fluid and electrolyte EAQ

Which action is the function of antidiuretic hormone (ADH)? 1. Reduces blood volume 2. Decreases water loss in urine 3. Increases urine output 4. Initiates the thirst mechanism

2. Decreases water loss in urine

For which reason would clients who receive intravenous (IV) fluids rather than total parenteral nutrition for gastrointestinal problems lose weight? 1. Lack of bulk in the diet 2. Deficient carbohydrate intake 3. Insufficient intake of water-soluble vitamins 4. Increasing concentrations of electrolytes in the cells

2. Deficient carbohydrate intake

Which action will a nurse take first when caring for a client reporting chest pain, difficulty breathing, and feeling cold twenty minutes after an infusion of packed red blood cells begins? 1. Stop the transfusion. 2. Notify the health care provider. 3. Provide several warm blankets. 4. Assess vital signs.

1. stop the transfusion

List the actions in the order in which they will be performed by the nurse transfusing packed red blood cells prescribed for a client with anemia. 1. initiate the transfusion slowly 2. don a pair of new gloves 3. determine the clients vitals 4. verify that the number on the blood product, laboratory record, and client armband match 5. ensure that the client signed a consent for the transfusion

5. ensure that the client signed a consent for the transfusion 3. determine the clients vitals 4. verify that the number on the blood product, laboratory record, and client armband match 2. don a pair of new gloves 1. initiate the transfusion slowly

Which finding by the nurse when assessing a client who is receiving intravenous (IV) fluids indicates need for a change in the fluid infusion rate? 1. Crackles in lungs 2. Supple skin turgor 3. Urine output of 480 mL over 8 hours 4. Heart rate decrease from 126 beats/minute to 96 beats/minute

1. Crackles in lungs

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. 1. Diuretics 2. Low-salt diet 3. Daily weight checks 4. Fluid restriction 5. Intake and output 6. Oxygen administration

1. Diuretics 2. Low-salt diet 3. Daily weight checks 4. Fluid restriction 5. Intake and output 6. Oxygen administration

Which finding would lead the nurse to suspect a transfusion reaction caused by incompatible blood in a client receiving a unit of packed red blood cells? Select all that apply. One, some, or all responses may be correct. 1. Respiratory distress 2. Backache 3. Chills 4. Bradycardia 5. Hypertension

1. Respiratory distress 2. Backache 3. Chills

Which clinical finding is important for the nurse to monitor for when a total parenteral nutrition (TPN) solution is prescribed to infuse at 1 liter every 12 hours? Select all that apply. One, some, or all responses may be correct. 1. Activity tolerance 2. Intake and output 3. Orthostatic vital signs 4. Glucose levels 5. Serum electrolytes

2. Intake and output 4. Glucose levels 5. Serum electrolytes

Which molecule excessively accumulates in the blood to precipitate the signs and symptoms associated with a diabetic coma? 1. Sodium bicarbonate, causing alkalosis 2. Ketones as a result of rapid fat breakdown, causing acidosis 3. Nitrogen from protein catabolism, causing ammonia intoxication 4. Glucose from rapid carbohydrate metabolism, causing drowsiness

2. Ketones as a result of rapid fat breakdown, causing acidosis

A client is 36 hours after admission with severe burns and the nurse identifies the client's potassium level is 6.0 mEq/L (6.0 mmol/L). The nurse would recommend substituting current dietary fluids with which drink? 1. Milk 2. Tea 3. Orange juice 4. Tomato juice

2. tea

When assessing a client during the postoperative period of receiving a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mmol/L). Which action would the nurse take first in response to this laboratory report? 1. Notify the primary health care provider. 2. Obtain current blood test results. 3. Assess for decreased urine output. 4. Check the intravenous (IV) infusion.

3. Assess for decreased urine output.

Which action will the nurse take when a client appears flushed and complains of palpitations ten minutes after the start of intravenous (IV) vancomycin scheduled to infuse over 30 minutes? 1. Stop the infusion. 2. Continue the infusion but monitor the client. 3. Contact the primary health care provider to obtain a prescription to decrease the infusion rate. 4. Contact the primary health care provider to obtain a prescription for an antianxiety medication.

3. Contact the primary health care provider to obtain a prescription to decrease the infusion rate.

Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide? 1. Chvostek sign 2. Muscle weakness 3. Anxious behavior 4. Abdominal cramping

2. Muscle weakness

Which principle explains how loop diuretics promote diuresis? 1. Osmosis 2. Filtration 3. Diffusion 4. Active transport

1. osmosis

Which electrolyte deficiency triggers the secretion of renin? 1. Sodium 2. Calcium 3. Chloride 4. Potassium

1. sodium

Which fluid shift will the nurse take into consideration when assessing a client with type 1 diabetes who is experiencing a fluid imbalance? 1. Intravascular to interstitial as a result of glycosuria 2. Extracellular to interstitial as a result of hypoproteinemia 3. Intracellular to intravascular as a result of hyperosmolarity 4. Intercellular to intravascular as a result of increased hydrostatic pressure

3. Intracellular to intravascular as a result of hyperosmolarity

When a client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? 1. Complete a head-to-toe assessment. 2. Start infusion of normal saline 500 mL. 3. Ask the client about current medications 4. Obtain blood samples for laboratory testing.

2. Start infusion of normal saline 500 mL.

Which complication would a nurse try to avoid by slowly administering a parenteral preparation of potassium? 1. Metabolic acidosis 2. Cardiac arrest 3. Seizure activity 4. Respiratory depression

2. cardiac arrest

Which response would a nurse monitor for when a client is receiving furosemide to relieve edema? Select all that apply. One, some, or all responses may be correct. 1. Weight loss 2. Negative nitrogen balance 3. Increased urine specific gravity 4. Excessive loss of potassium ions 5. Pronounced retention of sodium ions

1. Weight loss 4. Excessive loss of potassium ions

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? 1. Body weight control 2. Decreased fluid retention 3. Lowering of blood pressure 4. Prevention of hypernatremia

2. Decreased fluid retention

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1. Serum sodium of 139 mEq/L (139 mmol/L) 2. Serum chloride of 100 mEq/L (100 mmol/L) 3. Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4. Serum potassium of 7.2 mEq/L (7.2 mmol/L)

4. Serum potassium of 7.2 mEq/L (7.2 mmol/L)

Which nursing intervention would be taken when the mother of an adolescent reports that her child does not eat properly, performs strenuous physical exercise, and is very introverted? Select all that apply. One, some, or all responses may be correct. 1. Monitoring the adolescent's fluid and electrolyte status 2. Checking for evidence of self-induced vomiting 3. Monitoring the adolescent for disturbances in family interactions 4. Counseling the adolescent about good personal hygiene and sanitation 5. Developing a mutually agreeable targeted daily caloric intake goal

1. Monitoring the adolescent's fluid and electrolyte status 2. Checking for evidence of self-induced vomiting 3. Monitoring the adolescent for disturbances in family interactions 5. Developing a mutually agreeable targeted daily caloric intake goal

Which client would the nurse see first among this group of clients? 1. A toddler with diarrhea 2. An adult who is nauseated 3. An adult who has vomiting because of food poisoning 4. An older adult whose last bowel movement was 3 days ago.

1. A toddler with diarrhea

Which statement by a client receiving diuretic therapy indicates that the teaching about potassium supplements is understood? 1. "I will report any abdominal distress." 2. "I should use salt substitutes with my food." 3. "The medication must be taken on an empty stomach." 4. "The dosage is correct if my urine output increases."

1. "I will report any abdominal distress."

Which gland is affected in aldosteronoma? 1. Kidney cortex 2. Thyroid gland 3. Pituitary gland 4. Adrenal cortex

4. adrenal cortex

Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct. 1. Bone pain 2. Convulsions 3. Muscle spasms 4. Tingling of extremities 5. Depressed deep tendon reflexes

1. Bone pain 5. Depressed deep tendon reflexes

Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the intravenous fluid infusion rate for an older client with an infection? 1.Pruritus 2. Erythema 3. Acute confusion 4. General malaise

3. Acute confusion

Which adverse effect would a nurse will assess for at each clinic visit of a client taking furosemide? 1. Rapid weight loss 2. Xanthopsia 3. Hyporeflexia 4. Bronchospasm

3. Hyporeflexia

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? 1. Prevent constipation 2. Prevent dehydration 3. Prevent vomiting 4.Prevent electrolyte imbalance

4.Prevent electrolyte imbalance

Which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns? 1. Blood urea nitrogen (BUN) 2. Sedimentation rate 3. Hematocrit (Hct) 4. Blood pH

3. Hematocrit (Hct)

Which food would a nurse instruct the client to include in the diet when being prescribed furosemide? 1. Liver 2. Apples 3. Cabbage 4. Bananas

4. bananas

Which symptom in a client recieving hydrochlorothiazide would cause a nurse to notify the health care provider? 1. Insomnia 2. Nasal congestion 3. Increased thirst 4. Generalized weakness

4. generalized weakness

Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels? 1. Epinephrine 2. Glucagon 3. Calcitonin 4. Aldosterone

4. aldosterone

The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

1. hypokalemia

Which concern when caring for a client prescribed furosemide 40 mg every day in conjunction with digoxin would prompt the nurse to ask the health care provider about potassium supplements? 1. Digoxin causes significant potassium depletion. 2. The liver destroys potassium as digoxin is detoxified. 3. Lasix requires adequate serum potassium to promote diuresis. 4. Digoxin toxicity occurs rapidly in the presence of hypokalemia.

4. Digoxin toxicity occurs rapidly in the presence of hypokalemia.

When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider 1. Equal 2. Unrelated 3. Inversely related 4. Directly proportional

4. Directly proportional

Which factor would a nurse identify as precipitating hyponatremia? Select all that apply. One, some, or all responses may be correct. 1. Wound drainage 2. Diuretic therapy 3. Gastrointestinal (GI) suction 4. Parenteral infusion of 0.9% sodium chloride 5. Inappropriate antidiuretic hormone (ADH) secretion

1. Wound drainage 2. Diuretic therapy 3. Gastrointestinal (GI) suction 5. Inappropriate antidiuretic hormone (ADH) secretion

Which physiological alteration will the nurse monitor to best determine the effectiveness of a client's hydrochlorothiazide therapy? 1. Blood pressure 2. Decreasing edema 3. Serum potassium level 4. Urine specific gravity

1. blood pressure

Which medication will the nurse expect the health care provider to prescribe to a client who had a thyroidectomy and is pale with spasms of the hand when taking the blood pressure? 1. Calcium 2. Magnesium 3. Bicarbonate 4. Potassium chloride

1. calcium

Which intravenous (IV) solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration? 1. 3% sodium chloride 2. 0.9% sodium chloride 3. 5% dextrose and 0.9% sodium chloride 4. 5% dextrose and lactated Ringer solution

2. 0.9% sodium chloride

While providing care for a client who sustained a severe head injury in an accident, the nurse observes the client is constantly passing urine and dehydrated. Which condition would the nurse suspect as the cause of the client's condition? 1. Decreased secretion of aldosterone 2. Decreased secretion of antidiuretic hormone 3. Decreased secretion of parathyroid hormone 4. Decreased secretion of atrial natriuretic peptide

2. Decreased secretion of antidiuretic hormone

Which action is important when administering blood? 1. Warm the blood to body temperature to prevent chilling the client. 2. Obtain baseline vital signs before beginning blood administration. 3. Draw a blood sample from the client before each unit is transfused. 4. Maintain patency of the intravenous catheter with dextrose solution.

2. Obtain baseline vital signs before beginning blood administration

Which antidiarrheal medication would the nurse anticipate administering to a client with severe diarrhea who is prescribed intravenous fluids, sodium bicarbonate, and an antidiarrheal medication? 1. Psyllium 2. Bisacodyl 3. Loperamide 4. Docusate sodium

3. Loperamide

For which reason would lactated ringer solution and 5% dextrose be prescribed for a client with partial- and full-thickness burns over 25% of the total body surface? 1. Preventing fluid shifts 2. Expanding the plasma 3. Maintaining blood volume 4. Replacing lost electrolytes

3. Maintaining blood volume

Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Providing oxygen 2. Encouraging carbohydrates 3. Administering fluid replacement 4. Teaching facts about dietary principles

3. Administering fluid replacement

Which mechanism of action is responsible for the therapeutic effects of mannitol precribed for a client with a head injury? 1. Decreasing the production of cerebrospinal fluid 2. Limiting the metabolic requirements of the brain 3. Drawing fluid from brain cells into the bloodstream 4. Preventing uncontrolled electrical discharges in the brain

3. Drawing fluid from brain cells into the bloodstream

Which clinical manifestation would the nurse expect the client who has chronic kidney disease with hypocalcemia to exhibit? Select all that apply. One, some, or all responses may be correct. 1. Acidosis 2. Lethargy 3. Fractures 4. Osteomalacia 5.Eye calcium deposits

3. Fractures 4. Osteomalacia 5.Eye calcium deposits

Which adverse medication effect will a nurse monitor for in a client with cirrhosis of the liver who develops ascites and is prescribed spironolactone? 1. Bruising 2. Tachycardia 3. Hyperkalemia 4. Hypoglycemia

3. Hyperkalemia

Which adverse effect would a nurse monitor for when caring for a client receiving furosemide to relieve edema? 1. Hypernatremia 2. elevated blood urea nitrogen 3. Hypokalemia 4. Increase in the urine specific gravity

3. Hypokalemia

Which is the primary fluid shift that occurs with diabetes mellitus? 1. Intravascular to interstitial because of glycosuria 2. Interstitial to extracellular because of hypoproteinemia 3. Intracellular to intravascular because of hyperosmolarity 4. Intercellular to intravascular because of increased hydrostatic pressure

3. Intracellular to intravascular because of hyperosmolarity

A client with a femoral fracture and osteomyelitis is immobilized for 3 weeks. Which rationale explains the nurse's plan to assess for the development of renal calculi? 1. The client's dietary patterns have changed since admission. 2. The client has more difficulty urinating in a supine position. 3. Lack of weight-bearing activity promotes bone demineralization. 4. Fracture healing requires more calcium, which increases calcium metabolism.

3. Lack of weight-bearing activity promotes bone demineralization.

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? 1. Give the client orange juice by mouth. 2. Increase the client's intravenous (IV) flow rate. 3. Moisten the client's lips with a wet 4 × 4 gauze. 4. Offer the client 4 oz (120 mL) of water by mouth.

3. Moisten the client's lips with a wet 4 × 4 gauze.

Which action would be most important for the nurse take when caring for a client who started furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L (2.8 mmol/L)? 1. Hold the morning dose of the diuretic. 2. Continue to monitor the level to ensure that it stays within the normal limits. 3. Notify the primary health care provider of the critically low result. 4. Anticipate a prescription for an increase in the dosage of the furosemide.

3. Notify the primary health care provider of the critically low result.

Which purpose would potassium chloride added to the intravenous solution of a client with diabetic ketoacidosis serve? 1. Treats hyperpnea 2. Prevents flaccid paralysis 3. Prevents hypokalemia 4. Treats cardiac dysrhythmias

3. Prevents hypokalemia

Which medication requires the nurse to monitor the client for signs of hyperkalemia? 1. Furosemide 2. Metolazone 3. Spironolactone 4. Hydrochlorothiazide

3. Spironolactone

In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? 1. Isotonic 2. Isomeric 3. Hypotonic 4. Hypertonic

3. hypotonic

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. 1. Diplopia 2. Skin rash 3. Leg cramps 4. Tachycardia 5. Muscle weakness

3. leg cramps 5. muscle weakness

Which intravenous fluid is a hypertonic solution? 1. Ringer solution 2. 5% dextrose in water 3. Lactated Ringer solution 4. 5% dextrose in normal saline

4. 5% dextrose in normal saline

Which clinical manifestation would the nurse expect when assessing a client with hypercalcemia? Select all that apply. One, some, or all responses may be correct. 1. Muscle tremors 2. Abdominal cramps 3. Increased peristalsis 4. Cardiac dysrhythmias 5. Hypoactive bowel sounds

4. Cardiac dysrhythmias 5. Hypoactive bowel sounds

Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tissue colloid osmotic pressure 4. Decrease in plasma colloid oncotic pressure

4. Decrease in plasma colloid oncotic pressure

Which purpose of insulin would a nurse identify when caring for a client prescribed insulin added to a solution of 10% dextrose in water after an intravenous solution containing potassium inadvertently was infused too rapidly? 1. Glucose with insulin increases metabolism, which accelerates potassium excretion. 2. Increased potassium causes a temporary slowing of the pancreatic production of insulin. 3. Increased insulin accelerates the excretion of glucose and potassium, thereby decreasing the serum potassium level. 4. Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level.

4. Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level.

Which clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. One, some, or all responses may be correct. 1. Edema 2. Polyuria 3. Bradycardia 4. Muscle cramps 5. Hyponatremia

4. muscle cramps 5. hyponatremia

Which client would a nurse recognize as having an age-related impairment of the thirst mechanism when reviewing the laboratory reports of a group of older adult clients? 1. client A 2. client B 3. client C 4. client D

1. client A

A client with renal failure receives prescriptions for vitamin D and calcium supplements. The client asks the nurse, "Why do I need to take these?" The nurse explains that, with renal failure, which condition exists? 1. A decrease in the inactive forms of vitamin D in the body 2. A decrease in the active metabolite of vitamin D in the body 3. An increase in the conversion of skin cholesterol into vitamin D 4. An increase in the vitamin D-associated intestinal absorption of calcium

2. A decrease in the active metabolite of vitamin D in the body

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? 1. Rapid, thready pulse 2. Distended jugular veins 3. Elevated hematocrit level 4. Increased serum sodium level

2. Distended jugular veins

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. 1. Pulse quality 2. Pulse pressure 3. Bounding pulse 4. Presence of dependent edema 5. Neck vein distention in the upright position

3. Bounding pulse 4. Presence of dependent edema 5. Neck vein distention in the upright position

Which factor must the nurse determine to adjust the drip rate when administering intravenous (IV) fluids to be delivered at 80 mL/h? 1. Total volume of fluid in the IV bag 2. Size of the needle or catheter in the vein 3. Drops per milliliter delivered by the infusion set 4. Diameter of the tubing being used to instill the fluid

3. Drops per milliliter delivered by the infusion set

Which disease increases the risk of hyperkalemia? 1. Crohn disease 2. Cushing disease 3. End-stage renal disease 4. Gastroesophageal reflux disease

3. End-stage renal disease

Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity? 1. Constipation 2. Decreased urination 3. Cardiac dysrhythmias 4. Metallic taste in the mouth

3. cardiac dysrhythmias

Which nursing action has a specific gerontological implication the nurse must consider when caring for an older adult receiving chemotherapy for cancer whose severe nausea and vomiting causes dehydration requiring hospital admission for rehydration therapy? Select all that apply. One, some, or all responses may be correct. 1. Assessment of skin turgor 2. Documentation of vital signs 3. Assessment of intake and output 4. Administration of antiemetic medications 5. Replacement of fluid and electrolytes

1. Assessment of skin turgor 4. Administration of antiemetic medications 5. Replacement of fluid and electrolytes

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? 1. Clear breath sounds 2. Positive pedal pulses 3. Normal potassium level 4. Decreased urine specific gravity

1. Clear breath sounds

Which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure? Select all that apply. One, some, or all responses may be correct. 1. Daily weight 2. Intake and output 3. Monitor for edema 4. Daily pulse oximetry 5. Auscultate breath sounds

1. Daily weight 2. Intake and output 3. Monitor for edema 4. Daily pulse oximetry 5. Auscultate breath sounds

Which action is the nurse's priority when caring for client admitted for dehydration on an intravenous (IV) infusion of normal saline at 125 mL/h who begins screaming, "I can't breathe!" one hour after the IV is initiatied? 1. Elevate the head of the bed and obtain vital signs. 2. Discontinue the IV and contact the primary health care provider. 3. Change the IV to an intermittent infusion device. 4. Contact the primary health care provider to obtain a prescription for a sedative.

1. Elevate the head of the bed and obtain vital signs.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. Which electrolyte imbalance is causing these clinical findings? 1. Hypokalemia 2. Hyponatremia 3. Hyperglycemia 4. Hypercalcemia

1. Hypokalemia

An older client is admitted to the hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? 1. Calcium 2. Chlorides 3. Potassium 4. Phosphates

3. potassium

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? 1. Pain 2. Coolness 3. Localized swelling 4. Cessation in flow of solution

2. coolness

Which length of time is the maximum that the nurse would allow an intravenous bag of solution to infuse? 1. 6 hours 2. 12 hours 3. 18 hours 4. 24 hours

4. 24 hours

The nurse is teaching a nursing student about caring for a client who is undergoing blood studies for antidiuretic hormone stimulation. Which statements made by the nursing student indicate effective instruction? Select all that apply. One, some, or all responses may be correct. 1. "I will assess the pulse rate after rehydrating the client." 2. "I will perform the test if the serum sodium level is high." 3. "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." 4. "I will hydrate the client with oral fluids before performing the test." 5. "I will discontinue the test if the client's weight loss is greater than 4.4 pounds (2 kg)."

1. "I will assess the pulse rate after rehydrating the client." 3. "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." 5. "I will discontinue the test if the client's weight loss is greater than 4.4 pounds (2 kg)."

Which action would the nurse take after identifying that a client's urinary output is less than 40 mL/h over the past 3 hours? 1. Assess breath sounds and obtain vital signs. 2. Decrease the intravenous flow rate and increase oral fluids. 3. Insert an indwelling catheter to facilitate emptying of the bladder. 4.. Check for dependent edema by assessing the lower extremities

1. Assess breath sounds and obtain vital signs.

Which nursing assessment would performed by a nurse before administering intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? Select all that apply. One, some, or all responses may be correct. 1. Urinary output 2. Deep tendon reflexes 3. Last bowel movement 4. Arterial blood gas results 5. Last serum potassium level 6. Patency of the intravenous access

1. Urinary output 5. Last serum potassium level 6. Patency of the intravenous access

Which indicator of client status is important for the nurse to assess in a client receiving total parenteral nutrition? 1. Blood glucose 2. Occult blood in stool 3. Urine specific gravity 4. Presence of bowel sounds

1. blood glucose

Which complication would the nurse suspect when the cardiac monitor shows the appearance of a U wave in a client being treated with intravenous fluids and insulin for diabetic ketoacidosis when the client develops peripheral paresthesias and shortness of breath? 1. Hypokalemia 2. Hypoglycemia 3. Hypernatremia 4. Hypercalcemia

1. Hypokalemia

Why would the nurse advise the client a client who takes furosemide and digoxin for heart failure to drink a glass of orange juice every day? 1. Maintaining potassium levels 2. Preventing increased sodium levels 3. Limiting the medications' synergistic effects 4. Correcting the associated dehydration

1. Maintaining potassium levels

Which statement about administration of IV potassium would a nurse make to a client with a diagnosis of hypokalemia? 1. Oliguria is an indication for withholding IV potassium. 2. Rapid infusion of potassium prevents burning at the IV site. 3. Clients with severe deficits should be given IV push potassium. 4. Average IV dosage of potassium should not exceed 60 mEq in 1 hour.

1. Oliguria is an indication for withholding IV potassium.

Which statement explains why an intravenous (IV) infusion of 50% glucose with regular insulin is prescribed to a client diagnosed with acute kidney failure secondary to dehydration? 1. To correct hyperkalemia 2. To increase urinary output 3. To prevent respiratory acidosis 4. To increase serum calcium levels

1. To correct hyperkalemia

Which clinical indicator would the nurse expect when an intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. 1. Heat 2. Pallor 3. Edema 4. Decreased flow rate 5. Increased blood pressure

2. Pallor 3. Edema 4. Decreased flow rate

Which factor is a likely cause of hyponatremia? Select all that apply. One, some, or all responses may be correct. 1. Diabetes insipidus 2. Profuse diaphoresis 3. Excess sodium intake 4. Removal of the parathyroid glands 5. Rapid intravenous (IV) infusion of 5% dextrose in water (D 5W)

2. Profuse diaphoresis 5. Rapid intravenous (IV) infusion of 5% dextrose in water (D 5W)

Which intervention is indicated for treatment of a client admitted to the hospital with a diagnosis of acute salmonellosis? 1. Cathartics 2. Electrolytes 3. Antidiarrheals 4. Antispasmodics

2. electrolytes

After reviewing the chart of a client recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately? 1. pain medication 2. intravenous fluids 3. multiple antibiotics 4. packed red blood cells

2. intravenous fluids

Which client problem would the nurse expect to decrease in response to the administration of serum albumin intravenously to a client with ascites? 1. Confusion 2. Urinary output 3. Abdominal girth 4. Serum ammonia level

3. abdominal girth

Which action will the nurse take when a client with an intravenous (IV) infusion containing 40 mEq of potassium reports a stinging pain at the IV site? Select all that apply. One, some, or all responses may be correct. 1. Restart the IV in a different vein. 2. Assist the client through guided imagery. 3. Assess the IV site. 4. Ask the health care provider for pain medication. 5. Verify that the potassium is adequately diluted and not infusing too rapidly.

3. assess the IV site 5. 5. Verify that the potassium is adequately diluted and not infusing too rapidly.

The nurse is planning care for a client with hyperparathyroidism and subsequent hypocalcemia and low bone density. Which information would the nurse provide the unlicensed assistive personnel (UAP) to prevent injury? 1. Record urinary output. 2. Document respirations. 3. Initiate cardiac monitoring. 4. Use a lift sheet for transfers.

4. Use a lift sheet for transfers.