Fluid and Electrolyte NCLEX Questions

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient? A. Restrict fluid intake and monitor daily weights B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output C. Administer hypotonic IV fluid and administer sodium tablets. D. No interventions are expected

The answer is B. The patient must be re-hydrated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells.

You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true? A. The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure B. This is known as Trousseau's Sign and is present in patients with HYPERcalcemia C. This is known as Chvostek's Sign D. This is known as Trousseau's Sign and is present in patients with hypocalcemia

The answer is D. The correct answer is "this is known as Trousseau's Sign and is present in patients with hypocalcemia". Patient's with hypokalemia may present with a positive Trousseau's and Chvostek sign.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client record and determines that the client was at risk for developing the potassium deficit because of which situation? 1 - Sustained tissue damage 2 - Requires nasogastric suction 3 - Has a history of Addison's disease 4 - Is taking potassium-retaining diuretics

2 - Required nasogastric suction Reason: - Hyopkalemia - potassium deficit (normal levels 3.5 mEq/L - 5.0 mEq/L) - The other points are risks for HYPERkalemia

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? Encourage fluids orally. Administer 10% saline solution IVPB. Administer antidiuretic hormone intranasally. Place on seizure precautions.

place on seizure precautions

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? Serum calcium. Serum phosphorus. Serum potassium. Serum sodium.

serum potassium

A client is being seen for care after developing abdominal distention, cramping, and hypotension. The client is diagnosed with hypokalemia secondary to excessive use of diuretics. Which of the following nursing interventions is most appropriate for this client

Arrange for an ECG as ordered and report the findings to the provider A client who has developed hypokalemia is at risk of harmful cardiac dysrhythmias. If the client is experiencing symptoms of hypokalemia, the nurse should set up for an ECG to assess the client's heart rhythm and ensure that dysrhythmias are not present as a result of the electrolyte imbalance.

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? Request a physical therapy consult from the physician Ensure the client is safe from falls and check the most recent potassium level Allow uninterrupted rest periods throughout the day Encourage the client to increase intake of dairy products and green leafy vegetables.

Ensure the client is safe from falls and check the most recent potassium level

Which patient is at most risk for fluid volume deficient? A. A patient who has been vomiting and having diarrhea for 2 days. B. A patient with continuous nasogastric suction. C. A patient with an abdominal wound vac at intermittent suction .D. All of the above are correct.

The answer is D. All the patients above are at risk for losing too much fluid volume.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? 50-year-old with pneumonia, diaphoresis, and high fevers 62-year-old with congestive heart failure taking loop diuretics 39-year-old with diarrhea and vomiting 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

50-year-old with pneumonia, diaphoresis, and high fevers

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? Prominent U waves Prolonged PR interval Depressed ST segment Widened QRS complexes

Depressed ST segment

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. Administer an antiemetic prior to giving the digoxin Encourage the client to increase fluid intake Call the physician Report the urine output report indications of nausea

Call the physician Report the urine output Report indications of nausea

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? Call the physician and report the change in client's condition Turn the client's O2 up to 4 liters nasal cannula Encourage the client to sit down and to take deep breaths Encourage the client to rest and to use pursed-lip breathing technique

Encourage the client to rest and to use pursed-lip breathing technique

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? Administer a sedative Place client in left lateral position Place client in high-Fowler's position Assist the client to breathe into a paper bag

Place client in high-Fowler's position

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

Sodium chloride

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? Notify the health care provider immediately. Tap the cheek about two (2) centimeters anterior to the ear lobe. Check the serum calcium and magnesium levels. Prepare to administer calcium gluconate IVP.

Tap the cheek about two (2) centimeters anterior to the ear lobe.

A client has developed hyponatremia as a result of syndrome of inappropriate anti-diuretic hormone. Which type of IV fluid would the nurse most likely administer? 0.9% NaCl D5W 0.45% NS 3% Normal saline

3% Normal saline When a client has developed hyponatremia, he has a low level of sodium in the bloodstream. The nurse can increase sodium levels in circulation by providing hypertonic IV fluids. In this case, 3% Normal saline is a hypertonic solution can help raise sodium levels. Generally, water restrictions are put in place to aid in correction of hyponatremia.

The nurse caring for a client who has been receiving IV diuretics suspects they are experiencing fluid volume deficit. Which assessment finding would the nurse note in this condition? 1 - Lung congestion 2 - Decreased hematocrit 3 - Increased BP 4 - Decreased central venous pressure

4 - Decreased central venous pressure Reason: This is a finding in fluid volume deficit

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A client with osteoporosis taking vitamin D and calcium supplements A client who is alcoholic receiving total parenteral nutrition A client with chronic renal failure awaiting the first dialysis run A client with hypoparathyroidism secondary to thyroid surgery

A client who is alcoholic receiving total parenteral nutrition

A nurse is caring for a client who has had thyroid surgery. The client's calcium result has returned at 7.5 mg/dL. Which nursing interventions are the most appropriate based on this calcium level? Select all that apply. Implement seizure precautions Assess for signs of hypocalcemia Administer intravenous furosemide Administer intravenous calcium gluconate

Implement seizure precautions One of the symptoms of hypocalcemia is seizures. Implementing seziure precautions will provide for the client's safety until calcium levels are within normal ranges. Assess for signs of hypocalcemia The client who has had thyroid surgery is at risk for hypocalcemia due to possible trauma to the parathyroid. Normal calcium levels are 8.4-10.2 mg/dL, so a level of 7.5 mg/dL indicates hypocalcemia. The nurse should assess for signs of hypocalcemia, which include numbness or tingling of the face and extremities, muscle cramps and twitching, seizures, cardiac dysrhythmias, and a positive Chvostek's sign. Chvosteks' sign occurs when you tap the facial nerve and the facial muscle twitches on the respective side. Administer intravenous calcium gluconate Calcium gluconate is given to increase the serum calcium level. We would not wait to treat this level, since we know the client is likely not going to be able to self-correct, and the consequences of hypocalcemia can be life-threatening.

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? Call the physician and report results Question the results and redraw the specimen Encourage the client to increase the intake of bananas

Question the results and redraw the specimen

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells them to consume which of the following (select all that apply)? 1 - Peas 2 - Raisins 3 - Potatoes 4 - Cantaloupe 5 - Cauliflower 6 - Strawberries

Raisins, Potatoes, cantaloupe, strawberries

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor: Urine output. Blood pressure. Bowel movements. ECG for tall, peaked T waves.

bowel movements

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? Hyponatremia Hypocalcemia Hyperkalemia hypomagnesia

hypocalcemia

The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? Change the IV fluid from 0.9% NS to D5W. Restrict the client's sodium in the diet. Monitor blood glucose levels. Prepare the client for hemodialysis

restrict the client's sodium in the diet

A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? Prolonged bed rest Renal insufficiency Hyperparathyroidism Excessive ingestion of vitamin D

Prolonged bed rest

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of Acute renal failure. Malabsorption syndrome. Nasogastric drainage. Laxative abuse

Acute renal failure.

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect?

third spacing Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values.

The nurse is assigned to care for a group of clients. On review of the medical records, the nurse determines that which client is most likely at risk for fluid volume deficit? 1 - A client with an ileostomy 2 - A client with heart failure 3 - A client on long term corticosteroid therapy 4 - A client receiving frequent wound irrigations

1 - A client with an ileostomy Reason: - Ileostomy = stoma created in the ileum and brought to the surface of the abdomen - Increases fluid deficit risk

The nurse reviews a client's lab report and notes the serum phosphorus level is 2mg/dL. Which condition most likely caused this level? 1 - Alcoholism 2 - Renal insufficiency 3 - Hypoparathyroidism 4 - Tumor lysis syndrome

1 - Alcoholism Reason: - Normal phosphorus levels: 2.7 - 4.5 mg/dL - This patient is HYPOphosphatemic - A cause of this would be malnutrition (a common factor associated with alcoholism)

The nurse is reading a health care provider's progress notes in the client record and notes they have documented "insensible fluid loss of approx.. 800 mL daily". The nurse interprets that this type of fluid loss can occur through which route? 1 - The skin 2 - Urinary output 3 - Wound drainage 4 - GI tract

1 - The skin Reason: - Insensible water loss is defined as those where the individual is unaware they are losing water (via skin and lungs) - Sensible water losses are those the individual is aware of

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note? 1 - twitching 2 - Hypoactive bowel sounds 3 - Negative Trousseau's sign 4 - Hypoactive deep tendon reflexes

1 - Twitching Reason: - This is a common finding in hypocalcemia - The rest of the symptoms are associated with HYPERcalcemia

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrolyte cardiogram as a result of the lab value? 1 - U waves 2 - Absent P waves 3 - Elevated T waves 4 - Elevated ST segment

1 - U waves Reason: - Level is below normal limit (HYPO) - This results in the following ECG results: ST depression, shallow/flat/inverted T wave, prominent U wave

The nurse is assigned to care for a group of clients. On review the nurse determines that which client is at risk for fluid volume excess? 1 - The client taking diuretics 2 - The client with kidney disease 3 - The client with an ileostomy 4 - The client who required GI suctioning

2 - The client with kidney disease Reason: - This is a cause of fluid volume excess

A client has a calcium reading of 11 mg/dL. What does the nurse expect the clients phosporus reading to be? 2 mg/dL 3 mg/dL 4 mg/dL 5 mg/dL

2 mg/dL Calcium and phosphorus have inverse relationships, therefore since the normal range for calcium is 8.4-10.2 mg/dL, it is high. Therefore the client will have a low phosphorus level. The normal phosphorus range is 3-4.5 mg/dL.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect in hyponatremia? 1 - Muscle twitches 2 - Dec urinary output 3 - Hyperactive bowel sounds 4 - Increased specific gravity of urine

3 - Hyperactive bowel sounds Reason: (from all nurses) fluid moves from a lower concentration to a higher concentration. Since there is hyponatremia (low concentration of sodium in the blood), the body will try to even up the ratio, so the fluid might move into the digestive tract. this movement may cause increased peristalsis (for excretion).

The nurse is caring for a client with heart failure. On Assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1 - weight loss 2 - Flat neck and head veins 3 - An increase in BP 4 - Decreased central venous pressure

3 - Increase in BP Reason: -Dyspneic - difficulty breathing and crackles are findings of fluid volume excess (overhydration) -The other symptoms would not match because they should be the opposite (weight gain, distended veins, elevated CVP)

The nursing student needs to administer potassium chloride IV as prescribed to client with hypokalemia. The instructor determines that the student is unprepared if the student states that which action is part of the plan for preparation and administration of the potassium? 1 - obtaining IV infusion pump 2 - Monitoring urine output during administration 3 - Preparing the medication for bolus administration 4 - Ensuring the med is diluted in the appropriate amount of normal saline

3 - Preparing for bolus administration Reason: - Bolus = IV push - Potassium is NEVER given by IV push (AKA bolus)

The nurse is reviewing lab results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the level to the health care provider and they prescribe dietary instructions based on the sodium level. Which food does the client need to avoid? 1 - Peas 2 - Nuts 3 - Cauliflower 4 - Processed oat cereals

4 - Processed oat cereal Reason: - Normal levels: 135 - 145 mEq/L - The patient has an elevated level meaning they should not consume sodium rich foods, and processed foods have elevated amounts of sodium

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the ECG as a result? 1 - ST depression 2 - Inverted T wave 3 - Prominent U wave 4 - Tall peaked T wave

4 - Tall peaked T wave Reason: - Normal potassium levels: 3.5 - 5.0 mEq/L - This patient is HYPERkalemic meaning the ECG results would be: tall peaked T waves, flat P waves, widened QRS complex, prolonged PR interval

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? Deep tendon reflexes decreasing from +2 to +1 Bicarbonate rising from 20 mEq/L to 22 mEq/L Urine pH less than 6 Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

Deep tendon reflexes decreasing from +2 to +1

A client who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this client to correct the situation? IV administration of potassium Oral intake of potassium by electrolyte preparations Encouraged intake of potassium-rich foods, such as bananas No intervention but continue to monitor the client's hemodynamic status

IV administration of potassium Hypokalemia occurs when there is not enough potassium in the body. The decrease in potassium can cause life-threatening arrhythmias. Although hypokalemia may be treated in various ways by adding potassium to the diet, if the condition is severe enough that it is causing heart conduction changes, the client should receive potassium as soon as possible to correct the situation, preferably through an IV.

A student nurse is reviewing electrolytes and understands that which of the following is the function of calcium in heart conduction? Depolarize the cell Repolarize the cell Increase the strength of contraction Increase the heart rate

Increase the strength of contraction It is the function of calcium in the heart's conduction.

A nurse is reviewing the laboratory results for a client and notes that the client has hyperkalemia. Which of the following EKG abnormalities would be consistent with this finding? Select all that apply. peaked T waves wide QRS prolonged QT interval U wave

Peaked T waves Since potassium plays a role in ventricular depolarization and repolarization, hyperkalemia will present with peaked T waves and a wide QRS. This means the process of allowing the ventricles to fully contract and relax is slower and longer because there is TOO much potassium present. Wide QRS Since potassium plays a role in ventricular depolarization and repolarization, hyperkalemia will present with peaked T waves and a wide QRS. This means the process of allowing the ventricles to fully contract and relax is stronger and longer because there is TOO much potassium present.

The client is being evaluated for a low calcium condition. The nurse knows to recognize which of the following clinical manifestations of low calcium? Select all that apply. tetany muscle flaccidity Negative Trousseau's sign Positive Chvostek's sign skeletal fractures

Tetany Signs of low calcium include tetany and muscular irritability, positive Trousseau's sign, positive Chvostek's sign, longer clotting times, and skeletal fractures. EKG changes and ventricular tachycardia may also occur in severe hypocalcemia. Positive Chvostek's sign Positive Chvostek's sign is an indication of hypocalcemia. Chvostek's sign is positive when the facial nerve is tapped and the facial muscles twitch in response. Skeletal fractures Skeletal fractures may result from low calcium levels due to compromise in bone structure.

Which patient is at more risk for an electrolyte imbalance? A. An 8 month old with a fever of 102.3 'F and diarrhea B. A 55 year old diabetic with nausea and vomiting C. A 5 year old with RSV D. A healthy 87 year old with intermittent episodes of gout

The answer is A. The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.

Which patient is at most risk for hypomagnesemia? A. A 55 year old chronic alcoholic B. A 57 year old with hyperthyroidism C. A patient reporting overuse of antacids and laxatives D. A 25 year old suffering from hypoglycemia

The answer is A. The correct answer is a 55 year old who is a chronic alcoholic. Patients who suffer from alcoholism have an increased secretion of magnesium and usually do not eat a proper diet, therefore, they are at risk for lower magnesium levels.

Which patient below would have a potassium level of 5.5? A. A 76 year old who reports taking Lasix (Furosemide) four times a day B. A patient with Addison's disease C. A 55 year old woman who have been vomiting for 3 days consistently D. A patient with liver failure

The answer is B. A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.

After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A. Magnesium level of 2.2 B. Potassium level of 5.6 C. Potassium level of 2.2 D. Phosphorus level of 2.0

The answer is C. Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings.

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? Absent patellar reflex Diarrhea Premature ventricular contractions Increase in blood pressure

absent patellar reflex

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. Eggs Broccoli Organ meats Nuts Canned salmon

broccoli, nuts, canned salmon

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? Overhydration. Anemia. Dehydration. Renal failure.

dehydration

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? Sodium Phosphorus Calcium

magnesium

The nurse caring for a group of clients reviews the electrolyte lab results and notes a sodium level of 130 mEq/L on one lab report. The nurse understands that which client is at the highest risk for development of this sodium level value? 1 - the client taking diuretics 2 - the client with hyperaldosteronism 3 - the client with Cushing's Syndrome 4 - the client taking corticosteroids

1 - the client taking diuretics Reason: - Normal sodium levels: 135 - 145 mEq/L - This patient is HYPOnatremic - Most times salt follows water, so diuretics cause loss of Na as well

The nurse is caring for a client with hypocalcemia would expect to note which change to the ECG? 1 - Widened T wave 2 - Prominent U wave 3 - Prolonged QT interval 4 - Shortened ST segment

3 - Prolonged QT interval reason: - ECG findings in hypocalcemia include: prolonged QT interval and prolonged ST segment

A nurse is caring for a client who is recovering from surgery. The client has developed a headache, muscle weakness, and mental status changes. The nurse notes that the client's glucose level is 85 mg/dL, sodium is 126 mEq/L, potassium is 4.8 mEq/L and calcium is 8.6 mg/dL. What intervention is most appropriate for the nurse to perform in this situation? Administer 3% sodium chloride solution Give potassium chloride in 5% dextrose Offer the client a drink containing glucose Administer calcium supplements orally

Administer 3% sodium chloride solution This client is showing signs of hyponatremia, as well as lab values that reflect a low sodium level. A client with hyponatremia can develop symptoms that include skeletal muscle weakness, headache, confusion, hyperactive bowel sounds, nausea, abdominal cramping, increased urinary output, and dry mucous membranes. The nurse would most likely administer a hypertonic solution that contains extra sodium, such as 3% sodium chloride.

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? Assess for depressed deep tendon reflexes Call the physician to report calcium level Place an intravenous catheter in anticipation of administering calcium gluconate Check to see if a serum albumin level is available

Check to see if a serum albumin level is available A drop in serum albumin will result in a false low total calcium level.

In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority? A. Set-up bedside suction B. Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions D. None of the above are correct

The answer is C. As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.

A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment? A. Flat neck and hand veins B. Furrowed dry tongue C. Increased blood pressure and crackles throughout the lungs D. Bradycardia and pitting edema in lower extremities

The answer is C. The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia.

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? D5.45 NS at 50 ml/hr 0.9 NS at an open rate D5W at 125 ml/hr 0.45 NS at open rate

0.9 NS at an open rate client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume.

The nurse caring for group of clients reviews the electrolyte lab results and notes a potassium level of 5.5 mEq/L on one lab report. The nurse understands that which client is at risk for the development of a potassium value at this level? 1 - The client with colitis 2 - The client with Cushing's syndrome 3 - The client who has been overusing laxatives 4 - The client who has sustained a traumatic brain injury

4 - the client who has sustained a traumatic brain injury Reason: - Normal potassium levels: 3.5 - 5 mEq/L - This patient is HYPERkalemic - Causes of this include movement of potassium into the ECF because of tissue damage - K is stored more in ICF

A client with magnesium depletion has laboratory testing which showed a calcium level of 7.9 mg/dL. Which nursing interventions are most appropriate in this situation? Select all that apply Increase intake of dairy products and leafy green vegetables Include vitamin D supplements with calcium Perform laboratory testing for vitamin K levels Monitor intake and output Encourage bed rest and frequent naps

Increase intake of dairy products and leafy green vegetables Dietary intake of calcium-rich foods will help increase a client's calcium level. Include vitamin D supplements with calcium This client has a low calcium level, which is called hypocalcemia. It can be caused by a number of factors, including dehydration, thyroid problems, or deficiency in vitamin D. Nursing interventions include increasing calcium intake and vitamin D supplements and monitoring overall intake and output. Monitor intake and output Monitoring overall intake and output is going to help the nurse address the client's calcium issue, as calcium can be affected by diarrhea, some diuretics, and intake of calcium rich and vitamin D rich foods.