Fluid And Electrolyte Practice Questions
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A. Skin turgor B. Urine output C. Weight D. Mental status
D. Mental status rationale: The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration
Clients who have been diagnosed with hypernatremia are at risk for injury. What is an appropriate intervention for the nurse to include in the plan of care for this client? A. Ask the family to keep the client's personal items at home. B. Keep visitors away. C. Keep the bed at waist level. D. Monitor neurologic status.
D. Monitor neurologic status. rationale: The nurse should develop a plan of care that includes monitoring electrolytes, neurologic status, and manifestations of increased intracranial pressure.
The nurse is caring for a client experiencing hypocalcemia. For which complications should the nurse monitor the client? (SATA) A. Heart failure B. Kidney stones C. Peptic ulcer D. Airway obstruction E. Convulsions
A. Heart failure D. Airway obstruction E. Convulsions
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Administer IV fluids evenly over 24 hr. B. Provide the client with a salt substitute. C. Assess for pitting edema. D. Encourage the client to rise slowly when standing up. E. Weigh the client every 8 hr.
A. Administer IV fluids evenly over 24 hr D. Encourage the client to rise slowly when standing up E. Weigh client every 8 hr A client who has excessive fluid loss is typically prescribed IV replacement fluids. There is no reason to limit the client's sodium intake. Assess pitting edema is appropriate for a client who has fluid overload. Encouraging the client to rise slowly when standing up can prevent injury from falls caused by orthostatic hypotension. Weighing the client every 8 hr will provide information regarding fluid balance.
A client is diagnosed with metabolic alkalosis. What action by the nurse will assist in restoring this imbalance? A. Administer potassium chloride. B. Administer sodium bicarbonate. C. Administer a bronchodilator. D. Administer IV insulin.
A. Administer potassium chloride. rationale: In metabolic alkalosis, the administration of potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions.
The nurse is administering magnesium sulfate therapy. Which of the following interventions would be performed during the administration of the drug? (SATA) A. Assess deep tendon reflexes. B. Maintain a constantly stimulating environment. C. Monitor serum magnesium, potassium, and calcium levels. D. Reporting and treating electrocardiographic changes E. Report lethargy and weakness to the primary health care provider.
A. Assess deep tendon reflexes. C. Monitor serum magnesium, potassium, and calcium levels. D. Reporting and treating electrocardiographic changes E. Report lethargy and weakness to the primary health care provider.
Which of the following can be used as a temporary emergency treatment for hyperkalemia? A. Calcium chloride B. Diuretics C. Sodium polystyrene sulfonate D. Sorbitol
A. Calcium chloride rationale: Calcium chloride administered IV can be used as a temporary emergency measure to counteract the toxic effects of hyperkalemia on myocardial conduction and function. Although potassium-wasting diuretics enhance the renal excretion of potassium, and Sorbitol and sodium polystyrene sulfonate can be used to treat moderate to severe hyperkalemia, their onsets are too long to be used in an emergency.
The nurse is caring for a client with hypophosphatemia. Understanding that hypophosphatemia can have systemic consequences, which body systems should the nurse assess? (SATA) A. Cardiovascular B. Integumentary C. Hematologic D. Gastrointestinal E. Musculoskeletal
A. Cardiovascular C. Hematologic D. Gastrointestinal E. Musculoskeletal rationale: Hypophosphatemia causes reduced oxygen delivery to the cells, which could compromise the hematologic system, causes decreased adenosine triphosphate production, leading to muscular weakness. Hypophosphatemia causes decreased myocardial contractility and decreased oxygenation of the heart, the stomach, bowel, and accessory digestive organs. The integumentary system (skin) is not affected by hypophosphatemia.
Which of the following is an early manifestation of hyponatremia? A. Decreased BUN B. Increased hematocrit C.Increased serum osmolality D. Decreased serum creatinine
A. Decreased BUN
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? A. Decreased muscle strength B. Decreased gastric motility C. Increased heart rate D. Increased blood pressure
A. Decreased muscle strength
Which of the following are central nervous system effects of hypomagnesemia? (SATA) A. Hallucinations B. Tremors C. Seizures D. Depression E. Confusion
A. Hallucinations D. Depression E. Confusion
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? A. Hyperactive Deep- tendon reflexes B. Increased bowel sounds C. Drowsiness D. Decreased blood pressure
A. Hyperactive Deep- tendon reflexes rationale: Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling.
The nurse assesses a client who is experiencing hypotension, facial flushing, and sweating. The nurse reports this assessment as consistent with which of the following? A. Hypermagnesemia B. Hypomagnesemia C. Hyponatremia D. Hypernatremia
A. Hypermagnesemia
The nurse is caring for a client who is complaining of a headache, thirst, and decreased urination. What would the nurse anticipate finding on the client's laboratory work? A. Hypernatremia B. Hyponatremia C. Decreased specific gravity D.Normal specific gravity
A. Hypernatremia
Which of the following can lead to hypernatremia? (SATA) A. Hyperventilation B. Gastrointestinal suctioning C. Diabetes insipidus D. Water deprivation E. Excessive administration of tap water enemas
A. Hyperventilation C. Diabetes insipidus D. Water deprivation rationale: Water deprivation will cause cellular dehydration. Hyperventilation causes excessive insensible water loss. Diabetes insipidus causes both excessive thirst and excessive urination, the net result being a high serum sodium level.
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. Hypotension B. Peripheral edema C. Facial flushing D. Hyperreflexia
A. Hypotension rationale: respiratory acidosis causes vasodilation
A client was admitted to the MICU after being found lying on the floor for an unknown amount of time but estimated to be 3 to 4 days. The client was unable to move because of a right hip fracture. Upon admission, the client was found to be severely hypernatremic. What are the manifestations of late hypernatremia? (SATA) A. Hypotension B. Coma C. Tachycardia D. Vascular collapse E. Hypertension
A. Hypotension B. Coma C. Tachycardia D. Vascular collapse rationale: The late manifestations of hypernatremia include hypotension, vascular collapse, tachycardia, and coma. The client will not be hypertensive because of fluid volume deficit and dehydration.
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? A. Implement seizure precautions B. Administer phosphate C. Initiate diuretic therapy D. Prepare client for hemodialysis
A. Implement seizure precautions rationale: The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level
A nurse assess a client with fluid volume excess. Which of the following manifestations indicates fluid volume excess? (SATA) A. Jugular vein distention B. Decreased hematocrit C. Postural hypotension D. Increased heart rate E. Fever
A. Jugular vein distention B. Decreased hematocrit D. Increased heart rate
A client has a serum phosphorous level of 2.0 mg/dL. What would the nurse most likely assess in this client? (SATA) A. Lack of coordination B. Hypotension C. Bone pain D. Decreased bowel sounds E. Seizures
A. Lack of coordination C. Bone pain D. Decreased bowel sounds
Which of the following is a central nervous system manifestation of hypophosphatemia? (SATA) A. Lack of coordination B. Hyperreflexia C. Intention tremor D. Positive Chvostek sign E. Seizures
A. Lack of coordination C. Intention tremor E. Seizures
Which of the following are manifestations of hypokalemia? (SATA) A. Lethargy B. Anorexia C. Peaked T waves D. Development of U waves E. Muscle tremors
A. Lethargy B. Anorexia D. Development of U waves
The nurse is caring for a client with hyponatremia. During morning rounds, the nurse will complete an assessment. What are the early manifestations of hyponatremia? (SATA) A. Muscle cramps B. Nausea and vomiting C. Hypotension D. Weakness E. Anorexia
A. Muscle cramps B. Nausea and vomiting D. Weakness E. Anorexia rationale: early manifestations can include muscle cramps, weakness, nausea and vomiting, and anorexia. Hypernatremia can cause hypotension due to dehydration.
Which of the following should be monitored for a client with hypokalemia? (SATA) A. Muscle weakness B. Muscle tremors C. Paresthesia D. Orthostatic hypotension E. Cardiac rhythm
A. Muscle weakness D. Orthostatic hypotension E. Cardiac rhythm
The nurse is planning care for a client who has a nasogastric tube and is recovering from abdominal surgery. What interventions will the nurse identify for addressing the problem of ineffective tissue perfusion? (SATA) A. Observing mental status B. Turning the client every 2 hours C. Instructing the client to stand slowly D. Monitoring for evidence of skin breakdown E. Obtaining daily weight
A. Observing mental status B. Turning the client every 2 hours D. Monitoring for evidence of skin breakdown
The nurse is caring for a client with hypophosphatemia and is reinforcing the teaching on foods high in phosphorus. Which foods does the nurse encourage the client to eat? (SATA) A. Peas B. Beets C. Poultry D. Brazil nuts E. Organ meats
A. Peas C. Poultry D. Brazil nuts E. Organ meats
The nurse is caring for a client experiencing diarrhea. What data indicate that the client is experiencing fluid volume deficit? (SATA) A.Increased heart rate B. Orthostatic hypotension C. Increased urine output D. Poor skin turgor E. Weight gain
A.Increased heart rate B. Orthostatic hypotension D. Poor skin turgor
A nurse is caring for a client with congestive heart failure whose EKG shows a flattening of the T wave. Which of the following lab results should the nurse anticipate with this EKG change? A. Potassium 2.8 B. Digitalis level of 2 C. Hemoglobin of 9.8 D. Serum calcium 8
A. Potassium 2.8
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A. Respiratory acidosis rationale: Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.
The nurse is caring for a client admitted with hypermagnesemia. Which of the following assessments would indicate that the magnesium levels are unchanged? (SATA) A. Serum magnesium level 3.0 mg/dL B. Decreased heart rate C. Insomnia D. Neuromuscular excitability E. Decreased blood pressure
A. Serum magnesium level 3.0 mg/dL B. Decreased heart rate E. Decreased blood pressure rationale: Decreased blood pressure would indicate and A decreased heart rate would indicate that the client continues to have hypermagnesemia which affects the cardiovascular system, causing decreased heart rate and bradydysrhythmias. A serum magnesium level of 3.0 mg/dL is elevated.
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? A. Sodium 128 mEq/L B. Potassium 4.8 mEq/L C. Calcium 9.1 mg/dL D. Magnesium 2.0 mEq/L
A. Sodium 128 mEq/L rationale: Na+ = neurologic effects
The nurse is caring for a client with hyperphosphatemia. For which symptoms does the nurse assess the client? (SATA) A. Tetany B. Chvostek sign C. Trousseau sign D. Intention tremor E. Seizures
A. Tetany B. Chvostek sign C. Trousseau sign E. Seizures rationale: Manifestations of hyperphosphatemia-related hypocalcemia include a positive Chvostek sign (facial muscle twitching), a positive Trousseau sign (flexion of the lower arm in response to the pressure of a blood pressure cuff), tetany (severe muscle spasms), and seizures.Intention tremor is a sign of hypophosphatemia, not hyperphosphatemia.
A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? (SATA) A. dysrhythmias B. tachycardia C. weakness D. Kussmaul respirations E. cold, clammy skin
A. dysrhythmias C. weakness D. Kussmaul respirations rationale : manifestations of metabolic acidosis
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis? A. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L B. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L C. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
A. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L rationale: elevated pH and HCO3- with a PaCO2 within the expected reference range
A 28-year-old male patient is admitted with diabetic ketoacidosis. Which electrolyte should the nurse expect to be replaced in this patient? A. potassium B. magnesium C. sodium D. calcium
B. magnesium
The nurse is caring for a client who is experiencing possible third spacing. A delay in recognizing and treating third spacing can lead to what client complication? A. Peripheral edema B. Nausea and vomiting C. Multi-organ system failure D. Confusion
C. Multi-organ system failure
The nurse is caring for a client admitted for renal failure. What assessment findings indicate that the client is experiencing fluid volume excess? (SATA) Anasarca Decreased systolic blood pressure Poor skin turgor Altered mental status Orthopnea
Anasarca Altered mental status Orthopnea
The nurse is educating a group of nursing students on the complications of hypomagnesemia. Which of the following assessment data reflect hypomagnesemia? (SATA) A. Bradyarrhythmias B. Increased respiratory rate C. Hypertension D. Elevated heart rate E. Sudden death
C. Hypertension D. Elevated heart rate E. Sudden death
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? A. Sodium polystyrene sulfonate 30 g/day B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr C. Bumetanide 8 mg/day D. 100 mL of dextrose 10% in water with 10 units of insulin
B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr rationale: This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.
After reviewing a client's laboratory values that were completed upon admission to the hospital, the nurse notes that the client's serum calcium level is 7.5 mg/dL. For what manifestation should the nurse monitor? A. Anorexia B. Acute abdominal pain C. Constipation D. Nausea and vomiting
B. Acute abdominal pain rationale: Acute abdominal pain from visceral muscle spasms can occur because of hypocalcemia,
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? A. Deep-tendon reflexes B. Cardiac rhythm C. Peripheral sensation D. Bowel sounds
B. Cardiac rhythm rationale: Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.
The nurse is observing assigned clients for fluid volume excess. This is essential to prevent clients from developing what potential complication? A. Gastroesophageal reflux disease B. Congestive heart failure C. Acute renal failure D. Pneumonia
B. Congestive heart failure
The nurse has received report from the emergency department. A client is being admitted with hypernatremia but with a normal blood pressure and pulse. The nurse is preparing for the client. The nurse is aware that the health care provider could order what intravenous fluids for the client upon admission? (SATA) A. 5% NS B. D5W C. 0.45% NS D. 0.9% NS E. 3% NS
B. D5W C. 0.45% NS rationale: IV solutions used for this replacement include 0.45% NS or D5W. The treatment of hyponatremia includes intravenous fluids and diuretics. Isotonic fluids are administered when both sodium and water are lost. 3% or 5% saline solutions are used cautiously in clients with hyponatremia
A nurse is reviewing lab date of 4 clients. Which of the following serum lab values should the nurse expect for a client experiencing 2+ pitting edema? A. Sodium 138 B. Hematocrit 34% C. BUN 22 D. Protein 9g
B. Hematocrit 34% rationale: indicates fluid overload
The nurse is providing care to a client who was recently admitted to rehabilitation after a motor vehicle crash. The client sustained a traumatic brain injury. The client was progressing well but is now complaining of muscle cramps and abdominal cramps. What electrolyte imbalance would the nurse consider as a cause of the cramping? A. Hypoglycemia B. Hyponatremia C. Hyperosmolality D. Hypernatremia
B. Hyponatremia
Which of the following assessment findings may present if a client is hypocalcemic? (SATA) A. Confusion B. Hypotension C. Hypoactive deep tendon reflexes D. Acute abdominal pain E. Numbness and muscle spasm of the face, hands and feet
B. Hypotension D.Acute abdominal pain E. Numbness and muscle spasm of the face, hands and feet rationale: In hypocalcemia neuromuscular irritability occurs resulting in visceral muscle spasms and acute abdominal pain. Hypotension results from a decrease in contractility of cardiac muscle fiber. Numbness and muscle spasms of the face, hands, and feet result from the increased neuromuscular irritability associated with hypocalcemia.
A nurse is caring for a client who is experiencing respiratory distress as a result of acute pulmonary edema. Which of the following actions should the nurse take first? A. Assist with intubation. B. Initiate high-flow oxygen therapy. C. Administer a rapid-acting diuretic. D. Administer morphine IV.
B. Initiate high-flow oxygen therapy. rationale: ABC's
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A. Hyperactive deep-tendon reflexes B. Orthostatic hypotension C. Rapid, deep respirations D. Strong, bounding pulse
B. Orthostatic hypotension rationale: Hypokalemia can lead to hypotension
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate
B. PaCO2 rationale: In respiratory alkalosis PaCO2 is decreased
The nurse reviews a client's electrolyte laboratory report and notes that the magnesium level is decreased at 1.4 mg/dL. Which of the following would indicate neuromuscular effects as a result of the magnesium level? A. Flaccidity B. Paresthesias C. Negative Trousseau sign D. Drowsiness
B. Paresthesias
A nurse is caring for a client with a history of congestive heart failure at risk for developing fluid volume excess. The nurse realizes that a late manifestation of fluid volume overload is which of the following? A. Weight gain of 1 kg in 1 day B. Pitting edema 3+ C. Urine output of 20mL/hr D. Blood pressure of 170/84 mm Hg
B. Pitting edema 3+
A nurse is caring for a client who has heart failure and is receiving furosemide. The client is experiencing irritability and anxiety. Which of the following actions should the nurse anticipate taking? A. Offer whole grain wheat breads with meals. B. Recommend a potassium-sparing diuretic. C. Give potassium 20 mEq/L by IV bolus. D. Restrict oral fluids.
B. Recommend a potassium-sparing diuretic. rationale: The findings indicate hypokalemia likely caused by furosemide. The nurse should anticipate a prescription for a potassium-sparing diuretic.
Which IV fluid would you expect to be ordered in a client who is hyponatremic? A. 0.45% saline B. Ringer solution C. D5W with 0.9% saline D. D5W with 0.45% saline
B. Ringer solution rationale: Ringer solution is isotonic and would be expected as treatment for a client who is hyponatremic. It would help raise the serum sodium level. D5W with 0.9% saline and D5W with 0.45% saline are both hypertonic, and 0.45% saline is hypotonic.
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? A. BUN 26 mg/dL B. Serum sodium 138 mEq/L C. Hct 56% D. Urine specific gravity 1.035
B. Serum sodium 138 mEq/L rationale: Within expected range
The nurse is completing discharge teaching with a client diagnosed with congestive heart failure. What findings should the client notify his/her health care provider about regarding fluid volume excess? (SATA) A. Dizziness when standing B. Five-pound weight gain in a week C. Urine output of 320 mL in 8 hours D. Dry mouth E. Cough with increased sputum production
B. Five-pound weight gain in a week E. Cough with increased sputum production
An older patient with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which symptoms indicate hypermagnesemia? A. excessive urination B. hypotension, warmth, and sweating C. nausea and vomiting D. hyperreflexia
B. hypotension, warmth, and sweating
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 instructions? A. "If my stockings feel tight, I'll just roll them down for a while." B. "I'll put on my elastic stockings at the first sign of swelling." C. "When I sit down to watch television, I'll be sure to put my feet up." D. "It's okay to cross my legs as long as it's for less than an hour."
C. "When I sit down to watch television, I'll be sure to put my feet up." rationale: Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.
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? A. Monitor the client's bowel sounds. B. Review the client's daily laboratory results. C. Auscultate the client's lungs. D. Palpate the client's peripheral pulses.
C. Auscultate the client's lungs. rationale: ABC's
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? A. Increased urine specific gravity B. Hypoactive bowel sounds C. Bounding peripheral pulses D. Decreased respiratory rate
C. Bounding peripheral pulses rationale: Fluid volume overload increases vascular volume
Which of the following is the most profound manifestation of hyperphosphatemia? A. Ileus B. Coma C. Coronary artery calcification D. Platelet dysfunction
C. Coronary artery calcification rationale: For each 1-mg/dL increase in serum phosphate level, the risk of coronary artery calcification increases by 21%.
Which of the following assessment findings are associated with hypercalcemia? (SATA) A. Seizures B. Tachycardia C. Dysrhythmias D. Behavioral changes E. Polyuria
C. Dysrhythmias D. Behavioral changes E. Polyuria rationale: Behavioral changes may be manifested because of decreased neuromuscular excitability. Dysrhythmias occur from the decreased neuromuscular activity of the cardiac muscle. Increased urine production results from the body's response to the elevated calcium level, which causes excess sodium and water loss.
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has respirations of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? A. Instruct the client to cough forcefully. B. Assist the client with ambulation. C. Provide calming interventions. D. Discontinue the PCA.
C. Provide calming interventions. rationale: The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.
The nurse is caring for a client admitted with COPD complaining of a dull headache, impaired memory, and personality changes. Which aciddash-base imbalance might this client be experiencing? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis
C. Respiratory acidosis
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A. Urine output of 30 mL/hr B. Blood glucose of 180 mg/dL C. Serum potassium 3.0 mEq/L D. BUN 18 mg/dL
C. Serum potassium 3.0 mEq/L Rationale: out of expected range
A nurse is assessing a client who has a serum phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? A. Hepatic failure B. Abdominal pain C. Slow peripheral pulsations D. Increase in cardiac output
C. Slow peripheral pulsations rationale: Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.
The nurse is administering intravenous magnesium to correct a low magnesium level. Which assessment finding would alert the nurse that the medication must be discontinued? A. Insomnia B. Hypertension C. Weak deep tendon reflexes D. Nausea and vomiting
C. Weak deep tendon reflexes rationale: indicate elevated levels of magnesium
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A. Administer a hypertonic solution. B. Repeat the potassium level. C. Withhold the medication. D. Monitor for paresthesia.
C. Withhold the medication. rationale: The greatest risk to this client is injury from hyperkalemia
What IV fluid replacement would you expect in a client with hypernatremia? A. Ringer solution B. D5W with 0.9% saline C. 0.45% saline D. 0.9% saline
C. 0.45% saline rationale: 0.45% saline is hypotonic and would be expected in the treatment of hypernatremia. Both D5W with 0.9% saline and 0.9% saline are hypertonic solutions and would be contraindicated with a client with hypernatremia.
The nurse is reviewing the client's laboratory tests. What laboratory value indicates that the client is experiencing fluid volume excess? A. Chloride, 102 mEq/L B. Sodium, 142 mEq/L C. Hemoglobin, 9.9 g/dL D. Serum osmolality, 290 mOsm/kg
C. Hemoglobin, 9.9 g/dL rationale: The hemoglobin will decrease because of plasma dilution from excess extracellular fluid
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? A. "I will eat extra cheese because I can't drink milk." B. "I need to avoid foods with vitamin D because I am allergic to milk." C. "I will stop taking my calcium supplements if they irritate my stomach." D. "I will add broccoli and kale to my diet."
D. "I will add broccoli and kale to my diet." rationale: broccoli and kale are good sources of calcium as alternatives to milk products
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I should conserve energy by limiting my physical activity." B. "I will wait until my pain is at least 6 out of 10 before I use the PCA." C. "I will limit my daily fluid intake to 2 to 3 glasses." D. "I will use the incentive spirometer every hour."
D. "I will use the incentive spirometer every hour." rationale: Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion
A client was admitted to the ICU earlier today. The client had an extensive workup revealing a sodium level of 113 mEq/L. The nurse would anticipate the health care provider ordering what intravenous solutions for a client who was symptomatic with this sodium level? A. 3% normal saline B. D5.45 NS C. D5W D. 0.9% NS
D. 0.9% NS rationale: The treatment of hyponatremia includes intravenous fluids and diuretics. Isotonic fluids, such as 0.9% normal saline or Ringer solution are administered when both sodium and water are lost.
A nurse is caring for a client with suspected hypovolemic shock. Which solution is appropriate for the nurse to administer in this circumstance? A. 0.45% sodium chloride B. D5% in 0.9% sodium chloride C. D10% in water D. 0.9% sodium chloride
D. 0.9% sodium chloride
A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering? A. 1,000 mL dextrose 5% in 0.9% sodium chloride B. 1,000 mL dextrose 5% in lactated Ringer's C. 1,000 mL dextrose 10% in water D. 1,000 mL 0.225% sodium chloride
D. 1,000 mL 0.225% sodium chloride rationale: hypotonic solution, to gradually reduce hypernatremia without causing cerebral edema.
Which of the following medications is used to reverse the neuromuscular and cardiovascular effects of hypermagnesemia? A. Potassium B. Magnesium citrate C. Sodium bicarbonate D. Calcium gluconate
D. Calcium gluconate
The nurse is concerned that a client with chronic renal failure is developing hyperphosphatemia. For which manifestation should the nurse assess the client? A. Confusion B. Chest pain C. Joint stiffness D. Muscle spasms
D. Muscle spasms rationale: The manifestations of hyperphosphatemia are more the result of hypocalcemia that develops secondary to an elevated serum phosphorous level. Manifestations of hypocalcemia include muscle spasms
The nurse is caring for a client with a potassium level of 5.3 mEq/L. The nurse should assess the client for which cardiac change? A. Delayed depolarization B. Shortened PR interval C. Narrowing of QRS complex D. Peaked T wave
D. Peaked T wave
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? A. Sodium 152 mEq/L B. Chloride 102 mEq/L C. Magnesium 1.8 mEq/L D. Potassium 6.1 mg/L
D. Potassium 6.1 mg/L rationale: Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.
A nurse is planning dietary teaching for a client who has hypermagnesemia. Which of the following food choices contains the most magnesium and is, therefore, a food the nurse should plan to instruct the client to avoid? A. Hard-boiled eggs B. Cheddar cheese C. Raw rhubarb D. Raw spinach
D. Raw spinach
Which of the following is the most significant complication of hypomagnesemia? A. Respiratory distress B. Diarrhea C. Renal insufficiency D. Ventricular dysrhythmias
D. Ventricular dysrhythmias rationale: may lead to sudden death
A patient is admitted for treatment of hypercalcemia. Which type of intravenous fluid should the nurse expect to be prescribed for this patient? A. dextrose 5% and 0.9% normal saline B.dextrose 5% and 0.45% normal saline C. dextrose 5% and water D. normal saline
D. normal saline rationale: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? A. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L B. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L C. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L rationale: pH and HCO3- are both above or below the expected reference range,
