HCD Fluid/Electrolytes and Nutrition
a nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. the nurse notifies the provider. which of the following nutritional therapies will likely be prescribed?
supplements via nasogastric tube
a nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and indicates cardiac monitoring. which of the following findings should the nurse expect during the initial assessment?
lethargy
you are the nurse caring for a client at risk for dehydration
maintaining intake approximately equal to output
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?
muscle tremors
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 vomting
a nurse is assessing four female clients for obesity. which of the following clients have manifestations of obesity?
a client who weighs 28% above ideal body weight
a nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. which of the following statements by the client's partner indicates the need for further teaching?
"I will monitor my husband for tilting his head forward when he swallows"
which of the following nursing interventions would you do for a patient with fluid volume excess?
- LOC - strict I&O - daily weights - assess potassium levels
health risks associated with obesity include
- colorectal cancer - polycystic ovarian syndrome - non alcoholic steatohepatitis
at risk for hyponatremia?
- diuretics - wound vac - low sodium diet - sweating
a nurse is preparing a sickle cell anemia pt for discharge
- drink plenty of fluids in hot water - avoid being in high altitudes where less O2 is available - know that pregnance with sickle cell disease increases risk for crisis
a nurse is assessing a client who has fluid overload. which of the following findings should the nurse expect?
- increased HR - increased BP - increased RR
the nurse is teaching a moderately obese woman interventions for the management of obesity. initially, which strategies will support restricting dietary intake to below energy requirements:
- limit alcohol - determine portion sizes
a nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?
- poor skin turgor - hypotension - flat neck veins
a nurse is calculating the output of a client at the end of the shift. the nurse notes the following: client voided 400mL at 1100 and 350mL at 1430. the closed chest drainage system was previously marked at 155mL and is now at 175mL. the NG tube 575mL in drainage container, and 25mL is emptied out of the jackson pratt drainage tube. how many mL should the nurse record in the medical record as the client's output?
1,370mL
what is normal sodium level
135 - 145
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?
2 mL/kg/hr
a nurse is reviewing the laboratory results of a client who is dehydrated. which of the following BUN lab values should the nurse report to the provider?
25 mg/dL
a nurse is calculating the intake of a client during the past 9hr. the client's intake includes lactated ringers IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBC's of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50mL of dextrose 5% in water. how many mL of intake should the nurse record?
2525 mL
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
260 mL
what is a normal potassium level?
3.5 - 5
normal calcium level
8.5 - 10.5
what clinical manifestations would you see in a patient with hypokalemia?
ECG changes
what is a normal cholesterol level (HDL)
anything less than 200
you are caring for a client who had a recent stroke. what are they at highest risk for?
aspiration
a nurse is an emergency dept caring for an infant who has a 2 day history of vomiting and an elevated temp. which of the following should the nurse recognize as the most reliable indicator of fluid loss?
body weight
what electrolyte is low when a client has Chvosteks?
calcium
a nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent lab results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
call the prescribing physician and inform her of the client's serum potassium level results
what patient is at risk for hypocalcemia?
client with parathyroid gland removed
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?
decreased potassium level
clinical manifestations of an infant with dehydration?
depressed fontanels
what medication would you think the provider would order for fluid volume excess and confusion?
diuretic (lasix, furosemide)
a nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. which of the following instructions should the nurse include?
encourage the client to take small bites
a nurse in a community clinic is assessing an older adult client for manifestations of dehydration. which of the following findings should the nurse expect?
furrows in the tongue
a nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. the nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. which of the following actions should the nurse take?
give the KCL as prescribed
positive chvostek sign is in relationship to what electrolyte
hypocalcemia
which electrolyte imbalance would you see a positive troussaus sign?
hypocalcemia
a nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse affects should the nurse monitor?
hypokalemia
a nurse is planning care for a client who has acute dysphagia. which of the following nursing interventions should be included in the plan of care?
instructing the client to tilt head forward when swallowing
a nurse in an emergency dept is assessing an infant who is dehydrated. which of the following findings should the nurse expect?
irritablity
self care for varicose veins
keep the legs elevated when sitting or lying down
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?
skin tenting present
a nurse is reviewing a client's lab results. which of the following lab values should the nurse report to the provider?
sodium 126 mEq/L
a nurse is reviewing the lab report of a client and identifies a serum potassium level of 6.8 mEq/L. which of the following meds should the nurse administer?
sodium polystryene
a nurse is caring for a client who is experiencing dysphagia. The nurse should recommend a referral to which of the following members of the health care team?
speech therapist
what do do when administering RBC to a client
stay with patient for 15 mins after starting infusion
a client is having a blood transfusion reaction. what do you do first?
stop the infusion
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 gastroenteritis and is febrile
before selecting a weight reduction plan with an obese patient, which is most important for the nurse to assess first?
the patient's motivation to lose weight
a nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. which of the following findings should the nurse expect?
tingling of the extremities
what is a positive chvosteks sign
twitching of facial muscles in response to tapping over the nerve
a nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. which of the following findings should the nurse expect?
weak, irregular pulse
