PrepU F&E

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV administration of lactated Ringer's

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?

"I sleep on three pillows each night."

A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

"I will increase my fluid and calcium intake."

Which term is used to describe the concentration of urea and other nitrogenous wastes in the blood?

Azotemia

What food would the nurse provide for a client who has hypokalemia?

Bananas

A client with a diagnosis of renal failure is being treated for anemia with epoetin alfa. Frequent assessment of which laboratory values should be prioritized before and during treatment?

CBC

What intervention should the nurse provide to reduce the incidence of renal damage when a patient is taking a chemotherapy regimen?

Encourage fluid intake to dilute the urine.

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. His wife reports that he acted confused and was extremely weak when he awoke that morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?

Hydrocortisone

Fluid moves into the arterial end of a capillary due to:

Hydrostatic pressure

A primary health care provider prescribes regular insulin 10 units intravenously (IV) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Hyperkalemia

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

Ketones in urine.

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?

Presence of Trousseau sign

The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following?

The adrenal gland

Why would potassium-sparing diuretics be contraindicated for clients experiencing renal failure?

They may cause hyperkalemia.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Urine output of 20 ml/hour

The 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

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:

canned peas.

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?

decreased ability to detect thirst

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.

The nurse starts an intravenous (IV) line on a client with edema. The order reads 500 mL bolus of D5LR over 30 min. The nurse knows that this IV fluid will cause water to move out of the cell because it is which type of fluid?

hypertonic

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:

hypotension.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

intake and output

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time?

maintaining fluid and electrolyte balance

The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?

noisy respirations

Trousseau's sign is elicited by which of the following?

Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.

The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate?

"Offer 'magic mouthwash' followed by a popsicle."

The nursing instructor is teaching about urinary incontinence and informs the students that dysfunction of either the bladder, the urethra, or the levator muscle can cause incontinence. She also lists which contributing factors for incontinence? Select all that apply.

fluids such as alcohol and caffeinated and carbonated drinks constipation habitual "preventive" emptying advancing age pregnancy and birth obesity

A neonatal intensive care nurse is caring for a preterm newborn diagnosed with transient tachypnea who is NPO and receiving intravenous fluid therapy. When would the nurse expect the newborn to begin oral feedings?

When the respiratory rate is 44 BPM.

The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching?

"I will remind her that she will need an IV if she does not drink."

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess:

Trousseau's sign.

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

Sodium retention and potassium excretion are modulated by which hormone?

Aldosterone

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

Arterial blood gas

A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations?

Fatigue, cramps, and weakness

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

Promoting adequate hydration

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

The client has Maalox ordered for administration before meals. Which condition is contraindicated with the administration of Maalox?

Renal dysfunction

A nurse is caring for a client with irritation of the lower genitourinary tract. The client is administered phenazopyridine. Which condition in clients contraindicates the use of the drug?

Renal impairment

A 15-year-old client is brought to the emergency department by his friends. He reports visual changes, drowsiness, and tinnitus. He is confused and hyperventilating. These symptoms may be attributable to which condition?

Salicylate intoxication

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which of the following would be included in a focused assessment?

Signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

The nurse is caring for a child, weighing 100 pounds, on the burn unit who has partial-thickness burns over 30% of the body. During the beginning shift assessment, which assessment finding is of most concern to the nurse?

Urine output of 15 mL per hour over the last 4 hours

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for:

hypokalemia.