Module 6 Fluids and Electrolytes and Exemplar 6.A
11) A child weighing 33 lbs. is prescribed to receive 50 mL/kg of oral fluids for the next 4 hours. How many total mL of fluid should the nurse provide to the client? Calculate to the nearest whole number
750
11) The nurse is caring for a child who weighs 33 lb and has been diagnosed with dehydration. The healthcare provider's orders state that the child is to receive 50 mL/kg of oral fluids for the next 4 hours. How many total mL of fluid should the nurse provide to the client? Calculate to the nearest whole number. ________ mL
750
10) The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. What should the nurse include in this teaching? Select all that apply. A) Drink diet soda. B) Drink more fluids during hot weather. C) Drink flat cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea. E) Exercise during the hours of 10 am and 2 pm.
b,c,d
1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit and documents that the client is experiencing the following symptoms: tachycardia; pale, cool skin; and a decreased urine output. The nurse knows that these symptoms are caused by: A) The body's natural compensatory mechanisms. B) Cardiac failure. C) Pharmacological effects of a diuretic. D) Effects of rapidly infused intravenous fluids.
a
14) The nurse is instructing a client diagnosed with heart failure about a prescribed sodium-restricted diet. Which client statement indicates that additional teaching is required? A) "I can use as much salt substitute as I want." B) "I have to read the labels on foods to find out the sodium content." C) "I have to limit the intake of food with baking soda or baking powder." D) "I can use spices and lemon juice to add flavor to food when cooking."
a
14) The nurse is instructing a client with heart failure about a prescribed sodium-restricted diet. Which client statement indicates that additional teaching is required? A) "I can use as much salt substitute as I want." B) "I have to read the labels on foods to find out the sodium content." C) "I have to limit the intake of food with baking soda or baking powder." D) "I can use spices and lemon juice to add flavor to food when cooking."
a
16) Which of the following statements is correct with regard to hypercalcemia? A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. B) Hypercalcemia is often a result of hyperparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. C) Hypercalcemia is often a result of hypoparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. D) Hypercalcemia is often a result of hypoparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
a
4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Which nurse response is most appropriate? A) "You should bring the infant in to be seen by the doctor." B) "Give your baby at least 2 ounces of juice every 2 hours." C) "Give your baby 50 mL of glucose water every hour." D) "Measure your baby's urine output for 24 hours and call back tomorrow."
a
7) A client is being seen in the Emergency Department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The physician has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have been successful? A) 40 mL per hour B) 20 mL per hour C) 25 mL per hour D) 30 mL per hour
a
8) The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare provider prescribes both glucose and insulin for the client. The client's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate? A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood." B) "Insulin is safer than other medications that can lower potassium levels." C) "The insulin lowers his blood sugar levels and causes the extra potassium to be excreted." D) "The insulin will help his kidneys excrete the extra potassium."
a
8) The nurse is caring for a male client with a potassium level of 5.9 mEq/L. The physician orders the nurse to administer both glucose and insulin to the client. The client's wife says, "He doesn't have diabetes, so why is he getting insulin?" What is the best response by the nurse? A) "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood." B) "Insulin is safer than other medications that can lower potassium levels." C) "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted." D) "The insulin will help his kidneys excrete the extra potassium."
a
10) When monitoring indicates that a client has a severe fluid and electrolyte imbalance, a nurse should be prepared to execute physician's orders to: Select all that apply. A) Initiate intravenous therapy. B) Initiate hypodermoclysis. C) Administer antibiotics. D) Administer diuretics.
a,b,d
1) An older adult client is brought to the emergency department. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis should the nurse most anticipate for this client? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging
b
11) The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. What should the nurse explain to the client about the purpose of this medication? A) It is vital in regulating muscle contraction and relaxation. B) It is needed to maintain skeletal, cardiac, and neuromuscular activity. C) It controls and regulates water balance in the body. D) It is used in the body to synthesize ingested protein
b
14) During an assessment, the nurse becomes concerned that an older client is at risk for dehydration. What did the nurse assess to come to this conclusion? A) Poor skin turgor B) Ingests 2 glasses of water each day. C) Blood pressure 140/98 mmHg D) Body mass index 20.5
b
17) During an assessment, the nurse learns that a client seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The air temperature is 88 degrees and the client states that water has been ingested several times throughout the day because of heavy sweating. What should the nurse instruct the client at this time? A) Eat something sweet when drinking water. B) Eat something salty when drinking water. C) Double the amount of water being ingested. D) Drink juices and carbonated sodas.
b
2) The nurse has just received a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. The nurse is reviewing the assignment and determines that which child is at greatest risk for dehydration? A) A 4-year-old child with a broken leg B) A 15-month-old child with tachypnea C) A 16-year-old child with migraine headaches D) A 10-year-old child with cellulitis of the left leg
b
2) The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? A) Measure vital signs every 8 hours. B) Assist the client to ambulate around the room at least three times daily. C) Irrigate the client's Foley catheter daily. D) Assist the client to turn, cough, and deep breathe every 2 hours
b
2) The nurse receives a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client should the nurse plan to assess first based on an increased risk for dehydration? A) A 4-year-old child with a broken leg B) A 15-month-old child with tachypnea C) A 16-year-old child with migraine headaches D) A 10-year-old child with cellulitis of the left leg
b
6) Which of the following terms refers to severe, generalized edema, which may occur as a result of fluid volume excess? A) Ascites B) Anasarca C) Hypervolemia D) Orthopnea
b
7) The nurse is caring for a client diagnosed with heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which drug on the client's medication administration record may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin
b
7) The nurse is caring for a client with congestive heart failure who is admitted to the medicalsurgical unit with acute hypokalemia. The client is on multiple medications. Which medication may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin
b
8) An elderly client is admitted to the hospital after a fall. The client appears intermittently confused. What is a primary concern of the nurse regarding fluid and electrolytes when caring for this client? A) Risk of kidney damage B) Risk of dehydration C) Risk of stroke D) Risk of bleeding
b
9) The nurse is caring for an elderly client who has been receiving intravenous fluids at 150 mL/hr. The nurse assesses that the client has crackles, shortness of breath, and jugular vein distention. The nurse would recognize these findings as an indication of which complication of IV fluid therapy? A) Speed shock B) Fluid volume excess C) Pulmonary embolism D) An allergic reaction
b
Exemplar 6.1 Fluid and Electrolyte Imbalance 1) An 86-year-old client is brought to the Emergency Department from a long-term care facility. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. The nurse would interpret this finding to be consistent with which of the following? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging
b
12) The nurse is concerned that a client with a fluid imbalance is at risk for an alteration in perfusion. Which assessment findings indicate that the client's perfusion status is being maintained? Select all that apply. A) Skin turgor 20 seconds B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time E) Bowel sounds sluggish in all four quadrants
b,c,d
10) The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply. A) Drink diet soda. B) Drink more fluids during hot weather. C) Drink flat caffeine-free cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea. E) Exercise between the hours of 10 a.m. and 2 p.m.
bcd
12) The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client diagnosed with heart failure. Which assessment finding supports the use of this diagnosis for the client? A) Shortness of breath with ambulation B) Productive cough C) +3 pitting edema both feet D) Heart rate 104 and regular
c
13) A client's serum sodium level is 150 mg/dL. Which interventions should the nurse plan for this client? Select all that apply. A) Monitor heart rate and rhythm. B) Elevate the head of the bed. C) Instruct on a low-sodium diet. D) Administer diuretics as prescribed. E) Administer potassium supplement as prescribed.
c
15) The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should the nurse identify as supporting the diagnosis of dehydration? A) Serum osmolality 230 mOsm/kg B) Hematocrit 30% C) Hematocrit 53% D) Serum potassium 3.8 mEq/L
c
15) What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance? A) Antidiuretic hormone B) Parathyroid hormone C) Aldosterone D) Progesterone
c
16) The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. What should the nurse conclude about the client's treatment for dehydration? A) Treatment needs to include a diuretic. B) Treatment has not been effective. C) Treatment is effective and should continue. D) Treatment has been effective and should end.
c
17) An increase in blood hydrostatic pressure would result in which fluid volume disturbance? A) Fluid volume excess, because the pressure would force fluid out through the lymphatic system and into the interstitial compartment. B) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the lymphatic system. C) Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment. D) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the capillaries.
c
4) The nurse is planning care for a client admitted to the unit with a diagnosis of dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines that Risk for Electrolyte Imbalance is an appropriate nursing diagnosis. Which medical condition supports this nursing diagnosis? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure
c
4) The nurse is planning care for a client admitted to the unit with dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines an appropriate nursing diagnosis to be electrolyte imbalance. Which condition is known to result in fluid loss that is characterized by a proportionately greater loss of sodium than water? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure
c
5) A home health nurse is seeing a client with congestive heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Which food would the nurse encourage this client to choose from the dinner menu? A) Baked fish B) Iced tea C) Banana D) Peas
c
5) The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. What is the best response by the nurse? A) "Fluid volume excess is caused by new onset liver failure caused by the surgery." B) "Fluid volume excess is caused by the intravenous fluids." C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D) "Fluid volume excess is caused by inactivity."
c
5) The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. Which response by the nurse is the most appropriate? A) "Fluid volume excess commonly occurs due to new onset liver failure caused by the surgery." B) "Fluid volume excess is frequently caused by the administration of intravenous fluids." C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D) "Fluid volume excess is frequently caused by inactivity."
c
9) A client in the Emergency Department is being admitted for fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal
c
9) A client in the emergency department is being admitted with a diagnosis of fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal
c
13) A client diagnosed with heart failure is prescribed an oral fluid restriction of 1200 mL per day. How many ounces of fluid would the client be permitted during the day shift? A) 200 mL B) 300 mL C) 400 mL D) 600 mL
d
13) A client with heart failure is prescribed an oral fluid restriction of 1,200 mL per day. How many ounces of fluid should the nurse teach the client is permitted during the daylight shift? A) 200 mL B) 300 mL C) 400 mL D) 600 mL
d
3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is 2.0 mg/dL. The nurse is planning care for this client. Which nursing intervention would address this client's phosphorus level? A) Enforce contact precautions. B) Encourage consumption of a high-calorie carbohydrate diet. C) Strain all urine. D) Encourage consumption of milk and yogurt
d
3) The nurse is teaching a group of children and their parents about the importance of exercise. The topic for this specific session is preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught? A) "It is important for my child to wear dark clothing while exercising in the heat." B) "Water is the drink of choice to replenish fluids that are lost during exercise." C) "My child only needs to hydrate at the end of an exercise session." D) "I will have my child stop every 15-20 minutes during the activity for fluids."
d
3) The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the session? A) "It is important for my child to wear dark clothing while exercising in the heat." B) "Water is the drink of choice to replenish fluids that are lost during exercise." C) "My child only needs to hydrate at the end of an exercise session." D) "I will have my child stop every 15 to 20 minutes during physical activity to drink fluids."
d
6) The nurse is caring for a client receiving a blood transfusion. Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. Which is the priority intervention for this client? A) Decrease the rate of the transfusion. B) Notify the client's physician. C) Prepare to resuscitate the client. D) Discontinue the transfusion.
d
6) The nurse is caring for a client who is experiencing a multisystem fluid volume deficit following hemodialysis. The nursing assessment reveals the client is tachycardic; has pale, cool skin; and has a decreased urine output. The nurse determines that the client has not met which expected outcomes for a client on hemodialysis? A) Cardiac decompensation B) The pharmacological effects of a diuretic infused in the dialysate C) The effects of rapidly infused intravenous fluids D) A reduction of extracellular fluid
d
