EAQ Adv. F&E
Which clinical manifestations would the nurse expect the client who has chronic kidney disease with hypocalcemia to exhibit? Select all that apply. One, some, or all responses may be correct. A. Acidosis B. Lethargy C. Fractures D. Osteomalacia E. Eye calcium deposits
CDE Because of calcium loss from the bone, fractures, osteomalacia, and eye calcium deposits occur. Acidosis decreases calcium that binds to albumin, resulting in more ionized calcium (free calcium) in the blood. Lethargy and weakness are associated with hypercalcemia.
A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? A. Acidosis B. Calcium depletion C. Potassium retention D. Sodium chloride depletion
B In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.
A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? A. Sodium B. Calcium C. Potassium D. Phosphorus
B The muscle contraction-relaxation cycle requires an adequate serum calcium/phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. The major route of sodium excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.
20. A client develops an intestinal obstruction. A nasogastric tube is inserted and connected to low, continuous suction. The nurse monitors the client for fluid volume deficit. Which clinical finding would the nurse expect if the client become dehydrated? a. Restlessness b. Constipation c. Inelastic skin turgor d. Increased blood pressure
C
5. When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? a. Weighing the client b. Monitoring the intake and output c. Assessing the extent of pitting edema d. Asking client about subjective symptoms
A
7. A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct. A. Rapid, thready pulse B. Elevated specific gravity C. Oliguria D. Dyspnea E. Hypotension F. Pulmonary crackles G. Tenting skin turgor
ABCEG With dehydration, the body tries to conserve fluid, resulting in lowered urinary output (oliguria). Dehydration leads to hypovolemia and less circulatory volume, causing decreased cardiac output and hypotension. Fluid volume deficit causes decreased skin turgor and skin tenting when pinched. Difficulty breathing (dyspnea) is a result of pulmonary congestion, which is associated with hypervolemia. Auscultation of crackles is a result of pulmonary congestion, which does not occur with dehydration.
A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's serum chloride level is decreased. Which method is the most efficient way to correct this problem? A. Low-residue diet B. Intravenous (IV) therapy C. Oral electrolyte solution D. Total parenteral nutrition (TPN)
B IV ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.
A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. Which item would the nurse keep at the bedside in case of magnesium sulfate toxicity? A. Oxygen B. Naloxone C. Calcium gluconate D. Suction equipment
C The antagonist of magnesium sulfate is calcium gluconate. The priority intervention is to try to prevent a seizure. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure.
17. A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. a. Diplopia b. Skin rash c. Leg cramps d. Tachycardia e. Muscle weakness
CE Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. Skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.
6. The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? a. Clear breath sounds b. Positive pedal pulses c. Normal potassium level d. Decreased urine specific gravity
A Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.
When administering albumin intravenously, which fluid shift would the nurse anticipate? A. Interstitial compartment to the intracellular compartment B. Intravascular compartment to the interstitial compartment C. Interstitial compartment to the intravascular compartment D. Extracellular compartment to the intracellular compartment
C Intravenous albumin increases colloid osmotic pressure, resulting in a pull of fluid from the interstitial compartment to the intravascular compartment. Intravascular compartment to the interstitial compartment and Extracellular compartment to the intracellular compartment are opposite to the actual shift of fluids when albumin is administered.
21. Intravenous (IV) potassium is prescribed for a client with a diagnosis of hypokalemia. Which statement about administration of IV potassium is accurate? a. Oliguria is an indication for withholding IV potassium b. Rapid infusion of potassium prevents burning at the IV site c. Clients with severe deficits should be given IV push potassium d. Average IV dosage of potassium should not exceed 60 mEq in 1 hour
A
34. Which disease increases the risk of hyperkalemia? a. Chron disease b. Cushing disease c. End-stage renal disease d. Gastroesophageal reflux disease
C
13. The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia
A
14. The nurse identifies that a client's urinary output is less that 40 mL/h over the past 3 hours. Which action would the nurse take? a. Assess breath sounds and obtain vital signs b. Decrease the intravenous flow rate and increase oral fluids c. Insert an indwelling catheter to facilitate emptying of the bladder d. Check for dependent edema by assessing the lower extremities
A
26. The nurse is reviewing the laboratory reports of a group of older adult clients. Which client has an age- related impairment of the thirst mechanism? Client Serum Sodium Concentration A. 167 mEq/L B. 143 mEq/L C. 118 mEq/L D. 101 mEq/ L
A
40. Which finding would the nurse anticipate when reviewing the laboratory reports of a client with an acute kidney injury? Select all that apply. One, some, or all responses may be correct. a. Calcium: 7.6 mg/dL b. Calcium: 10.5 mg/ dL c. Potassium: 6.0 mEq/L d. Potassium: 3.5 mEq/L e. Creatinine: 3.2 mg/dL f. Creatinine: 1.1 mg/dL
ACE NORMAL RANGES: Calcium: 9.0 to 10.5 mEq/L Potassium: 3.5 to 5.0 mEq/L Creatinine: female .5 to 1.1 mg/dL male .6 to 1.2 mg/dL
33. A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily based metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next? a. Send another blood sample to the laboratory to retest the serum potassium level b. Notify the health care provider that the potassium level is above normal c. Notify the health care provider that the potassium level is below normal d. No action is required because that potassium level is within normal limits
C
24. The nurse assesses an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? a. Sunken eyes b. Dry, flaky skin c. Change in mental status d. Decreased bowl sounds
C Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the older adult client.
The laboratory reports of a client reveal a total serum calcium level of 8.1 mg/dL (0.45 mmol/L). Identify the correct order of events to correct this client's total serum calcium level. A. Stimulation of osteoclastic activity B. Release of calcium into the blood C. Increase of parathyroid hormone (PTH) D. Elevation of serum calcium levels
CABD When serum calcium levels lower, parathyroid hormone secretion increases and stimulates bones to promote osteoclastic activity. This activity releases calcium into the blood. PTH then reduces the renal excretion of calcium and facilitates the mineral's absorption from the intestines.
32. The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? a. Administering sodium polystyrene sulfonate b. Instructing a client to increase potassium and sodium intake c. Monitoring glucose levels hourly d. Providing potassium- sparing diuretics
A
When a client is receiving total parenteral nutrition, which indicator of client status is important for the nurse to assess? A. Blood glucose B . Occult blood in stool C. Urine specific gravity D. Presence of bowel sounds
A Blood glucose that exceeds the renal threshold for glucose reabsorption in the kidney tubules (approximately 160-180 mg/dL) will cause cellular osmotic diuresis, resulting in dehydration. Stool for occult blood determines the presence of digested blood in the stool; it is unrelated to total parenteral nutrition. An altered specific gravity is nonspecific; increases can result from causes other than glycosuria. Checking the abdomen for bowel sounds assesses for increased or decreased peristalsis; it is unrelated to total parenteral nutrition.
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload. a. Crackles in the lungs b. Decreased heart rate c. Decreased blood pressure d. Cyanosis of nail beds
A Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.
A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous solution will be prescribed initially? A. 3% sodium chloride B. 0.9% sodium chloride C. 5% dextrose and 0.9% sodium chloride D. 5% dextrose and lactated Ringer solution
B An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client, because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. 3% sodium chloride, is a high concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. 5% dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be appropriate fluids to infuse after 0.9% sodium chloride.
An older client who was found unconscious at home was admitted to the hospital with a fractured hip, renal failure, and dehydration. In the 24 hours since admission, the client has received 3 L of intravenous fluid. The client has also developed hyponatremia. Which element would the nurse conclude is the most likely to have contributed to the client developing hyponatremia? A. Reduced dietary salt intake B. Intravenous fluid infusion C. Potassium reabsorption rate D. Increased glomerular filtration
B Hemodilution has most likely occurred because 3 L of intravenous fluid will lower the serum sodium level by increasing intravenous fluid and reducing the serum concentration of sodium. A reduced dietary salt intake is not the most likely cause of hyponatremia developing during the first 24 hours of this hospitalization. Changes to the serum potassium reabsorption rate are not likely to have caused hyponatremia in the past 24 hours. A decreased, not increased, glomerular filtration rate occurs with renal failure.
Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? A. Give the client orange juice by mouth. B. Increase the client's intravenous (IV) flow rate. C. Moisten the client's lips with a wet 4 × 4 gauze. D. Offer the client 4 oz (120 mL) of water by mouth.
C No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary health care provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary health care provider's prescription.
37. The nurse administers sodium polystyrene sulfonate to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? a. Pruritus decreases b. Mental status improves c. Sodium decreases to 137 mEq/L d. Potassium decreases to 4.2 mEq/L
D
A client with severe hyperkalemia develops acidosis. Immediate administration of which medication can help prevent a life-threatening crisis? A. 50% dextrose B. Furosemide C. Sodium bicarbonate D. Epinephrine
Sodium bicarbonate decreases the potassium level if acidosis is present. Infusion of sodium bicarbonate moves the pH toward alkalinity and thereby increases cellular uptake of potassium. Administration of glucose and insulin can promote movement of potassium into cells, but glucose alone doesn't have this effect. Loop diuretics such as furosemide are useful for mild to moderate hyperkalemia, but when the severity of the condition has progressed to a stage of acidosis, other medications are indicated. Epinephrine is an emergency medication, but it is not indicated for this purpose.
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. a Assessment of skin turgor b Documentation of vital signs c Assessment of intake and output d Administration of antiemetic medications e Replacement of fluid and electrolytes
ade When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic medications; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.
8. A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. a. Wound drainage b. Diuretic therapy c. Gastrointestinal (GI) suction d. Parenteral infusion of 0.9% sodium chloride e. Inappropriate antidiuretic hormone (ADH) secretion
A,B,C,E
3. Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct. a. Decreased urine b. Hypotension c. Dyspnea d. Dry mucous membranes e. Lung crackles f. Poor skin turgor
A,B,D,F
25. For a client with the diagnosis of bulimia nervosa, purging type, which clinical manifestation would be monitored? a. Weight gain b. Dehydration c. Hyperactivity d. Hyperglycemia
B
18. When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? a. Complete blood cell count b. Serum potassium level c. X-ray film of long bones d. Blood culture X3
B
22. The nurse is providing care for a client who is hospitalized for dehydration and expects which assessment findings? Select all that apply. One, some or all responses may be correct. a. Protruding eyeballs b. Postural hypotension c. The client reports eating an average of two meals daily d. The skin on the client's forehead remains tented after being pinched e. Within 4 days, the client lost 4 ounces (0.11kg) of weight
B,D
30. The nurse identifies a disease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for great concern for this client? a. Calcium b. Chloride c. Potassium d. Phosphate
C
10. A client arrives at the emergency department reporting minimal urinary output despite drinking adequate fluid. The client blood pressure is 190/94 mm Hg. Which additional clinical manifestation would the nurse assess the client for? a. Thirst b. Weight gain c. Urinary retention d. Urinary hesitancy
B
12. Which would the nurse identify as a risk factor of hyponatremia? a. Inadequate fluid intake b. Drainage from a T-tube c. Total parenteral nutrition d. Hypertonic tube feedings
B
23. Which clinical sign is the most important indication of an accurate degree of dehydration? a. Dry skin b. Weight loss c. Sunken fontanel d. Decreased urine output
B
4. Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? a. Rapid, thready pulse b. Distended jugular veins c. Elevated hematocrit level d. Increased serum sodium levels
B
16. The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? a. Skin condition b. Fluid and electrolyte balance c. Food intake d. Fluid intake and output
B Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.
A client develops hyponatremia. Which factors are likely causes of hyponatremia? Select all that apply. One, some, or all responses may be correct. A. Diabetes insipidus B. Profuse diaphoresis C. Excess sodium intake D. Removal of the parathyroid glands E. Rapid intravenous (IV) infusion of 5% dextrose in water (D5W)
BE Common causes of hyponatremia from loss of sodium-rich body fluids include draining wounds, diarrhea, vomiting, and primary adrenal insufficiency. Inappropriate use of sodium-free or hypotonic IV fluids (like D5W) causes hyponatremia from water excess. Because perspiration contains high levels of sodium, this is a cause of hyponatremia. Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and hypernatremia. Excess sodium intake can lead to hypernatremia. Removal of the parathyroid glands can lead to hypocalcemia.
11. The nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. Which serum blood level would the nurse monitor? a. Urea b. Chloride c. Potassium d. Creatinine
C
28. When caring for a client who has hyponatremia, the nurse would monitor for which symptom? a. Increased urine output b. Deep rapid respirations c. Change in level of consciousness d. Distended neck veins
C
27. The nurse gave a client the prescribed sodium polystyrene sulfonate. Which assessment finding indicates that the medication has been effective? a. Control of diarrhea b. An increase in serum sodium level c. An increase in serum calcium level d. A decrease in serum potassium level
D
29. An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value would the nurse report to the health care provider? a. Sodium of 140 mEq/L (140mmol/L) b. Ionized calcium of 2.35 mEq/L (1.2 mmol/L) c. Chloride of 102 mEq/L (102 mmol/L) d. Potassium of 3.0 mEq/L (3.0 mmol/L)
D
9. Which clinical finding would the nurse associate with hypokalemia? a. Edema b. Muscle spasms c. Kussmaul respirations d. Muscle weakness
D
39. Which serum hormone level elevates in response to a client's total serum calcium concentration of 7.9 mg/dL? a. Estrogen b. Thyroxine C. Growth hormone D. Parathyroid hormone (PTH)
D Normal range of serum Ca is between 9 to 10.5, when total serum Ca concentration levels lower, PTH is secreted & increases which stimulates bones to promote osteoclastic activity which increases serum Ca levels)
31. A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor with laboratory results? a. Sodium and chloride levels b. Bicarbonate and sulfate levels c. Magnesium and protein levels d. Calcium and phosphate levels
A
38. An older client is admitted to hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? a. Calcium b. Chlorides c. Potassium d. Phosphates
C
2. A client is taking furosemide. At each clinic visit, the nurse will assess for which adverse effect? a. Rapid weight loss b. Xanthopsia c. Hyporeflexia d. Bronchospasm
C
When a client develops internal bleeding after abdominal surgery, which clinical manifestations would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct. A. Pallor B. Polyuria C. Bradypnea D. Tachycardia E. Hypertension
AD Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates (tachycardia) in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases (the opposite of polyuria) with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase (the opposite of bradypnea) and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension, not hypertension, occurs in response to hemorrhage as the person experiences hypovolemia.
When the health care provider prescribes a diet high in potassium for a client who is taking a daily diuretic, which foods will the nurse suggest that the client eat? Select all that apply. One, some, or all responses may be correct. A. Corn B. Bananas C. Strawberries D. Cucumber salad E. Baked potatoes with skins
BE Bananas and baked potatoes with skins are high in potassium. Corn, strawberries, and cucumbers are not high in potassium. Foods high in potassium, which include apricots, avocados, bananas, cantaloupe, fish, honeydew, kiwi, meat, milk, oranges, potatoes, poultry, prunes, spinach, sweet potatoes, tomatoes, winter squash, and yams.
Which laboratory result is most important to communicate quickly to the health care provider? A Blood glucose 98 mg/dL B. Hemoglobin 14.1 g/dL C. Potassium 3.0 mEq/L D. White blood cell 9200/mm3
C A potassium level of 3.0 mEq/L is indicative of hypokalemia, which needs to be quickly communicated to the provider so that potassium supplementation can be started. Normal values for an adult are 3.5 to 5.0 mEq/L. The blood glucose level is within the normal range of 70 to 100 mg/dL. A hemoglobin of 14.1 is within normal values. WBC level of 9200 cells/mm3 is within the normal range of 4000 to 11,000 cells/mm3.
36. A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L), and the potassium level is 3.0 MEq/L (3.0 mmol/L). The nurse notifies the primary health care provider. Which prescription would the nurse be prepared to administer? a. Add potassium chloride (KCL) to the existing intravenous (IV) lactated Ringer solution. b. Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. c. Discontinue the IV NaCl with 20 mEq KCI solution and replace with IV 5% dextrose in water (D5W) solution. d. Discontinue the IV 5% D5W with 40 mEq KCI solution and replace with IV 5% D5W solution
A
Which action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure 102/56 mm Hg? A. Offer oral fluids at frequent intervals. B. Give fluid boluses through a nasogastric tube. C. Administer intravenous antiemetic medications. D. Insert a peripheral intravenous line for fluid infusion.
A Replacement of fluids in dehydrated clients is best done through the oral route, when possible. In this healthy young adult whose vital signs indicate mild hypovolemia, the nurse would offer oral fluids to correct hypovolemia. Clients who cannot swallow oral fluids may need a nasogastric tube for fluid replacement. Because nausea and vomiting are not the cause of the client's dehydration, antiemetic medications are not needed. Intravenous fluid infusion is needed for clients who are unable to take adequate amounts of oral fluids.
Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? A. Monitor for cardiac dysrhythmias B. Inquire about changes in bowel patterns. C. Assess for leg muscle twitching or weakness. D. Assess for signs and symptoms of dehydration.
A Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate levels
A Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.
Which clinical manifestation would the nurse associate with successful fluid replacement therapy? A. A trended urinary output of at least 30 mL/h B. Central venous pressure reading of 1.5 mm Hg C. Baseline pulse rate of 120 beats per minute decreasing to 110 beats per minute within a 15-minute period D. Baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period
A The nurse would consider a urinary output rate of 30 mL/h adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats per min decreasing to 110 beats per minute within a 15-minute period and a baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period indicates improved tissue perfusion, but not necessarily adequate tissue perfusion. Compensatory mechanisms such as the renin-angiotensin-aldosterone system may continue reabsorption of fluids. Clinical manifestations reflecting adequate tissue perfusion also means the client does not need the compensatory mechanisms any longer, and urinary output increases.
A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? A. Blood urea nitrogen (BUN) B. Sedimentation rate C. Hematocrit (Hct) D. Blood pH
C An increased Hct level indicates hemoconcentration secondary to fluid loss. The BUN level may be used to indicate dehydration from burns, but interpretation can be complicated by other conditions accompanying burns that also cause an increase in the BUN. An increase in the sedimentation rate indicates the presence of an inflammatory process, not fluid loss. The pH level reflects acid-base balance.
During a client's paracentesis, 1500 mL of fluid is removed. Which assessment finding by the nurse is indicative of a potentially severe response? A. Abdominal girth decrease B. Mucous membranes becoming drier C. Heart rate increases from 80 to 135 beats per minute D. Blood pressure rises from 130/70 to 190/80 mm Hg
C Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.
In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? A. Isotonic B. Isomeric C. Hypotonic D. Hypertonic
C Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
An older adult client states, "I walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." Which statement would the nurse use to respond to this client? A. "Drink fruit juices if you start to feel dehydrated." B. "Thirst is a good guide to use to determine fluid intake." C. "Fluids should be increased if the urine becomes darker." D. "Water should be consumed when the skin becomes dry."
C In hot weather, dark-colored urine indicates dehydration. When urine is dark, there is a decreased amount of fluid excreted and the body is attempting to conserve fluid. Avoid fruit juices during rehydration because of their high sugar content. By the time people become thirsty, they already are dehydrated, especially older adults. Dry skin in older adults typically relates to aging rather than to dehydration and is not a good indicator of dehydration in older adults.
The nurse adds 20 mEq of potassium chloride to the intravenous solution of a client with diabetic ketoacidosis. Which purpose would this medication serve? A. Treats hyperpnea B. Prevents flaccid paralysis C. Prevents hypokalemia D. Treats cardiac dysrhythmias
C Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with replacement fluids, is needed to prevent hypokalemia. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. There is no mention of dysrhythmias in the scenario; they are not a universal finding in diabetic ketoacidosis (and are commonly absent) and hypokalemia does not always cause these to occur.
A postoperative client has these changes in heart rate (HR) and blood pressure (BP) with position changes: Lying HR = 70 beats/minute, BP = 110/70 mm Hg; Sitting HR = 78 beats/minute, BP = 106/66 mm Hg; Standing HR = 85 beats/minute, BP = 108/64 mm Hg. Which collaborative intervention will the nurse anticipate? A. Increase in diuretic dose B. Decrease in activity level C. Intravenous fluid infusion D. Continue current plan of care
D Because the assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure), there is no indication that a change in the current therapeutic plan is needed. An increase in diuretic dose would cause hypovolemia. Because the client does not have postural hypotension and there is no other indication of poor activity tolerance, the client can continue or increase the current activity level. Intravenous fluids are not needed because there is no significant change in HR or BP with position change.
When reviewing laboratory results for a client with heart failure who has been receiving furosemide daily, the nurse notes a blood urea nitrogen (BUN) of 42 mg/dL (15.2 mmol/L) and a creatinine of 1.1 mg/dL (97 mcmol/L). Which action by the nurse is a priority? A. Administering the furosemide as scheduled B. Starting strict intake and output measurements C. Sending a urine specimen for specific gravity testing D. Notifying the health care provider about the results.
D Elevations in BUN and creatinine can occur because of hypovolemia caused by diuresis or because of poor renal perfusion caused by heart failure. The nurse will notify the provider and anticipate a change in the treatment plan to avoid further stress on the kidneys. The furosemide would be discussed with the provider before administration, because a change in dose may be needed. Strict intake and output measurements should be done, but will not improve the client's current status. Urine specific gravity testing may be needed to determine the kidney's ability to concentrate urine, but will not improve the current decreased renal function.
19. When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. a. Oliguria b. Dyspnea c. Hypotension d. Pulmonary crackles e. Tenting skin turgor
A,C,E
43. A client is receiving furosemide. For which sign of hypokalemia will the nurse monitor the client? a. Chvostek sign b. Muscle weakness c. Anxious behavior d. Abdominal cramping
B Furosemide is a Loop diuretics drug which inhibit sodium and chloride reabsorption from the loop of Henle and distal tubule. symptoms of hypokalemia are --Constipation. --Heart palpitations. --Extreme tiredness (fatigue). --Muscle weakness and spasms. --Tingling and numbness.
15. When a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks, which assessment is the priority? a. Palpate the abdomen b. Check for ankle edema c. Auscultate breath sounds d. Ask about dietary salt intake
C
When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next? A. Perform a head-to-toe assessment. B. Place the client on restricted fluid intake. C. Discuss a restricted sodium diet with the client. D. Document the findings in the health care record.
A Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary crackles associated with left-sided heart failure. More assessment data is needed before deciding whether fluid restrictions are needed for this client. Restricting sodium in the diet is appropriate for most clients with heart failure, but assessment for symptoms of worsening heart failure is a higher priority. Documentation of findings is needed, but not as important as assessing the client for symptoms that may indicate a need for changes in the therapeutic plan.
When receiving hemodialysis, the client may develop hyponatremia. Which clinical findings related to the potential development of hyponatremia would the nurse monitor? Select all that apply. One, some, or all responses may be correct. A. Diarrhea B. Seizures C. Chvostek sign D. Cardiac dysrhythmias E. Increased temperature
AB Sodium is the most abundant cation in the extracellular fluid and functions as part of the sodium/potassium pump. In the presence of a deficit, the client will exhibit confusion, lethargy, diarrhea, and seizures. Spasm of the facial muscles after a tap over the facial nerve (Chvostek sign) indicates hypocalcemia. Cardiac dysrhythmias are associated with increases or decreases in potassium and calcium. An increase in body temperature reflects a possible infection, not an electrolyte imbalance.
41. Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct. a. Bone pain b. Convulsions c. Muscle spasms d. Tingling of extremities e. Depressed deep tendon reflexes
AE The signs and symptoms include muscle weakness, constipation, anorexia, nausea and vomiting, dehydration, hypoactive deep tendon reflexes lethargy, calcium stones, flank pain, pathologic fractures, and deep bone pain.
The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? A. Hypokalemia and hyponatremia B. Hyperkalemia and hyponatremia C. Hypokalemia and hypernatremia D. Hyperkalemia and hypernatremia
B Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.
During an 8-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? A 240 mL B -340 mL C 440 mL D 540 mL
C 440 mL is the correct calculation. The client's intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which when subtracted from 540 mL equals 440 mL. The IV fluid intake and the urinary output are equal; therefore they do not influence the final fluid balance.
35. Which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? Select all that apply. One, some, or all responses may be correct. a. Anorexia b. Constipation c. Muscle weakness d. Irregular health rhythm e. Hyperactive bowl tones
CDE Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. The most serious complications of hyperkalemia are fatal cardiac rhythms such as complete heart block, asystole, and ventricular fibrillation. Hyperactive bowel sounds, diarrhea, and anorexia are symptoms of hyperkalemia. Dysrhythmias such as bradycardia and prolongation of the PR interval and QRS duration occur with hypokalemia.
A child with a diagnosis of acute renal failure has additional blood drawn for laboratory testing. Which serum level requires immediate intervention? A. Sodium 126 mEq/L B. Bilirubin 0.3 mg/dL C. Creatinine 1.3 mg/dL D. Potassium 6.1 mEq/L
D A high potassium level can cause cardiac dysrhythmias; the expected range for serum potassium in a child is 3.4 to 4.7 mEq/L. The expected range for serum sodium is 136 to 146 mEq/L . Hyponatremia is expected with acute renal failure. In a child the expected range for both total and direct bilirubin is 0.2 to 0.8 mg/dL; indirect bilirubin is expected to be 0.1 to 1.0 mg/dL. The bilirubin level is not related to renal failure. The expected range for serum creatinine is 0.3 to 0.7 mg/dL. An increase is expected with acute renal failure.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription would the nurse question? A. Add table salt to each meal. B. Fluid restriction of 1000 mL per day. C. Assess neurological status every 2 hours. D. Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h.
D Because 0.45 % NaCl (one-half normal saline) is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. It is important for the nurse to assess for neurological changes.
Which is the primary reason an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium is prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? A. Prevent constipation B. Prevent dehydration C. Prevent vomiting D. Prevent electrolyte imbalance
D When clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern. Constipation is usually not a concern in this situation. Although dehydration is a possible effect of an NG tube that removes gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.
42. Which clinical manifestations would the nurse identify when assessing a client with hypercalcemia? Select all that apply. One, some, or all responses may be correct. a. Muscle tremors b. Abdominal cramps c. Increased peristalsis d. Cardiac dysrhythmias e. Hypoactive bowel sounds
DE The signs and symptoms include muscle weakness, constipation, anorexia, N/V, dehydration, hypoactive DTRs, lethargy, calcium stones, flank pain, pathologic fractures, and deep bone pain.
