Fluid and Electrolytes

A nurse is caring for a patient with renal failure on a medical surgical floor. The patient's potassium level is 6.0 on serum laboratory testing. The nurse is aware that this condition may be treated in which of the following ways? A. Dietary changes including increased intake of bananas and orange juice B. Intravenous administration of regular insulin and dextrose 50% solution C. Intravenous fluid infusion of lactated ringers with 20 mEq of potassium D. Potassium chloride supplements by mouth daily

B - Normal serum potassium levels are 3.5 to 5.0 - A potassium level of 6.0 or higher is called hyperkalemia - Potassium will be restricted when hyperkalemia is present, so no potassium supplements, foods high in potassium, or intravenous fluids containing potassium will be given - regular insulin that is given intravenously can reduce serum potassium levels and insulin will be given with dextrose 50% to prevent hypoglycemia

A client experiencing hyperkalemia is scheduled for dialysis. The nurse anticipates an order for what therapy to help drive potassium back into the cells prior to dialysis? A. Blood transfusion B. Insulin C. Antidiuretic hormone D. Potassium supplements

B Glucose and insulin are administered to the client with hyperkalemia to help drive potassium back into the intracellular fluid, reducing the amount of potassium in the blood.

Which fluid or electrolyte imbalance is best treated with dialysis? A. Hyperkalemia B. Fluid volume deficit C. Hyponatremia D. Blood loss

A Clients with hyperkalemia are treated with dialysis to remove excess potassium from the blood. Fluid volume deficit is treated with fluid. Blood loss is treated with blood transfusions or IV colloids. Hyponatremia is treated with sodium supplements.

The nurse is caring for a client with acute renal failure. When providing the dietary instruction, the nurse would evaluate that the client has understood the instructions when the client makes which statement? A. "I will avoid coffee, eggs, and rye toast." B. "I will avoid cereal with bananas and orange juice." C. "I will avoid tilapia, baked macaroni and cheese, and stewed tomatoes." D. "I will avoid meatloaf, green beans, and country biscuits."

B A client with renal failure should avoid foods high in potassium and sodium. Foods high in potassium include nonsalt seasoning mixed, potatoes, bananas, and orange juice.

An experienced LPN/LVN reports to you that a client's blood pressure and heart rate have decreased, and when his face is assessed, one side twitches. What action should you take at this time? A. Reassess the client's blood pressure and heart rate B. Review the client's morning calcium level C. Request a neurologic consult today D. Check the client's pupillary reaction to light

B A positive Chvostek sign is a neurologic manifestation of hypocalcemia

The nurse is administering a blood transfusion to a client who is hemorrhaging. The nurse identifies that the client is experiencing a deficit in which body fluid compartment? A. Transcellular fluid B. Intravascular fluid C. Intracellular fluid D. Interstitial fluid

B Blood loss causes a deficit in the intravascular fluid compartment, which is a subcompartment of extracellular fluid (ECF).

The nurse is caring for a client with a fluid volume deficit. Which nursing intervention addresses the client's potential for poor perfusion? A. Monitoring for signs of blood loss B. Assessing client's nail beds C. Administering whole blood D. Checking client's temperature

B Fluid and electrolyte balance is related to several nursing concepts, including perfusion, cellular regulation, and cognition. Fluid volume loss can lead to decreased perfusion, so the nurse should assess pulses, nail beds, and color to assure that perfusion is adequate.

A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report? A. Repeated episodes of nausea and vomiting B. Reports of pain associated with exertion C. Failure to eat all the food on the breakfast tray D. Client hair loss during the morning bath

A Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis.

How often should the nurse reposition a client with fluid volume deficit? A. Every 120 minutes B. Every 30 minutes C. Every 180 minutes D. Every 90 minutes

A The client with fluid volume deficit should be repositioned every 2 hours, or 120 minutes

The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. What should the nurse include in this teaching? (Select all that apply) A. Drink diet soda B. Drink more fluids during hot weather C. Drink flat cola or ginger ale if vomiting D. Exercise during the hours of 10 am and 2 pm E. Reduce the intake of coffee and tea

B,C,E Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea.

Which interventions would you include in a plan of care for a client with fluid volume excess? (Select all that apply) A. Reading food labels to note fiber content B. Elevating legs and feet when sitting C. Keeping track of how many cups of fluid they drink D. Reducing intake of caffeinated drinks E. Monitoring daily weight

B,C,E For a client with fluid volume excess, appropriate interventions would include monitoring fluid intake to stay within fluid restrictions; monitoring weight daily and reporting significant increases to the healthcare provider; and elevating the legs and feet to reduce dependent edema.

A client is admitted with end stage renal disease and a potassium level of 7.1. The nurse anticipates which medication prescription from the healthcare provider? A. Calcium gluconate 1.5 g IV B. Potassium 20 mEq IV C. Magnesium 1 gm IV D. Lactated ringers 500 mL IV bolus

A 7.1 is a critically high potassium level. Pharmacologic treatment includes calcium gluconate.

The nurse has just received a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. The nurse is reviewing the assignment and determines that which child is at greatest risk for dehydration? A. A 4-year-old child with a broken leg B. A 16-year-old child with migraine headaches C. A 10-year-old child with cellulitis of the left leg D. A 15-month-old child with tachypnea

D The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age experiencing tachypnea which increases insensible fluid loss.

During the summer, a 27-year-old construction worker presents to the emergency room with complaints of flank pain, extreme fatigue, and decreased urination. Initial assessment reveals a temperature of 100.3 F, blood pressure of 88/40, respirations of 22, and a heart rate of 116 beats per minute. Laboratory values reveal a potassium level of 5.4 and a sodium level of 150. the nurse recognizes that these findings likely indicate which of the following? A. Chronic renal insufficiency related to overhydration B. Fluid volume excess related to dehydration C. Heat exhaustion with possible acute renal failure D. Work-related back injury

C - Heat exhaustion is a risk factor in people who work in the heat and do not adequately rehydrate for fluid replacement

When caring for a client with hypervolemia and concurrent heart failure, the nurse identifies what sign that the client's condition is deteriorating? A. Irregular pulse B. Nonproductive cough C. Pink, frothy sputum D. Rapid heart rate

C - hypervolemia is excess fluid in the intravascular space. A bounding pulse and high blood pressure would be noted. If untreated, symptoms would progress to a productive cough and pink frothy sputum as the pressure increases in the lungs, resulting in pulmonary edema

The nurse is planning care for a client admitted for congestive heart failure who has a priority problem of fluid volume excess. What is occurring in the body that places the client at risk for retaining fluids? A. Impaired renal excretion of potassium B. Low serum osmolality level stimulates the thirst center C. Retention of water and sodium D. Decrease in ADH and aldosterone

C Fluid volume excess results from conditions that cause retention of water and sodium.

Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply) A. Checking fingerstick glucose results every hour B. Recording intake and output every hour C. Measuring vital signs every 15 minutes D. Assessing for indicators of fluid imbalance E. Notifying the provider of changes in glucose level

B,C The UAP's training and education includes how to measure vital signs and record intake and output.

The nurse is performing an assessment on a client who has had nothing by mouth since the previous evening. Which manifestation related to the client's fluid restriction would be of concern to the nurse? (Select all that apply) A. Edema B. Increased hematocrit C. Tenting skin D. Increased blood pressure E. Dry mucous membranes

B,C,E Oral fluid restriction can cause dehydration. The nurse should monitor for manifestations of dehydration such as dry mucous membranes, increased hematocrit, and tenting skin.

The nurse is completing discharge teaching with a client diagnosed with congestive heart failure. Which symptoms will the nurse teach the client to immediately report to the healthcare provider? (Select all that apply) A. Dizziness when standing B. Cough with increased sputum production C. Urine output of 320 mL in 8 hours D. Five-pound weight gain in a week E. Dry mouth

B,D The client with congestive heart failure is at risk for developing fluid volume excess. Weight gain of more than 5 pounds in a week and a cough with increased sputum production are indications of excess fluid volume, and the healthcare provider must be notified of these findings.

The nurse is reviewing the intake and output (I&O) records of a client. Which entry in the intake record would cause the nurse concern? (Select all that apply) A. Tube feedings B. Vomitus C. Parenteral fluids D. Tube drainage E. Intravenous medications

B,D Tube feedings, parenteral fluids, and intravenous medications should all be documented in the client's intake record. Tube drainage and vomitus should be documented in the client's output and would cause the nurse concern.

The nurse is caring for a hospitalized client who is experiencing anxiety-related hyperventilation. To account for the client's hyperventilation, when recording the client's fluid intake and output, the nurse should adjust the amount of fluid lost through which route? A. Urine B. Sweat C. Feces D. Insensible loss

D With increased respirations, the client will experience a greater-than-normal insensible loss of through the lungs.

A nurse working in the pediatric ICU is admitting a 16-year-old patient with type 1 diabetes mellitus who presents with complaints of elevated blood glucose, hot and dry skin, and polyuria. Urinalysis reveals glucosuria and ketonuria. Upon physical assessment of the patient, the nurse notes that the eyes appear sunken and the patient has poor skin turgor. The nurse recognizes the patient will likely be treated for which of the following? A. Dehydration related to diabetic ketoacidosis (DKA) B. Dehydration related to hyperglycemic hyperosmolar nonketotic syndrome (HHNS) C. Fluid volume excess related to hyperglycemic hyperosmolar nonketotic syndrome (HHNS) D. Volume overload related to diabetic ketoacidosis (DKA)

A - Patients with type 1 diabetes mellitus may experience diabetic ketoacidosis (DKA) when there is insufficient insulin to transport glucose into cells for energy. - This condition can lead to fluid volume depletion due to polyuria as the kidneys attempt to filter glucose from the bloodstream. - Cells are unable to get glucose for energy production due to lack of insulin. This causes the body to break down fat and protein for energy. The by-products of this process are ketones which make the blood acidic. - Patients with type 2 diabetes mellitus still produce some insulin in the pancreas so DKA does not occue in these patients.

The nurse is reviewing client data to begin planning care. Which client is at greatest risk for developing fluid volume excess? A. A client admitted for cirrhosis B. A client admitted for nausea and vomiting C. A client admitted for oral surgery D. A client admitted for overuse of laxatives

A A client admitted for liver cirrhosis is at greatest risk for developing fluid volume excess.

A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately? A. Respiratory rate of 8 to 10 breaths per min B. Decrease in pain level from 6 to 2 on scale of 10 C. Request by the client that the room door be closed D. Heart rate of 90 to 100 beats per min

A A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis.

A home health nurse is seeing a client with congestive heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium. which was 3.4 mEq/L. Which food would the nurse encourage this client to choose from the dinner menu? A. Banana B. Peas C. Baked fish D. Iced tea

A A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is banana.

A client is admitted for diarrhea. Which laboratory value indicates that the client is experiencing dehydration? A. Hematocrit 57% B. Urine specific gravity 1.000 C. Hemoglobin 9.0 g/dL D. Sodium 132 mEq/L

A An elevated hematocrit indicates dehydration caused by intravascular volume loss and hemoconcentration.

An elderly client is admitted to the hospital after a fall. The client appears intermittently confused. What is a primary concern of the nurse regarding fluid and electrolytes when caring for this client? A. Risk of dehydration B. Risk of bleeding C. Risk of kidney damage D. Risk of stroke

A As an adult ages, the thirst mechanism declines. In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality.

The nurse is reviewing the medication record of a client admitted with dehydration. Which medication would cause the nurse concern? A. Benzodiazepine B. Nonsteroidal anti-inflammatory drug (NSAID) C. Vasodilator D. Selective serotonin reuptake inhibitor (SSRI)

A Clients with dehydration are likely to develop electrolyte imbalances as the body attempts to compensate for the lost fluid. Benzodiazepines are associated with electrolyte imbalances and would cause the nurse concern since they could worsen the client's electrolyte imbalances.

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism

A Crohn's disease is a risk factor for hypocalcemia. This malabsorption disorder places the client at risk for hypocalcemia due to inadequate calcium absorption

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with diabetic ketoacidosis

The nurse is planning care for a client admitted for dehydration. Which assessment findings indicates that current interventions are not improving the client's hydration status? A. Hypotension B. Warm, dry skin C. Urine output of 40 mL/hr D. Weight gain of 1.2 kg

A Hypotension indicates hypovolemia. This assessment finding would indicate that the client's status is not improving.

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate

A Hypotonic IV fluids, such as 0.225% sodium chloride, are indicated for the treatment of hypernatremia related to fluid loss to expand the ECF volume and rehydrate the cells

What is the result of the fluid in third spacing? A. Fluid from the vascular space becomes unavailable for physiological functioning B. Fluid is excreted from the body through stimulation of urine production C. Fluid shifts into the subcutaneous tissue D. Fluid returns to the intracellular space

A In third spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may locate into the peritoneal space or pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss attributable to third spacing may be difficult to detect because the client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.

The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? A. Flattened neck veins when the client is in the supine position B. Full and bounding pedal and post-tibial pulses C. Pitting edema located in the feet, ankles, and calves D. Shallow respirations with crackles on auscultation

A Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position.

A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-moth-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Which nurse response is most appropriate? A. "You should bring the infant in to be seen by the doctor." B. "Give your baby at least 2 ounces of juice every 2 hours." C. "Measure your baby's urine output for 24 hours and call back tomorrow." D. "Give your baby 50 mL of glucose water every hour."

A Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation.

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP? A. Providing oral care every 3 to 4 hours B. Monitoring for indications of dehydration C. Administering 0.45% saline by IV line D. Assessing daily weights for trends

A Providing oral care is within the scope of practice of the UAP

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should you expect to correct this problem? A. Increase in ventilator rate from 6 to 10 breaths per min B. Decrease in ventilator rate from 10 to 6 breaths per min C. Increase in oxygen concentration from 30% to 40% D. Decrease in oxygen concentration from 40% to 30%

A The blood gas component responsible for respiratory acidosis is carbon dioxide. Increasing the ventilator rate will blow off more carbon dioxide and decrease the acidosis.

A client's potassium level is 6.7. Which intervention should you delegate to the first-year student nurse who you are supervising? A. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally B. Administer spironolactone (Aldactone) 25 mg orally C. Assess the electrocardiogram (ECG) strip for tall T waves D. Administer potassium 10 mEq orally

A The client's potassium level is high. Kayexalate removes potassium from the body through the gastrointestinal system

An 86-year-old client is brought to the Emergency Department from a long-term care facility. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. The nurse would interpret this finding to be consistent with which of the following? A. Dehydration B. Normal changes of aging C. Fluid overload D. Congestive heart failure

A The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration.

A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Hypotension

A The nurse should assess for ECG changes. Potassium levels can affect the heart and result in arrhythmias

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an overdose of sodium bicarbonate antacids

A The nurse should identify that a client who has nasogastric suctioning is at risk for hypovolemia due to excessive gastrointestinal losses.

A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A Three tap water enemas can result in a decrease in serum sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution

A nurse is unable to secure an intravenous access site due to severe dehydration. Which order does the nurse anticipate receiving from the healthcare provider? A. Hypodermoclysis B. Diuretics C. Sodium supplements D. Oral fluid replacement

A When IV access is problematic, fluids can be administered subcutaneously, a method called hypodermoclysis.

The nurse is providing education to a group of volunteers who are planting trees in a city part on a hot, sunny day. What teaching should the nurse provide about avoiding heat-related illness? (Select all that apply) A. Avoid participating in the tree planting if ill B. Wear lightweight clothes C. Take frequent rest breaks D. Older adults are at less risk E. Drink water when they feel thirsty

A,B,C Individuals should take frequent rest and water breaks, and wear lightweight clothes to avoid heat-related illness. Those who are ill are at greater risk for heat-related illness, so they should avoid participating. Individuals should drink water before they feel thirsty, not just when they feel thirsty. Older adults and small children are at greater risk for heat-related illness

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply) A. Reminding the client to avoid commercial mouth-washes B. Encouraging mouth rinsing with warm saline C. Observing the lips, tongue, and mucous membranes D. Providing mouth care every 2 hours while the client is awake E. Seeking a dietary consult to increase fluids on meal trays

A,B,C,D The LPN/LVN scope of practice and educational preparation includes oral care and routine observation.

A 6-month-old infant is admitted with severe dehydration. Effectiveness of therapy is evaluated with which of the following assessment measures? (Select all that apply) A. Level of consciousness B. Mucous membrane assessment for moisture C. Intake and Output D. Abdominal girth E. Daily weights

A,B,C,E All of the choices represent assessment measures that measure the effectiveness of therapy except abdominal girth, which does not provide information regarding hydration status.

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes, temperature 38.5 C, pulse 92/min, respirations24/min, skin cool with tenting present, and blood pressure of 102/64 mm Hg. Urine is concentrated with a high specific gravity. Which of the following are manifestations of fluid volume deficit for which the nurse should monitor? (Select all that apply) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A,B,D,E All these represent fluid volume deficit

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1 + bilateral edema of the lower extremities. The client has temperature of 37.2 C, pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A,B,D,E All these represent fluid volume excess

The nurse is providing care to a client who is exhibiting clinical manifestations of severe fluid and electrolyte imbalance. Based on this data, which health care provider prescriptions does the nurse prepare to implement? (Select all that apply) A. Initiate hypodermoclysis B. Initiate intravenous therapy C. Administer antibiotics D. Administer red blood cells E. Administer diuretics

A,B,E Intravenous fluids may be ordered for the client with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults.

An emergency room nurse is assessing a client who overhydrated during a marathon. Which assessment is essential for the nurse to perform during the physical examination? (Select all that apply) A. Level of consciousness B. Teeth C. Lung sounds D. Blood pressure E. Eye accommodation

A,C,D The client with water intoxication is experiencing a fluid volume excess and likely low electrolyte levels. Measuring blood pressure, auscultating lung sounds, and assessing level of consciousness are all priority assessments for the nurse to perform.

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (Select all that apply) A. Hct 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 mEq/L D. Urine specific gravity 1.035 E. Serum creatinine 0.6 mg/dL

A,C,D These levels are all high therefore they indicate dehydration

A patient with chronic renal failure on dialysis is being cared for by a nurse on the renal floor. A review of morning laboratory results reveals a serum calcium level of 8 mg/dL and hyperphosphatemia. The patient has complaints of pruritus. Which of the following are appropriate interventions? (Select all that apply) A. Administer aluminum hydroxide with meals, as ordered B. Hold the patient's dose of sodium bicarbonate C. Provide frequent skin care with emollient skin cream D. Provide high-protein meals E. Restrict intake of milk, soda, and beans

A,C,E -Normal calcium levels are 9.0 to 10.5 -Normal phosphate levels are 3.0 to 4.5 -An increased phosphate level can cause pruritus (skin itching). Appropriate nursing interventions include frequent skin care with the application of emollient skin creams to reduce itching -Meals with low protein and low phosphorus should be provided due to decreased kidney function. Beans, milk, chocolate, and soda contain phosphorus and should be avoided, as well as certain high protein foods that are high in phosphorus such as milk, yogurt, cheese, dried beans, nuts, seeds, soy and peanut butter. -Aluminum hydroxide (Amphojel) should be administered with meals to help bind phosphate in the gastrointestinal tract, contributing to lower phosphate levels.

A client who has experienced a burn injury over 40 percent of the body is at risk for acute tubular necrosis. What will the nurse do to prevent renal failure in this client? (Select all that apply) A. Maintain adequate fluid balance B. Reduce sodium intake C. Maintain blood pressure D. Increase fluids to prevent crystal formation E. Prevent infection

A,C,E Acute tubular necrosis results from burns and hypovolemia sepsis. The nurse should prevent ischemia by maintaining blood flow to the kidney and prevent hypotension and infection. Because sodium and water are lost in equal amounts, there is no need to limit sodium intake. The nurse does not increase fluids without an order; however, fluid resuscitation in a burn client is carefully calculated to prevent kidney failure

The nurse is caring for a client who is experiencing diarrhea. Which data indicates that the client is experiencing fluid volume deficit? (Select all that apply) A. Poor skin turgor B. Weight gain C. Orthostatic hypotension D. Increased urine output E. Increased heart rate

A,C,E Orthostatic hypotension, increased heart rate, and poor skin turgor are acute manifestations of fluid volume deficit.

The nurse is caring for a client with hyponatremia. What are independent interventions that the nurse can perform to help manage the client's electrolyte imbalance? (Select all that apply) A. Monitor intake and output B. Administer intravenous sodium C. Administer oral sodium supplements D. Weigh client daily E. Involve client in meal planning

A,D,E Monitoring intake and output, weighing the client daily, and involving the client in meal planning are all independent interventions that the nurse can perform to help manage the client's hyponatremia.

The nurse caring for a client preparing to undergo hemodialysis will include which in the plan of care? (Select all that apply) A. Obtain weight and orthostatic vital signs B. Determine urine specific gravity and pH. C. Restrict fluid and protein intake D. Monitor serum creatinine, BUN, and hematocrit levels E. Assess blood pressure of extremity where fistula has been created

A,D,E Weight and orthostatic vital signs are indicators of fluid volume status and electrolyte balance. Laboratory tests are monitored to evaluate the effects of treatment. Restriction of fluid and food during dialysis is not necessary and may contribute to decreased fluid volume. The client does not produce urine to be tested. Blood pressure is never taken in the arm where the fistula is placed.

What are the some of the methods by which body fluids move across fluid compartments? (Select all that apply) A. Osmosis B. Third spacing C. Compensation D. Hypoperfusion E. Filtration

A,E Compensation is the body's attempt to adjust for a fluid and electrolyte imbalance. Hypoperfusion is decreased blood flow through an organ. Third spacing is a shifting of fluid into interstitial spaces. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure.

A nurse is caring for a patient with chronic kidney disease who receives hemodialysis. The routine daily laboratory studies reveal a potassium level of 5.2 mEq/L. The nurse knows the patient is at risk for which of the following? A. Auditory halluciantions B. Bradycardia and ventricular fibrillation C. Hypersensitivity of hands and feet D. Increased appetite and dysphagia

B - Patients with hyperkalemia may exhibit bradycardia with widened QRS waveform on EKG and may develop ventricular fibrillation - Hyperkalemia may cause numbness and tingling of the fingertips and numbness around the mouth. Nausea, vomiting, and abdominal cramps may also occur with hyperkalemia

The nurse on the renal floor is caring for a diabetic patient. A bedside blood glucose check revealed a blood glucose of 322 mg/dL. The nurse prepares to administer 4 units of regular insulin subcutaneously as ordered on the insulin sliding scale. Prior to administering the dose of insulin, the nurse should do which of the following? A. Administer the insulin intramuscularly (IM) instead of subcutaneously, so the blood glucose will decrease more quickly B. Draw up the ordered dose of insulin and have it verified by a second nurse C. Give the patient 4 ounces of apple juice while administering the insulin, so that the blood glucose will not drop too quickly D. Immediately administer the insulin dose since the blood glucose is at a critically high level

B - When a diabetic patient with elevated blood glucose requires insulin, the nurse must always have the insulin does verified by a second nurse

A nurse is caring for a patient scheduled for heart valve surgery the next day. The patient has been on Coumadin and has an INR of 2.3 on daily laboratory work. The provider wants the INR <2.0 prior to surgery and has ordered vitamin K IM. Which of the following interventions can the nurse perform to assist in reaching the INR goal? A. Administer an extra dose of Coumadin to prevent the vitamin K from making the blood too thick B. Encourage the patient to eat a green leaf salad or spinach with the evening meal C. Have the patient drink orange juice and eat bananas to increase potassium intake D. Increase the room temperature to prevent cold air from thinning the blood

B -Patients who require Coumadin to thin the blood may need the effect to be counteracted if the blood is too thin prior to surgical procedures -Vitamin K is the antidote for Coumadin. Green leafy vegetables are a good source of vitamin K and can reduce the effects of Coumadin when eaten -Vitamin K should not be confused with potassium because potassium will have no effect on the thickness of the blood -Though the patient will be NPO for 6-8 hours before surgery, NPO will not begin until midnight.

An 87-year-old patient is admitted to the cardiac telemetry floor for exacerbation of congestive heart failure (CHF). The nurse assesses the patient and finds 3+ pitting edema to the lower extremities. Besides fluid intake restriction, the nurse should implement which of the following interventions? A. Assist patient to sit in the beside chair with feet firmly on the floor B. Assist patient with frequent position changes throughout the shift and keep feet elevated C. Ensure the patient has at least 3 grams of dietary sodium intake daily D. Remove compression socks to ensure skin gets enough air exposure

B -Patients with congestive heart failure (CHF) in exacerbation have fluid volume excess -In a patient with right-sided heart failure, the edema is seen peripherally, in the extremities and organs. In left-sided heart failure, the fluid backs up into the lungs, causing impaired gas exchange and breathing difficulties -These right-sided heart failure patients often have lower extremity edema. This swelling can make the legs sore and tender. The nurse can assist the patient to keep the legs elevated to help reduce swelling -These patients should also maintain a diet with less than 2 grams of sodium intake in 24 hours

An emergency room nurse is evaluating laboratory results of a 62-year-old patient who presented to the ED with complaints of shortness of breath for 2 days. The nurse notes that the troponin level is 1.26 which indicates which of the following? A. The patient's shortness of breath is likely related to asthma B. The patient's shortness of breath is likely related to cardiac injury C. The patient's shortness of breath is likely related to gastric reflux D. The patient's shortness of breath is likely related to pneumonia

B -When a patient presents to the ER with complaints of shortness of breath, serum cardiac enzymes will be evaluated. Cardiac enzyme laboratory panels include several different markers that may indicate muscle damage including CK-MB, CK, and troponin -Ck-MB and troponin are cardiac muscle-specific enzymes. Troponin levels will remain elevated in the presence of cardiac muscle damage for up to 15 days after the injury -Troponin levels will be less than 0.01 in patients without cardiac injury

Which nursing actions are instituted for the client with kidney trauma? A. Observe urine for oliguria and proteinuria B. Observe for hypertension and check urine for hematuria C. Monitor vital signs for hypotension and bradycardia D. Monitor level of consciousness and urine output

B Damage to the kidney resulting in reduced renal perfusion will stimulate the renin-angiotensin system causing hypertension and reducing the ability of the kidney to prevent blood from escaping into the urine.

The nurse is caring for a client admitted for dehydration. What assessment finding indicates a loss of fluid over a period of time? A. Bradycardia B. Dry, sticky mucous membranes C. Polyuria D. Increase in tongue size

B Dry, sticky mucous membranes are an assessment finding indicating fluid loss over an extended period of time.

The nurse is caring for a client with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia. The client is on multiple medications. Which medication may have contributed to the client's current hypokalemic state? A. Demerol B. Cortisol C. Skelaxin D. Hydrochlorothiazide

B Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia.

The nurse is caring for an elderly client who has been receiving intravenous fluids at 150 mL/hr. The nurse assesses that the client has crackles, shortness of breath, and jugular vein distention. The nurse would recognize these findings as an indication of which complication of IV fluid therapy? A. Pulmonary embolism B. Fluid volume excess C. An allergic reaction D. Speed shock

B Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly.

The nurse is reviewing laboratory values for a client with hyperthyroidism. Which component of the complete blood count will be most useful to the nurse in determining the client's fluid status? A. Platelet count B. Hematocrit C. White blood cell count D. Red blood cell count

B Hematocrit (Hct) and hemoglobin (Hb) are useful in assessing a client's fluid status because they are influenced by plasma volume. Hct and Hb values are high with dehydration (as may occur with uncontrolled hyperthyroidism) and low with overhydration.

The nurse is planning care for a client admitted to the unit with dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines an appropriate nursing diagnosis to be electrolyte imbalance. Which condition is known to result in fluid loss that is characterized by a proportionately greater loss of sodium than water? A. Hydrostatic pressure B. Hypotonic dehydration C. Osmotic pressure D. Isotonic dehydration

B Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels.

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response? A. It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing B. The client may have a metabolic alkalosis due to the NG suctioning., and the decreased respiratory rate is a compensatory mechanism C. Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem D. The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis

B Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide.

The nurse evaluates client teaching as effective when the client recovering from acute renal failure states: A. "I will consume only vegetable proteins." B. "I will avoid taking drugs that may be nephrotoxic." C. "I will self-catheterize for residual urine at least once a week." D. "I will limit my intake to 1500 mL or less per day."

B Nephrotoxic drugs, including over-the-counter products, can produce further damage to the kidney cells and should be avoided.

A client is being seen in the Emergency Department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The physician has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have been successful? A. 25 mL per hour B. 40 mL per hour C. 20 mL per hour D. 30 mL per hour

B Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour.

Which blood test result would you be sure to monitor for the client taking HCTZ? A. Sodium level B. Potassium level C. Chloride level D. Calcium level

B Postassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly

A client is admitted to the emergency department with hypovolemia. Which intravenous solution would the nurse anticipate administering? A. 10% dextrose in water B. Ringer's solution C. 0.45% sodium chloride D. 3% sodium chloride

B Ringer's solution is an isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance. Hypertonic solutions such as 10% dextrose and 3% sodium chloride pull interstitial and intracellular fluid into the vascular system, leading to cellular dehydration. A hypotonic solution such as 0.45% sodium chloride may be used to treat cellular dehydration.

You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? A. Sodium B. Potassium C. Magnesium D. Calcium

B Suspect hyposkalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves

The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths per min. Which acid-base imbalance should you suspect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis

The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. The nurse understands that it is priority to monitor the client for manifestations of which imbalance? A. Hyperkalemia B. Fluid overload C. Fluid deficit D. Hypernatremia

B The client receiving intravenous (IV) colloids or any IV fluid is at risk for fluid overload. It is therefor important to monitor the client for manifestations of fluid overload.

As the charge nurse, you would assign which client to the step-down unit nurse floated to the intensive care unit for the day? A. 68-year-old on a ventilator with acute respiratory failure and respiratory acidosis B. 72-year-old with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent C. Newly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip D. 38-year-old on a ventilator with narcotic overdose and respiratory alkalosis

B The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group

A client in the Emergency Department is being admitted for fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A. Genitourinary B. Gastrointestinal C. Musculoskeletal D. Cardiovascular

B The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage.

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites

B The nurse should anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 30 mL/hr D. Encourage independent ambulation four times a day

B The nurse should include obtaining the client's weight each day in the plan of care. To ensure accuracy the client's weight should be obtained at the same time each day using the same scale. By determining the client's weight gain or loss each day the nurse can evaluate the client's response to treatment

When engaging the client in the plan of care for end stage renal disease, to what should the nurse pay particular attention? A. Weighing client daily B. Meal planning when dietary modifications are required C. Monitoring input and output D. Medication regimens and their side effects

B The nurse should involve the client in meal planning if dietary modifications are required. The nurse can provide education about medication regimens, but the client is not usually involved in planning these regimens. Weighing the client and monitoring input and output are interventions carried out by the nurse, with little involvement by the client.

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypomagnesemia

B The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium

A client is admitted with a serum sodium level of 140 mEq/L, hematocrit level of 31%, and generalized edema. Which priority intervention is indicated for this client? A. Encourage the client to drink ginger ale B. Restrict fluid intake C. Increase sodium intake in the diet D. Prepare to administer a blood transfusion

B This client is experiencing fluid volume excess. Therefore, the priority nursing intervention is restricting fluid intake.

The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? A. Administering IV fluids as prescribed by the physician B. Providing straws and offering fluids between meals C. Developing a plan for added fluid intake over 24 hours D. Teaching family members to assist the client with fluid intake

B UAPs can reinforce additional fluid intake once it is part of the care plan.

After a client has returned from surgery, the nurse needs to report which urinary output? A. 300 mL per 8 hours B. 20 mL per hour C. 40 mL per hour D. 400 mL per 8 hours

B Urine output of less than 30 mL/hr should be reported, specifically urine output less than 30 mL/hr on average over a 4-hour period of time.

Mrs. Rivera reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which assessment would you expect to not with Mrs. Rivera? A. Warm, flushed skin B. Tachycardia C. Ascites D. Dyspnea

B When a client experiences a deficiency in fluid volume, the heart rate will increase (tachycardia) in an attempt to improve circulation.

The nurse caring for a client with acute hypernatremia includes which of the following in the plan of care? (Select all that apply) A. Limit length of visits B. Conduct frequent neurologic checks C. Restrict fluids to 1500 mL per day D. Maintain intravenous access E. Orient to time, place, and person frequently

B,D,E Frequent neurological checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function as can rapid correction of hypernatremia. Fluid replacement is the primary treatment for hypernatremia. Maintaining intravenous access is necessary for administration fluids and possible emergency medications. There is no reason to limit visit length.

The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? (Select all that apply) A. Take this medication in the morning B. This medication should be taken in 2 divided doses when you get up and when you go to bed C. Eat foods with extra sodium every day D. Inform you prescriber if you notice weight pain or increased swelling E. You should expect your urine output to increase

B,D,E HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so you should teach the client about eating foods rich in potassium.

A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocoricoids. Which of the following findings should the nurse expect? (Select all that apply) A. Hyperreflexia B. Confusion C. Positive chvostek's sign D. Bone pain E. Nausea and vomiting

B,D,E The nurse should expect the client who has hypercalcemia to have confusion and a possible decreased level of consciousness. The nurse should expect the client who has hypercalcemia to have bone pain. The nurse should expect the client who has hypercalcemia to have nausea and vomiting along with anorexia

A client with chronic renal failure has been prescribed diuretics. What are some important nursing activities for this client's care? (Select all that apply) A. Check for swallowing problems B. Check hydration status C. Monitor client for anxiety D. Check temperature regularly E. Monitor intake and output

B,E Temperature alteration, anxiety, and swallowing disorders are not normally associated with the administration of diuretics. The accurate measurement of intake and urine output is significant since diuretics increase urine excretion of both water and electrolytes. Understanding Diuretics can affect hydration status.

A nurse in the medical ICU is caring for a patient with liver failure related to cirrhosis. Physical assessment reveals increasing ascites. The nurse reviews the patient's daily laboratory results and notes the albumin level is 2.9g/dL. Which of the following would be an appropriate action? A. Encourage the patient to remain supine in bed to prevent development of dependent pedal edema B. Monitor dietary intake to help maintain a diet low in calories C. Notify the doctor of the albumin level and increasing ascites D. Place the patient in Trendelenburg position to redistribute ascites fluid and release pressure against the gastrointestinal tract

C -Normal Albumin range: 3.5 - 5.0g/dL -Patients with cirrhosis and liver failure often have low albumin levels. Albumin is the measurement of protein in the bloodstream. These patients often have dietary needs for increased protein. -Ascites (abdominal fluid retention) is a common occurrence in cirrhosis and liver failure and can lead to physical discomfort. Patients withs ascites should be maintained in an upright position with the head of the bed elevated to at least 45 degrees. This will reduce shortness of breath from the abdominal fluid restricting the diaphragm during respiration.

A nurse on the postpartum floor is caring for a new mother of twins. Review of daily laboratory results reveals a hemoglobin of 8.6 and hematocrit of 24.8. The doctor has ordered the supplement ferrous sulfate (iron) 325 mg by mouth daily for six weeks. The nurse is giving the patient discharge instructions. The nurse should include which of the following when discussing the iron supplement? A. Advise patient that iron supplements should be taken with a glass of milk. B. Advise the patient that iron supplements may cause diarrhea and light brown stools C. Advise the patient that iron supplements should be taken with orange juice. D. Advise the patient to take iron supplements at the same time as calcium supplements daily

C -Patients with reduced hemoglobin and hematocrit who are started on iron supplements should be given instructions to know how to properly take these supplements to increase absorption so that more red blood cells are produced -Ferrous sulfate (iron) supplements should be taken with orange juice or vitamin C to increase absorption -Iron supplements may cause constipation and dark brown or black stools -Iron supplements should not be taken with milk or calcium as this prevents absorption in the GI tract

The nurse is assessing a difficult-to-obtain blood pressure with a manual cuff. After inflating it and listening for a while, the nurse immediately tries again. During the second attempt, while the cuff is still inflated, the patient's hand and forearm spasms and the fingers adduct involuntarily. The nurse recognizes this sign as a possible sign of which of the following? A. Hypercalcemia B. Hypermagnesemia C. Hypocalcemia D. Hypokalemia

C -Trousseau sign of latent tetany is sign seen in patients with hypocalcemia. This sign is believed to be more sensitive an indicator than the Chvostek sign -To see the sign, you must inflate a blood pressure cuff for a couple minutes to occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and resulting neuromuscular irritability will induce the spasm of the hand and forearm

The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? A. "The client's low phosphorus is probably due to malnutrition" B. "The client is just worn out from not getting enough rest" C. "The client's skeletal muscles are weak because of the low phosphorus" D. "The client will do more for himself when his phosphorus level is normal"

C A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown. Phosphate is necessary for energy production in the form of ATP, and when not produced, leads to generalized muscle weakness.

The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is 2.0 mg/dL. The nurse is planning care for this client. Which nursing intervention would address this client's phosphorus level? A. Enforce contact precautions B. Encourage consumption of a high-calorie carbohydrate diet C. Encourage consumption of milk and yogurt D. Strain all urine

C A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus.

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should anticipate which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

C A potassium level of 5.2 mEq/L indicates hyperkalemia. The nurse should anticipate the initiation of continuous cardiac monitoring due to the client's risk for dysrhythmias such as ventricular fibrillation

You are administering intravenous crystalloid solutions to 26-year-old Marco Ramirez, who suffered severe heat exhaustion at an outdoor concert. Mr. Ramirez asks, "What is this stuff you're giving me?" What is the best response for you to give to Mr. Ramirez? A. "I'm giving you a solution that has proteins in it. It will help replace the fluid you lost." B. "I'm giving you a solution with a drug that will keep you from losing water." C. "I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." D. "I'm giving you a solution that is a lot like your blood. It will replace the fluid you lost."

C Crystalloid solutions are given IV to clients like Mr. Ramirez who have lost fluids from excessive sweating, inadequate intake, or insensible water loss. Crystalloid solutions mimic the body's extracellular fluid and replace lost fluids.

The nurse is teaching a group of children and their parents about the importance of exercise. The topic for this specific session is preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught? A. "My child only needs to hydrate at the end of an exercise session." B. "Water is the drink of choice to replenish fluids that are lost during exercise." C. "I will have my child stop every 15-20 minutes during the activity for fluids." D. "It is important for my child to wear dark clothing while exercising in the heat."

C During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? A. Assist the client to turn, cough, and deep breathe every 2 hours B. Irrigate the client's Foley catheter daily C. Assist the client to ambulate around the room at least three times daily D. Measure vital signs every 8 hours

C Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.

Laboratory results for a client shoe a serum potassium level of 2.2 mEq/L. Which of the following nursing actions is of highest priority for this client? A. Initiate seizure precautions B. Start oxygen at 2 L/min C. Initiate cardiac monitoring D. Keep the client on bed rest

C Hypokalemia affects nerve impulse transmission, including the transmission of cardiac impulses. The client may develop ECG changes and atrial or ventricular dysrhythmias. Although hypokalemia can lead to muscle weakness and activity intolerance, bed rest fenerally is unnecessary. Starting oxygen would be appropriate only if the client is in respiratory distress. The client is more likely to experience cardiac arrest, not seizures; in any case, the priority is cardiac monitoring. The client is not hypoxic, so oxygen is not needed.

What is the most important nursing interventions to prevent acute renal failure in a critically ill client? A. Assessing for a history of diabetes or systemic lupus erythematosus B. Avoiding all potentially nephrotoxic drugs C. Maintaining fluid volume and cardiac output D. Administering antihypertensive drugs

C Ishemia is the most common cause of acute renal failure (ARF); therefore, maintaining fluid volume, cardiac output, and renal output are the highest priority nursing interventions to prevent renal failure.

The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte imbalances, which question is most important for the nurse to ask? A. "Describe your anxiety level on a typical day." B. "Are you currently being treated for joint problems?" C. "Describe what you eat and drink on a typical day." D. "Have you recently had a cold?"

C It is important for the nurse to consider socioeconomic factors affecting food and fluid intake when assessing a client's risk for fluid and electrolyte imbalances, especially with a vulnerable population like the homeless. Asking a client to describe a typical day's food and fluid intake will help the nurse determine if a client's oral intake is adequate.

The healthcare provider ordered a diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. The nurse recognizes that this medication is part of what class of diuretics? A. Thiazide B. Osmotic C. Loop D. Potassium sparing

C Loop diuretics inhibit sodium and chloride reabsorption in the ascending loop of Henle.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia

C SIADH causes a relative sodium deficit due to excessive retention of water

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm B. Place the stethoscope bell over the client's carotid cheek C. Tap lightly on the client's cheek D. Ask the client to lower her chin to her chest

C The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of her face.

The nurse is caring for a client receiving a blood transfusion. Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. Which is the priority intervention for this client? A. Notify the client's physician B. Decrease the rate of the transfusion C. Discontinue the transfusion D. Prepare to resuscitate the client

C The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued.

When ADH and aldosterone are secreted, what change occurs in the body? A. Intracellular fluid is depleted B. Urine output is increased C. Sodium and water are retained by the kidneys D. Third-space shifting occurs

C The release of ADH and aldosterone causes sodium and water to be retained by the kidneys. The secretion of ADH and aldosterone are part of the renin-angiotensin-aldosterone system.

When caring for a client with acute renal failure, the nurse would plan which treatment goal for the client? A. Maintain adequate nutrition by encouraging a high-protein and high-calorie diet B. Increase fluids to prevent nephrolithiasis C. Compensate for renal impairment by restoring fluid balance D. Prevent infection by administering antibiotics

C The treatment goals for acute renal failure include identifying and correcting underlying cause, preventing kidney damage, restoring urine output and kidney function, and compensating for renal impairment.

The student nurse is assisting the nurse in administering intravenous normal saline to a dehydrated client. The nurse explains to the student that active transport is essential in maintaining sodium and potassium ion concentrations in the body's fluid compartments. The student asks how active transport differs from other transport processes. What is the best response by the nurse? A. "Unlike diffusion, active transport moves solutes from a solution with a higher concentration of solutes to a less concentrated solution." B. "Unlike diffusion, active transport moves water from a solution with a lower concentration of solutes to a more concentrated solution." C. "Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." D. "Unlike diffusion, active transport moves water from a solution with a higher concentration of solutes to a less concentrated solution."

C Unlike diffusion, active transport moves solutes against their concentration gradients from a solution with a lower concentration to a more concentrated solution.

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

C,D,E These are all expected findings of hypovolemia

The nurse is planning care for a client who has congestive heart failure and is experiencing generalized edema. Which interventions will the nurse plan for the client who is at risk for altered skin integrity secondary to edema? (Select all that apply) A. Observing mental status B. Obtaining daily weight C. Turning the client every 2 hours D. Instructing the client to stand slowly E. Monitoring for evidence of skin breakdown

C,E Turning the client every 2 hours and monitoring for evidence of skin breakdown are nursing interventions to prevent alterations in skin integrity.

A nurse on the medical surgical floor is caring for a patient who is postoperative day 5 after 2-vessel coronary artery bypass graft. Upon reviewing the patient's daily laboratory results, the nurse notes that the serum creatinine level is 1.9 mg/dL, and the BUN level is 32 mg/dL. The nurse reviews the patient's urine output which was 630 mL over the last 24 hours. Which of the following should the nurse do next? A. Ask the patient if they have a history of kidney problems in the past B. Continue to monitor the patient's urine output because increasing creatinine and BUN is normal after surgery C. Continue to monitor the patient's urine output since the doctor should be aware of the patient's renal function D. Review serum creatinine and BUN levels that were done prior to surgery to determine if these are new findings

D - BUN 10-20 mg/dL - Creatinine 0.6-1.3 (male), 0.5-1.1 (female) - A postoperative patient with elevated creatinine and BUN should have their preoperative blood work evaluated to determine if the issue was present prior to surgery. If the patient had normal renal function prior to surgery, the nurse should notify the doctor of the changes - Informing the doctor quickly of any changes to renal functioning is very important to implement treatments to prevent long-term or permanent kidney damage

The nurse is caring for a patient with hypermagnesemia. She expects the physician to order which of the following to correct the condition? A. Calcium citrate B. Loop diuretics C. Magnesium citrate D. Oral and IV fluids

D - Encouraging fluid and administering IV fluids will promote natural diuresis, which will promote excretion of excess magnesium by the kidneys.

A nurse on the medical-surgical floor is caring for a patient with acute renal failure. While assessing the patient, the nurse notes cold, clammy skin and a rapid pulse. The patient has complaints of twitching and dizziness. The nurse then reviews the patient's laboratory results and notes a sodium level of 125. The nurse knows which of the following to be true? A. Hypernatremia can be treated with hypertonic IV fluid infusion B. Hypernatremia is common in acute renal failure patients due to excessive urinarion C. Hyponatremia can be treated with hypotonic IV fluid infusion D. Hyponatremia is common in acute renal failure patients due to oliguria

D - Hyponatremia occurs frequently in patient's with acute renal failure because these patients often have decreased urine output causing dilute blood associated with fluid retention - Hyponatremia in acute renal failure patients can be treated with fluid restriction. If this alone does not resolve the hyponatremia, a hypertonic 3% saline solution can be given intravenously for sodium replacement

A patient is transported to the emergency room trauma unit by ambulance after a motor vehicle crash. The patient is exhibiting symptoms of shock. The nurse recognizes the symptoms of shock as which of the following? A. Systolic blood pressure greater than 90 with bradycardia and respiratory rate of 20 B. Systolic blood pressure greater than 90 with sinus bradycardia and urine output of greater than 30 mL/hr C. Systolic blood pressure less than 90 with normal sinus rhythm and respiratory rate of 18 D. Systolic blood pressure less than 90 with tachycardia and altered mental status

D - The condition of systemic shock from trauma often involves fluid volume depletion from blood loss. The decreased circulatory blood volume causes an increased heart rate and decreased blood pressure - The respiratory rate is usually increased to greater than 22 breaths per minute - Patients with shock usually have an altered mental status due to decreased blood volume resulting in decreased oxygen to the brain

A nurse is caring for a patient who is 4 days post-burn. His edema is beginning to decrease and he has been diuresing for the last 36 hours. Which of the following should the nurse monitor for in the fluid mobilization phase? A. Hyperkalemia B. Hypermagnesemia C. Hypernatremia D. Hypokalemia E. Hypomagnesemia

D - in the fluid mobilization stage, which begins 2 days post-burn, fluid begins to shift from the intracellular compartment back to the intravascular compartment - Beginning around day 4, as the fluid continues, serum potassium levels can become low as potassium moves back into the cells or is lost in urine along with sodium

A nurse on the cardiac step-down unit is preparing to discharge a patient with congestive heart failure. The nurse will educate the patient prior to discharge on strategies to prevent fluid volume excess. The nurse should include which of the following in the teaching? A. Instruct patient to increase hydration to flush excess sodium out through urination B. Instruct patient to monitor all calcium intake and maintain an intake of less than 400 mg of calcium daily C. Instruct patient to monitor sodium intake and maintain intake of less than 2 to 4 grams of sodium daily D. Instruct the patient to weigh daily and report any weight gain of 2 pounds or more in 24 hours

D - patients with congestive heart failure need to manage this condition at home with daily weight measurements. Patients should weigh each morning and report a weight increase of 2 or more pounds in 24 hours, or 5 or more pounds in 1 week - CHF patients require a low sodium diet with less than 2 grams of sodium in 24 hours daily to prevent fluid retention and edema - CHF patients also need to limit overall fluid intake to prevent overhydration which can contribute to fluid retention, edema, and shortness of breath

A nurse is caring for a 76-year-old patient with an exacerbation of congestive heart failure. The patient has been receiving furosemide 80 mg IV every 12 hours and has had a total urine output of 3.8 liters in the last 24 hours. The patient's recent laboratory work reveals a serum potassium level of 3.0 mEq/L. The nurse reports this lab result to the doctor and anticipates which of the following orders? A. Change patient's diet order to "potassium-sparing renal diet" B. Give regular insulin 5 units IV with 20 mL of dextrose 50% solution now C. Initiate normal saline IV infusion at a rate of 125 mL/hr for 8 hours D. Replace potassium with 60 mEq oral Potassium solution by mouth now

D -A patient on diuretics for congestive heart failure with increased urine output may have decreased serum potassium levels. This occurs when the kidneys produce large amounts of urine output where potassium is excreted - A potassium level of less than 3.5 will require supplemental potassium replacement to prevent cardiac arrhythmias

You are reviewing the client's morning laboratory results. Which of these results is of most concern to you? A. Serum potassium level of 5.2 B. Serum sodium level of 134 C. Serum calcium level of 10.6 D. Serum magnesium level of 0.8

D Although all these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias

The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. What is the best response by the nurse? A. "Fluid volume excess is caused by inactivity." B. "Fluid volume excess is caused by the intravenous fluids." C. "Fluid volume excess is caused by new onset liver failure caused by the surgery." D. "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."

D Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system.

The health care provider has written all these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? A. Weigh the client every morning B. Maintain accurate intake and output records C. Restrict fluids to 1500 mL/day D. Administer furosemide (Lasix) 40 mg IV push

D Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs.

You are preparing to discharge a client whose calcium level was low but is now just barely within the normal range. Which statement by the client indicates to you the need for additional teaching? A. "I will call my doctor if I experience muscle twitching or seizures" B. "I will make sure to take my vitamin D with my calcium each day" C. "I will take my calcium citrate pill every morning before breakfast" D. "I will avoid dairy products, broccoli, and spinach when I eat"

D Clients with low calcium levels should be encouraged to eat diary products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium

A client admitted for nausea and vomiting has a urine-specific gravity of 1.061. Upon assessment of the client, the nurse finds that the client is experiencing orthostatic hypotension and has dry skin and flat neck veins. What is the priority nursing diagnosis for this client when planning care? A. Impaired gas exchange B. Ineffective tissue perfusion C. Impaired skin integrity D. Deficient fluid volume

D Fluid volume deficit can be caused by nausea and vomiting with assessment findings of orthostatic hypotension, dry skin, and flat neck veins, which will lead to the priority nursing diagnosis of deficient fluid volume. The client is demonstrating fluid volume deficit.

When assessing a client with fluid volume deficit, the nurse would expect to find: A. Dyspnea and respiratory crackles B. Increased pulse rate and blood pressure C. Headache and muscle cramps D. Orthostatic hypotension and flat neck veins

D In fluid volume deficit, there is less volume in the vascular system, which decreases venous return and cardiac output, leading to manifestations of dizziness, orthostatic hypotension, and flat neck veins. The heart rate increases and the blood pressure falls. Dyspnea and crackles usually are associated with excess fluid volume. Headache and muscle cramps are often due to electrolyte imbalance, not fluid loss.

You are providing discharge instructions for Mr. Dickson, who has had frequent episodes of fluid volume excess requiring hospitalization. He will continue to take furosemide (Lasix) after discharge. Which statement by Mr. Dickson would indicate that there is a need for addition instruction? A. "I will wear shoes that fit well and not walk barefoot." B. "It is important to change position frequently." C. "I will eat a banana every day." D. "I will weigh myself weekly and notify my healthcare provider if I gain more than 1 pound."

D It is important for the client to weigh himself daily, not weekly, after discharge for fluid volume excess.

The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than are older children. Which of the following parent comments would indicate that further education is needed? A. "Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do." B. "Infants have a higher metabolic rate than older children do." C. "An infant has little body water for reserve, as compared with an adult." D. "Infants maintain their temperature by losing heat through their heads."

D Losing heat through their heads will have minimal effect on fluid loss in infants. All the other answers are appropriate responses.

You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalance? A. History of myocardial infarction 1 year ago B. Antacid use for occasional indigestion C. Shortness of breath with extreme exertion D. Chronic renal insufficiency

D Risk factors for acid-base imbalances in the older adult include chronic kidney disease and pulmonary disease.

The nurse is caring for a male client with a potassium level of 5.9 mEq/L. The physician orders the nurse to administer both glucose and insulin to the client. The client's wife says, "He doesn't have diabetes so why is he getting insulin?" What is the best response by the nurse? A. "Insulin is safer than other medications that can lower potassium levels." B. "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted." C. "The insulin will help his kidneys excrete the extra potassium." D. "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood."

D Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells.

A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit

The nurse is caring for a client who is experiencing a multisystem fluid volume deficit following hemodialysis. The nursing assessment reveals the client is tachycardic; has pale, cool skin; and has a decreased urine output. The nurse determines that the client has not met which expected outcomes for a client on hemodialysis? A. Cardiac decompensation B. The pharmacological effects of a diuretic infused in the dialysate C. The effects of rapidly infused intravenous fluids D. A reduction of extracellular fluid

D The client on hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the client at risk.

The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit and documents that the client is experiencing the following symptoms: tachycardia; pale, cool skin; and a decreased urine output. The nurse knows that these symptoms are caused by: A. Effects of rapidly infused intravenous fluids B. Pharmacological effects of a diuretic C. Cardiac failure D. The body's natural compensatory mechanisms

D The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart.

A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "You will receive magnesium in a series of intramuscular injections." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "You will have you deep-tendon reflexes monitored while you are receiving magnesium."

D The nurse should instruct the client on the need to monitor deep-tendon reflexes during administration of magnesium. This assessment helps identify hypermagnesemia that can occur during IV administration of magnesium sulfate.

A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He at 40% of his breakfast and lunch. The client's temperature is 38.3 C, pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost 3/4 lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake B. Observe for signs of peripheral edema C. Encourage the client to ambulate to promote oxygenation D. Monitor for orthostatic hypotension

D The nurse should monitor for orthostatic hypotension because he has manifestations of dehydration due to decreased circulatory volume.

The RN is providing care for a patient diagnosed with dehydration and hypovolemic shock. Which order should the RN question? A. Blood pressure every 15 minutes B. Place two 18-guage IV lines C. Oxygen at 3L via nasal cannula D. D5W to run at 250mL/hr

D To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline.

The nurse is monitoring a client who has undergone a thyroidectomy. The nurse suspects the parathyroid glands may have been inadvertently removed if imbalances are seen in which serum electrolyte level? (Select all that apply) A. Chloride B. Sodium C. Potassium D. Calcium E. Magnesium

D,E Parathyroid hormone (PTH) regulates serum levels of calcium and magnesium. If imbalances in these electrolytes are seen, the PTH may be absent due to inadvertent removal of the parathyroid glands.