Ch. 42 Fluid and Electrolyte Practice Questions

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? Select all that apply. A. Infiltration at vascular access device (VAD) site B. Patient lying on tubing C. Roller clamp wide open D. Tubing kinked in bedrails E. Circulatory overload

A, B, D Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails).

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply A. Ensure adequate oxygenation. B. Provide assistance to prevent falls. C. Monitor medication administration of diuretics. D. Monitor for numbness and tingling around the mouth. E. Prevent complications during potassium administration.

A, B, C, E The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. A. Peas B. Nuts C. Cheese D. Cauliflower E. Processed oat cereals

A, B, D The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. A. Bounding pulse B. Difficulty breathing C. Increased urine output D. Presence of dependent edema E. Neck vein distention in the upright position

A, B, D, E Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply A. Ensure adequate fluid intake. B. Implement safety measures to prevent falls. C. Encourage low-fiber foods to prevent diarrhea. D. Instruct the client about foods that contain potassium. E. Encourage the client to obtain assistance to ambulate.

A, B, D, E Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. A. Dehydration B. Hypertension C. Physiological stress D. Decreased blood volume E. Decreased plasma osmolarity

A, C, D ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

Your patient has severe hypercalcemia. What are your priority nursing interventions? Select all that apply. A. Fall prevention interventions B. Teaching regarding sodium restriction C. Encouraging increased fluid intake D. Monitoring for constipation E. Explaining how to take daily weights

A, C, D Severe hypercalcemia causes lethargy, which creates a risk for falling and constipation. Increased fluid intake is important to prevent renal calculi during hypercalcemia.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. A. U waves B. Absent P waves C. Inverted T waves D. Depressed ST segment E. Widened QRS complex

A, C, D The normal serum potassium level is **3.5 to 5.0 mEq/L** (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. A. Blood transfusions B. Metabolic alkalosis C. Bleeding or hemorrhage D. Decreased sodium excretion E. Ingestion of potassium in medications F. Failure to restrict dietary potassium

A, C, E, F With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? Select all that apply. A. Fall prevention interventions B. Teaching regarding sodium restriction C. Encouraging increased fluid intake D. Monitoring for constipation E. Explaining how to take daily weights

A, D Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. It also causes gastrointestinal smooth muscle weakness, which produces constipation.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply. A. Tetany B. Constipation C. Renal calculi D. Hypotension E. Prolonged QT interval F. Positive Chvostek's sign

A, D, E, F The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

You assess four patients. Which patient has greatest risk for hypomagnesemia? A. A 72-year-old with chronic alcoholism B. A 79-year-old with bone cancer C. A 41-year-old with hypernatremia D. A 46-year-old with respiratory acidosis

A. A 72-year-old with chronic alcoholism Patients who have chronic alcoholism are at high risk for hypomagnesemia because of decreased magnesium intake and absorption and increased magnesium excretion

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? A. A client with an ileostomy B. A client with heart failure C. A client on long-term corticosteroid therapy D. A client receiving frequent wound irrigations

A. A client with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? A. Daily weight B. Urinary output C. IV fluid intake D. NG tube intake

A. Daily weight Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? A. Dehydration B. Hypokalemia C. Fluid overload D. Hypernatremia

A. Dehydration When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography (ECG)

A. Hypotension Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? A. Malnutrition B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A. Malnutrition The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias. B. Encourage increased intake of phosphate antacids. C. Discontinue any magnesium-containing medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.

A. Monitor the client for dysrhythmias. The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? A. Prolonged bed rest B. Renal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A. Prolonged bed rest The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A. The client who is taking diuretics B. The client with hyperaldosteronism C. The client with Cushing's syndrome D. The client who is taking corticosteroids

A. The client who is taking diuretics The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes

A. Twitching The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium? A. Urine output B. Arterial blood gases C. Fullness of neck veins D. Level of consciousness

A. Urine output Increased potassium intake when potassium output is decreased is a major risk for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? A. Weight loss and poor skin turgor B. Lung congestion and increased heart rate C. Decreased hematocrit and increased urine output D. Increased respirations and increased blood pressure

A. Weight loss and poor skin turgor A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

B, C, D, E The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

Which patient do you plan to teach regarding water restriction? A. A 23-year-old with extracellular fluid volume (ECV) deficit B. A 34-year-old with hyponatremia C. A 47-year-old with hypercalcemia D. A 69-year-old with metabolic acidosis

B. A 34-year-old with hyponatremia Hyponatremia involves excessive water for the amount of sodium in the blood; the body fluids are too dilute. Therefore water restriction is the most common therapy for hyponatremia.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8°F (37.1°C) B. A urine specific gravity of 1.043 C. A urine output that is pale yellow D. A blood pressure of 120/80 mm Hg

B. A urine specific gravity of 1.043 The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8°F (37.1°C) is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? A. Hang the solution. B. Contact the health care provider (HCP). C. Check the client's daily laboratory results. D. Ask the client if any liver study tests have ever been done.

B. Contact the health care provider (HCP). The nurse must contact the HCP before administering the solution. Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? A. Confusion B. Muscle weakness C. Mental status changes D. Depressed deep tendon reflexes

B. Muscle weakness Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires nasogastric suction C. Has a history of Addison's disease D. Uric acid level of 9.4 mg/dL (559 mmol/L)

B. Requires nasogastric suction The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? A. A client with ulcerative colitis B. A client with Cushing's syndrome C. A client admitted 6 hours ago with a 40% burn injury D. A client who has a history of long-term laxative abuse

C. A client admitted 6 hours ago with a 40% burn injury Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP)

C. An increase in blood pressure and increased respirations A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? A. Urinary output B. Wound drainage C. Integumentary output D. The gastrointestinal tract

C. Integumentary output Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability

C. Areflexia Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lungs

C. Changes in mental status A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? A. Document this assessment finding. B. Call another nurse to verify this finding. C. Check skin turgor over the client's sternum. D. Call the health care provider (HCP) to obtain a prescription for fluid replacement

C. Check skin turgor over the client's sternum In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action? A. Notify a health care provider B. Record in medical record C. Decrease the IV flow rate D. Discontinue the IV site

C. Decrease the IV flow rate When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of extracellular fluid volume excess. For patient safety the IV flow rate must be decreased immediately.

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? A. Dryness of mucous membranes B. Presence or absence of edema C. Fullness of neck veins when supine D. Fullness of neck veins when upright

C. Fullness of neck veins when supine ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV neck veins are full when the individual is supine. With ECV deficit they are flat.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C. Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips? A. The total volume B. Two-thirds of the volume C. One-half of the volume D. One-quarter of the volume

C. One-half of the volume When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? A. Sodium 135 mEq/L (135 mmol/L) B. Sodium 140 mEq/L (140 mmol/L) C. Potassium 3.0 mEq/L (3.0 mmol/L) D. Potassium 5.0 mEq/L (5.0 mmol/L)

C. Potassium 3.0 mEq/L (3.0 mmol/L) The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? A. Tremors B. Hyperactive reflexes C. Respiratory depression D. No specific signs or symptoms because this value is a normal level

C. Respiratory depression The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

Which assessment do you interpret as a transfusion reaction? A. Crackles in dependent parts of lungs B. High fever, severe hypotension C. Anxiety, itching, confusion D. Chills, tachycardia, and flushing

D. Chills, tachycardia, and flushing A transfusion reaction occurs when the immune system reacts against the blood that is being transfused. Chills, tachycardia, and flushing are common manifestations.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau sign D. Loss of deep tendon reflexes

D. Loss of deep tendon reflexes The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? A. Tap water B. Sterile water C. Distilled water D. Sodium chloride

D. Sodium chloride A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution.

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first? A. Apply a warm, moist compress B. Monitor the patient's blood pressure C. Aspirate the infusing fluid from the VAD D. Stop the infusion and discontinue the intravenous infusion

D. Stop the infusion and discontinue the intravenous infusion Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped, and the VAD removed as the highest priority.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? A. The client with colitis B. The client with Cushing's syndrome C. The client who has been overusing laxatives D. The client who has sustained a traumatic burn

D. The client who has sustained a traumatic burn The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? A. The client taking diuretics and has tenting of the skin B. The client with an ileostomy from a recent abdominal surgery C. The client who requires intermittent gastrointestinal suctioning D. The client with kidney disease and a 12-year history of diabetes mellitus

D. The client with kidney disease and a 12-year history of diabetes mellitus A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment A. Urine pH of 6 B. Urine that is pale yellow C. Urine output of 40 mL/hr D. Urine specific gravity of 1.032

D. Urine specific gravity of 1.032 The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

T or F: Is the pt that suffered a stroke at risk for third-spacing?

False Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.