Exam 2, NUR 145 Chapter 25 Assessment of Cardiovascular Function NCLEX Questions

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication would the nurse plan to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D

1. Calcitonin Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.2.5-2.75 mmol/L). This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration. Test-Taking Strategy(ies):Focus on the subject, serum calcium level of 13 mg/dL (3.25 mmol/L). Recalling the normal serum calcium level will assist you with determining that the client is experiencing hypercalcemia. With this knowledge, you can easily eliminate calcium chloride and calcium gluconate, because you would not administer medication that adds calcium to the body. Remembering that excessive vitamin D is a causative factor of hypercalcemia will assist you with eliminating that option.

fluid volume excess causes

1. Overhydration with IV fluids 2. Kidney damage 3. Heart failure 4. Long-term use of corticosteroids 5. Excessive sodium ingestion 6. Syndrome of inappropriate antidiuretic hormone secretion 7. Irrigation of wounds or body cavities with hypotonic fluids

Which fluids are identified as insensible fluid losses? Select all that apply. 1. Sweat 2.Sputum 3.Nasogastric tube output 4.Output from Jackson-Pratt drain 5.Urine output from indwelling catheter

1. Sweat 2.Sputum Rationale:Insensible fluid losses are those that cannot be perceived by the senses or measured because they occur through the skin, such as sweat, and the lungs, such as sputum. They occur on a daily basis without the client's awareness. Sensible losses are those that are perceivable and measurable and include wound drainage, including output from wound drains such as a Jackson-Pratt drain; gastrointestinal tract losses, such as output from a nasogastric tube; and urine output. Test-Taking Strategy(ies):Focus on the subject, insensible fluid losses. The key point to recall is that insensible fluid losses cannot be measured. This will direct you to the correct option.

Fluid volume deficit data collection

1. Thirst 2. Poor skin turgor and dry mucous membranes 3. Increased heart rate, thready pulse, dyspnea, and postural hypotension 4. Weight loss 5. Flat neck or hand veins 6. Dizziness or weakness 7. Decrease in urine volume and dark, concentrated urine 8. Increased specific gravity of the urine 9. Confusion 10. Increased hematocrit level

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium? 1. Milk 2.Butter 3. Spinach 4.Collard greens

2. Butter Rationale:Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet. Test-Taking Strategy(ies):Note the subject, the item that is lowest in calcium. Milk can be easily eliminated first. Eliminate spinach and collard greens next, because they are comparable or alike.

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse would be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply. 1. Dried fruits are good for snacks. 2. Use eggs as a source for protein. 3.Limit cereals and bread products. 4.Avoid eating lunch meats and bolognas. 5.Eat salads with cabbage and lettuce and avoid spinach.

2. Use eggs as a source for protein. 4.Avoid eating lunch meats and bolognas. 5.Eat salads with cabbage and lettuce and avoid spinach. Rationale:Potassium is in most foods. Eggs are a protein source that is not as high in potassium as meats, especially organ and preserved meats such as lunch meats and bolognas. Most common salad ingredients such as lettuce, cabbage, carrots, celery, and onions are not rich in potassium. Spinach, however, is a good source of potassium. The client should avoid dried fruits, which are high in potassium. The client may eat bread and cereals that are not rich in potassium. Test-Taking Strategy(ies):Focus on the subject, the foods to include in a diet low in potassium content. Use knowledge about this subject and recall that meats and dairy are high in potassium, and eggs and breads are less so. Particular fruits are also high in potassium.

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient? 1. Vitamin C 2. Vitamin D 3. Complete protein 4Low saturated fat

2. Vitamin D Rationale:Calcitriol is a natural form of vitamin D and is an important regulator for calcium and phosphorus homeostasis. This vitamin improves calcium absorption from the intestine. Few foods are naturally rich in vitamin D except for oily fish such as salmon. Many foods are enriched with vitamin D such as milk. Vitamin D can be obtained by the body with exposure to sunlight. Test-Taking Strategy(ies):Focus on the subject, calcitriol. Use the data in the question that the medication is used in treating hypocalcemia in a client undergoing dialysis for renal failure. Recall that calcium and vitamin D work together to maintain bone health.

Hypermagnesemia

A serum magnesium level that exceeds 2.6 mg/dL.

What does decreased pulse pressure reflect? A. Reduced stroke volume B. Reduced distensibility of the arteries C. elevated stroke volume D. tachycardia

A. Reduced stroke volume

The nurse cares for a client in the ICU diagnosed with CAD. Which assessment data indicates the client is experiencing a decrease in cardiac output? A. disorientation, 20 mL of urine over the last 2 hours B. reduced pulse pressure and heart murmur C. elevated jugular venous distention and postural changes in BP D. BP 108/60 mm Hg, ascites, and crackles

A. disorientation, 20 mL of urine over the last 2 hours reduced pulse pressure, hypotension, reduced urine output, lethargy, and disorientation.

Which term describes the ability of the heart to initiate an electrical impulse? A. excitability B. Automaticity C. Contractility D. Conductivity

B. Automaticity

The nurse cares for a client with an intra-arterial pressure monitoring device. The nurse recognizes that most preventable complication associated with hemodynamic monitoring includes which condition? A. hemorrhage B. Catheter-related bloodstream infection C. pneumothorax D. Air embolism

B. Catheter-related bloodstream infection

Which area of the heart that is located at the third intercoastal space to the left of the sternum? A. Pulmonic area B. Erb point C. Aortic area D. Epigastric area

B. Erb point

The nurse is caring for a client in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? A. Ventricular hypertrophy B. Heart Failure C. Pulmonary Edema D. Myocardial infarction

B. Heart Failure Anything higher than 100 is suggestive of HF

A nurse prepares to assess a client for postural blood pressure changes. Which action indicates the nurse needs further education? A. positioning the client supine for 10 minutes prior to taking the initial BP & HR B. Letting 30 seconds elapse after each position change before measuring BP & HR C. Taking the client's BP with the client sitting on the edge of the bed, feet dangling D. Obtaining the supine measurements prior to sitting and standing measurements

B. Letting 30 seconds elapse after each position change before measuring BP & HR

The nurse screen a client prior to a magnetic resonance angiogram (MRA) of the heart. Which action should the nurse complete prior to the client undergoing the procedure? Select all that apply. A. Sedate the client prior to the procedure B. Remove the client's transderm Nitro patch C. Remove the client's jewelry D. Off the client a headset to listen to music during the procedure E. Position the client on the stomach for the procedure

B. Remove the client's transderm Nitro patch C. Remove the client's jewelry D. Off the client a headset to listen to music during the procedure

The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, is is most important for the nurse to ask which question? A. When was the last time you ate or drank B. What was your morning blood sugar reading C. Are you allergic to shellfish D. Are you having chest pain?

C. Are you allergic to shellfish? Radiopaque contrast agents are used to visualize the coronary arteries. Some agents contain iodine. Shellfish = iodine allergy. If suspected, then antihistamine and methylprednisolone may be administered prior to procedure.

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? A. Observing the client for bleeding B. Checking for cardiac dysrhythmias C. Checking peripheral pulses D. Hemodynamic monitoring

C. Checking peripheral pulses

The nurse prepares to apply ECG electrodes to a male client who require continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? A. Clean the client's chest with alcohol prior to application of the electrodes B. Once the electrodes are applied, change then every 72 hours C. Clip the client's chest hair prior to application D. Apply baby powder to the client's chest hair prior to placement.

C. Clip the client's chest hair prior to application

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? A. Depolarization B. Repolarization C. Contractility D. Diastole

C. Contractility

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? A. You can take a tub bath or a shower when you get home B. Contact your primary care provider if you develop a temp above 102 F C. Do not bend at the waist, strain, or lift heavy objects for the next 24 hours D. If any discharge occurs at the puncture site, call 911 immediately.

C. Do not bend at the waist, strain, or lift heavy objects for the next 24 hours Contact PCP if swelling, new bruising, pain from puncture site, or temp of 101 F. If bleeding occurs, lie down apply firm pressure.

Age-related changes associated with the cardiac system include A. Decreased size of the left atrium B. Myocardial thinning C. Endocardial fibrosis D. Increase in the number of SA node cells.

C. Endocardial fibrosis increased size of left atrium, a decreasing number of SA node cells, and myocardial thickening

During auscultation of the heart, what is revealed by an atrial gallop? A. Turbulent blood flow B. Heart failure C. HTN heart disease D. Diseased heart valves

C. HTN heart disease An extra sounds just before S1 is an S4 heart sound, or atrial gallop. An S4 sounds often is associated with hypertensive heart disease.

The nurse auscultates the PMI (point of maximal impulse) at which anatomic location? A. Midsternum B. 5 cm to the left of the lower end of the sternum C. Left midclavicular line, fifth intercoastal space D. 2.5 cm to the left of the xiphoid process

C. Left midclavicular line, fifth intercoastal space

When the balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured, the measurement obtained is referred to as the A. Pulmonary artery pressure B. Central venous pressure C. Pulmonary artery wedge pressure D. Cardiac Output

C. Pulmonary artery wedge pressure

The nurse uses which term for the normal pacemaker of the heart? A. Bundle of His B. AV node C. SA Node D. Purkinje fibers

C. SA Node

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? A. HR changes 78 to 112 B. BP Change 148/80 to 166/90 C. ST-segment change on the ECG D. Dizziness and leg cramping

C. ST-segment change on the ECG A decreased in BP or HR, serious dysrhythmias or ST-segment changes on the ECG during the stress test all warrant stopping the test.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? A. Opening snap B. Ejection click C. Murmur D. Friction rub

D. Friction rub During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub.

The nurse auscultates the apex beat at which anatomical location? A. 5 cm to the left of the lower end of the sternum B. Midsternum C. 2.5 cm to the left of the xiphoid process D. fifth intercoastal space, midclavicular line

D. fifth intercoastal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercoastal space.

for both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. which of the following data is necessary to collect if the patient is experiencing chest pain? a. pulse rate in upper extremities b. blood pressure in the left arm c. description of the pain d. sound of the apical pulses

Description of the pain A history of its location, frequency, and duration is necessary.

Hypernatremia Causes and signs/symptoms

Excessive use of diuretics Profuse, watery diarrhea Inhalation or ingestion of saltwater Dry sticky mucous membranes Oliguria or anuria

Which symptom is an early sign of Acute Coronary Syndrome (ACS) and heart failure (HF)? A. Hypotension B. Weight gain C. Fatigue D. change in LOC

Fatigue Also an early warning sign for HF & valvular disease.

The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8mm Hg and recognizes that this finding indicates the client is experiencing which condition? A. overdiuresis B. Left-sided heart failure C. Excessive blood loss D. Hypervolemia

Hypervolemia The normal CVP is 2 to 6 mm HG. Greater than 6 indicated an elevated R ventricular preload. Many problems can cause increased CVP, but most common is hypervolemia or R-sided HF.

Hypocalcemia

Hypocalcemia is a serum calcium level less than 9.0 mg/dL

Body fluid trasport: osmosis

Osmosis is the movement of solvent molecules across a membrane in response to a concentration gradient, usuusually from a solution of lower to one of higher solute concentration. b. If a membrane is permeable to water but not to all solutes present, the membrane is a selective or semipermeable membrane. c. When a more concentrated solution is on one side of a selectively permeable membrane and a less concentrated solution is on the other side, a pull called osmotic pressure draws the water through the membrane to the more concentrated side, or the side with more solute.

Central venous pressure is measured in which chamber of the heart? A. R ventricle B. L Atrium C. R atrium D. L ventricle

R atrium

Which term describes the amount of blood ejected per heartbeat? A. Ejection fraction B. Stroke volume C. Afterload D. Cardiac output

Stroke Volume determined by preload, afterload, and contractibility of the heart.

Pseudohyperkalemia

a condition that can occur as a result of methods of blood specimen collection and cell lysis; if an increased serum value is obtained in the absence of clinical symptoms, the specimen needs to be redrawn and evaluated.

Hypophophatemia

a serum phosphorus level lower than 3.0 mg/dL A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level.

Electrolytes

a substance that,once dissolved in a solution ionizes that is some of its molecules split of dissociate into electrically charged items

Body fluid transport: Filtration

a. Filtration is the movement of solutes and solvents by hydrostatic pressure. b. The movement is from an area of higher pressure to an area of lower pressure.

Intracellular compartment

all fluid inside of cells, mostly body vfluids are instide the cells

Intravascular Compartment

fluid inside a blood vessel

Hypercalcemia

serum calcium level that exceeds 10.5 mg/dL

Hypomagnesemia

serum magnesium level less than 1.8 mEq/L

Which term describes the ability of the heart to initiate an electrical impulse? A. Automaticity B. Excitability C. Contractility D. Conductivity

A. Automaticity The ability of specialized electrical cells of the cardiac conduction system to initiate electrical impulse.

What does decreased pulse pressure reflect? A. reduced stroke volume B. tachycardia C. reduced distensibility of the arteries D. elevated stroke volume

A. reduced stroke volume Also reduced ejection velocity or obstruction to blood flow during systole.

extacellular compartment

a. Refers to all fluid outside of the cells b. Includes interstitial fluids, which is the fluid between cells (sometimes called third space), blood, lymph, bone, connective tissue, water, and transcellular fluid

Hyperkalemia

1. Hyperkalemia is a serum potassium level that exceeds 5.0 mEq/L

Hyperphosphatemia

1. Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dL 2. Most body systems tolerate elevated serum phosphorus levels well. 3. An increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level. 4. The problems that occur in hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase.

Hyperphosphatemia interventions

1. Interventions entail the management of hypocalcemia. 2. Assist to administer phosphate-binding medications that increase fecal excretion of phosphorus by binding phosphorus from food in the GI tract. 3. Reinforce instructions to avoid phosphate-containing medications, including laxatives and enemas. 4. Reinforce instructions to decrease the intake of food that is high in phosphorus 5. Reinforce instructions in medication administration: take phosphate-binding medications, emphasizing that they must be taken with meals or immediately after meals.

Hypermagnesemia interventions

1. Monitor cardiovascular, respiratory, neuromuscular, and central nervous system status; the client is placed on a cardiac monitor. 2. Diuretics are prescribed to increase renal excretion of magnesium. 3. IV administered calcium chloride or calcium gluconate may be prescribed to reverse the effects of magnesium on cardiac muscle. 4. Reinforce instructions to restrict dietary intake of magnesium-containing foods 5. Reinforce instructions to the client to avoid the use of laxatives and antacids that contain magnesium. 6. Calcium gluconate is the antidote for magnesium overdose!

Hypophosphatemia interventions

1. Monitor cardiovascular, respiratory, neuromuscular, central nervous system, and hematological status. 2. Medications that contribute to hypophosphatemia will be discontinued. 3. Prepare to administer phosphorus orally along with a vitamin D supplement. 4. IV phosphorus may be prescribed when serum phosphorus levels fall below 1 mg/dL and when the client experiences critical clinical manifestations; assist with monitoring the client closely if IV phosphorus is prescribed. 5. Check for adequate renal function before administering phosphorus. 6. Move the client carefully, and monitor for signs of a pathological fracture. 7. Reinforce instructions to increase the intake of phosphorus-containing foods while decreasing the intake of calcium-containing foods A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level, and an increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level. This is called reciprocal relationship.

A nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which lab value should the nurse also evaluate? A. CBC B. PTT C. INR D. Sodium

INR The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different labs.

Hypernatremia

is a serum sodium level that exceeds 145 mEq/L

fluid volume excess data collection

1. Cough and dyspnea 2. Lung crackles ' 3. Increased respirations and heart rate 4. Increased blood pressure and bounding pulse 5. Pitting edema 6. Weight gain 7. Neck and hand vein distention 8. Increased urine output if kidneys can compensate; decreased if kidney damage is the cause 9. Confusion 10. Decreased hematocrit level

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea 2.The client with diabetes insipidus 3.The client with an inadequate daily water intake 4.The client with the syndrome of inappropriate secretion of antidiuretic hormone

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone Rationale:Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia. Test-Taking Strategy(ies):Focus on the subject, sodium level of 130 mEq/L (130 mmol/L), and determine that this represents hyponatremia. Knowledge regarding the normal sodium level and the causes of hyponatremia is required to answer the question. Remember that hyponatremia can occur secondary to SIADH.

Body Fluid Transport: Diffusion

a. Diffusion is the process whereby a solute (substance that is dissolved) may spread through a solution or solvent (solution in which the solute is dissolved). b. Diffusion of a solute spreads the molecules from an area of higher concentration to an area of lower concentration. c. Diffusion occurs within fluid compartments and from one compartment to another if the barrier between the compartments is permeable to the diffusing substances.

Body bluid transport: Hydrostatic pressure

a. The force exerted by the weight of a solution b. When a difference exists in the hydrostatic pressure on two sides of a membrane, water and diffusible solutes move out of the solution that has the higher hydrostatic pressure by the process of filtration.

Body fluid transport : osmolality

a. The force exerted by the weight of a solution b. When a difference exists in the hydrostatic pressure on two sides of a membrane, water and diffusible solutes move out of the solution that has the higher hydrostatic pressure by the process of filtration.

Fluid volume deficit

1. Dehydration occurs when the body's fluid intake is not sufficient to meet the body's fluid needs. 2. The goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of the fluid volume deficit.

Hypernatremia interventions

1. Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and integumentary status. 2. If the cause is fluid loss, IV fluids may be prescribed. 3. If the cause is inadequate renal excretion of sodium, diuretics that promote sodium loss may be prescribed. 4. Restrict sodium and fluid intake as prescribed

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? A. high pitched sounds B. Wheezes with wet lung sounds C. Laboring breathing D. Stridor

B. Wheezes with wet lung sounds

Hypokalemia

1. Hypokalemia is a serum potassium level lower than 3.5 mEq/L. 2. Potassium deficit is potentially life-threatening because every body system is affected.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1.A premature infant 2. A 101-year-old man 3.A client with heart failure 4.A client with diabetes mellitus 5.A client receiving renal dialysis 6.A 29-year-old client with pneumonia

1. A premature infant 2. A 101-year-old man 3. A client with heart failure 5. A client receiving renal dialysis Rationale:Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients. Test-Taking Strategy(ies):Note the strategic words, most likely. Focus on the subject, those at risk for fluid (circulatory) overload. Thinking about the physiology associated with each client described in the options will assist you with answering correctly.

Third-spacing

1. The accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury 2. The trapped fluid represents a volume loss and is unavailable for normal physiological processes. 3. Fluid may be trapped in body spaces such as the pericardial, pleural, peritoneal, or joint cavities; the bowel; the abdomen; or within soft tissues after trauma or burns. 4. Gathering data about intravascular fluid loss is difficult. It may not be reflected in weight change or intake and output (I&O) records, and it may not become apparent until after organ malfunction occurs.

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply. 1. Pulse oximetry reading 92% 2. Ileostomy output of 650 mL in 4 hours 3. Skin returns to position after being pinched up 4. Fine inspiratory crackles that clear with coughing 5. Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute

2. Ileostomy output of 650 mL in 4 hours 5. Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute Rationale:The client with an ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses. An output of 650 mL in 4 hours would amount to a loss of over 3500 mL in 24 hours. Vital signs indicate a risk with the slightly low BP (104/66 mmHg) and a slight tachycardia (106 beats per minute). The borderline normal pulse oximetry reading with crackles that clear with coughing indicates the client may be breathing shallowly and developing atelectasis. The normal skin turgor is not indicative of risk for fluid volume deficit.

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply. 1. Tetany 2. Twitches 3. Chest pain 4. Hypotension 5.Muscular excitability 6.Loss of deep tendon reflexes

4. Hypotension 6.Loss of deep tendon reflexes Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). A client with a magnesium level of 3 mEq/L (1.5 mmol/L) is experiencing hypermagnesemia. Improvement is noted if the hypotension and loss of deep tendon reflexes have resolved. Signs of hypermagnesemia include neurological depression, drowsiness, and lethargy; loss of deep tendon reflexes; respiratory insufficiency; tachycardia and hypotension; and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia. Chest pain is not associated with alterations in magnesium.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign would the nurse expect to note in the client, based on this magnesium level? 1. Twitching 2. Irritability 3. Hyperactive reflexes 4. Loss of deep tendon reflexes

4. Loss of deep tendon reflexes Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability, and hyperactive reflexes should be noted in a client with hypomagnesemia. Test-Taking Strategy(ies):Knowledge regarding the subject, normal magnesium level, and the associated sign related to an imbalance are helpful for answering this question. Note that twitching, irritability, and hyperactive reflexes are comparable or alike, because they reflect neurological excitability.

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom would be noted in the client if hyperkalemia is present? 1. Muscle pain 2.Mental confusion 3.Muscle weakness 4.Depressed deep tendon reflexes

3.Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness, not muscle pain. Mental status changes and confusion are most likely noted in the client experiencing hypocalcemia hyponatremia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia. Test-Taking Strategy(ies):Focus on the subject, hyperkalemia. It is necessary to recall that muscle weakness is associated with hyperkalemia. This will direct you to option 3.

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4.The client receiving nasogastric suction

4. The client receiving nasogastric suction -Rationale:Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, or metabolic acidosis is at risk for hyperkalemia. -Test-Taking Strategy(ies):Focus on the subject, potassium deficit (hypokalemia). Read the question carefully and note that it asks for the client who is at risk for hypokalemia. Read each option and think about the electrolyte loss that can occur with each condition. Nasogastric suction not only results in a loss of body fluid, but also of electrolytes.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply. 1. A client with pneumonia 2. A client with an ileostomy 3. A client with heart failure 4. A client with acute kidney injury (AKI) 5.A client with a temperature of 102.5° F (39.2° C)

1. A client with pneumonia 2. A client with an ileostomy 5.A client with a temperature of 102.5° F (39.2° C) Rationale:The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. The client with pneumonia is at risk due to fever and coughing up respiratory secretions. The client with a high fever will lose fluid through the skin, which responds by vasodilation to cool off the body. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy. Clients who have heart failure or renal failure often retain fluids and are at risk for excess fluid volume.

Edema

1. An excess accumulation of fluid in the interstitial space; it occurs as a result of alterations in oncotic pressure, hydrostatic pressure, capillary permeability, and lymphatic obstruction. 2. Localized edema occurs as a result of traumatic injury from accidents or surgery, local inflammatory processes, or burns. 3. Generalized edema, also called anasarca, is an excessive accumulation of fluid in the interstitial space throughout the body as a result of a condition such as cardiac, renal, or liver failure.

hypokalemia interventions

1. Assist to monitor cardiovascular, respiratory, neuromuscular, GI, and renal status; client is placed on a cardiac monitor; anticipate a prescription for an electrocardiogram (ECG). 2. Monitor vital signs closely. 3. Monitor I&O. 4. Monitor electrolyte values. 5. Check for adequate renal function before administering prescribed potassium; monitor I&O during administration. 6. Administer potassium supplements as prescribed (orally or monitor by IV). 7. Oral potassium supplements - Oral potassium supplements may cause nausea and vomiting, and they would not be taken on an empty; if the client complains of abdominal pain, distention, nausea, vomiting, diarrhea, or GI bleeding, the supplement may need to be discontinued. -L

fluid volume excess interventions

1. Monitor vital signs and respiratory and neurological status closely. 2. Position the client in semi-Fowler's position. 3. Administer oxygen as prescribed. 4. Check for edema. 5. Monitor I&O. 6. Monitor daily weight. 7. Administer diuretics as prescribed. 8. Monitor hematocrit and electrolyte levels. 9. Restrict fluids as prescribed. 10. Provide a low-sodium diet as prescribed. A client with kidney damage or failure is at high risk for fluid volume excess.

Fluid volume deficit interventions

1. The cause of the fluid volume deficit is treated (e.g., antidiarrheal, antiemetic, antipyretic, and antimicrobial medications may be prescribed), and fluids are replaced through administration of IV solutions as prescribed and oral rehydration. 2. Monitor vital signs and respiratory and neurological status closely. 3. Administer oxygen as prescribed. 4. Check mucous membranes and skin turgor. 5. Monitor weight daily. 6. Monitor I&O. 7. Test urine for specific gravity. 8. Monitor hematocrit and electrolyte levels; prepare to correct electrolyte imbalance if needed.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? 1. U waves 2. Flat P waves 3. Elevated T waves 4. Prolonged PR interval

1. U waves Rationale:A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life-threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves. Test-Taking Strategy(ies):Focus on the subject, a potassium level of 2.7 mEq/L, and that this represents hypokalemia. It is necessary to recall the cardiac changes for a client with hypokalemia. Options 2, 3, and 4 are all characteristic cardiac changes noted with hyperkalemia.

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented? 1. The skin when pinched remained elevated when released. 2. The skin when pinched failed to return to normal when released. 3. The skin when pinched immediately fell back to normal when released. 4. The skin when pinched remained tented for several seconds when released.

3. The skin when pinched immediately fell back to normal when released. Rationale:Turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia. Test-Taking Strategy(ies): Recall the signs/symptoms of hypocalcemia and hypercalcemia. Note that twitching, positive Trousseau's sign, and hyperactive bowel sounds are comparable or alike, because they all reflect a hyperactivity of body systems. The option that is different is muscle weakness.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4. Increased specific gravity of the urine Rationale:Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess. Test-Taking Strategy(ies):Focus on the subject, long-term use of diuretics, and realize that this can lead to a fluid volume deficit. Eliminate gurgling respiration and increased blood pressure first because they would be noted in clients with fluid volume excess. Next, remember that the specific gravity of urine is increased in a client with a fluid volume deficit.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4. Narrow, peaked T waves -Rationale:A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves. Test-Taking Strategy(ies):Focus on the subject, potassium level of 5.4 mEq/L (5.4 mmol/L). Determine next that this condition is a hyperkalemic one. From this point, it is necessary to know the cardiac changes that are expected when hyperkalemia exists.

FLuid volume excess

1. Fluid intake or retention exceeds the body's fluid needs. 2. Also called overhydration, fluid overload, or circulatory overload 3. The goals of treatment are to restore fluid balance; correct electrolyte imbalance, if present; and eliminate or control the underlying cause of the overload (impaired cardiac or renal function can lead to fluid volume excess).

Maintaining fluid and electrolyte balance

1. Homeostasis is a term that indicates the relative stability of the internal environment. 2. Concentration and composition of body fluids must be nearly constant. 3. When one of the substances in a client is deficient—either fluid or electrolytes—the substance must be replaced normally by the intake of food and water or by therapy, such as intravenous (IV) solutions and medications. 4. When the client has an excess of fluid or electrolytes, therapy is directed toward assisting the body with eliminating the excess. -The kidneys play a major role in controlling the balance of fluid and electrolytes. -The adrenal glands, through the secretion of aldosterone, also aid with controlling the extracellular fluid volume by regulating the amount of sodium reabsorbed by the kidneys. -Antidiuretic hormone from the pituitary gland regulates the osmotic pressure of extracellular fluid by regulating the amount of water reabsorbed by the kidney.

Body fluid compartments

1. Fluid in each of the body compartments contains electrolytes. 2. Each compartment has a particular composition of electrolytes that differs from that of other compartments. 3. To function normally, body cells must have fluids and electrolytes in the right compartments and in the right amounts. 4. Whenever an electrolyte moves out of a cell, another electrolyte moves in to take its place. 5. The numbers of cations and anions must be the same for homeostasis to exist. 6. Compartments are separated by semipermeable membranes.

Hypomagnesemia interventions

1. Monitor cardiovascular, respiratory, GI, neuromuscular, and central nervous system status; the client is placed on a cardiac monitor. 2. Because hypocalcemia frequently accompanies hypomagnesemia, interventions also aim to restore normal serum calcium levels. 3. Oral preparations of magnesium may cause diarrhea and increase magnesium loss. 4. Magnesium sulfate by the IV route may be prescribed in severe cases (intramuscular injections cause pain and tissue damage); assist to monitor the client closely during administration; seizure precautions are initiated, serum magnesium levels are monitored frequently, and the client is monitored for diminished deep tendon reflexes that suggest hypermagnesemia. 5. Reinforce instructions to the client to eat food that is high in magnesium

A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply. 1.Cabbage 2.Peaches 3.Soybeans 4.Mushrooms 5.Strawberries

1.Cabbage 4.Mushrooms 5.Strawberries Rationale:Sodium polystyrene sulfonate is a cationic exchange resin used as treatment for hyperkalemia (potassium level greater than 5.0 mEq/L [5.0 mmol/L]) Besides taking the medication, the client should avoid foods that are high in potassium content, including cabbage, mushrooms, and strawberries. Foods low in potassium are peaches and soybeans. Test-Taking Strategy(ies):Focus on the subject, sodium polystyrene sulfonate, which indicates the desired effect of potassium excretion. Note the word avoid. Use knowledge regarding the foods that are high and low in potassium to answer correctly. This will assist in directing you to select foods high in potassium content.

Body fluid output

a. Water lost through the skin is called insensible loss (the individual is unaware of losing that water). b. The amount of water lost by perspiration varies according to the temperature of the environment and of the body, but the average amount of loss by perspiration alone is 100 mL/day. c. Water lost from the lungs is called insensible loss and is lost through expired air that is saturated with water vapor. d. The amount of water lost from the lungs varies with the rate and the depth of respiration. e. Large quantities of water are secreted into the gastrointestinal (GI) tract, but almost all this fluid is reabsorbed. f. A large volume of electrolyte-containing liquids moves into the GI tract and then returns again into the extracellular fluid. g. Severe diarrhea results in the loss of large quantities of fluids and electrolytes. h. The kidneys play a major role in regulating fluid and electrolyte balance and excrete the largest quantity of fluid. i. Normal kidneys can adjust the amount of water and electrolytes leaving the body. j. The quantity of fluid excreted by the kidneys is determined by the amount of water ingested and the amount of waste and solutes excreted. As long as all organs are functioning normally, the body is able to maintain balance in its fluid content. The client with diarrhea is at high risk for a fluid and electrolyte imbalance.

Hyponatremia

1. precipitates lithium toxicity in a client taking lithium. 2. is a serum sodium level less than 135 mEq/L 3. Sodium imbalances are usually associated with fluid imbalances.

Hypocalcemia intervention

1. Monitor cardiovascular, respiratory, neuromuscular, and GI status; the client is placed on a cardiac monitor. 2. Assist to administer calcium supplements orally; calcium may be prescribed IV. 3. Assist to monitor the client receiving IV calcium; monitor for electrocardiographic changes, observe for infiltration, and monitor for hypercalcemia. 4. Medications that increase calcium absorption may be prescribed. a. Aluminum hydroxide reduces phosphorus levels, causing the counter effect of increasing calcium levels. b. Vitamin D aids in the absorption of calcium from the intestinal tract. 5. Provide a quiet environment to reduce environmental stimuli. 6. Initiate seizure precautions. 7. Calcium gluconate 10% needs to be readily available for treatment of acute calcium deficit. 8. Reinforce instructions regarding consuming foods high in calcium

Hypercalcemia intercentions

1. Monitor cardiovascular, respiratory, neuromuscular, renal, and GI status; the client is placed on a cardiac monitor. 2. IV infusions of solutions containing calcium and oral medications containing calcium or vitamin D will be discontinued. 3. Thiazide diuretics may be discontinued and replaced with diuretics that enhance the excretion of calcium. 4. Assist to administer medications as prescribed that inhibit calcium resorption from the bone, such as phosphorus, calcitonin, bisphosphonates, and prostaglandin synthesis inhibitors (aspirin, nonsteroidal anti-inflammatory drugs). 5. Assist to prepare the client with severe hypercalcemia for dialysis if medications fail to reduce the serum calcium level. 6. Monitor for flank or abdominal pain and strain the urine to check for the presence of urinary stones. 7. Reinforce instructions about what foods to avoid that are high in calcium A client with a calcium imbalance is at risk for a pathological fracture. Move the client carefully and slowly; assist the client with ambulation.

Fluid volume deficit causes

1. Vomiting and/or diarrhea 2. Continuous GI irrigation 3. GI suctioning 4. Ileostomy or colostomy drainage 5. Draining wounds, burns, or fistulas 6. Increased urine output from the use of diuretics

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply. 1.Hypokalemia 2.Hyperkalemia 3.Hyponatremia 4.Hypernatremia 5.Hypomagnesemia 6.Hypermagnesemia

1.Hypokalemia 3.Hyponatremia 5.Hypomagnesemia Rationale:Prolonged gastric suction can result in electrolyte imbalances. There can be deficits of potassium, sodium, or magnesium blood levels. Test-Taking Strategy(ies):Focus on the subject, electrolyte imbalance. Prolonged gastric suction results in a loss of gastric juices containing potassium, sodium, and magnesium. This leads to the correct options 1, 3, and 5; all hypo- conditions.

The nurse is told in a report that the client has hypocalcemia. Which signs would the nurse expect to note during the data collection? Select all that apply. 1. Coma 2. Tetany 3. A positive Chvostek sign 4. Hypoactive bowel sounds 5.A positive Trousseau sign Submit

2. Tetany 3.A positive Chvostek sign 5. A positive Trousseau sign Rationale:Calcium is an electrolyte that is necessary for muscle movement. The adult normal calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A low calcium level tends to cause muscle irritability. A positive Chvostek sign (striking the side of the face and noting twitching) and positive Trousseau sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) are indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesia, twitching, cramps, tetany, seizures, hyperactive bowel sounds, and a prolonged QT interval on the electrocardiogram rhythm.

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which IV fluids would provide free water, sodium, and chloride to the client? Select all that apply. 1. Lactated Ringer's solution 2. 0.9% sodium chloride in water solution 3. 0.45% sodium chloride in water solution 4. Dextrose 5% in 0.225% sodium chloride solution 5. Dextrose 5% in lactated Ringer's solution

3. 0.45% sodium chloride in water solution 4. Dextrose 5% in 0.225% sodium chloride solution Rationale:The IV fluid 0.45% sodium chloride in water solution provides free water in addition to sodium and chloride, Dextrose 5% in 0.225% sodium chloride solution provides sodium, chloride, and free water. Lactated Ringer's solution is similar in composition to plasma except that it has excess chloride, no magnesium, and no bicarbonate. It does not provide free water or calories. The IV fluid 0.9% sodium chloride in water solution does not provide free water, calories, or other electrolytes. Dextrose 5% in lactated Ringer's solution is similar in composition to normal plasma except it does not contain magnesium. It does not provide free water.

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)? 1. A client receiving chemotherapy 2. A client with hypoparathyroidism 3. A client with a history of alcoholism 4. A client admitted with vitamin D intoxication

3. A client with a history of alcoholism Rationale:The normal serum phosphorus level is 3.0 to 4.5 mg/dL (0.97-1.45 mmol/L) so a value of 2.0 mg/dL (0.64 mmol/L) is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia. Test-Taking Strategy(ies):Focus on the strategic words, most likely. Apply knowledge regarding normal phosphorus levels to determine the condition that this client is experiencing. From this point, it is necessary to know the causes of hypophosphatemia. Remember that causative factors relate to decreased nutritional intake and malnutrition.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

4. An increase in blood pressure -Rationale: Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level. -Test-Taking Strategy(ies):Note that rapid weight loss; flat hand and neck veins; and weak, thready pulse are comparable or alike in that they all relate to a decrease in fluid volume. The correct option is the only option that reflects an increase in fluid volume.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom would the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4. Postural blood pressure changes Rationale:Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply. 1. "The loss of electrolytes is greater than the loss of water." 2."The loss of water is greater than the loss of electrolytes." 3."Serum sodium level rises above 150 mEq/L (150 mmol/L)." 4."The client is likely to have impaired mental status due to low sodium levels." 5."Water and electrolytes are lost in approximately the same proportion as they exist in the body." 6."A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

5. "Water and electrolytes are lost in approximately the same proportion as they exist in the body." 6. "A client who has a large blood loss due to an accident will initially have an isotonic dehydration." Rationale:Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal (135 to 145 mEq/L [135 to 145 mmol/L]). A client who loses a large amount of blood initially is dehydrated, but the electrolytes are lost proportionately. Options 1 and 4 describe hypotonic dehydration in which the serum sodium level is less than 130 mEq/L (130 mmol/L). Options 2 and 3 describe hypertonic dehydration. Test-Taking Strategy(ies):The subject of the question is the various types of dehydration. Select the options that correctly describe isotonic or balanced dehydration. However, thinking about the terms, hypotonic and hypertonic, and situations that are examples of these may assist you in eliminating the incorrect options.

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and would include which instructions? Select all that apply. 1. Take the calcium carbonate with or just after meals. 2. Avoid foods such as beets, spinach, and bran in the diet. 3. Take the medication with a full glass of water (8 oz/240 mL). 4. It is permissible to swallow whole and not chew the chewable tablets. 5.It is permissible to take an extra calcium pill if the client develops tremors.

1. Take the calcium carbonate with or just after meals. 2. Avoid foods such as beets, spinach, and bran in the diet. 3. Take the medication with a full glass of water (8 oz/240 mL). Rationale:Calcium carbonate is best absorbed with or just after meals. Foods that are high in oxalate, such as beets and spinach, or insoluble fiber, such as bran, may interfere with calcium absorption if eaten in excess. The medication should be taken with a full glass of water (8 oz/240 mL). Chewable tablets should be chewed and taken with a full glass of water to improve absorption of the calcium. The client should follow the prescribed dose and contact the PHCP if symptoms such as tremors occur.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse would take which action? 1Document the value in the client's record. 2Inform the registered nurse of the laboratory value. 3Place the laboratory result form in the client's record. 4Reassure the client that the laboratory result is normal.

2. Inform the registered nurse of the laboratory value. Rationale:The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia, and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions. Test-Taking Strategy(ies):Focus on the laboratory value in the question to determine that the client is experiencing hypercalcemia. Note that options 1 and 3 are comparable or alike and indicate that no action would be taken to report the abnormal value. From the remaining options, eliminate option 4 because the value is elevated.

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation? 1. Blood pressure (BP) is 138/74. 2. Left foot has 4+ pitting edema. 3. Skin instantly returns to position after being pinched up. 4. Abdomen is slightly distended with active bowel sounds.

2. Left foot has 4+ pitting edema. Rationale: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 tissues where an injury or burn occurred, the pleural and peritoneal cavities, and the pericardial sac. Clients at high risk for third spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The left foot that was crushed and is grossly edematous is an example of third spacing of body fluid. The blood pressure represents intravascular fluid status. Normal skin turgor and slight abdominal distention are not examples of third-spacing of fluids.

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids? 1. Major burn 2. Renal failure 3. Hypertension 4. Laënnec's cirrhosis

3. Hypertension Rationale: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 body tissues, the pleural and peritoneal cavities and the pericardial sac. In clients with severe burns, fluid shifts out to the tissues in the area of the burn as sometimes evidenced by blistering. In clients with renal failure, there is a loss of protein due to failure of the kidney to retain protein, and fluid shifts from the blood out into the tissues causing the client to have edema in extremities and face. In Laënnec's cirrhosis the liver becomes fibrotic because of insufficient protein intake, alcoholism, and other conditions. The liver normally produces protein as albumin. With the loss of sufficient levels of albumin in clients with cirrhosis, the fluid shifts out into the abdomen (ascites) or tissues. Hypertension, elevated blood pressure, by itself is not a mechanism leading to fluid shifts. Risk factors for third spacing of fluids include the older client, and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition.

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply. 1. Increased heart rate 2. Increased blood pressure 3. Positive Trousseau's sign 4. Hypoactive bowel sounds 5. Fine tremors noted in hands

3. Positive Trousseau's sign 5. Fine tremors noted in hands Rationale:Normal calcium levels are 9 to 10.5 mg/dL (2.25-2.75 mmol/L). Signs of hypocalcemia, calcium less than 9.0 mg/dL (2.25 mmol/L), include a positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) and increased neuromuscular excitability causing fine tremors when holding the hands out. Additional signs of hypocalcemia include paresthesias, hyperactive reflexes, Chvostek's sign (striking the side of the face and noting twitching), a decreased heart rate, hypotension, hyperactive bowel sounds, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Increased blood pressure, increased heart rate, and hypoactive bowel sounds are all signs of hypercalcemia. Rationale:Normal calcium levels are 9 to 10.5 mg/dL (2.25-2.75 mmol/L). Signs of hypocalcemia, calcium less than 9.0 mg/dL (2.25 mmol/L), include a positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) and increased neuromuscular excitability causing fine tremors when holding the hands out. Additional signs of hypocalcemia include paresthesias, hyperactive reflexes, Chvostek's sign (striking the side of the face and noting twitching), a decreased heart rate, hypotension, hyperactive bowel sounds, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Increased blood pressure, increased heart rate, and hypoactive bowel sounds are all signs of hypercalcemia.

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. The client with sepsis 2.The client with cirrhosis 3.The client with kidney failure 4.The client with diabetes mellitus

4. The client with diabetes mellitus Rationale:Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age. Test-Taking Strategy(ies):Note the subject, the client least likely to develop third-spacing. Eliminate cirrhosis and kidney failure first, because it is likely that fluid balance disturbances will occur with these conditions. From the remaining options, sepsis is the option that is the most acute and therefore the most similar to cirrhosis and kidney failure

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. Test-Taking Strategy(ies):Focus on the subject, serum calcium level of 8.0 mg/dL (2.0 mmol/L). Knowledge regarding the normal serum calcium level will assist you with determining that the client is experiencing hypocalcemia. This should help you to eliminate excessive ingestion of vitamin D. Recalling the causative factors associated with hypocalcemia is necessary to select the correct option from those remaining. Remember that the long-term effect of prolonged bed rest is hypocalcemia.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information would the nurse reinforce when instructing the client about taking this medication? 1.Take with milk. 2.Take with meals. 3. Take with an antacid. 4. Take 2 hours before meals.

4. Take 2 hours before meals. Rationale:Etidronate is a bisphosphonate that works by slowing the resorption of bone and allowing new bone to be formed. Etidronate should be taken on an empty stomach 2 hours before meals. It should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron, or albumin.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? A. Assess the client's capillary refill B. Obtain an O2 stat C. Assess the client for pitting edema D. Obtain a 12 lead ECG tracing

B. Obtain an O2 stat

Body fluid

a. Body fluids transport nutrients to the cells and carry waste products from the cells. Distribution of fluid by compartments in the average adult. b. Total body fluid (intracellular and extracellular) amounts to about 60% of body weight in the adult, 55% in the older adult, and 80% in the infant. c. Thus, infants and older adults are at higher risk for fluid-related problems than younger adults; children

Hyponatremia Interventions

1. Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and GI status. 2. If hyponatremia is accompanied by a fluid volume deficit (hypovolemia), IV sodium chloride infusions may be prescribed to restore sodium content and fluid volume. 3. If hyponatremia is accompanied by fluid volume excess (hypervolemia), osmotic diuretics may be prescribed to promote the excretion of water rather than sodium. 4. If hyponatremia is caused by inappropriate or excessive secretion of antidiuretic hormone, medications that antagonize antidiuretic hormone may be prescribed. 5. Reinforce instructions about the need to increase oral sodium intake and inform the client about what foods to include in his/her diet 6. If the client is taking lithium, monitor the lithium level because hyponatremia can cause diminished lithium excretion, resulting in toxicity.

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply. 1. A client with ulcerative colitis 2. A client with a new burn injury 3. A client with Cushing's syndrome 4. A client diagnosed with acute kidney injury (AKI) 5. A client who has a history of long-term laxative abuse

2. A client with a new burn injury 4. A client diagnosed with acute kidney injury (AKI) Rationale:Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium (from intracellular to extracellular) from early massive cell destruction such as in trauma or burns. Clients with altered kidney function, such as those with AKI, are at risk because the normally functioning kidney excretes potassium. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia. Test-Taking Strategy(ies):Focus on the subject, conditions likely to cause hyperkalemia. Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options 1 and 5 first because they reflect gastrointestinal losses. Remember that cell destruction causes potassium shifts and kidneys regulate potassium to direct you to the correct options. Also recall that Cushing's syndrome presents a risk for hypokalemia and that Addison's disease presents a risk for hyperkalemia.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn -Rationale:A serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia. -Test-Taking Strategy(ies):Eliminate diarrhea and overuse of laxatives first, because they are comparable or alike and reflect a gastrointestinal loss. From the remaining options, recalling that cell destruction, occurring with traumatic burns, causes potassium shifts will direct you to the correct option. Remember that Cushing's syndrome presents a risk for hypokalemia.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance? 1. Checking for moistness of the skin 2. Checking for skin turgor with tenting 3. Monitoring for decreased urine output and hypotension 4. Precisely measuring vomitus and diarrhea

3. Monitoring for decreased urine output and hypotension Rationale:With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid and chronic illness in clients with HIV.

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider? 1. Administer a blood transfusion. 2.Force oral fluid intake to 2000 mL per day. 3.Include foods high in potassium in the diet. 4. Administer hypertonic normal saline solution intravenously.

4. Administer hypertonic normal saline solution intravenously. Rationale:Normal sodium levels are 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). When hyponatremia is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution and the client often is impaired neurologically with altered mental status. Intravenous hypertonic saline (normal saline 3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L). Administration of a blood transfusion or forcing fluids would add to the blood volume and not address the sodium problem. Potassium will not treat a sodium deficit. Test-Taking Strategy(ies):Focus on the subject, severe hyponatremia levels. To answer this question accurately it is necessary to know that hyponatremia is a low sodium level and hypervolemia is excess circulating blood volume. Evaluate each option and select the correct answer by choosing the response that adds sodium to the circulating blood volume.

hyperkalemia Interventions

1. Monitor cardiovascular, respiratory, neuromuscular, renal, and GI status; the client is placed on a cardiac monitor. 2. If IV potassium is being administered, it is stopped immediately (however, the IV catheter is not removed and is kept patent); in addition, oral potassium supplements are withheld. 3.Assist to initiate a potassium-restricted diet. 4. Prepare to administer potassium-excreting diuretics as prescribed if renal function is not impaired. 5. If renal function is impaired, prepare to administer sodium polystyrene sulfonate as prescribed, a cation-exchange resin that promotes GI sodium absorption and potassium excretion. 6. Prepare the client for dialysis if potassium levels are critically high. 7. IV calcium may be prescribed if the hyperkalemia is severe to avert myocardial excitability. 8. IV hypertonic glucose followed by regular insulin may be prescribed to move excess potassium into the cells. 9. When blood transfusions are prescribed for a client with a potassium imbalance, the client would receive fresh blood, if possible; transfusions of stored blood may elevate the potassium level because the breakdown of older blood cells releases potassium. 10. Reinforce instructions to avoid foods high in potassium 11. Reinforce instructions to avoid the use of salt substitutes or other potassium-containing substances. Monitor the serum potassium level closely when a client is receiving a potassium-sparing diuretic!

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2.The client with an ileostomy 3.The client with heart failure 4.The client with decreased kidney function

2. The client with an ileostomy Rationale: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 ileostomy. A client with cirrhosis, heart failure, or decreased kidney function is at risk for fluid volume excess. Test-Taking Strategy(ies):Focus on the subject, fluid volume deficit. Read the question carefully, and note that it asks for the client who is at risk for a deficit. Read each option, and think about the fluid imbalance that can occur in each client. Clients with cirrhosis, heart failure, and decreased kidney function all retain fluid. The only condition that can cause a fluid volume deficit is the condition noted in the correct option.

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply. 1. The client on diuretics 2. The client with renal failure 3. The client with an ileostomy 4. The client on gastrointestinal (GI) suctioning 5. The client with chronic congestive heart failure (CHF)

2. The client with renal failure 5. The client with chronic congestive heart failure (CHF) Rationale:Certain disease processes or medical treatments can put a client at risk for fluid volume excess. The causes of excess fluid volume include decreased kidney function, heart failure, cirrhosis, the use of hypotonic fluids to replace isotonic fluid losses, and the excessive ingestion of table salt. The clients with renal failure and CHF are at risk because the organs are impaired in regulating blood volume. The client with an ileostomy, the client on diuretics, and the client on GI suctioning are at risk for deficient fluid volume due to removal of fluids due to those specific medical treatments. Test-Taking Strategy(ies):Focus on the subject, the client at risk for a fluid volume excess. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 1, 3, and 4 lose fluid. The conditions that can cause an excess are the conditions noted in options 2 and 5.

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor are noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions would the primary health care provider (PHCP) likely prescribe? Select all that apply. 1. Monitor vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor electrolyte levels. 5. Provide a sodium-reduced diet. 6. Administer sodium replacements.

1. Monitor vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4.Monitor electrolyte levels. 5.Provide a sodium-reduced diet. Rationale:Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply. 1. Lung crackles 2. Flat neck veins 3.Weakly palpable peripheral pulses 4. Heart rate of 104 beats per minute 5.Blood pressure (BP) of 136/86 mmHg

2. Flat neck veins 3.Weakly palpable peripheral pulses 3.Weakly palpable peripheral pulses 4. Heart rate of 104 beats per minute Rationale:A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins, a slightly tachycardic pulse rate (104 beats per minute), and weakly palpable peripheral pulses. Other findings are increased respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The lung crackles are consistent with consolidation in the lungs occurring with pneumonia and the borderline elevated BP may relate to pain associated with breathing. Test-Taking Strategy(ies):Focus on the subject, dehydration. Next discriminate between the signs of fluid volume deficit and the signs of fluid volume excess. Recalling that the intravascular compartment is depleted with fluid volume deficit and how the body compensates will help you choose correctly.

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply. 1. Affects the plasma osmolarity 2. Is the same solution as sodium chloride 0.9% 3. Is used to administer red blood cell transfusion 4. Is hypotonic with the plasma and other body fluids 5. Is hypertonic with the plasma and other body fluids 6. Is used to treat hypotension due to fluid volume deficit

2. Is the same solution as sodium chloride 0.9% 3. Is used to administer red blood cell transfusion 6. Is used to treat hypotension due to fluid volume deficit Rationale:Sodium chloride 0.9%, also referred to as normal saline 0.9%, is isotonic. Isotonic solutions frequently are used for intravenous infusion because they have the same osmolarity as blood. Isotonic IV solutions do not affect the plasma osmolarity. The solution is used for administration in blood transfusions because it will not affect the blood cells. Because the fluid stays in the circulation, isotonic fluids are given to treat hypotension. Test-Taking Strategy(ies):Focus on the subject, characteristics of normal saline 0.9%. Recalling that normal saline is the same as sodium chloride and is used with red blood cell transfusions and to treat hypotension will direct you to options 2, 3, and 6.

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The gastroenterologist prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse would utilize in performing this procedure. Select all that apply. 1. Follow strict sterile technique. 2. Utilize 30 mL of 0.9% normal saline for the irrigating solution. 3. Inject the irrigating solution through the air vent of the Salem sump tube. 4. After injecting the irrigating solution, pull back on the irrigation syringe. 5. Check the client's electrolyte lab results to determine the correct irrigating solution.

2. Utilize 30 mL of 0.9% normal saline for the irrigating solution. 4. After injecting the irrigating solution, pull back on the irrigation syringe. Rationale:A nasogastric tube is usually a Salem sump tube that is inserted through the naris with the end of the tube in the stomach. The tube is connected to low suction to remove gastric secretions and rest the bowel. Irrigation is done to maintain patency of the tube. Normal saline is used to limit loss of electrolytes. The usual amount is 30 mL injected through the tube, not the air vent, and then aspirated back into the syringe. The nurse should follow aseptic technique wearing clean gloves, not sterile technique. The client's serum electrolyte results do not need to be monitored since normal saline is the correct solution for irrigation. Test-Taking Strategy(ies):Focus on the subject, irrigation of nasogastric tube technique. Visualize the procedure. Evaluate each option and determine if the action will safely maintain tube patency. Recall that the gastrointestinal tract is not sterile so only aseptic technique is indicated.

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse would determine that this is an expected finding if the client had which health problems? Select all that apply. 1. Diarrhea 2. Ulcerative colitis 3. Severe burn injury 4. Cushing's syndrome 5. Untreated ketoacidosis

3. Severe burn injury 5. Untreated ketoacidosis Rationale:The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Potassium is mostly intracellular, so the cell destruction releases potassium into the blood. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. The body physiologically responds to acidosis by moving hydrogen ions intracellularly and potassium ions extracellularly to compensate and maintain a normal pH (7.35 to 7.45). The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia. Test-Taking Strategy(ies):Focus on the subject, conditions that have increased risk for hyperkalemia. Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options 1 and 2 first because they both reflect gastrointestinal losses. From the remaining options, recalling that cell destruction causes potassium shifts will direct you to the correct option. Also remember that Cushing's syndrome presents a risk for hypokalemia, whereas Addison's disease presents a risk for hyperkalemia.

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply. 1. Dry flaky skin 2. Bleeding from the gums 3. Weakness in all extremities 4. Confusion with garbled speech 5. Diarrhea with abdominal cramping

3. Weakness in all extremities 4. Confusion with garbled speech 5. Diarrhea with abdominal cramping Rationale:The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Thus the client is experiencing low sodium, or hyponatremia, as evidenced by the weakness in extremities, confusion, and diarrhea with abdominal cramping. Signs of hyponatremia include rapid and thready pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion, and apprehension. The neurological functioning of the client relates to the swollen brain cells that impair functioning. The gastrointestinal system is stimulated and hyperactive bowel sounds often occur. Dry skin and bleeding gums are not related to the low sodium level. Test-Taking Strategy(ies):Focus on the subject, the symptoms of hyponatremia. Remember that low sodium impairs the neuromuscular system and stimulates the gastrointestinal system

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply. 1. The client with renal failure 2. The client with an ileostomy 3. The client with chronic cirrhosis 4. The client with a draining abdominal wound 5. The client with a nasogastric tube to low suction

1. The client with renal failure 3. The client with chronic cirrhosis Rationale:The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. The client with chronic cirrhosis is at risk for fluid volume excess due to fluid retention secondary to portal hypertension and low levels of protein. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube attached to suction is at risk for deficient fluid volume.

A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply. 1. Make the client NPO. 2. Restrict fluid intake. 3. Provide a 4-g sodium diet. 4.Monitor electrolytes every 24 hours. 5. Prescribe salt, 1 g, orally twice daily. 6.Administer intravenous hypertonic saline.

2. Restrict fluid intake. 4.Monitor electrolytes every 24 hours. Rationale:Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). Normal serum sodium levels are 135 to 145 mEq/L (135 to 145 mmol/L). When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution. The serum electrolytes will be monitored daily to determine effectiveness of treatment. There is no indication that the oral intake should be withheld from the client. Salt tablets would not be indicated because the sodium will likely increase to a normal level with the fluid restriction. A 4-g sodium diet is a no-added-salt diet. Intravenous hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L). Test-Taking Strategy(ies):Focus on the subject, a slightly deficit serum sodium level due to hypervolemia. To answer this question accurately, it is necessary to know that the serum sodium level is low and the cause is excess fluid. Knowing this will help you select the correct answers.

The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance? 1.Hyponatremia 2.Hypercalcemia 3.Hypocalcemia 4.Hypomagnesemia

2.Hypercalcemia Rationale:The nurse will review the electrolyte results and consider the client at high risk for hypercalcemia, a calcium level higher than 10.5 mg/dL (2.75 mmol/L). The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a history of malignancy is at risk for a high calcium level, especially if bone metastasis has occurred. Muscle weakness and heart irregularities are associated with hypercalcemia. Bowel sounds are often absent and peristalsis is seriously depressed. Hyponatremia, low sodium level, is noted to cause hyperactive bowel sounds and diarrhea. Hypocalcemia, low calcium level, is associated with tremors and hyperactive reflexes. Hypomagnesemia, low magnesium level, has similar neuromuscular effects to hypocalcemia, and often clients have painful muscle contractions.

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions would the nurse initiate? Select all that apply. 1. Monitor the client for dysrhythmias. 2. Instruct the client to consume low-calcium foods. 3. Instruct the client to include a banana in the daily diet. 4. Instruct the client to consume foods low in magnesium. 5. Notify the primary health care provider (PHCP) of the laboratory results.

1. Monitor the client for dysrhythmias. 5. Notify the primary health care provider (PHCP) of the laboratory results. Rationale:Magnesium is important for cellular function, metabolism, and skeletal and cardiac muscle function. Normal levels for an adult are 1.8 to 2.6 mEq/L. Hypomagnesemia is defined as a plasma magnesium level less than 1.8 mEq/L. The nurse should notify the PHCP so treatment can be initiated to correct the problem as soon as possible. The client should be monitored for dysrhythmias because the client is predisposed particularly to ventricular dysrhythmias. The client also should consume foods high in magnesium such as beans. Bananas are high in potassium, not magnesium. Because hypocalcemia frequently accompanies hypomagnesemia, high-calcium foods should be consumed, but this will not treat the low magnesium. Test-Taking Strategy(ies):Note the subject, a specific magnesium level. To answer this question accurately, it is necessary to know the normal magnesium level and determine the appropriate interventions when the level is low. If you are uncertain of the answer to this question, use the ABCs—airway, breathing, and circulation—and select options that involve notifying and obtaining input from the PHCP and monitoring heart function. Also, knowing that dysrhythmias can affect circulation will direct you to option 1.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply. 1. Monitor vital signs. 2. Monitor electrolyte levels. 3. Monitor intake and output. 4. Increase water intake orally. 5. Maintain sodium-reduced diet. 6.Administer hypertonic saline intravenously.

1. Monitor vital signs. 2. Monitor electrolyte levels. 3. Monitor intake and output. 4. Increase water intake orally. 5. Maintain sodium-reduced diet. Rationale:Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. Hypertonic saline is prescribed for severe hyponatremia. Test-Taking Strategy(ies):Focus on the subject, a confused client with twitching who is having seizures. Noting that a sodium level of 150 mEq/L (150 mmo/L) is elevated will assist in eliminating option 6 and direct you to the correct options.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take? 1. Obtain orthostatic vital signs. 2. Prepare to insert a nasogastric tube feeding. 3. Prepare to insert a parenteral nutrition infusion. 4. Check the client's skin for irritation caused by diarrhea.

1. Obtain orthostatic vital signs. Rationale:The initial nursing action is to determine the client's level of dehydration. Orthostatic vital signs (blood pressures and pulses, lying, sitting, standing) are actions to determine the probability of fluid losses. A drop of more than 10 to 20 mm Hg and an increased pulse rate of 10 to 20 beats per minute probably indicate a significant intravascular fluid volume deficit. With a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is facing a life-threatening problem. Generally, the fluid levels must be increased quickly with lactated Ringer's or normal saline intravenous solutions as prescribed. Option 4 may be an intervention, but it is not the initial action. Options 2 and 3 are not initial measures to treat dehydration. Test-Taking Strategy(ies):Focus on the subject, dehydration, and the client's symptoms. Using the steps of the nursing process will assist in eliminating options 2 and 3. From the remaining options, select option 1 based on the situation presented and because this option addresses the ABCs—airway, breathing, and circulation.

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level would the nurse collect? Select all that apply. 1. Presence of Chvostek's sign 2. Presence of muscle weakness 3. Presence of decreased deep tendon reflexes 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

1. Presence of Chvostek's sign 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes Rationale:The laboratory result reveals hypocalcemia, a lower than normal calcium level. The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Tetany, electrocardiogram abnormalities, and tingling can be present in hypocalcemia. To test for tetany, the nurse should check for a positive Chvostek's sign (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) and Trousseau's sign (checking for a carpal spasm induced by inflating a blood pressure cuff over the systolic blood pressure for a few minutes). Muscle weakness is commonly associated with potassium abnormalities. Decreased deep tendon reflexes are associated with both hypercalcemia and hypermagnesemia. Test-Taking Strategy(ies):Focus on the subject, a low serum calcium level. First it is necessary to know that the laboratory result noted in the question indicates hypocalcemia. Next, recall the manifestations associated with a low calcium level, which include hyperactive neuromuscular functioning. Remember that a low serum calcium level causes tetany, electrocardiogram abnormalities, and tingling.

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply. 1. Increasing pulse 2. Decreasing body weight 3. Decreasing urine output 4. Decreasing abdominal girth 5. Increasing central venous pressure

2. Decreasing body weight 4. Decreasing abdominal girth Rationale:A sign that fluid overload is resolving is loss of body weight and a decrease in the abdominal girth. The client with cirrhosis with resolving fluid overload will have less ascites. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, decreased urine output, and a decreased hematocrit. These symptoms must reverse if the fluid overload is to be resolved. Test-Taking Strategy(ies):Focus on the subject, fluid overload, and note the word, resolving. Recalling the effects of fluid on various physical assessment findings will direct you to options 2 and 4. With the condition resolving or improving, select the change in vital signs that are showing less stress and improved body function.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1. The client with a draining wound 2.The client with a urinary catheter 3.The client with a fast respiratory rate 4.The client with a nasogastric tube to low suction

3. The client with a fast respiratory rate Rationale:Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal (GI) tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Test-Taking Strategy(ies):Focus on the subject, insensible fluid loss. Note that wound drainage, urinary output, and gastric secretions are comparable or alike in that they represent visible losses. These types of losses can be measured for accurate output. Fluid loss through a fast respiratory rate cannot be accurately measured, only approximated.