NCLEX Fluid & Electrolyte

Butter

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium?

Monitoring for decreased urine output and hypotension

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?

Hypertension

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

A client with a new burn injury, A client diagnosed with acute kidney injury (AKI)

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

Monitor vital signs. 2Monitor electrolyte levels. 3Monitor intake and output. 4Increase water intake orally. 5Maintain sodium-reduced diet.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply.

Cabbage, Mushrooms, Strawberries

A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply.

Flat neck veins, 3Weakly palpable peripheral pulses, 4Heart rate of 104 beats per minute

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.

Positive Trousseau's sign, Fine tremors noted in hands

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.

Obtain orthostatic vital signs.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Vitamin D

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient?

Take the calcium carbonate with or just after meals., Avoid foods such as beets, spinach, and bran in the diet., Take the medication with a full glass of water (8 oz/240 mL).

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and would include which instructions? Select all that apply.

Take 2 hours before meals.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information would the nurse reinforce when instructing the client about taking this medication?

Presence of Chvostek's sign, Presence of electrocardiogram abnormalities, Presence of tingling in the fingertips and around the mouth, Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level would the nurse collect? Select all that apply.

The skin when pinched immediately fell back to normal when released.

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented?

Muscle weakness

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom would be noted in the client if hyperkalemia is present?

Generalized muscle weakness

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

The client with renal failure, The client with chronic cirrhosis

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

The client receiving nasogastric suction

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit?

Monitor the client for dysrhythmias., Notify the primary health care provider (PHCP) of the laboratory results.

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions would the nurse initiate? Select all that apply.

Severe burn injury, Untreated ketoacidosis

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse would determine that this is an expected finding if the client had which health problems? Select all that apply.

Prolonged bed rest

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?

An increase in blood pressure

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client?

"Water and electrolytes are lost in approximately the same proportion as they exist in the body.", "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.

Sweat, Sputum

Which fluids are identified as insensible fluid losses? Select all that apply.

2520 mL

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

Increased specific gravity of the urine

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use?

Hypotension, Loss of deep tendon reflexes

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply.

Utilize 30 mL of 0.9% normal saline for the irrigating solution., After injecting the irrigating solution, pull back on the irrigation syringe.

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The gastroenterologist prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse would utilize in performing this procedure. Select all that apply.

Weakness in all extremities, Confusion with garbled speech, Diarrhea with abdominal cramping

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.

Left foot has 4+ pitting edema.

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?