is within the scope of practice for a UAP.Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor would be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? A. Consulting with a health care provider about a client's laboratory results B. Infusing 500 mL of normal saline over 60 minutes C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr D. Providing oral care every 1 to 2 hours

D. Providing oral care every 1 to 2 hours RATIONALE: Appropriate intervention by an UAP to a client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent oral care is important for a client with fluid volume deficit. Consulting with a primary care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would be performed by licensed personnel.

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? Elevated sodium level Decreased potassium level Elevated magnesium level Decreased calcium level

Decreased potassium level Rationale: Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning.

The student nurse asks, "what it interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid outside cells." "Fluid in the tissue space between and around cells."

"Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? -"I will eat more cheese because I can't drink milk." -"I need to avoid foods with vitamin D because I am allergic to milk." -"I will stop taking my calcium supplements if they irritate my stomach." -"I will add broccoli and kale to my diet."

"I will add broccoli and kale to my diet." The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? - Compare the client's intake with the normal range of adult fluid intake. - Report the exact milliliter of intake to the physician's office nurse. - Ensure that the information is included in the verbal end-of-shift report. - Compare the total intake and output of fluids for the 24 hours.

- Compare the total intake and output of fluids for the 24 hours. Rationale: The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? -Assist with intubation -Initiate high-flow oxygen therapy -Administer a rapid-acting diuretic -Provide cardiac monitoring

-Initiate high-flow oxygen therapy When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs and increasing peripheral edema. Which disorder do the findings reflect? A. Fluid volume deficit B. Fluid volume excess C. Fluid Homeostasis D. Fluid Dehydration

B. Fluid volume excess

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor

D. Place the client on a cardiac monitor RATIONALE:Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress at this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium excess is determined.

A client who comes to the clinic complaining of perineal pain, dysuria and fever is diagnosed with prostatitis. The nurse understands that which of the following organisms would be the most likely cause? Staphylococcus Streptococcus Escherichia coli Paramyxovirus

Escherichia coli Rationale: Escherichia coli and microbes that cause sexually transmitted infections often are responsible.

After teaching about self-care measures to a client who has been diagnosed with prostatitis, the nurse determines that the teaching was successful when the client states which of the following? Ill take the antibiotic until all the symptoms are gone. If I have discomfort, a cool shower will give me relief. I should avoid fluids like coffee and tea. I need to make sure that I drink lots of fluid.

I should avoid fluids like coffee and tea. Rationale: With prostatitis, the client should avoid foods and liquids with diuretic action such as coffee and tea.

A nurse is caring for a client who has hypertension and has a potassium level of 6.6 mEq/L. Which of the following actions should the nurse take? Suggest that the client use a salt substitute. Obtain a 12-lead ECG. Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level.

Obtain a 12-lead ECG. Rationale: This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes

Which condition or laboratory result supports a diagnosis of pyelonephritis? Myoglobinuria Ketonuria Pyuria Low white blood cell (WBC) count

Pyuria Rationale: Pyelonephritis is diagnosed by the presence of pyuria, leukocytosis, hematuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Myoglobinuria is seen with any disease process that destroys muscle. Ketonuria indicates a diabetic state. Because the client with pyelonephritis typically has signs of infection, the WBC count is more likely to be high rather than low.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.) infusion of intravenous solution eating a sandwich urination vomiting drinking milk

infusion of intravenous solution urination vomiting drinking milk Rationale: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: fluid volume deficit .myocardial Infarction .fluid volume excess. atelectasis.

fluid volume excess Rationale: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note? 1 - twitching 2 - Hypoactive bowel sounds 3 - Negative Trousseau's sign 4 - Hypoactive deep tendon reflexes

1 - twitching Reason:- This is a common finding in hypocalcemia- The rest of the symptoms are associated with HYPERcalcemia

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells them to consume which of the following (select all that apply)? 1 - Peas 2 - Raisins 3 - Potatoes 4 - Cantaloupe 5 - Cauliflower 6 - Strawberries

2 - Raisins 3 - Potatoes 4 - Cantaloupe 6 - Strawberries

The nurse is assigned to care for a group of clients. On review the nurse determines that which client is at risk for fluid volume excess? 1 - The client taking diuretics 2 - The client with kidney disease 3 - The client with an ileostomy 4 - The client who required GI suctioning

2 - The client with kidney disease

Which patient is at risk for excess insensible water loss? A. Patient with constant GI suctioning B: Patient with slow, deep respirations C. Patient receiving O2 therapy D. Patient with hypothermia

A. Patient with constant GI suctioning

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? -"If my stockings feel tight, I'll just roll them down for a while." -"I'll put on my elastic stockings at the first sign of swelling." -"When I sit down to watch television, I'll be sure to put my feet up." -"It's okay to cross my legs as long as it's for less than an hour."

-"When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating her feet will increase the return. The client should elevate her feet for at least 20 min several times per day.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? -Skin turgor -Urine output -Weight -Mental status

-Mental status The greatest risk to this client is injury from a fall due to a decline in the client's mental status. Therefore, assessing the client's mental status is the nurse's priority.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? Lactated Ringer's Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water

0.45% sodium chloride Rationale: A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

The nurse caring for a group of clients reviews the electrolyte lab results and notes a sodium level of 130 mEq/L on one lab report. The nurse understands that which client is at the highest risk for development of this sodium level value? 1 - the client taking diuretics 2 - the client with hyperaldosteronism 3 - the client with Cushing's Syndrome 4 - the client taking corticosteroids

1 - the client taking diuretics Reason:- Normal sodium levels: 135 - 145 mEq/L- This patient is HYPOnatremic- Most times salt follows water, so diuretics cause loss of Na as well

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance? 0.5 mL/kg/hr 2 mL/kg/hr 7.5 mL/kg/hr 15 mL/kg/hr

2 mL/kg/hr Rationale: The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect in hyponatremia? 1 - Muscle twitches 2 - Dec urinary output 3 - Hyperactive bowel sounds 4 - Increased specific gravity of urine

3 - Hyperactive bowel sounds Reason:(from all nurses)fluid moves from a lower concentration to a higher concentration. Since there is hyponatremia (low concentration of sodium in the blood), the body will try to even up the ratio, so the fluid might move into the digestive tract. this movement may cause increased peristalsis (for excretion).

The nurse caring for a client who has been receiving IV diuretics suspects they are experiencing fluid volume deficit. Which assessment finding would the nurse note in this condition? 1 - Lung congestion 2 - Decreased hematocrit 3 - Increased BP 4 - Decreased central venous pressure

4 - Decreased central venous pressure Reason:This is a finding in fluid volume deficit

The nurse works at an agency that automatically places certain clients on intake and output (I&O;). For which client will the nurse document all I&O;? 23-year old with ulnar and radial fracture 55-year old with congestive heart failure on furosemide 34-year old whose urinary catheter was discontinued yesterday 48-year old who has had a bowel movement after surgery

55-year old with congestive heart failure on furosemide Rationale: Agencies often specify the types of clients that are placed automatically on I&O;Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O;documented. The other clients do not require the nurse to document all I&O;.

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? A client who has a urine specific gravity of 1.010. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. A client who has a hematocrit of 45% A client who has a temperature of 39° C (102° F)

A client who has a temperature of 39° C (102° F) Rationale: This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration.

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? A. Alcoholism B. Intestinal resection C. Loss of gastric acid D. Inflammatory bowel disease

A. Alcoholism Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.

Which serum value does the nurse expect to see for a patient with hyponatremia? A. Sodium less than 136 mEq/L B. Chloride less than 95 mEq/L C. Sodium less than 145 mEq/L D. Chloride less than 103 mEq/L

A. Sodium less than 136 mEq/L

What does the nurse understand is the primary method by which fluid volume is regulated? A. Urine excretion B. Breathing C. Bowel elimination D. Perspiration

A. Urine excretion Fluid volume is regulated primarily by the excretion of water in the form of urine and the promotion of thirst. Breathing, bowel elimination, and perspiration are methods the body uses to excrete fluid, but they are not the primary regulatory method for fluid volume.

A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? Phlebitis Extravasation Air embolism Circulatory overload

Circulatory overload Rationale: The nurse should identify that a client who has been receiving IV therapy & whose daily weight has increased is at risk for circulatory overload. Other indications of circulatory overload include tachycardia, increased BP, edema, cough & tachypnea

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is MOST important to determine changes in the client's hypervolemia status? Daily weight intake and output edema vital signs

Daily weight Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb (0.9 kg) weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema.4

A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? Dry mucous membranes Decreased urine output Report of thirst Decrease in level of consciousness

Decrease in level of consciousness Rationale: This is an indication that the hypovolemia has progressed to a critical level & requires immediate interventionsDry mucous membranes, decreased urine output, report of thirst are non-urgent because it is an early & expected finding of hypovolemia

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? -Decreased muscle strength -Decreased gastric motility -Increased heart rate -Increased blood pressure

Decreased muscle strength The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea.

After teaching a group of students about erectile dysfunction, the instructor determines that the teaching was successful when the students identify which of the following as true? Erectile dysfunction is unrelated to anxiety or depression. Erectile dysfunction is primarily a normal response to aging. Erectile dysfunction may be due to testosterone insufficiency. Erectile dysfunction rarely occurs in clients with diabetes mellitus.

Erectile dysfunction may be due to testosterone insufficiency. Rationale: Common causes of erectile dysfunction include neurologic disorder like spinal cord injury, perineal trauma, testosterone insufficiency, side effects of drug therapy such as antihypertensive or antidepressants, atherosclerosis, hypertension, and complications of diabetes mellitus.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? Collect a urine specimen for culture and sensitivity. Continue routine care because the results are within the expected reference range. Decrease the IV fluid infusion rate and limit oral fluid intake. Evaluate urine for amount and for specific gravity.

Evaluate urine for amount and for specific gravity. Rationale: These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? Impaired Urinary Elimination Urinary Retention Impaired Skin Integrity Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume Rationale: An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights

Which of the following accounts for the majority of ureteral injuries? Gunshot wounds Unintentional injuries Knife wounds Sports injuries

Gunshot wounds Rationale: Gunshot wounds account for 90% of ureteral injuries, which may range from contusions to complete transection.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? -Hyperactive deep tendon reflexes -Increased bowel sounds -Drowsiness -Decreased blood pressure

Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling.

The nurse is called to a clients room by a family member who voices concern about the clients status. On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this clients signs and symptoms? Hyperchloremia Hypocalcemia Hyponatremia Hypophosphatemia

Hyperchloremia Rationale: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, arrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? -Implement seizure precautions -Administer phosphate -Initiate diuretic therapy -Prepare the client for hemodialysis

Implement seizure precautions. The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? Decreased urine specific gravity Decreased Hgb Increased BUN Increased urine ketones

Increased BUN Rationale: Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss.

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? Intravascular Interstitial Intracellular Extracellular

Intracellular Explanation:Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? Lethargy Hyperactive deep tendon reflexes Prolonged ST segment Hyperactive bowel sounds

Lethargy Rationale: A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion.

A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? Potassium 4.5 mEq/L Sodium 138 mEq/L Magnesium 3 mEq/L Calcium 10 mg/dL

Magnesium 3 mEq/L Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? Dry, sticky mucous membranes Polyuria Negative Chvostek's sign Muscle tremors

Muscle tremors Rationale: A serum calcium level of 8.0 mg/dL is below the expected reference range. A preschooler who has hypocalcemia is likely to have muscle tremors and cramps that can progress to tetany and convulsions.

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? Nausea and vomiting Extreme thirst Flushed skin Fever

Nausea and vomiting Rationale: A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - metabolic acidosis - increased intracranial pressure (ICP) - cardiac irregularities - muscle weakness

cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.

Which of the following is considered first-line treatment for prostate cancer? Radical prostatectomy Radiation Hormonal therapy Cryosurgery

Radical prostatectomy Rationale: Radical prostatectomy is the complete surgical removal of the prostate, seminal vesicles, and often the surrounding fat, nerves, lymph nodes and blood vessels. It is considered the standard first-line treatment for prostate cancer.

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? Low body temperature Jugular vein distention Skin tenting present Blood pressure 178/90 mm Hg

Skin tenting present Rationale: A client who has dehydration has poor skin turgor, or skin tenting, which the nurse should observe for over the sternum or the back of the hand.

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

Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia

A nurse is collecting data from a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance? The client reports working in a warehouse in 21.1° C (70° F) temperature. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. The client reports that their provider decreased their diuretic dose. The client reports they had a 24-hr intestinal virus 2 weeks ago.

The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. Rationale: The nurse should identify that working outside in high temperature for an extended period can cause profuse sweating & lead to a fluid & electrolyte imbalance

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances? Calcium Uric acid Struvite Cystine

Uric acid Rationale: Uric acid stones are found in patients with gout and myeloproliferative disorders. Therefore, a diet low in purines is recommended

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? Urine specific gravity 1.035 Hematocrit 44% BUN 19 mg/dL Sodium 155 mEq/L

Urine specific gravity 1.035 Rationale: A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? Check the pedal pulses. Verify the most recent calcium level. Request prescription for a relaxant. Administer an oral potassium supplement.

Verify the most recent calcium level. Rationale: A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching fingerprinting over sternum distended neck veins nausea and vomiting

distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Edema happens when there is which fluid volume imbalance? water excess extracellular fluid volume excess water deficit extracellular fluid volume deficit

extracellular fluid volume excess Rationale: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? 3% sodium chloride solution 0.9% sodium chloride solution 0.45% sodium chloride solution Dextrose 10% in water

0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic & is used for hydration needs such as from vomiting, diarrhea, hemorrhage & shock.3% sodium chloride solution is hypertonic & is used for emergent replacement solutes experiencing manifestations of hyponatremia. 0.45% sodium chloride solution is hypotonic & is used to treat hypernatremia & DKA. Dextrose 10% in water is hypertonic & is used to treat hypoglycemia

On assessment, the patient has respiratory muscle weakness resulting in shallow respirations. Which electrolyte abnormality would the nurse suspect? A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia

A. Hypokalemia

The nurse is assessing a patient with a mild increase in sodium level. What early manifestation does the nurse observe in this patient? A. Muscle twitching and irregular muscle contractions B. Inability of muscles and nerves to respond to a stimulus C. Muscle weakness occurring bilaterally with no specific pattern D. Reduced or absent bilateral deep tendon reflexes.

A. Muscle twitching and irregular muscle contractions

The nurse is working in a long term care facility where there are numerous patients who are immobile and at risk for dehydration. Which test is best to delegate to the UAP? A. Offer patients a choice of fluids every 1 hour B. Check patients at the beginning the shift to see who is thirsty. C. Give patients extra fluids around medication times. D. Evaluate oral intake and urinary output.

A. Offer patients a choice of fluids every 1 hour

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? Restrict fluids and salt for 24 hours. Correct the sodium deficit rapidly with salt. Administer small volumes of a hypertonic solution. Administer large volumes of a hypertonic solution.

Administer small volumes of a hypertonic solution. Rationale: If neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema.

Which of the following would be least appropriate to suggest to a client with a urinary diversion to control odor? Avoid foods such as buttermilk or yogurt. Eat plenty of cheese and eggs. Avoid pouches with carbon filters. Add a few drops of diluted white vinegar to the pouch.

Eat plenty of cheese and eggs. Rationale: While foods such as asparagus, cheese, and eggs may impart an odor to the urine

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? -Monitor the client's bowel sounds. -Review the client's daily laboratory results. -Auscultate the client's lungs. -Palpate the client's peripheral pulses

Auscultate the client's lungs. An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids.

Avoid salty or excessively sweet fluids. Rationale: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is assisting in the care of a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? Initiate continuous cardiac monitoring. Elevate the head of the client's bed. Instruct the client to deep breathe and cough. Initiate continuous SpO2 monitoring.

Elevate the head of the client's bed. Rationale: The 1st action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the HOB. Placing the client in a Fowler's or semi-Fowler's position will promote effective breathing & chest expansion

The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for the patient, what does the nurse expect to find on assessment? A. No changes, because respiratory system is not involved. B. Increased respiratory rate, because the body perceives hypovolemia as hypoxia C. Hypoventilation, because the respiratory system is trying to compensate for low ph D. Normal respiratory rate, but a decrease oxygen saturation.

B. Increased respiratory rate, because the body perceives hypovolemia as hypoxia

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position

Elevates the head of the bed The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be performed first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily BUN and serum creatinine monitoring daily electrolyte monitoring daily weights output measurements

daily weights Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? - a newly admitted 88-year-old with a 2-day history of vomiting and loose stools - a 47-year-old who had a colon resection yesterday and is reporting pain - a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today - a 60-year-old who is 3 days post-myocardial infarction and has been stable.

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious to lethargic B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours

A. Client behavior that changes from anxious to lethargic RATIONALE: Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure (BP) C. Increases in edema D. Sodium level

A. Heart rate RATIONALE:The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be expected in this scenario unless fluid volume deficit is present.

A client diagnosed with bladder cancer wants to avoid surgery. For which intravesical treatment will the nurse prepare teaching for this client? Bacillus Calmette Guerin (BCG) Live Radiation therapy Periodic cystoscopy Infusion of a cytotoxic agent

Bacillus Calmette Guerin (BCG) Live Rationale: BCG Live is now considered the most predominant and conservative intravesical agent for recurrent bladder cancer, especially superficial transitional cell carcinoma, because it is an immunotherapeutic agent that enhances the bodys immune response to cancer

After receiving change-of-shift report, which client does the RN assess first? A. A client with nausea and vomiting who complains of abdominal cramps B. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg D. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg RATIONALE:The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia. Immediate interventions are needed.The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems which are not urgent at this time.

The nurse is reviewing orders for several patients who are at risk for fluid volume overload. For which patient condition does the nurse question and order for diuretics? A. Pulmonary Edema B. Congestive Heart Failure C. End Stage Renal Disease D. Ascites

C. End Stage Renal Disease

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? A. Give medications that promote fluid retention. B. Teach client behaviors that decrease urination. C. Limit sodium and water intake. D. Assess for dehydration.

C. Limit sodium and water intake. Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? A. No, start with the sodium chloride IV. B. Yes, this will correct the sodium deficit. C. No, sodium intake should be restricted. D. Yes, along with the hypotonic IV.

C. No, sodium intake should be restricted. The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.

The nurse knows which is the normal serum value for potassium? A. 8.5-10.5 mg/dL (2.13-2.63 mmol/L). B. 96-106 mEq/L (96-106 mmol/L) C. 135-145 mEq/L (135-145 mmol/L). D. 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

D. 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A. Restrict the client's intake of sodium B. Administer a diuretic C. Monitor the serum osmolarity D. Encourage fluid intake

D. Encourage fluid intake RATIONALE: When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels. Hypernatremia and fluid loss typically occur in tandem in the older adult. Restricting sodium does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid volume deficit the client is experiencing. Monitoring the osmolarity will detect an abnormality, but not resolve the problem.

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's weight

D. Measurement of the client's weight RATIONALE:The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of care has been effective.Assessment, education, and instruction are higher-level nursing actions within the scope of practice of the professional nurse.

An older adult patient at risk for fluid and electrolyte problems is carefully monitored by the nurse for the first indication of a fluid balance problem. What is the indication? A. Fever B. Elevated BP C. Poor Skin Turgor D. Mental Status Changes

D. Mental Status Changes

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? COPD Diabetes mellitus Anemia Osteoporosis

Diabetes mellitus Rationale: Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has been NPO since midnight for endoscopy. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. The client who has end-stage renal failure and is scheduled for dialysis today. The client who has gastroenteritis and is febrile.

The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.