Fluid and Electrolytes and Pain Questions thePoint

muscle weakness and a weak, irregular pulse

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

Document the client's choice and re-assess pain in 1 hour

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

rapid, deep respirations

A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatesteffect on fluid loss?

Deficient fluid volume related to osmotic diuresis

A client with a serum glucose level of 618 mg/dl (34.33 mmol/L) is admitted to the facility. The client is awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

assess lung sounds

A client with an I.V. of normal saline at 150 mL/hour reports dyspnea and restlessness. What is the priority nursing action?

lactated Ringer's solution

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Deficient fluid volume

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

The client achieves a therapeutic level of analgesia.

The use of a patient-controlled analgesia (PCA) pump is effective in which situation?

auscultation of all four quadrants using a stethoscope

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse?

oxygen saturation

The nurse is monitoring a client who is receiving moderate sedation for a procedure. The client begins to display signs of restlessness and agitation. What assessment does the nurse perform first?

a decreased potassium

A client has been taking furosemide for 2 days. The nurse should review the laboratory record for changes in which blood level?

"What were you doing when the pain started?"

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask?

Help the client assume a more comfortable position.

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?

weighing the client daily at the same time each day

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Milk products

A client reports occasional numbness in the fingers and lips. Which dietary choices should the nurse encourage the client eat?

The client's intake and output are balanced

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client?

Emphasize the importance of outpatient follow-up care for chronic concerns.

An adult client has been seen in the emergency department three times this week for chronic back pain. What is the nurse's best action when providing discharge instructions for this client to ensure the promotion of cost-effective care?

intravenous fluid hydration

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?

pain rating of 0, 1, or 2 on a scale of 0 to 10 by the client

For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes morphine sulfate, 1 to 2 mg per hour, given intravenously (IV) as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met?

-level of sedation -oxygen saturation -vital signs

In the first 12 hours after starting a patient-controlled analgesia (PCA) infusion to administer an opioid, what should the nurse monitor every 1 to 2 hours? Select all that apply.

"You are concerned that the client is receiving too much narcotic medication?"

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the most therapeutic response by the nurse?

-"You are having pain related to muscle strain so ibuprofen is appropriate." -"You are having pain related to muscle strain so acetaminophen is appropriate." -"You are having pain related to muscle strain so naproxen is appropriate."

The client comes to the clinic for shoulder pain related to muscle strain. Which analgesics would be appropriate for the nurse to teach the client about? Select all that apply

"When did you last have a bowel movement?"

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?

the client's self-report

When a nurse is assessing a client's pain level, what is the most reliable indicator of the existence and intensity of acute pain?

decreased blood pressure

When assessing a client diagnosed with third spacing, a nurse should expect to assess manifestation?

slow the intravenous rate and notify the physician

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse?

hypokalemia

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hyperkalemia

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Maintain adequate oxygenation

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?

orthostatic blood pressure changes

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?

Trousseau's sign

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess

to prevent signs of hypovolemic shock and restore circulation

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

Spironolactone PO

A client is admitted for acute kidney injury and has a potassium level of 5.6 mEq/L (mmol/L), a blood glucose level of 80 mg/dL (4.4 mmol/L), and an electrocardiogram demonstrating peaked T waves. What prescription would the nurse question?

Numbness Tingling Muscle twitching and spasms

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

decrease foods high in potassium

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?

Document the client's response to pain medication

A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA?

Assess the client's neurological status

A client post-epidural infusion received naloxone 0.2 mg intravenously 20 minutes ago. The client's respiratory rate was 6 breaths per minute and is now 10 breaths per minute. Which intervention should the nurse perform first?

Potassium

An older adult client with heart failure and 2+ pitting edema is prescribed furosemide. Due to the effects of furosemide, which additional medication should the nurse recommend to the client to supplement when taking furosemide?

-Tell the client to push the button when in pain. -Check the patient-controlled analgesia (PCA) settings with another nurse. -Assess the IV insertion site

The client has just undergone abdominal surgery and returned from the post-anesthesia care unit (PACU) with a patient-controlled analgesia (PCA) pump. Which interventions should the nurse implement? Select all that apply.

hypercapnic respiratory failure

The nurse is caring for a client who is suspected to have overdosed on opioids. Assessment findings include a heart rate of 60 beats/minute, respiratory rate of 6 breaths/minute, a blood pressure of 95/55 mmHg, and an oxygen saturation of 96% on room air. Based on the assessment findings, what is the nurse's priority concern?

dextrose 5% in water (D5W)

The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question?

"The machine will only give me the prescribed amount of pain medication even if I push the button too soon."

The nurse is teaching the client how to use the patient-controlled analgesia (PCA) pump. The nurse determines that the client understands the use of the PCA pump when the client makes which statement?

clients with terminal cancer may develop tolerance to opioids.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that:

hypertonic

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

Administer Naloxone

A nurse administers morphine sulfate to a client in the recovery room. Within 15 minutes after receiving the dose of morphine, the client is very lethargic; respiratory rate is 7 breaths per minute and shallow. What is the appropriate action of the nurse?

With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves.

The student nurse asks why a client is receiving an I.V. of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse?

-"Right to refuse." -"Right time or frequency." -"Right assessment."

The student nurse is learning how to administer medications. The nurse instructor asks, "What are the client's rights when administering medication?" What are the most appropriate response(s) by the student? Select all that apply.

noisy respirations

The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?