PREPU

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

Diarrhea

A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order?

Explain to the client why this is needed.

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?

Hypokalemia

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Infants have more total body fluid and ECF than adults

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output?

Perspiration

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

The kidneys store and release antidiuretic hormone to increase water retention."

Which of the following is not true regarding magnesium?

The liver regulates magnesium levels by breaking down the ion when serum levels are low.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

he oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

A client who is n.p.o. prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

By which route do oxygen and carbon dioxide exchange in the lung?

diffusion

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address?

increased hydrostatic pressure

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:

increasing ventilation through the lungs.

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

A client is diagnosed with body fluid hypoosmolality. Treatment involves restricting his intake of free water. Which fluids would the nurse most likely restrict? Select all that apply.

• Apple juice • Tea

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.

• Metabolic alkalosis • Hypokalemia

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.)

• drinking milk • urination • vomiting • infusion of intravenous solution

The nurse is caring for a client who was found after spending 2 days without food or water in the desert and was admitted through the emergency department. The client is severely dehydrated. What are reasons why the human body requires fluid? Select all that apply.

• facilitates cellular metabolism • helps maintain normal body temperature • acts as a solvent for electrolytes

A nurse is providing care to a client with an ECF volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

• orthostatic hypotension • decreased urine output • slow-filling peripheral veins

The student nurse asks, "what it interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

The nurse is teaching a nursing student how to record strict I&O;for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.

0.9% NaCl (normal saline) • Lactated Ringer's solution • 5% dextrose in 0.9% NaCl

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis?

7.30

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

Which is a common anion?

Chloride

Which is not a primary intracellular electrolyte?

Chloride

The nurse works at an agency that automatically places certain clients on intake and output (I&O;). For which client will the nurse document all I&O;?

55-year old with congestive heart failure on furosemide

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

A client is prescribed a diuretic as part of the treatment plan for heart failure. The nurse educates the client about the drug and dietary measures to prevent complications. The nurse determines that the client needs more education when he states that he will increase his consumption of:

spinach

A client has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the most accurate way that the care team can achieve this assessment goal?

weighing the client once per day

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

• respiratory muscle weakness • confusion • ventricular dysrhythmia

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

3,000

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

Banana

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

electrolytes.