CNF Exam 2: Fluid, Electrolyte, Acid-Base Balance (39)

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? - "I have never given blood before." - "I received a blood transfusion in the United Kingdom." - "My blood type is B positive." - "My spouse would also like to donate blood."

"I received a blood transfusion in the United Kingdom." Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains each of the buffer systems to the students. Which of the following are buffer systems that will be discussed by the instructor? Select all that apply. - Carbonic acid-sodium bicarbonate buffer system - Phosphate buffer system - Protein buffer system - Potassium buffer system Respiratory buffer system

- Protein buffer system - Carbonic acid-sodium bicarbonate buffer system - Phosphate buffer system Carbonic acid-sodium bicarbonate buffer system, phosphate buffer system, and the protein buffer system are all used by the body to maintain acid-base balance. Potassium and respiratory are not buffer systems.

What is the rate of administration for packed red blood cells? - As fast as the patient can tolerate - 1 unit over 2 to 3 hours, no longer than 4 hours - IV push over 3 minutes - 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? - 20 gtt/min - 30 gtt/min - 40 gtt/min - 50 gtt/min

50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? - 30 drops/mL - 60 drops/mL - 90 drops/mL - 120 drops/mL

60 drops/mL Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? - Dairy products - Apricots - Processed meat - Bread products

Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? - Avoid salty or excessively sweet fluids. - Use regular gum and hard candy. - Eat crackers and bread. - Use an alcohol-based mouthwash to moisten your mouth.

Avoid salty or excessively sweet fluids. To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? - Fluid volume excess - Pulmonary embolus - Cardiac dysrhythmias - Tetany

Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? - Select a primary tubing of about 37 inches (94 cm) long. - Ensure that the prescribed solution is clear and transparent. - Use half-instilled IV solutions before infusing a new one. - Avoid replacing IV solution every 24 hours.

Ensure that the prescribed solution is clear and transparent. Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

The nursing student's assessment has revealed that a patient has dependent edema in his lower legs. The student recognizes that this is caused by alterations in ECF, which is normally present in what location? - The cytoplasm of red blood cells - Muscle fibers - Interstitial spaces - Adipose tissue

Interstitial spaces ECF is found between the cells in the interstitial space. ICF is located within cells, such as muscle fibers, red blood cells, and adipose tissue.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? - Hypertonic - Colloid - Isotonic - Hypotonic

Isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations will you be alert? - Muscle weakness, fatigue, and dysrhythmias - Nausea, vomiting, and constipation - Diminished cognitive ability and hypertension - Muscle weakness, fatigue, and constipation

Muscle weakness, fatigue, and dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

Which client has more extracellular fluid? - Adult woman - Adolescent man - Female school-age child - Newborn

Newborn Newborns have more extracellular fluid than intracellular fluid.

The nurse is caring for a patient who has a peripherally inserted central catheter (PICC) in place for fluid replacement and antibiotic therapy. When monitoring and accessing the patient's PICC, the nurse should prioritize which of the following nursing diagnoses? - Impaired Tissue Integrity - Acute Pain - Risk for Deficient Fluid Volume - Risk for Infection

Risk for Infection PICCs are a safe and reliable form of IV access; however, the nurse must adhere closely to the principles of asepsis in order to prevent line sepsis. There is no pain associated with accessing the line and it does not pose a threat to the patient's fluid balance. The patient's tissue integrity is violated by the insertion of the PICC, but the risk for infection is a priority consideration.

Potassium is needed for neural, muscle, and: - optic function. - auditory function. - cardiac function. - skeletal function.

cardiac function. Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.) - drinking milk - urination - eating a sandwich - vomiting - infusion of intravenous solution

drinking milk infusion of intravenous solution urination vomiting The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

Edema happens when there is which fluid volume imbalance? - extracellular fluid volume deficit - water deficit - water excess - extracellular fluid volume excess

extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: - hypocalcemia. - hypothyroidism. - hypoglycemia. - hypokalemia.

hypokalemia The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? - asking the client to pump their fist several times - placing the tourniquet on the upper arm for 2 minutes - asking if the client is right or left handed - palpating the veins on the non-dominant hand

placing the tourniquet on the upper arm for 2 minutes The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? - platelets - granulocytes - albumin - cryoprecipitate

platelets Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

The primary extracellular electrolytes are: - potassium, phosphate, and sulfate. - magnesium, sulfate, and carbon. - sodium, chloride, and bicarbonate. - phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate. The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: - cellular hydration. - volume expander. - total parenteral nutrition. - blood transfusion therapy.

total parenteral nutrition. Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

The student nurse asks, "what it interstitial fluid?" What is the appropriate nursing response? - "Fluid inside cells." - "Fluid outside cells." - "Fluid in the tissue space between and around cells." - "Watery plasma, or serum, portion of blood."

"Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

Which client will have more adipose tissue and less fluid? - A woman - A man - An infant - A child

A woman Women have a lower fluid content because they have more adipose tissue then men.

The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid? - Isotonic - Hypertonic - Hypotonic - Osmolar

Hypotonic A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space.

A nurse is reading a journal article about fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? - Infants - Toddlers - Adolescents - Older adults

Infants Infants have a far greater volume of total fluid as a percentage of body weight than older individuals. However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? - Eggs - Chicken - Apples - Spinach

Spinach Sardines, whole grains, and green leafy vegetables also provide calcium.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? - Assess oxygen levels. - Stop the transfusion. - Assess for visible rash. - Call for assistance.

Stop the transfusion. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: - electrolytes. - non-electrolytes. - colloid solution. - interstitial fluid.

electrolytes. The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have non-electrolytes, colloid solution, or interstitial fluid restored. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? - "Granulocytes are a type of white blood cell that can help fight infection." - "Granulocytes replace clotting factors that are altered from infection." - "Granulocytes help third spacing of fluid that occurs with infection." - "Granulocytes help to control bleeding associated with infection."

"Granulocytes are a type of white blood cell that can help fight infection." Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? - "Unfortunately your own blood cannot be re-infused during surgery." - "Let me refer you to the blood bank so they can provide you with information." - "This surgery has a very low change of hemorrhage, so you will not need blood." - "We now have artificial blood products, so giving your own blood is not necessary."

"Let me refer you to the blood bank so they can provide you with information." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction? - "The lungs remove water though exhalation." - "The heart circulates water and nutrients through the body." - "The lungs regulate metabolic acid-base disturbances by controlling carbon dioxide." - "The kidneys store and release antidiuretic hormone to increase water retention."

"The kidneys store and release antidiuretic hormone to increase water retention." The pituitary glands store and release antidiuretic hormone rather than the kidneys. The other statements are correct regarding fluid and electrolyte balance.

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? - "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." - "We do not record fluids absorbed into undergarments." - "Estimate the amount of fluid that you think was excreted into the undergarment." - "You only record urine output in an adult undergarment; you do not record diarrhea output."

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL).

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? - 3,750 - 3,000 - 1,000 - 500

3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? - 3.5 cm H2O - 5 cm H2O - 9.5 cm H2O - 12 cm H2O

3.5 cm H2O The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? - 23-year old with ulnar and radial fracture - 34-year old whose urinary catheter was discontinued yesterday - 48-year old who has had a bowel movement after surgery - 55-year old with congestive heart failure on furosemide

55-year old with congestive heart failure on furosemide Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? - Constipation related to immobility - Pain related to surgical incision - Acute Confusion related to cerebral edema - Risk for Infection related to inadequate personal hygiene

Acute Confusion related to cerebral edema Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? - An implanted central venous access device (CVAD) - A peripheral venous catheter inserted to the antecubital fossa - A peripheral venous catheter inserted to the cephalic vein - A midline peripheral catheter

An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? - Banana - Milk - Yogurt - Turkey

Banana Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? - An increased sense of thirst - Increase in nephrons in the kidneys - Increased renal blood flow - Cardiac volume intolerance

Cardiac volume intolerance The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? - Abdominal distention - Vomiting - Paralytic ileus - Diarrhea

Diarrhea The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? - Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea - Congestive Heart Failure related to edema - Fluid Volume Excess related to loss of sodium and potassium - Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? - Fruit consumption - Sips of water - Parenteral fluids - Frozen fluids

Fruit consumption Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? - Notify the primary care provider immediately because these are signs of speed shock. - Notify the primary care provider immediately for possible fluid overload. - Check all clamps on the tubing and check tubing for any kinking. - No intervention is necessary as this is a normal finding with IV infusion.

Notify the primary care provider immediately for possible fluid overload. If the client's lung sounds were previously clear but some crackles in the bases are now auscultated, notify the primary care provider immediately. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? - Ask the client every hour to drink more fluid. - Offer small amounts of preferred beverage frequently. - Have a loved one tell the client to drink more. - Leave water on the bedside table.

Offer small amounts of preferred beverage frequently. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? - Sodium - Chloride - Phosphorous - Potassium

Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

A nursing student is reviewing the principles of fluid balance in anticipation of caring for a patient who has ascites secondary to liver disease. Which of the following statements most accurately describes the movement of fluids and solutes? - Solutes passively move from areas of high concentration to areas of lower concentration. - Intracellular fluid (ICF) and extracellular fluid (ECF) are isolated by impermeable membranes that protect the body's fluid balance. - Proteins and electrolytes generate osmotic pressure, which affects the movement of water between body compartments. - Water moves from areas with a low concentration of solutes to areas of high concentration by the process of active transport.

Proteins and electrolytes generate osmotic pressure, which affects the movement of water between body compartments. The process of osmosis refers to the movement of water from compartments where there is a low concentration of solutes (proteins and electrolytes) to areas of higher concentration; this is a passive process that does not require active transport. Movement of ICF and ECF occurs through semipermeable membranes. Differences in osmolarity and osmolality affect the movement of water, not of solutes themselves.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? - Weigh the volume of IV fluid before instilling. - Weigh the client's wet linen or dressing. - Weigh the client without soiled incontinence pads. - Weigh the client before and after meals

Weigh the client's wet linen or dressing. In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item. The nurse does not weigh the client without soiled incontinence pads. The nurse does not weigh the client before and after meals to obtain an accurate assessment of the fluid output.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? - a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today - a 60-year-old who is 3 days post-myocardial infarction and has been stable. - a 47-year-old who had a colon resection yesterday and is reporting pain - a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - cardiac irregularities - muscle weakness - increased intracranial pressure (ICP) - metabolic acidosis

cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? - muscle twitching - distended neck veins - fingerprinting over sternum - nausea and vomiting

distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A decrease in arterial blood pressure will result in the release of: - protein. - thrombus. - renin. - insulin.

renin. Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.