EAQ F&E

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

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

9. Which clinical finding would the nurse associate with hypokalemia? a. Edema b. Muscle spasms c. Kussmaul respirations d. Muscle weakness

D

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

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

C,D,E

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

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

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

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

34. Which disease increases the risk of hyperkalemia? a. Chron disease b. Cushing disease c. End-stage renal disease d. Gastroesophageal reflux disease

C

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

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

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

A,E

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

C,E

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

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 (137 mmol/L) d. Potassium decreases to 4.2 mEq/L (4.2 mmol/L)

D

39. Which serum hormone level elevates in response to a client's total serum calcium concentration of 7.9 mg/dL (0.43 mmol/L)? a. Estrogen b. Thyroxine C. Growth hormone D. Parathyroid hormone (PTH)

D

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

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

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

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

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

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

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

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 (1.9 mmol/L) b. Calcium: 10.5 mg/ dL (2.6 mmol/L) c. Potassium: 6.0 mEq/L (6.0 mmol/L) d. Potassium: 3.5 mEq/L (3.5 mmol/L) e. Creatinine: 3.2 mg/dL (194 mcmol/ L) f. Creatinine: 1.1 mg/dL (90 mcmol/L)

A,C,E

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

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

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

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

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

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

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

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

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. Supple skin turgor b. Rapid, thready pulse c. Decreased hematocrit d. Elevated specific gravity e. Adventitious breath sounds

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

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

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

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

D,E