Fluid and electroltes

The nurse notices flattened T waves on the electrocardiogram (ECG) of the client diagnosed with acute kidney injury. Based on this finding, the nurse should check the laboratory values for which electrolyte imbalance? 1. Hypocalcemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypokalemia

4. Hypokalemia

Two days after subtotal thyroidectomy, a client tells the nurse, "my lips feel all tingly". Which assessment of the client does the nurse make immediately ? a. check for Chvostek sign b. evaluate pt ability to cough c. assess for drainage under the pt neck d. monitor pulse rate

a. check for Chvostek sign

The nurse monitors a pt who experienced partial-thickness and full-thickness burns over the lower extremities 24hr ago. Which sign does the nurse anticipate during this phase of burn injury ? a. decreased urinary output b. increased BP c. decreased K and NA levels d. decreased Hct levels

a. decreased urinary output

The nurse provides care for a client diagnosed with hypokalemia. Which findings does the nurse expect when assessing the client ? a. electrocardiogram has a depressed ST segment and inverted T wave b. exhibits Kussmaul breathing c. electrocardiogram reflects widening of the QRS complex d. increased muscle strength

a. electrocardiogram has a depressed ST segment and inverted T wave

An adult client has a history of diabetes insipidus. The nurse identifies which imbalance is most likely to develop if this medical problem recurs ? a. hypernatremia b. hyponatremia c. hyperkalemia d. hypokalemia

a. hypernatremia

The ED nurse knows which cause is most frequently associated with tetany ? a. hypocalcemia b. puncture wound from dirty and rusty metal c. hypermagnesemia d. genetic cardiac defect

a. hypocalcemia

A client with full thickness burns over 30% of the body reports weakness and cramping in the lower extremities. The client also has occasional confusion and an irregular HR with palpitations. Which condition do these s/s indicate the client is experiencing ? a. hypokalemia b. hyperkalemia c. hypocalcemia d. hypercalcemia

a. hypokalemia

A pt dx with AIDS has recurrent bouts of diarrhea, n/v. Which is the most important goal for the pt ? a. maintenance of fluid and electrolyte balance b. decreased sense of social isolation c. improved activity tolerance d. expression of grief

a. maintenance of fluid and electrolyte balance

ABG are : pH 7.49 PaCO2 37 PaO2 96 SaO2 98 HCO3 24 Potassium 4.2 These suggest the pt is experiencing which condition ? a. resp alk b. met acid c. resp acid d. met alk

a. resp alk

Nurse provides care for a client diagnosed with dehydration. Which finding does the nurse anticipate when assessing a clients H&H ? a. Hgb and Hct are decreased b. Hgb and Hct are increased c. Hgb is decreased and Hct is increased d. Hgb is increased and Hct is decreased

b. Hgb and Hct are increased

Client diagnosed with gastroenteritis and dehydration is receiving fluid volume replacement with NS infusing at 100mL/hr. Four hours after the infusion is started, the nurse assesses the client and notes the BP 84/50, HR 110, and urine output is 15mL/hr and dark yellow. Which action does the nurse take initially ? a. increase IV fluids to 150mL/hr b. assess the IV access c. place in Trendelenburg position d. notify HCP

b. assess the IV access

The nurse provides care for the client receiving IV therapy. Which assessment findings best indicates the client may be experiencing fluid overload ? a. decreased BP and pedal edema b. crackles in bases of lungs and cough c. SOB and tracheal deviation d. decreased skin turgor and cool skin

b. crackles in bases of lungs and cough

The nurse understands that fatigue, weakness, and vomiting are signs of which problem ? a. hyponatremia b. hypokalemia c. hypernatremia d. hyperkalemia

b. hypokalemia

A client diagnosed with dehydration due to n/v was unable to eat or drink for two days and was receiving IV fluids. The client has begun to resume oral intake. Which nursing action has the highest priority ? a. assess daily serum electrolyte levels b. offer 20-30 mL of clear liquid every 30 min c. d/c IV fluids and remove the IV d. weigh the client before breakfast

b. offer 20-30 mL of clear liquid every 30 min

Which laboratory finding does the nurse expect if the pt is dx with a fluid volume deficit ? a. specific gravity 1.020 b. specific gravity 1.034 c. potassium 5.8 d. potassium 4.8

b. specific gravity 1.034

The nurse provides care for a client diagnosed with CHF who is receiving IV fluids. The client states, "I keep coughing and coughing. Maybe I am getting a cold". What action should the nurse take first ? a. stop the IV fluids b. place client in high fowlers c. auscultate lungs d. provide humidifier in the clients room

c. auscultate lungs

An older adult calls the clinic and speaks with the nurse. The pt reports feeling ill for two days and having poor appetite. The pt makes other statements which indicates the pt is confused. The pt baseline is alert and oriented. Which is the most likely cause of the pt confusion ? a. nasal congestion b. respiratory insufficiency c. decreased fluid intake d. normal aging process

c. decreased fluid intake

The nurse identifies which s/s as an early indication of fluid volume excess ? a. cyanosis b. diarrhea c. edema d. shock

c. edema

The nurse provides care for the pt who expresses apprehension about the dx of terminal lung cancer. The nurse notes the BP 140/88, P 92, RR 36. The ABG are : pH 7.52 PaO2 95 PaCO2 39 HCO3 24 What action does the nurse take first ? a. admin O2 at 2L b. prepare pt for tracheostomy c. encourages the pt to breathe into a paper bag d. administer bicarbonate IV

c. encourages the pt to breathe into a paper bag

Two days after a total thyroidectomy, a client reports painful spasms of the hands. The client says, "my muscles tingle and twitch". The nurse identifies the client has developed which electrolyte imbalance ? a. hypernatremia b. hypophosphatemia c. hypocalcemia d. hyperkalemia

c. hypocalcemia

A patient has a NG tube connected to intermittent suction. Which blood test results are of most concern to the nurse ? a. BUN 16 b. WBC 8,5000 c. potassium 2.9 d. glucose 90

c. potassium 2.9

The nurse assesses an older pt and prepares to admin a prescribed IV potassium supplement. Which assessment finding concerns the nurse ? a. normal ECG b. reports dizziness c. reports hx of low urine output d. is experiencing muscle cramps

c. reports hx of low urine output

A 3yo child is brought to the ED with a HX of vomiting and diarrhea for the past three days. Which finding is the nurse most likely to see ? a. SOB b. slow HR c. sunken eyes d. tremors

c. sunken eyes

A pt dx with HTN has been prescribed diuretic to take daily. Pt experiences lower leg cramps. The pt serum potassium level is 2.9. Which intervention does the nurse perform to assist in maintaining a normal serum potassium ? a. encourage pt to hold any prescribed diuretics when potassium level is below 3.5 b. allows pt to verbalize concerns about the dx of HTN c. teach pt about importance of eating bananas and drinking OJ d. encourage pt to engage in regular exercise

c. teach pt about importance of eating bananas and drinking OJ

The nurse provides care for a client dx with diarrhea and dehydration. Which assessment does the nurse expect to see ? a. dark circles around the eyes b. skin is hot and red c. voided 100mL of dark urine in 8 hours d. bounding pulse and high BP

c. voided 100mL of dark urine in 8 hours

Which OTC decreases hyperphosphatemia in clients diagnosed with CKD ? a. aluminum hydroxide/magnesium hydroxide b. bismuth subsalicylate c. kaolinite and pectin d. aluminum hydroxide

d. aluminum hydroxide

The nurse assesses a client and notes that the client is confused, has poor skin turgor, dry mucus membranes, sunken eyeballs, and has only produced a scant amount of amber urine on the previous shift. Which condition do these s/s suggest the client has ? a. potassium excess b. HF c. urinary retention d. dehydration

d. dehydration

A client receives fluid replacement because of dehydration. The nurse evaluates the effectiveness of the treatment. Which s/s cause the most alarm ? a. increased urinary output and a decrease in urinary osmolarity b. BP decreases by 5 mmHg when changing from lying to standing c. increasing LOC, including alertness and orientation d. develops dyspnea, crackles, and jugular vein engorgement

d. develops dyspnea, crackles, and jugular vein engorgement

Nurse cares for a client diagnosed with a fractured right hip. The clients lab values are : Hgb 15 Hct 46% Sodium 140 Potassium 6.2 Chloride 100 The nurse is most concerned if which finding is observed ? a. weight gain of 4lb in 1 day b. increase in nausea c. increase in muscle irritability d. episode of v-fib

d. episode of v-fib

Which explanation best describes the phenomena known as Third Spacing ? a. fluid moves from intracellular space to the intravascular space b. BP decreases due to a diminished intravascular volume c. movement of fluid from the blood vessels into cells d. fluid moves from the vasculature to interstitial spaces

d. fluid moves from the vasculature to interstitial spaces

The nurse identifies NG drainage, v/d and the use of diuretics as likely the cause of which electrolyte imbalance ? a. hypernatremia b. hyperkalemia c. hyponatremia d. hypokalemia

d. hypokalemia

A toddler pt has n/v/d. Which implementation is best for the nurse to use to maintain an adequate fluid intake ? a. keep pt NPO and give hypotonic solutions IV b. force fluids and give hypertonic solutions IV c. provide gelatin and ice pops to increase fluid intake d. offer oral rehydration solutions (ORS) to rehydrate

d. offer oral rehydration solutions (ORS) to rehydrate

The pt reports sleepiness, n/v. The nurse notes the pt is confused and respirations are deep, labored, with a rate of 32/min. ABG values are : PaCO2 30 pH 7.30 HCO3 20 Which action does the nurse take ? a. starts an infusion of 5% dextrose and water as per standing orders and contacts the HCP b. places paper bag over the pt nose and mouth to re-breath expired air c. gives morphine IV to relieve pain d. place in fowlers position and encourages measures to support hyperventilation

d. place in fowlers position and encourages measures to support hyperventilation

The nurse cares for a pt dx with hypotonic dehydration. Which lab study does the nurse monitor ? a. platelet count b. immunoglobulin E level c. albumin level d. sodium level

d. sodium level

Which assessment finding in the young adult client indicates to the nurse that there is a problem with fluid volume deficit ? a. taut, shiny skin b. perspiration in the axillae c. warm, smooth, elastic skin d. tenting of the skin

d. tenting of the skin

A nurse cares for a pt with CKD. During review of lab results, nurse notes the pt serum magnesium is increased. Which is the priority question for the nurse to ask the pt ? a. are you drinking many beverages that contain caffeine ? b. do you notice any tremors of your hands and fingers ? c. how many diary products do you consume daily ? d. what OTC meds do you take ?

d. what OTC meds do you take ?