1262 Test 6

Signs of hypokalemia (a sic walt):

A-lkalosis S-hallow respirations I-rritability C-onfusion and drowsiness W-eakness and fatigue A-rrhythmias L-ethargy T-hready pulse

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is a nurse's priority? Introduce a regular diet. Maintain fluid therapy. Rehydrate. Assess fluid balance.

Assess fluid balance.

sign/symptoms of hypercalcemia

B-one pain A-rrhythmias C-ardiac arrest K-idney stones M-uscle weakness E-xcessive urination

A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider? BUN 25 mg/dL Creatinine 0.9 mg/dL Hematocrit 45% Urine specific gravity 1.028

BUN 25 mg/dL

During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take? Request NPO status for the client. Elevate the head of the bed to high Fowler's. Measure the client's temperature. Check the client's respiratory rate and lung sounds.

Check the client's respiratory rate and lung sounds.

A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremeia. Which of the following laboratory findings should the nurse also expect to be below the expected reference range? Magnesium Calcium Potassium Chloride

Chloride

facial muscle response indicating positive _______ in hypocalcemia

Chvostek sign

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide. Which of the following should the nurse include? Eat foods that contain plenty of potassium. Take aspirin for headaches. Expect some swelling in the hands and feet. Take the medication at bedtime.

Eat foods that contain plenty of potassium.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take? Collect a urine specimen for culture and sensitivity. Evaluate urine output for amount and urine for specific gravity. Decrease the IV fluid infusion rate and limit oral fluid intake. Continue routine care because the results are within the expected reference range.

Evaluate urine output for amount and urine for specific gravity.

what type of fluid movement is found with Isotonic IV solution?

Isotonic IV solutions have the same osmolarity as our body fluid, so no shift in fluid occurs

The nurse caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom? Flushing Lethargy Hyperactivity Shallow, slow respirations

Lethargy

A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? Lethargy and constipation from hypercalcemia Positive Trousseau's sign from hypercalcemia Lethargy and constipation from hypocalcemia Positive Trousseau's sign from hypocalcemia

Lethargy and constipation from hypercalcemia

A nurse is caring for a child who has acute diarrhea and reports that he his thirsty. Which of the following fluids should the nurse give the child? Cherry gelatin Apple juice Pedialyte ​Broth

Pedialyte

A nurse is caring for an older adult client who has a new prescription for spironolactone. Which of he following laboratory values should the nurse monitor for this client? Potassium Total cholesterol Thyroid stimulating hormone (TSH) Hemoglobin

Potassium

What are the signs/symptoms of hypernatremia?

S-kin flushed A-gitation L-ow grade fever T-hirst

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. The nurse should anticipate a prescription for which of the following medications? Potassium iodide Acetylcysteine Potassium chloride Sodium polystyrene

Sodium polystyrene

A nurse is collecting data from a client who has a calcium level of 8 mg/dL. Which of the following manifestations should the nurse expect? Constipation Tetany Negative Chvostek sign Elevated blood pressure

Tetany

What type of fluid movement is found with Hypertonic IV solutions?

These solutions have a greater osmolarity; the higher solute concentration will pull water into the intravascular space Hypertonic solutions are also used to replace electrolytes.

Which of the following are blood cells? Thrombocytes Leukocytes Eosinocytes Erythrocytes

Thrombocytes Leukocytes Erythrocytes

A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement. Which of the following findings should the nurse identify as effectiveness of the treatment? Urine output 200 mL/4 hr Heart rate 104/min Peripheral pulses +1 Urine specific gravity 1.04

Urine output 200 mL/4 hr

A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions? Counting the number of wet diapers every shift Weighing the infant at the same time every day Taking the infant's vital signs every 2 hr Measuring the infant's head circumference twice per day

Weighing the infant at the same time every day

electrolyte that functions in acid-base balance

bicarbonate

What is hyponatremia?

electrolyte imbalance of sodium NA < 135 mEq/L (low sodium)

What is hypernatremia?

electrolyte imbalance of sodium Na>145 mEq/L (high sodium)

Example of Hypotonic IV Solution:

half normal saline (0.45% NS)

Electrolyte imbalance of Calcium when Ca+ >10.6 mg/dL

hypercalcium

Electrolyte imbalance of potassium when K+ >5.0 mEq/L

hyperkalemia

Electrolyte imbalance of magnesium when Mg>2.1 mEq/L

hypermagnesemia

Electrolyte imbalance of Calcium when Ca+ <8.4 mg/dL

hypocalcemia

Electrolyte imbalance of potassium when K+ <3.5 mEq/L :

hypokalemia

Electrolyte imbalance of magnesium when Mg is 1.3-2.1 mEq/L

hypomagnesemia

The thirst mechanism is located in the: adrenal gland. cerebral cortex. pituitary gland. hypothalamus.

hypothalamus.

Signs and symptoms of hyperkalemia:

muscle cramps-weakness-paralysis drowsiness decreased BP EKG changes Dysrhythmias Abdominal Cramping Diarrhea Oliguria

electrolyte that functions in nerve impulse transmission, muscle contraction, plasma, and acid-base balance

potassium

Lab findings with hypovolemia

serum osmolality--increase BUN, protein, electrolytes, glucose Urine specificity Gravity increase Na-Increased Hct-increase

The student nurse reviews the records of a patient with pneumonia and finds that the patient has a blood pH of 7.46. The student is correct in determining that this pH is considered __. slightly acidic grossly acidic slightly alkaline grossly alkaline

slightly alkaline

electrolyte that functions in water regulation and balance

sodium

Causes of localized edema

trauma allergies burns obstruction of lymph flow liver failure

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medications has been effective? ​Restoration of QRS complex amplitude ​Widening of the QRS complex Reduction of P wave duration ​Reduction of T wave amplitude

​Reduction of T wave amplitude

Potassium normal range:

3.5-5 mEq/L

Calcium normal range:

8.4-10.6 mg/dL

Chloride normal range:

96-106 mEq/L

A nurse on a pediatric unit is receiving report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first? A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95% A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F) A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002 A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale

A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002

Signs/Symptoms of Hyponatremia:

CNS and neuromuscular changes -fatigue -lethargy -headache -mental confusion -altered level of consciousness -anxiety -coma -decreased blood pressure etc.

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor? Chvostek's sign Brudzinski's sign Kernig's sign Cullen's sign

Chvostek's sign

A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance? SSRIs Corticosteroids ACE inhibitors NSAIDs

Corticosteroids

The nurse is caring for a patient with pitting edema to the lower extremities. Which intervention(s) for pitting edema are the nurse likely to include in the nursing care plan of this patient? (select all that apply) Daily weight High-calorie diet Intake and output record Skin care and mouth care Edema assessment using an edema scale every shift

Daily weight Intake and output record Edema assessment using an edema scale every shift

A nurse is collecting data from a client who has a calcium level of 12 mg/dL. Which of the following manifestations should the nurse expect? Diarrhea Decreased deep tendon reflexes Increased appetite Hypotension

Decreased deep tendon reflexes

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia? Decreased deep-tendon reflexes Hyperactive bowel sounds Restlessness Bounding peripheral pulses

Decreased deep-tendon reflexes

A nurse is collecting data from a client who has sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect? ​Increased salivation Decreased level of consciousness Cool, clammy skin Hypertension

Decreased level of consciousness

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.

Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively.

A nurse in a community clinic is collecting data from an older adult who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit? Dry mucous membranes Tenting Protruding eyeballs Elevated blood pressure

Dry mucous membranes

Which patient is at highest risk for dehydration? Infant who has a high fever Teenager who has intentionally limited fluid intake to avoid weight gain Young patient with diarrhea Elderly patient with fever and persistent nausea and vomiting (N&V)

Elderly patient with fever and persistent nausea and vomiting (N&V)

A nurse is reviewing the medication record of a client who has heart failure and has a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as a possible cause of the client's potassium level? Spironolactone Nitroglycerin Furosemide Metoprolol

Furosemide

A nurse is caring for a client who is taking furosemide. For which of the following adverse effects should the nurse monitor? Hypervolemia Hypertension Hypoglycemia Hypokalemia

Hypokalemia

What type of fluid movement is observed with hypotonic IV solution?

Hypotonic IV solutions are used when the goal is to get fluid into the cells. The osmolarity in the extracellular fluid is less, so the water shifts out of the intravascular space and into the cells

An 82-year-old patient is admitted to the unit with a temperature of 100.2° F, urine specific gravity (SG) of 1.032, and dry tongue. The nurse should recognize which to be the most critical aspect of the plan of care? A diuretic An antibiotic An antipyretic IV solution

IV solution

A nurse is reviewing the medical record for a toddler who has moderate dehydration. Which of the following findings should the nurse expect? Increased respiratory rate Increased platelet count Decreased heart rate Decreased hematocrit

Increased respiratory rate

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding? Decreased BUN Decreased hematocrit Increased urine ketones Increased urine specific gravity

Increased urine specific gravity

A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take? Hold the medication until the client has his evening meal. Give the medication as prescribed. Inform the provider of the client's potassium level. Obtain a prescription to increase the dosage of the medication.

Inform the provider of the client's potassium level.

Which organ in the body regulates fluid and electrolyte balance? Kidney Liver Heart Adrenal cortex

Kidney

A nurse is reviewing the laboratory data for a client who is to begin a new prescription for furosemide. Which of the following laboratory values is priority for the nurse to check before administering this medication? Hgb Uric acid level WBC Potassium

Potassium

A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider? Potassium 2.3 mEq/L Sodium 136 mEq/L Calcium 10 mg/dL Magnesium 1.4 mEq/L

Potassium 2.3 mEq/L

A nurse is caring for a 4-year-old who has dehydration. Which of the following findings should the nurse identify as the priority? Blood glucose 110 mg/dL Potassium 2.5 mEq/L Sodium 142 mEq/L Urine specific gravity 1.025

Potassium 2.5 mEq/L

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? Blood glucose 150 mg/dL Weight loss of 3% of total body weight. Urine specific gravity 1.035 Potassium 2.5 mEq/L

Potassium 2.5 mEq/L

palmar flexion indicating positive _______ in hypocalcemia

Trousseau sign

electrolyte that functions in muscle activity and blood coagulation

calcium

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated? Distended neck veins Urine specific gravity 1.034 Bounding pulse BP 146/94 mm Hg

Urine specific gravity 1.034

A nurse is collecting data from a client who has hypokalemia a a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? Weak, irregular pulse ​Paresthesia Extreme thirst Hyperactive reflexes

Weak, irregular pulse

Signs of overhydration:

weight gain crackles in lungs slow bounding pulse elevated blood pressure possibly edema

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? "I should drink a lot of tap water today." "I need to take more calcium tablets today." "I should avoid fruits with potassium in them." "I need to drink liquids with some sodium in them."

"I need to drink liquids with some sodium in them."

A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching? "Adding pecans will be a change I can readily make." "I can plan to eat rice instead of baked potatoes." "I will eat cantaloupe for my morning snack." "I will miss eating yogurt every day for breakfast."

"I will eat cantaloupe for my morning snack."

The health care provider has prescribed an isotonic IV solution administration for a patient. The nursing student correctly identifies which solutions as being isotonic? Sterile distilled water, 5% dextrose in water 0.9% normal saline, lactated Ringer's solution 5% dextrose in 0.45% normal saline, Ringer's solution 10% dextrose in water, 5% dextrose in 0.9% normal saline

0.9% normal saline, lactated Ringer's solution

Urine Specificity Gravity-normal range:

1.003 to 1.030

Urine Specificity Gravity average range:

1.010- to 1.025

Magnesium normal range:

1.3-2.5 mg/dL

Which fluid output measurement is the most concerning for a nurse? 720 mL of urine in a 24-hour period 600 mL of urine in a 10-hour period 100 mL of urine in a 5-hour period 60 mL of urine in a 2-hour period

100 mL of urine in a 5-hour period

sodium normal range:

135-145 mEq/L

Phosphate normal range:

2.5-4.5 mg/dL

Bicarbonate normal range:

22-26 mEq/L

A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have? 24 mg/dL 3.6 mg/dL 9 mg/dL 18.7 mg/dL

24 mg/dL

Examples of Hypertonic IV solutions:

5% Dextrose in Normal Saline 5% Dextrose in half Normal Saline 5% Dextrose in Lactated Ringers

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A client who has end-stage kidney disease who will undergo dialysis A client who has NPO status since midnight for an endoscopy A client who has gastroenteritis and is receiving oral fluids A client who has heart failure and is receiving diuretic therapy

A client who has gastroenteritis and is receiving oral fluids

Which transport mechanism involves cellular energy? Diffusion Osmosis Active Transport Filtration

Active Transport

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being a risk for hypokalemia? A nephrostomy tube to a drainage bag An indwelling urinary catheter to gravity drainage An NG tube to suction A chest tube to water-seal drainage

An NG tube to suction

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet? Cabbage ​Cheddar cheese White rice ​Bananas

Bananas

The patient has been prescribed a non-potassium-sparing diuretic. Which food(s) should the nurse suggest the patient include in his diet? (select all that apply) Eggs Bananas Tomatoes Aged cheese Baked potato with skin

Bananas Tomatoes Baked potato with skin

A nurse is collecting data from an older adults who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (select all that apply) Crackles in lung bases Periorbital edema Bounding radial pulse Swelling at the IV site Flat neck veins when supine

Crackles in lung bases Periorbital edema Bounding radial pulse

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? Extracellular fluid volume (ECV) excess Extracellular fluid volume (ECV) deficit Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia

Extracellular fluid volume (ECV) deficit Hypokalemia Hypocalcemia

Lab findings with volume excess:

Hct-decreased Na-may be normal Electrolyte, BUN, Creatinine decreased Chest-xray=pulmonary congestion

A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect? Increased appetite Hyporeflexia Constipation Headache

Headache

A patient's lab results indicate a potassium level of 5.6 mEq/L. Which of the following conditions would the nurse expect to see a potassium value at this level? Diarrhea Cushing's Massive third-degree burn Prolonged laxative use

Massive third-degree burn

The nurse is assessing a patient who was admitted for dehydration. Which assessment finding is an indication that the dehydration is resolving? Loose skin Sunken eyes 1200 mL urine output Moist mucous membranes

Moist mucous membranes

A nurse reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect? Positive Chvostek's sign Diarrhea Muscle hypotonicity Tachycardia

Muscle hypotonicity

A patient has ingested a large amount of a cathartic containing magnesium. The nurse should observe for which symptom of hypermagnesemia? Muscle weakness Hyperactive reflexes Respirations of 30 breaths/min Insomnia, twitching, and tremors

Muscle weakness

What are the examples of Isotonic IV solutions?

Normal saline (0.9% Sodium chloride) Lactated Ringers (LR) 5% dextrose in water (D5W)

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions? Restrict fluid intake. Administer potassium gluconate 40 mEq orally. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate. Obtain a 12-lead ECG.

Obtain a 12-lead ECG.

Which may cause hyperkalemia? Blood transfusion Diaphoresis Diarrhea Renal failure

Renal failure

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia? Positive Trousseau's sign Reports of fatigue Reports of numbness in the feet Increased bowel sounds

Reports of fatigue

A patient has end-stage chronic obstructive pulmonary disease (COPD). Which acid-base imbalance would be predictable in a patient with COPD? Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis

Respiratory acidosis

A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration? Jugular vein distention Red mucous membranes BP 178/90 mm Hg Skin tenting

Skin tenting

A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the provider? Magnesium 1.9 mg/dL Chloride 99 mEq/L Sodium 126 mEq/L Potassium 3.6 mEq/L

Sodium 126 mEq/L

A nurse is reviewing the readmission laboratory test results of a client who is scheduled for a carotid edartectomy in 3 days. Which of the following results should the nurse report to the provider? Sodium 151 mEq/L ​Potassium 3.8 mEq/L ​Calcium 9.6 mEq/L ​Chloride 105 mEq/L

Sodium 151 mEq/L

A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L. Which of the following medications should the nurse administer? Acetylcysteine Lactulose Triamterene Sodium polystyrene

Sodium polystyrene

When a patient receives a hypotonic solution intravenously (IV), what happens to the patient's cells? There is a net loss of water across the cell membrane. There is no change in the cells because there is no fluid shift. The cells begin to swell as water enters the intracellular compartment. The cells begin to shrink as water is pulled from the intracellular compartment.

The cells begin to swell as water enters the intracellular compartment.

The nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect? Hypoactive bowel sounds Skeletal muscle weakness Decreased deep-tendon reflexes Tingling of the lips

Tingling of the lips

A nurse is reviewing the medical record of a client who has a fluid volume deficit. The nurse should expect which of the following findings? BUN 12 mg/dL Urine output 15 mL/hr Urine specific gravity 1.020 Hct 43%

Urine output 15 mL/hr

electrolyte that functions in hydrochloric acid production and acid-base balance

chloride

Hyponatremia may be caused by: increased secretion of aldosterone. stroke. congestive heart failure (CHF). dehydration.

congestive heart failure (CHF).

electrolyte that functions in ATP production

phosphate

To understand what type of fluid a patient needs, the LPN/LVN should understand that the term semipermeable membrane indicates that: the membrane is only a temporary structure. only electrically charged particles may pass through the membrane. the membrane does not allow for the passage of anything but water. the membrane allows some particles to pass through and prohibits the passage of others.

the membrane allows some particles to pass through and prohibits the passage of others.

A nurse is caring for a client who is postoperative and has an NG tube that drained 2,500 mL in the past 6hr. The nurse should monitor which of the following electrolyte imbalances? Decreased calcium level ​Decreased potassium level ​Elevated magnesium level ​Elevated sodium level

​Decreased potassium level

A client who is postoperative s receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? ​Flushing ​Vomiting ​Bradycardia ​Dyspnea

​Dyspnea

A nurse is evaluating the 24hr I&O records of several clients. Which of the following client finding indicated an acceptable fluid balance? ​Intake 2,400 mL, output 2,500 mL ​Intake 2,500 mL, output 500 mL ​Intake 800 mL, output 2,100 mL ​Intake 1,200 mL, output 700 mL

​Intake 2,400 mL, output 2,500 mL