Electrolytes

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 should 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 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. 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.

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 should 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). 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. Focus on the subject, prescribed oral calcium supplements. Eliminate options 4 and 5 because they are comparable or alike and indicate incorrect client instructions.

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. 1.Client with asthma 2.Client with pancreatitis 3.Malnourished client 4.Client with diabetes mellitus 5.Client with status epilepticus 6.Client with severe prolonged diarrhea

2.Client with pancreatitis 3.Malnourished client 4.Client with diabetes mellitus 5.Client with status epilepticus 6.Client with severe prolonged diarrhea Clients who produce excessive acid, under produce bicarbonate, or overly eliminate bicarbonate develop metabolic acidosis. Clients with malnourishment, diabetes mellitus, and status epilepticus produce excessive acids leading to metabolic acidosis. Clients with pancreatitis under produce bicarbonate and develop metabolic acidosis. Clients with severe prolonged diarrhea develop metabolic acidosis due to the over elimination of bicarbonate. The client with asthma could develop an acid-base imbalance from a respiratory problem. Focus on the data in the question. Think of the pathophysiology that exists with each condition and the production of acid, or under or over production of bicarbonate. Because the subject relates to metabolic acidosis, you could eliminate the options with respiratory problems.

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 4.Heart rate of 104 beats per minute 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. 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.

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 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. Use the data in the question and focus on the client's history and signs and symptoms. Use knowledge of electrolyte imbalances to know that hypocalcemia and hypomagnesemia are similar and often exist together, so eliminate these incorrect options because they are comparable or alike.

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 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. 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 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. 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. Focus on the subject, gathering data regarding third spacing of fluids. Think about the relationship of each finding and the pathophysiology associated with third spacing of fluid to direct you to the correct option.

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

2.Metabolic alkalosis Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders such as respiratory alkalosis or acidosis or metabolic alkalosis. Focus on the subject, acid-base balance. Begin to answer this question by recalling that intestinal fluids are alkaline. With this in mind, you may eliminate options 2 and 4 first because alkaline secretions are lost in a client with an ileostomy. Note that the client condition described in the question is a client with a gastrointestinal disorder. This will direct you to choose the metabolic acidosis over the respiratory acidosis.

The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and finds which value to be of concern? 1.Sodium level, 145 mEq/L 2.Potassium level, 5.6 mEq/L 3.Magnesium level, 2.6 mg/dL 4.Phosphorus level, 4.5 mg/dL

2.Potassium level, 5.6 mEq/L Signs/symptoms of metabolic acidosis include weakness, malaise, and headache. Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the HCO3- ion level will be lower than 22 mEq/L. The remaining options identify normal laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia. Focus on the subject electrolyte changes that occur with acidosis. Knowledge regarding the signs/symptoms of metabolic acidosis along with normal laboratory values will assist you in answering the question. Focus on the options that are comparable or alike in that they are normal values and can be easily eliminated. The only abnormal laboratory value is the potassium level.

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

2.Tetany 3.A positive Chvostek's sign 5.A positive Trousseau's sign 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 tends to cause muscle irritability. A positive Chvostek's sign (striking the side of the face and noting twitching) and 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) 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. Focus on the subject, hypocalcemia. Recalling the signs of hypocalcemia will direct you to the correct options.

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

2.The client with a ileostomy Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with cirrhosis, heart failure (HF), or decreased kidney function is at risk for fluid volume excess. 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, HF, 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) 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. 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.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/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 A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/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. 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 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 should 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. 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. 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.

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The primary health care provider (PHCP) prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse should 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 client's electrolyte lab results to determine 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. A nasogastric tube is usually a Salem sump tube that is inserted through the nare 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. 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 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 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. Recall the concepts and physiology of third spacing of fluids. Noting the subject, the client least likely to develop third spacing will direct you to option 3.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply. 1.Keeping the head of the bed elevated 2.Monitoring the client's oxygen saturation level 3.Increase the liter flow to 5 L per nasal cannula 4.Assisting the client to turn, cough, and deep breathe 5.Encouraging the client to breathe slowly and shallowly

3.Increase the liter flow to 5 L per nasal cannula 5.Encouraging the client to breathe slowly and shallowly The client with respiratory acidosis is experiencing elevated carbon dioxide levels because of insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The nurse should increase the client's oxygen flow rate per nasal cannula to no more than 2 L, not 5L. Remember that the client with chronic pulmonary disease often does not respond to a high carbon dioxide level to breathe, but only low oxygen. If the nurse increases the oxygen too high, the client will have no stimulus to breathe. Elevating the head of the bed, monitoring the client's oxygen saturation level, and assisting the client to turn, cough, and deep breathe are helpful actions on the part of the nurse. Focus on the subject, respiratory acidosis. Note that the question contains the word avoid. With this in mind, eliminate options that are beneficial to airway status, and choose the one that would cause further impairment. This is a negative entry query asking you to select the action to avoid.

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 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. Focus on the subject, a reliable indicator of fluid balance. Eliminate options 1 and 2 first because they are comparable or alike. From the remaining options, focus on an indicator of fluid balance to direct you to option 3.

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 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. Focus on the subject hypocalcemia. Consider each option knowing that a low calcium level causes excess stimulation in the nervous system and creates a positive Trousseau's sign and fine tremors. Eliminate options 1 and 2 first because they are comparable or alike in that they both reflect an increase in relation to cardiovascular function. Finally eliminate option 4 because it is a sign of hypercalcemia.

The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3.Respiratory acidosis Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, which leads to respiratory acidosis resulting from progressive respiratory insufficiency as the paralysis ensues. Focus on the subject, Guillain-Barré syndrome. Recall that this disorder is an ascending paralysis that can progress and impair the client's respirations and eliminate options 1 and 2 first. Thinking through the effects of reduced ventilation will help you choose correctly between the remaining two options.

The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation should the nurse correctly make about these results? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3.Respiratory acidosis Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis. Focus on the subject, the noted results. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco2, as indicated in the question. Consider that the CO2 level is elevated and will form carbonic acid and therefore lead to acidosis. Consequently, metabolic options can be eliminated. Also remember that the pH is decreased in an acidotic condition. This will direct you to respiratory acidosis.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3.Respiratory acidosis Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD. Focus on the subject, COPD, to assist with guiding you to select a respiratory acid-base balance. Then remembering that primary defects in the function of the lungs result in respiratory acidosis will direct you to the correct option.

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 should 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 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. 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.

Which arterial blood gas (ABG) result should the nurse anticipate in the client who develops metabolic alkalosis after profuse vomiting for 2 days? 1.pH 7.32; Pco2 35; HCO3- 20 2.pH 7.30; Pco2 50; HCO3- 24 3.pH 7.49; Pco2 45; HCO3- 30 4.pH 7.52; Pco2 30; HCO3- 20

3.pH 7.49; Pco2 45; HCO3- 30 Vomiting results in a loss of hydrogen ions from the gastrointestinal tract, which leads to an increase in serum bicarbonate. Metabolic alkalosis occurs with an excess in serum bicarbonate. In metabolic alkalosis the pH rises as does the bicarbonate. The only option that indicates this characteristic is option 3. Option 1 indicates metabolic acidosis. Option 2 indicates respiratory acidosis. Option 4 indicates respiratory alkalosis. Focus on the subject, arterial blood gas analysis. First use knowledge of normal ABG values to interpret accurately each ABG result. Next knowing that vomiting will lead to a metabolic problem will help you eliminate options 2 and 4. Last apply knowledge of causes of metabolic disturbances to direct you to option 3.

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. 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. 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.

A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder? 1.Disorientation and dyspnea 2.Drowsiness, headache, and tachypnea 3.Tachypnea, dizziness, and paresthesias 4.Decreased respiratory depth and rate and dysrhythmias

4.Decreased respiratory depth and rate and dysrhythmias The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias. Disorientation and dyspnea could be associated with hypoxemia. Tachypnea, dizziness, and paresthesias are often associated with hyperventilation and respiratory alkalosis. Drowsiness, headache and tachypnea are not associated with metabolic alkalosis. Knowledge about the signs and symptoms of the subject, metabolic alkalosis, will direct you to the correct option. Remember that in this disorder the respiratory rate and depth decrease.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take? 1.Perform Allen's test. 2.Prepare the client for dialysis. 3.Administer insulin as prescribed. 4.Encourage the client to slow down breathing.

4.Encourage the client to slow down breathing. The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis. Focus on the data in the question. Because the pH is high and the Pco2 level is low, a respiratory problem is occurring. Then, applying the ABCs—airway, breathing, and circulation—you can determine that only one intervention deals with respirations.

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 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. Focus on the subject, magnesium imbalance. Eliminate options 1, 2, and 5 because they are comparable or alike in that they all reflect neurological excitability.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should 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 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. 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 observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record? 1.Apnea 2.Bradypnea 3.Cheyne stokes 4.Kussmaul's respirations

4.Kussmaul's respirations Abnormally deep, regular, and rapid respirations observed in the client with diabetic ketoacidosis are documented as Kussmaul's respirations. During apnea, respirations cease for several seconds. During bradypnea, respirations are regular but abnormally slow. Cheyne stokes respirations gradually become more shallow and are followed by periods of apnea (no breathing), with repetition of the pattern. Knowledge regarding the description of alterations in breathing patterns is required to answer this question. Focus on options that are comparable or alike, such as apnea and Cheyne Stokes respirations, where there are periods of apnea to help you eliminate these two options. Next, note the client's diagnosis and remember that Kussmaul's respirations occur in clients with diabetic ketoacidosis.

A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How should the nurse interpret the client's blood gas results? 1.Normal results 2.Respiratory acidosis 3.Metabolic acidosis 4.Respiratory alkalosis

4.Respiratory alkalosis The client has respiratory alkalosis. Normal ranges for pH are 7.35 to 7.45, for Paco2 35 to 45 mm Hg, and for bicarbonate 22 to 26 mEq/L. With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be elevated in respiratory acidosis. Bicarbonate levels would be low if a metabolic acidosis is present. Specific knowledge related to the subject, ABG analysis, is needed to answer this question correctly. Recalling that with alkalosis, the pH would be greater than 7.45 will direct you to option 4.

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 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. 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.

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 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. 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.

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 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. 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.

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 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. 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 is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? 1.A sodium level of 145 mEq/L (145 mmol/L) 2.A potassium level of 3.0 mEq/L (3.0 mmol/L) 3.A magnesium level of 1.3 mEq/L (0.65 mmol/L) 4.A phosphorus level of 3.0 mg/dL (0.97 mmol/L)

2.A potassium level of 3.0 mEq/L (3.0 mmol/L) Signs/symptoms of respiratory alkalosis include tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results. Recalling the clinical manifestations of respiratory alkalosis and the normal laboratory values will assist you with answering this question. Eliminate options that are comparable or alike in that they reflect normal laboratory values. You can then determine that the only abnormal laboratory value is the potassium level.

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 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. 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 should 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 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. 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 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 Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia. 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 calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

The client consumed a total of 84 oz of fluid. Because 1 oz is equal to 30 mL, multiply 84 oz by 30 mL/oz. This yields 2520 mL. The subject of the question is dosage fluid intake calculation. First, count the total milliliters that the client consumed in a 24-hour period. Next, multiply the total milliliters by 30, recalling that 1 oz equals 30 mL. Use a calculator to verify the amount.

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) 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. Focus on the subject, fluid volume deficit. Read each option, and think about the fluid imbalance that is likely to occur in each.

A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis Metabolic acidosis occurs when the pH falls below 7.35, and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L. Focus on the subject, arterial blood gas results. Knowing that a pH of 7.34 is acidotic allows you to eliminate options 2 and 4 first. From the remaining options, knowing that a metabolic condition exists when the bicarbonate follows the same up or down pattern as the pH helps you choose option 1 over option 3.

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 is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should 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. 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. Focus on the subject, a sodium level of 172 mEq/L (172 mmol/L). Knowledge that this level is elevated and knowledge of the treatment for hypernatremia will direct you to the correct options.

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply. 1.Clients with asthma 2.Clients with diabetes 3.Clients with pneumonia 4.Clients with kidney failure 5.Clients with severe anxiety 6.Clients with malnourishment

2.Clients with diabetes 4.Clients with kidney failure 6.Clients with malnourishment Diabetes mellitus, kidney failure, and malnutrition lead to metabolic acidosis by increasing acids in the body. Asthma, pneumonia, and severe anxiety lead to respiratory, not metabolic, imbalances. Focus on the subject, metabolic acidosis. First eliminate options that are comparable or alike in that they refer to respiratory problems—asthma and pneumonia. Identify diabetes and kidney failure as conditions that are metabolic and are also comparable or alike. Knowing that severe anxiety can result in hyperventilation will also assist you in eliminating this option because of its respiratory component. Then determine which options would lead to acidosis to direct you to the correct options.

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 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. Focus on the subject, risk for fluid volume deficit. Read each option and consider if it is a normal finding. Then analyze the option as to whether it indicates a potential fluid imbalance.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should 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 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. 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.

The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen? 1.Place the specimen on ice. 2.Record the client's temperature on the requisition. 3.Record the percent of oxygen on the requisition. 4.Obtain a 3-mL syringe that is used for parenteral medication.

4.Obtain a 3-mL syringe that is used for parenteral medication. The specimen is drawn into a heparinized syringe to prevent clotting of the blood. A 3-mL syringe used to administer parenteral medication is not used. The specimen should be placed on ice after it is obtained. The requisition is fully completed, identifying pertinent client information such as body temperature and amount of oxygen in use. Focus on the subject, supplies needed for obtaining blood for an ABG. Note the word avoids, which indicates a negative event query and asks you to select an action that is incorrect. Recalling that a heparinized syringe is used to prevent clotting of the blood will direct you to the correct option.

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel, which leads to the formation of ketones. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis. Focus on the subject, diabetes mellitus and the high serum glucose. This tells you that the primary problem is metabolic in nature rather than respiratory. Therefore, eliminate options 3 and 4. Use knowledge of acid-base concepts to choose correctly between the two remaining options, remembering that metabolic acidosis is a concern in diabetes mellitus.

The nurse is reviewing the health records of assigned clients. The nurse should 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 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. 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 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. 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.

The nurse is caring for a client who is nervous and is hyperventilating. The nurse should monitor the client for signs of which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

4.Respiratory alkalosis A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called respiratory alkalosis. The client is not at risk for metabolic acidosis or alkalosis or respiratory acidosis from hyperventilating. Focus on the subject, a client hyperventilating. This tells you that the correct option is likely to be related to respiration. Recalling that blowing off carbon dioxide triggers alkalosis will help you choose correctly from the remaining two options.

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 4.Low saturated fat

2.Vitamin D 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. 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.

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder? 1.Put the client in a supine position. 2.Provide emotional support and reassurance. 3.Withhold all sedative or antianxiety medications. 4.Tell the client to breathe very deeply but more slowly.

2.Provide emotional support and reassurance. An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication, if it is prescribed. The client should try to breathe more slowly and shallowly. Lying supine provides no benefit to the client. Focus on the subject, an intervention for an anxious client experiencing respiratory alkalosis. Visualize the items in each of the options and their anticipated effect on the client's respiratory status. This will direct you to option 2.

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 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. 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.

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 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. Focus on the subject, excess fluid volume. Read each option, and think about the fluid imbalance that can occur in each. Consider whether the condition leads to loss or retention of fluid.

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) 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. 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.

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder? 1.Furosemide 2.Acetazolamide 3.Spironolactone 4.Sodium bicarbonate

2.Acetazolamide Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide is a loop diuretic and spironolactone is a potassium-retaining diuretic. These are of no value when there is a need to excrete bicarbonate. Focus on the subject, an acid-base disorder. Begin to answer this question by interpreting the acid-base disorder as metabolic alkalosis. Eliminate option 4 first, based on this conclusion. You can choose correctly among the remaining options by knowing the pharmacological action and which of the three diuretics is used to excrete bicarbonate.

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 intravenous fluids should 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 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. Focus on the subject, the components of intravenous solutions. It is necessary to know the tonicity and components of the IV solutions identified in the options to answer correctly. Remember the purpose of intravenous fluids and the various types of intravenous fluids.

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply. 1.Client with emphysema 2.Client who is hyperventilating 3.Client with chronic kidney disease 4.Client who has been vomiting for 2 days 5.Client receiving oral furosemide 40 mg daily 6.Client admitted with acetylsalicylic acid overdose

4.Client who has been vomiting for 2 days 5.Client receiving oral furosemide 40 mg daily Metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or a deficit of acids, such as the client who has been vomiting for 2 days and the client receiving furosemide daily. Recall that clients with emphysema and hyperventilation are at risk for a respiratory acid-base disturbance. Chronic kidney disease and aspirin overdose will result in metabolic acidosis. Focus on the subject, those at risk for metabolic alkalosis. Eliminate options that are comparable or alike and refer to respiratory conditions. From the remaining metabolic conditions, determine whether there is an increase in bases or a deficit in acids to answer correctly.

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 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. Focus on the subject, the symptoms of hyponatremia. Remember that low sodium impairs the neuromuscular system and stimulates the gastrointestinal system.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should 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. 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. Eliminate options 1, 2, and 3 because they are comparable or alike. Note that each of these options suggests administering the medication with another substance. Option 4 is the only option that reflects administering the medication on an empty stomach.

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 should 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 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. 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.

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 should 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. Magnesium is important for cellular function, metabolism, and skeletal and cardiac muscle function. Normal levels for an adult are 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). Hypomagnesemia is defined as a plasma magnesium level less than 1.3 mEq/L (0.65 mmol/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. 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.

The nurse is assisting in the care of a client who had an ileostomy created a few days ago. The client has high output of drainage from the ileostomy. Based on this the nurse monitors the client for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. Clients with high intestinal output are not at risk for metabolic acidosis, or respiratory or metabolic alkalosis. Focus on the subject, ileostomy drainage and resulting blood gas value. Begin to answer this question by eliminating options 2 and 4 first. Intestinal fluids are alkaline in nature, and their loss would produce an acidotic state. Note that the client condition is a gastrointestinal disorder and eliminate the option that deals with a respiratory problem.

The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values should the nurse expect to note in this client? 1.Sodium of 145 mEq/L 2.Potassium 5.4 mEq/L 3.Magnesium 2 mEq/L 4.Phosphorus 2.3 mEq/L

2.Potassium 5.4 mEq/L Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering. In acidosis, extracellular hydrogen ion content increases, and hydrogen ions then begin to move into intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions must leave the cell, creating a relative hyperkalemia. Sodium, magnesium, and phosphorus would remain within normal range. Focus on the subject, respiratory acidosis. Knowledge regarding the signs/symptoms of respiratory acidosis along with normal laboratory values will assist you in answering the question. Consider the instant compensatory mechanism of hydrogen moving intracellularly and potassium moving extracellularly.

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 should 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 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. Focus on the subject, hyponatremia, and note the data in the question. Eliminate intense thirst and dry mucous membranes first, because they are comparable or alike (a client with dry mucous membranes is likely to have intense thirst). From the remaining options, it is necessary to recall the signs of hyponatremia.

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 should 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 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. 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 caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

2.Metabolic alkalosis The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition as a result of the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and alkalosis—can be easily eliminated. Focus on the subject, nasogastric tube to low suction. Remember that hydrochloric acid is lost when the client is receiving nasogastric suctioning. This will direct you to the options that identify an alkalotic condition. Because the question addresses a situation other than a respiratory one, the acid-base disorder would be a metabolic condition.

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis Acidosis is defined as a pH of less than 7.35, and alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Pco2 is greater than 45, and respiratory alkalosis is present when the Pco2 is less than 35. Metabolic acidosis is present when the pH is less than 7.35 and the HCO3- is less than 22 mEq/L, whereas metabolic alkalosis is present when the pH is greater than 7.45 and the HCO3- is greater than 27 mEq/L. This client's ABGs are consistent with metabolic acidosis. With a slightly alkalotic level of carbon dioxide there is evidence of some incomplete compensation. Focus on the subject, blood gas analysis. Remember that in a metabolic imbalance you will find that the pH and the HCO3- move in the same direction. Therefore, options 3 and 4 are eliminated first. Next, remember that the pH is elevated with alkalosis and low in acidosis. Option 1 reflects a metabolic acidotic condition and describes the blood gas values as indicated in the question.

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. 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. 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 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." 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. 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.