NCLEX -PN Fluids & Electrolytes

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.

"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 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.

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

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 should the nurse expect to note in this client?

An increase in blood pressure

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

Is the same solution as sodium chloride 0.9% Is used to administer red blood cell transfusion Is used to treat hypotension due to fluid volume deficit

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

Butter

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?

Calcitonin

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?

Left foot has 4+ pitting edema.

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.

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

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?

Hypertension

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.

Hypokalemia Hyponatremia Hypomagnesemia

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes

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 should the nurse initiate? Select all that apply.

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

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 should be noted in the client if hyperkalemia is present?

Muscle weakness

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

Positive Trousseau's sign Fine tremors noted in hands

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

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 should determine that this is an expected finding if the client had which health problems? Select all that apply

Severe burn injury Untreated ketoacidosis

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

Take 2 hours before meals.

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply.

Tetany A positive Chvostek's sign A positive Trousseau's sign

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

The client receiving nasogastric suction

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

The client with a fast respiratory rate

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

The client with diabetes mellitus

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply

The client with renal failure The client with chronic congestive heart failure (CHF)

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?

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

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply

Use eggs as a source for protein. Avoid eating lunch meats and bolognas. Eat salads with cabbage and lettuce and avoid spinach.

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

Vitamin D