Week 2

which action is most important for the nurse to perform to prevent harm before starting an IV infusion of potassium to a client who has a low serum potassium level? a. determine IV line patency and blood return b. assess oxygen saturation level with pulse oximetry c. evaluate baseline mental status d. check the apical pulse for a full minute e. check deep tendon reflexes f. measure intake and output

a. determine IV line patency and blood return d. check the apical pulse for a full minute

Which electrolyte change does the nurse expect to see in a client who produces excessive amounts of aldosterone? A. Low serum sodium level B. High serum potassium level C. Low serum calcium level D. High serum sodium level

D. High serum sodium level

which GI complication will the nurse monitor for in a client who has a serum potassium level of 2.4 mEq/L? a. hyperactive bowel sounds b. paralytic ileus c. esophageal reflux d. excessive flatus

b. paralytic ileus hypokalemia reduces GI motility and greatly increases the risk for a paralytic ileus

which serum lab value does the nurse expect to see in the client with hypokalemia? a. sodium less than 8.0 mEq/L b. potassium less than 3.5 mEq/L c. chloride less than 100.0 mEq/l d. calcium less than 9.0 mg/dL (2.25 mmol/dL)

b. potassium less than 3.5 mEq/L

Sodium (Na+)

136-145 mEq/L Elevated: hypernatremia, dehydration, kidney disease, hypercortisolism Low: hyponatremia; fluid overload; liver disease, adrenal insufficiency

Potassium (K+)

3.5-5.0 mEq/L Elevated: hyperkalemia, dehydration, kidney disease, acidosis, adrenal insufficiency, crush injuries Low: hypokalemia, fluid overload, diuretic therapy, alkalosis, insulin administration, hyperaldosteronism

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) A. Reports of palpitations B. Slow, shallow respirations C. Orthostatic hypotension D. Paralytic ileus E. Skeletal muscle weakness F. Tall, peaked T waves on ECG

A, E, F Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

With which client condition will the nurse remain most alert for insensible water loss ? A. Continuous GI suctioning B. Deep respirations C. Receiving oxygen therapy D. Hypothermia

A. Continuous GI suctioning

Clients with which problems will the nurse assess most frequently for dehydration? Select all that apply. A. Fever of 103 ° F ( 39.4 ° C ) B. Extensive burns C. Thyroid crisis D. Water intoxication E. Continuous fistula drainage F. Diabetes insipidus

A. Fever of 103 ° F ( 39.4 ° C ) B. Extensive burns C. Thyroid crisis E. Continuous fistula drainage F. Diabetes insipidus

Which potential problems does the nurse assess for when caring for a client whose urine output is less than what is needed as the obligatory urine output? Select all that apply. A. Lethal electrolyte imbalances B. Alkalosis C. Urine becomes diluted D. Toxic buildup of nitrogen F. Increased infection risk F. Acidosis

A. Lethal electrolyte imbalances D. Toxic buildup of nitrogen F. Acidosis

Which serum electrolyte finding on a newly admitted client does the nurse report immediately to the health care provider? Select all that apply A. Potassium 2.8 mEq / L (mmol / L) B. Sodium 143 mEq / L (mmol / L) C. Calcium 9.9 mg / dL (2.59 mmol / L) D. Chloride 101 mEq / L (mmol / L) E. Chloride 98 mEq / L (mmol / L) F. Magnesium 1.2 mEq / L (0.7 mmol / L)

A. Potassium 2.8 mEq / L (mmol / L) F. Magnesium 1.2 mEq / L (0.7 mmol / L)

Which health problems are most likely to activate the renin-angiotensin-aldosterone system ( RAAS )? Select all that apply? A. Shock B. Urinary tract infection C. Constipation D. Dehydration E. Severe asthma F. Hypertension

A. Shock D. Dehydration

Which types of fluid loss are considered " insensible fluid loss? " Select all that apply. A. Sweat B. Salivation C. Urine D. Diarrhea E. Vomit F. Wound drainage

A. Sweat B. Salivation D. Diarrhea E. Vomit F. Wound drainage

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

ANS: A Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? A. Assess the client's respiratory rate, rhythm, and depth. B. Measure the client's pulse and blood pressure. C. Document findings and monitor the client. D. Call the health care primary health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) A. Hypokalemia—muscle weakness with respiratory depression B. Hypermagnesemia—bradycardia and hypotension C. Hyponatremia—decreased level of consciousness D. Hypercalcemia—positive Trousseau and Chvostek signs E. Hypomagnesemia—hyperactive deep tendon reflexes F. Hypernatremia—weak peripheral pulses

ANS: A,B,C,E,F Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) A. Increased pulse rate B. Distended neck veins C. Decreased blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances

ANS: A,B,E,F Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) A. Calculate pulse pressure with each blood pressure reading. B. Assess skin turgor using the back of the client's hand. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium.

ANS: A,C,D,E,F Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? A. Encourage oral fluid intake. B. Connect the client to a cardiac monitor. C. Assess urinary output. D. Administer oral calcitonin.

ANS: B This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

ANS: B,C,D,E,F Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

ANS: B,C,D,F In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) A. Urine output of 25 mL/hr B. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) C. Urine specific gravity of 1.02 g/mL D. Serum sodium level of 128 mEq/L (128 mmol/L) E. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

ANS: B,E Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

ANS: BInsensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with risk for insensible fluid loss.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? A. Notifies the pharmacy of the IV potassium order. B. Assesses the client's IV site every hour during infusion. C. Sets the IV pump to deliver 30 mEq of potassium an hour. D. Double-checks the IV bag against the order with the precepting nurse.

ANS: C IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure.

ANS: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

ANS: C One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) A. Respiratory rate of 8 breaths/min B. Absent deep tendon reflexes C. Strong productive cough D. Active bowel sounds E. U waves present on the electrocardiogram (ECG)

ANS: C,D A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? A. Ask family members to speak quietly to keep the client calm. B. Assess urine color, amount, and specific gravity each day. C. Encourage the client to drink at least 1 L of fluids each shift. D. Dangle the client on the bedside before ambulating.

ANS: D An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? A. Assesses the client's Chvostek and Trousseau sign. B. Keeps the client's room quiet and dimly lit. C. Moves the client carefully to avoid fracturing bones. D. Administers bisphosphonates as prescribed.

ANS: D Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

ANS: D Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

ANS; B All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

Which client factors affect the amount and distribution of body fluids? Select all that apply A. Race B. Age C. Gender D. Height E. Body fat F. Muscle mass

B. Age C. Gender E. Body fat F. Muscle mass

What is the minimum amount of urine output per day needed to excrete toxic waste products? A. 200 to 300 mL B. 400 to 600 mL C. 500 to 1000 mL D. 1000 to 1500 mL

B. 400 to 600 mL much of the body's waste products, especially nitrogen, is excreted in the urine. depending on body size, 400 to 600 mL/day of urine must be generated to ensure waste product excretion. this is known as the obligatory urine output. less than this amount of urine will result in retained waste products that could lead to toxic levels.

The electrolyte magnesium is responsible for which functions? Select all that apply. A. Formation of hydrochloric acid B. Carbohydrate metabolism C. Contraction of skeletal muscle D. Regulation of intracellular osmolarity E. Vitamin activation F. Blood coagulation

B. Carbohydrate metabolism C. Contraction of skeletal muscle. E. Vitamin activation F. Blood coagulation

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of antidiuretic hormone (ADH) is extremely low? A. Decreased blood volume; decreased blood osmolarity B. Decreased blood volume; increased blood osmolarity C. Increased blood volume; decreased blood osmolarity D. Increased blood volume; increased blood osmolarity

B. Decreased blood volume ; increased blood osmolarity

What is the nurse's urine specific gravity of 1.039 ? interpretation of a client's A. B. Dehydration Overhydration C. Normal D. Renal disease value for an adult

B. Dehydration

what change in respiratory function does the nurse expect to find in a client who is dehydrated from severe diarrhea and vomiting? A. No changes, because the respiratory system is not involved B. Increased respiratory rate, because the body perceives dehydration as hypoxia C. Hypoventilation, because the respiratory system is trying to compensate for low pH D. Normal respiratory rate, but a decreased oxygen saturation

B. Increased respiratory rate, because the body perceives dehydration as hypoxia

What sign or symptom does the nurse expect to see in a client whose blood osmolarity is 310 mOsm / L ( mOsm / kg )? A. Body temperature below normal B. Increased thirst C. Pitting edema D. Diarrhea

B. Increased thirst

With which client does the nurse remain most alert for an electrolyte imbalance? A. 49 - year - old with intermittent asthma who also uses an albuterol inhaler PRN B. 60 - year old with a sprained wrist who also takes acetaminophen for pain C. 72 - year - old with diabetes mellitus who also takes a diuretic daily D. 80 - year - old anemia who also take an iron supplement

C. 72 year old with diabetes mellitus who also takes a diuretic daily

what is the main reason a nurse caring for a postoperative surgical client in the recovery room carefully monitoring the client's urine output? A. Decreasing urine output indicates poor kidney function B. increasing urine output can indicate excessive IV fluid during surgery c. decreasing urine output may mean hemorrhage and risk for shock d. increasing urine output may mean that kidney function is returning to normal

C. Decreasing urine output may mean hemorrhage and risk for shock

Which IV fluid does the nurse expect to administer to a client who is prescribed to receive hypotonic fluids? A. 9 % saline B. 3 % saline C. 0.9 % saline D. 0.45 % saline

D. 0.45 % saline

For which indication of a fluid balance problem will the nurse assess in an older client at risk for fluid and electrolyte problems? A. Fever B. Elevated blood pressure C. Poor skin turgor D. Mental status changes

D. Mental status changes

Which is the best technique to use for assessing the skin turgor of an 80 yr old client? A. Observing the skin for a dry, scaly appearance and compare it to a previous assessment B. Pinching the skin over the back of the hand and observe for tenting; count the number of seconds for the skin to recover position. C. Observing the mucous membranes and tongue for cracks, fissures, or a pasty coating D. Pinching the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.

D. Pinching the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.

Which electrolyte plays the largest role in maintaining blood osmolarity? A. Calcium B. Chloride C. Potassium D. Sodium

D. Sodium

which drug therapy does the nurse expect the health care provider to prescribe for a client with low serum sodium and signs of hypervolemia? a. conivaptan b. furosemide c. hydrochlorothiazide d. bumetanide

a. conivaptan the drug therapy should increase water loss without causing sodium loss. furosemide, hydrochlorothiazide, and bumetanide all promote sodium loss as well as water loss.

which assessment findings would indicate to the nurse that the client may have hyponatremia? SATA a. hyperactive bowel sounds on auscultation b. acute-onset confusion c. muscle weakness d. decreased deep tendon reflexes e. abdominal cramping f. nausea

a, b, c, d, e, f

which symptoms does the nurse expect to see first in a client whose plasma volume has an increased hydrostatic pressure? a. dependent edema b. decreased urine output c. poor skin turgor with "tenting" d. greatly increased sensation of thirst

a. dependent edema

plasma is part of which body fluid space compartments? SATA a. the intracellular compartment b. the extracellular compartment c. all fluids within the cells d. interstitial fluid e. intravascular fluid f. fluid within joint capsules

b. the extracellular compartment e. intravascular fluid

ankle and foot edema a nurse who has been standing for 12 hrs is a result of which type of pressure, force, or influence? a. filtration from the plasma volume the interstitial space as a result of increased capillary hydrostatic pressure b. filtration from the plasma volume to the interstitial space as a result of decreased capillary hydrostatic pressure c. osmosis from the interstitial space to the plasma volume as a result of increased osmotic pressure because the nurse also was dehydrated as well as overworked d. osmosis from the plasma volume to the interstitial space as a result of decreased cellular osmotic pressure because tissues damaged from standing released intracellular fluid

a. filtration from the plasma volume the interstitial space as a result of increased capillary hydrostatic pressure

which specific discharge instruction will the nurse provide to prevent harm in a client with advanced heart failure who is at continued risk for fluid volume overload? a. greater than 3 lb gained in a week or greater than 1-2 lb gained in a 24 hr period b. greater than 5 lb gained in a week or greater than 1-2 lb gained in a 24 hr period c. greater than 15 lb gained in a month or greater than 5 lb in a week d. greater than 20 lb gained in a month or greater than 5 lb gained in a week

a. greater than 3 lb gained in a week or greater than 1-2 lb gained in a 24 hr period

which findings indicate to the nurse that a client may have hypervolemia (fluid overload)? SATA a. increased, bounding pulse b. jugular venous distention c. presence of crackles d. excessive thirst e. elevated bp f. orthostatic hypotension

a. increased, bounding pulse b. jugular venous distention c. presence of crackles e. elevated bp

which sign or symptom does the nurse expect to see in a client who has mild hypernatremia? a. muscle twitching and irregular muscle contractions b. inability of muscles and nerves to respond to a stimulus c. muscle weakness occurring bilaterally with no specific pattern d. reduced or absent bilateral deep tendon reflexes

a. muscle twitching and irregular muscle contractions

the nurse will monitor which clients for development of hyponatremia? SATA a. postoperative client who has been NPO for 24 hrs with no IV fluid infusing b. client with decreased fluid intake for 3 days c. client receiving excessive intravenous fluids with 5% dextrose in water d. client with diabetes who has a blood glucose of 250 mg/dL e. client with overactive adrenal glands f. tennis player in 100 F (37.7C) weather who has been drinking water

a. postoperative client who has been NPO for 24 hrs with no IV fluid infusing c. client receiving excessive intravenous fluids with 5% dextrose in water d. client with diabetes who has a blood glucose of 250 mg/dL f. tennis player in 100 F (37.7C) weather who has been drinking water

which effect on respiratory effort does the nurse expect to find in a client with severe hypokalemia? a. shallow respirations and low oxygen saturation b. deep, rapid respirations with high oxygen saturation c. deep, slow respirations with high oxygen saturation d. no specific change in respiratory rate or effectiveness

a. shallow respirations and low oxygen saturation

which serum value indicates to the nurse that the client has hyponatremia? a. sodium 129 mEq/L b. chloride 98 mEq/L c. sodium 144 mEq/L d. chloride 103 mEq/L

a. sodium 129 mEq/L

which adult would normally be expected to have the highest total body water volume? a. 25 yr woman b. 25 yr old man c. 75 yr old woman d. 75 yr old man

b. 25 yr old man

which IV potassium solution can the nurse safely administer to a client with severe hypokalemia? a. KCl 5 mEq in 20 mL NS b. KCl 10 mEq in 100 mL NS c. KCL 15 mEq in 50 mL NS d. KCl 20 mEq in 100 mL NS

b. KCl 10 mEq in 100 mL NS Intravenous potassium is a high alert dangerous drug that can lead to death if administered too rapidly or at a high concentration. It must always be diluted. The maximum allowable concentration of the drug is 1 mEq per 10 mL of solution.

which conditions or health problems increase a client's risk for hypokalemia? SATA a. liver failure b. metabolic alkalosis c. Cushing syndrome d. hypothyroidism e. paralytic ileus f. kidney failure

b. metabolic alkalosis c. Cushing syndrome metabolic alkalosis causes relative hypokalemia by increasing the movement of potassium ions from extracellular fluid into the intracellular fluid in exchange for hydrogen ions. Cushing syndrome involved higher than normal levels of cortisol, which increases potassium loss resulting in an actual hypokalemia. paralytic ileus is not caused by hypokalemia and does not cause it. kidney failure causes hyperkalemia. potassium levels are not affected directly by hypothyroidism or liver failure.

for which serious complication will the nurse administering an IV potassium solution to a client carefully monitor to prevent harm? a. pulmonary edema b. cardiac dysrhythmia c. postural hypotension d. kidney failure

b. cardiac dysrhythmia

which possible imbalance does the nurse suspect when assessment findings on a newly admitted client include pitting dependent edema, engorged neck and hand veins, and headache? a. dehydration b. hypervolemia c. fluid volume deficit d. hemoconcentration

b. hypervolemia

which common signs and symptoms will the nurse be sure to assess for in the older client whose serum sodium level is 152 mEq/L? SATA a. intact recall of recent events b. increased pulse rate c. weight loss d. hypertension e. muscle weakness f. difficulty palpating peripheral pulses

b. increased pulse rate d. hypertension e. muscle weakness f. difficulty palpating peripheral pulses

which action will the nurse teach to the spouse of a client with reduced cognition who has been treated twice in the emergency department for dehydration to prevent this condition? SATA a. avoid offering fluids after 6pm b. weigh the client daily to check fluid status c. offer frequent snacks of gelatins and ice cream d. give the client salty crackers to increase his or her sensation of thirst e. offer 4 oz of the clients favorite fluids every hour while awake f. watch the client while he or she drinks any liquids to ensure it is ingested g. estimate or measure the number of liquid ounces ingested daily to ensure an intake of at least 1500 mL

b. weigh the client daily to check fluid status c. offer frequent snacks of gelatins and ice cream e. offer 4 oz of the clients favorite fluids every hour while awake f. watch the client while he or she drinks any liquids to ensure it is ingested g. estimate or measure the number of liquid ounces ingested daily to ensure an intake of at least 1500 mL

a client is talking to the nurse about sodium intake. which statement by a client indicates to the nurse a correct understanding of high sodium food sources? a. "I have bacon and eggs every morning for breakfast." b. "we never eat seafood because of the salt water." c. "I love Chinese food, but I gave it up because of the soy sauce." d. "pickled herring is a fish, and my doctor told me to eat a lot of fish."

c. "I love Chinese food, but I gave it up because of the soy sauce."

which client statement indicates to the nurse a correct understanding of the management of hypokalemia? a. "my wife does all the cooking. she shops for food high in calcium." b. "when I take the liquid potassium in the evening, ill eat a snack beforehand." c. "I will avoid bananas, orange juice, and salt substitutes." d. "If I switch to a vegetarian diet, I can stop taking the liquid potassium."

c. "I will avoid bananas, orange juice, and salt substitutes." In option A, the client is confusing calcium with potassium. Foods with more potassium include bananas, orange juice, and organ meats. salt substitutes are about 50% potassium.

for which client problem will the nurse question a prescription for a diuretic? a. pulmonary edema b. heart failure c. end-stage renal disease d. ascites

c. end-stage renal disease diuretics are a common and effective drug for the fluid overload associated with pulmonary edema, heart failure, and ascites. they are only used when kidney function is normal or at least adequate. in end-stage kidney disease kidney function is greatly and perhaps totally impaired.

what immediate response does the nurse expect as a result of infusing 1 liter of an isotonic intravenous solution into a client over a 3 hr time period if urine output remains at 100 mL per hr? a. extracellular fluid (ECF) osmolarity increases; body weight increases b. extracellular fluid (ECF) osmolarity decreases; body weight decreases c. extracellular fluid (ECF) osmolarity is unchanged; body weight increases d. extracellular fluid (ECF) osmolarity is unchanged; body weight decreases

c. extracellular fluid (ECF) osmolarity is unchanged; body weight increases Isotonic solutions have the same tonicity as plasma and other extracellular fluids. Therefore, the intravenous fluid would not change the ECF osmolarity. When 1000 mL is infused within 3 hrs and the client only urinates 300 mL, the extra fluid would increase the client's weight. Remember that 1 L of fluid is equal to 2.2 lb.

which body fluid compartment is considered the "third space"? a. extracellular fluid b. intracellular fluid c. interstitial fluid d. blood (plasma)

c. interstitial fluid

which precaution is most important for the nurse to teach a client at continued risk for hypernatremia? a. avoid salt substitutes b. avoid aspirin and aspirin-containing products c. read labels on canned or packaged foods to determine sodium content d. increase daily intake of caffeine-containing foods and beverages

c. read labels on canned or packaged foods to determine sodium content

the nurse observes clients with which of the following conditions for potential hypernatremia? SATA a. chronic constipation b. heart failure c. severe diarrhea d. decreased kidney function e. profound diaphoresis f. Cushing's syndrome

c. severe diarrhea d. decreased kidney function e. profound diaphoresis f. Cushing's syndrome

which serum values indicates to the nurse that the client has hypernatremia? a. potassium 3.9 mEq/L b. chloride 103 mEq/L c. sodium 149 mEq/L d. Potassium 4.9 mEq/L

c. sodium 149 mEq/L

How many milliliters will the nurse record as being lost by a client with pulmonary edema who initially weighed 178lb and now weighs 161.6 lb? a. 1000 b. 3000 c. 5000 d. 7000

d. 7000

which intervention does the nurse anticipate for a client who has hypernatremia caused by reduced kidney sodium excretion? a. IV administration of 0.9 sodium chloride solution b. Iv administration of Ringer's lactate solution c. administration of convaptan d. administration of furosemide

d. administration of furosemide

which symptom in a client with psychiatric issues who is continuously drinking water will the nurse monitor as an indicator of potential hyponatremia? a. insomnia b. pitting edema c. tremors d. decreased cognition

d. decreased cognition