HESI Electrolyte Imbalance
Lung chemical ____________ is _______________
CO2 / acidic
Which of the following electrolyte imbalances occur with adrenal insufficiency? a) Hypokalemia b) Hyponatremia c) Hypernatremia d) Hyperkalemia
Hyperkalemia
metabolic acidosis / alkalosis happens in
kidneys/body
respiratory alkalosis
ph ↑ (up) PaCO2 ↓ (down)
You are the nurse caring for a 65-year-old female patient who is in renal failure. During your shift assessment, the patient complains of tingling in her lips and fingers whenever anyone takes her blood pressure. She tells you that she gets a spasm in her wrist and hand and that it is very painful. What would you suspect? a) Hypophosphatemia b) Hypcalcemia c) Hypermagnesemia d) Hyperkalemia
Hypocalcemia
Acid Base Mnemonic
ROME Respiratory Opposite Metabolic Equal
HCO3 > 26
alkaline/base
ph > 7.45
alkaline/base
What percentage of potassium that is excreted daily, leaves the body by way of the kidneys? a) 40 b) 60 c) 80 d) 20
80
Which of the following is the most common cause of symptomatic hypomagnesemia? a) Alcoholism b) Sedentary lifestyle c) IV drug use d) Burns
Alcoholism
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? a) Tetany and increased blood urea nitrogen (BUN) levels b) Sunken eyeballs and spasticity c) Confusion and seizures d) Flaccidity and thirst
Confusion and seizures
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic acidosis Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.
A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. a) Rapid, shallow respirations b) Tender area around the insertion site c) Ecchymosis at the insertion site d) Cool area around the insertion site e) Reddended area along the path of the vein
Reddended area along the path of the vein • Tender area around the insertion site
HCO3 22 - 26
normal
The normal serum value for potassium is a) 135 to 145 mEq/L. b) 8.5 to 10.5 mg/dL. c) 3.5 to 5.5 mEq/L. d) 96 to 106 mEq/L.
3.5 to 5.5 mEq/L.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) "I will take a potassium supplement daily as prescribed." b) "I will be sure to buy frozen vegetables when I shop." c) "A good breakfast will include milk and couple of bananas." d) "I can use laxatives and enemas but only once a week."
"I can use laxatives and enemas but only once a week."
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "I'll drink cranberry juice w/ breakfast instead of coffee." b) "Bananas have a lot of potassium in them, I'll stop buying them." c)"I need to check if my cola beverage has potassium in it." d) "I will not salt my food, instead I'll use salt substitute."
"I will not salt my food, instead I'll use salt substitute."
The home health nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The nurse notes that the woman seems confused and has poor skin turgor. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? a) "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." b) "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of you fluids." c) "It is normal to be a little confused following surgery, and it's safe not to urinate a night." d) "Confusion following surgery is common in the elderly due to a loss of sleep."
"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of you fluids."
You are the nurse caring for a 77-year-old male who fell off his roof. You note that the patient's labs indicate minimally elevated serum creatinine levels. What can this indicate in older adults? a) Reduced respiratory function b) Substantially reduced renal function c) Increased cardiac function d) Alterations in ratio of body fluids to muscle mass
...Substantially reduced renal function
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) Lactated Ringer's solution b) 0.9% NaCl c) 5% NaCl d) 0.45% NaCl
0.45% NaCl
Which of the following solutions is hypotonic? a) Lactated Ringer's solution b) 0.45% NaCl c) 5% NaCl d) 0.9% NaCl
0.45% NaCl
Which of the following solutions is hypotonic? Lactated Ringer's solution 0.45% NaCl 0.9% NaCl 5% NaCl
0.45% NaCl Explanation: Half-strength saline is hypotonic. Lactated Ringer's solution is isotonic. Normal saline (0.9% NaCl) is isotonic. A solution that is 5% NaCl is hypertonic.
Which of the following is considered an isotonic solution? a) 0.45% normal saline b) 3% NaCl c) 0.9% normal saline d) Dextran in NS
0.9% normal saline
Which of the following is considered an isotonic solution? a) 3% NaCl b) 0.9% normal saline c) Dextran in NS d) 0.45% normal saline
0.9% normal saline
A 77-year-old retired male client visits your general practice office twice monthly to maintain control of his congestive heart failure. He measures his weight daily and phones it to your office for his medical record. In a 24-hour period, how much fluid is this client retaining if his weight increases by 2 lb? a) 1500 ml b) 1250 ml c) 1 L d) 500 ml
1 L
Kidney chemicals: 1) ___________________ is _____________ 2) ___________________ is _____________
1) HCO3 / basic 2) H+ / acidic
The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 115 mEq/L 130 mEq/L 145 mEq/L 160 mEq/L
115 mEq/L Explanation: Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.
A 42-year-old client has chronic hypo natremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur? a) 140 mEq/L b) 142 mEq/L c) 147 mEq/L d) 135 mEq/L
135 mEq/L
A 42-year-old client has chronic hyponatremia which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur? a) 142 mEq/L b) 135 mEq/L c) 145 mEq/L d) 140 mEq/L
135 mEq/L
Below which serum sodium level may convulsions or coma can occur? a) 145 mEq/L b) 142 mEq/L c) 140 mEq/L d) 135 mEq/L
135 mEq/L
A 42-year-old client has chronic hypo natremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur? 135 mEq/L 147 mEq/L 140 mEq/L 142 mEq/L
135 mEq/L Explanation: Normal serum concentration level ranges from 135 to145mEq/L. When the level dips below 135 mEq/L, there is hypo natremia. Manifestations include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur, if the deficit is severe. This level would indicate hyper natremia, which is serum sodium level above 145 mEq/L. Normal serum concentration level ranges from 135 to 145 mEq/L.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 155 mEq/L b) 125 mEq/L c) 135 mEq/L d) 145 mEq/L
155 mEq/L
ABG HCO3 range
22 - 26
The normal serum value for potassium is a) 135 to 145 mEq/L. b) 96 to 106 mEq/L. c) 8.5 to 10.5 mg/dL. d) 3.5 to 5.5 mEq/L.
3.5 to 5.5 mEq/L.
ABG PaCO2 range
35 -45 *** NOTE >35 is Alkalosis <45 is acidosis
ABG ph range
7.35 - 7.45
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? a) A 7-year-old with a fracture tibia b) A 72-year-old with a total knee repair c) A 65-year-old with a myocardial infarction d) A 52-year-old with diarrhea
A 52-year-old with diarrhea
What is one process by which dissolved chemicals from one area of the body to another? a) Passive osmosis b) Active transport c) Passive elimination d) Free flow
Active transport
Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? a) Alcoholism b) Loss of gastric acid c) Inflammatory bowel disease d) Intestinal resection
Alcoholism
Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? a) Inflammatory bowel disease b) Loss of gastric acid c) Alcoholism d) Intestinal resection
Alcoholism
The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). b) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago advanced to a regular diet. c) A 79-year-old man admitted with dx pneumonia. d) A 66-year-old woman who had open cholecystectomy with a T-tube draining 125 mL of bile per shift.
An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex).
A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing potassium through diet. Which of the following would be a good source of potassium? a) Apples b) Bananas c) Asparagus d) Carrots
Bananas
Which of the following are the insensible mechanisms of fluid loss? a) Nausea b) Bowel elimination c) Urination d) Breathing
Breathing
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Hypertension Slow pulse Jaundice
Chest pain Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Nausea b) Confusion c) Hallucinations d) Headache
Confusion
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels
Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? a) Hypovolemia b) Dehydration c) Hypervolemia d) Fluid volume excess
Dehydration
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? a) Dilute urine b) Joint pain c) Diarrhea d) Increased muscle tone
Dilute urine
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? a) Acute flank pain b) Tachycardia c) Diminished deep tendon reflexes d) Cool, clammy skin
Diminished deep tendon reflexes
You are caring for a patient admitted with a diagnosis of renal failure. When you review your patient's laboratory reports, you note that the patient's magnesium levels are high. What would be important for you to assess? a) Diminished deep tendon reflexes b) Tachycardia c) Cool, clammy skin d) Increased serum magnesium
Diminished deep tendon reflexes
The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Change the lactated Ringer's solution to 2.5% dextrose. b) Change the lactated Ringer's solution to 3% saline. c) Increase the rate of the IV lactated Ringer's solution. d) Discontinue the IV lactated Ringer's solution.
Discontinue the IV lactated Ringer's solution.
A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply. Drink at least eight glasses of fluid each day. Drink caffeinated beverages to retain fluid. Drink carbonated beverages to help balance fluid volume. Drink water as an inexpensive way to meet fluid needs. Respond to thirst
Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? a) Elevated hematocrit level b) Low white blood count c) Abnormal potassium level d) Low urine specific gravity
Elevated hematocrit level
Hypokalemia can cause which of the following symptoms to occur? a) Increased release of insulin b) Decreased sensitivity to digitalis c) Excessive thirst d) Production of concentrated urine
Excessive thirst
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? a) Extracellular fluid volume deficit b) Altered blood urea nitrogen (BUN) value c) Respiratory acidosis d) Metabolic alkalosis
Extracellular fluid volume deficit
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? a) Respiratory acidosis b) Metabolic alkalosis c) Extracellular fluid volume deficit d) Altered blood urea nitrogen (BUN) value
Extracellular fluid volume deficit
Which nerve is implicated in the Chvostek's sign? a) Facial b) Spinal accessory c) Optic d) Hypoglossal
Facial
You are caring for a patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. Your patient has specific gravities ordered every 4 hours. What does this test detect? a) Hypercalcemia b) Hyperkalemia c) Nutritional deficit d) Fluid volume status
Fluid volume status
Which of the following is a factor affecting an increase in serum osmolality? a) Overhydration b) Diuretic use c) Hyponatremia d) Free water loss
Free water loss
Which of the following is a factor that increases blood urea nitrogen (BUN)? a) Overhydration b) GI bleeding c) Hypothermia d) Decreased protein intake
GI bleeding
While admitting a new patient to your medical-surgical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. What do you know this intervention will do? a) Help distinguish hyponatremia from hypernatremia b) Help evaluate pituitary gland function c) Help distinguish reduced renal blood flow from decreased renal function d) Help provide an effective treatment for hypertension-induced oliguria
Help distinguish reduced renal blood flow from decreased renal function
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings? a) Hypercalcemia b) Hyperkalemia c) Hypermagnesemia d) Hyponatremia
Hypercalcemia
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings? a) Hyponatremia b) Hypermagnesemia c) Hyperkalemia d) Hypercalcemia
Hypercalcemia
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? a) Hyperkalemia b) Hypercalcemia c) Hypocalcemia d) Hypokalemia
Hypercalcemia
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? a) Hypercalcemia b) Hyperkalemia c) Hypokalemia d) Hypocalcemia
Hypercalcemia
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?
Hypercalcemia Explanation: The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? a) Hypercalcemia b) Hypernatremia c) Hyperglycemia d) Hyperkalemia
Hyperkalemia
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate? a) Hyperkalemia b) Hypocalcemia c) Hypercalcemia d) Hypermagnesemia
Hypocalcemia
The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances? a) Hypermagnesemia b) Hyponatremia c) Hypocalcemia d) Hyperchloremia
Hypocalcemia
You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition? a) Hypokalemia b) Hypomagnesemia c) Dehydration d) Hypocalcemia
Hypocalcemia
You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? a) Hypermagnesemia b) Hypophosphatemia c) Hypocalcemia d) Hyperkalemia
Hypocalcemia
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? a) Hypokalemia b) Hyperchloremia c) Hypernatremia d) Hypophosphatemia
Hypokalemia
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? a) Hypernatremia b) Hypokalemia c) Hyperchloremia d) Hypophosphatemia
Hypokalemia
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypomagnesium b) Hypokalemia c) Hyponatremia d) Hypocalcemia
Hypokalemia
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? a) Hypophosphatemia b) Hypernatremia c) Hypokalemia d) Hyperkalemia
Hypokalemia
During his annual physical exam, your 72-year-old male client complains of muscle cramps in his calves and that he feels "tired a lot." He is taking ethacrynic acid (Edecrin) for his hypotension. Your client will be evaluated for which of the following electrolyte imbalance based on his symptoms? a) Hypokalemia b) Hyperkalemia c) Hypercalcemia d) Hypocalcemia
Hypokalemia
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Na+ 134 mEq/L K+ 3.2 mEq/L Cl- 111 mEq/L Mg++ 1.1 mg/dL Ca++ 8.4 mg/dL Identify which of the following alterations is consistent with the client's findings. a) Hyponatremia b) Hypokalemia c) Hypomagnesemia d) Hypocalcemia
Hypomagnesemia
Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia? a) Hypercalcemia b) Hypervolemia c) Hypomagnesemia d) Hypermagnesemia
Hypomagnesemia
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? a) Cerebellum b) Thalamus c) Brainstem d) Hypothalamus
Hypothalamus
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? a) Thalamus b) Hypothalamus c) Brainstem d) Cerebellum
Hypothalamus
You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would you expect the patient to demonstrate? a) Hypovolemia b) Hypertension c) Hypervolemia d) Bradycardia
Hypovolemia
A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used? a) Fluid restriction b) Dialysis c) Oral magnesium oxide (MagOx) d) IV furosemide (Lasix)
IV furosemide (Lasix)
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? a) Similar causes are present in both conditions. b) In dehydration, only extracellular is depleted. c) Hypovolemia contains only low blood volume. d) Both conditions result in abnormal laboratory studies.
In dehydration, only extracellular is depleted.
You are the nurse evaluating a newly admitted patient's laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? a) Increased platelets b) Decreased serum potassium c) Decreased hemoglobin d) Increased serum sodium
Increased serum sodium
You are doing an admission assessment on an elderly patient newly admitted for end-stage liver disease. You must assess the patient's skin turgor. What should you remember when evaluating skin turgor? a) Dehydration causes skin to appear edematous +spongy. b) Overhydration causes the skin to tent. c) Normal skin turgor is moist and boggy. d) Inelastic skin turgor is a normal part of aging.
Inelastic skin turgor is a normal part of aging.
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about what Lung function Summer allergies Cardiovascular compromise Insensible fluid loss
Insensible fluid loss Explanation: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? a) Intracellular fluid b) Intravascular fluid c) Interstitial fluid d) Extracellular fluid
Intracellular fluid
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Weight loss of 4 lb b) Blood pressure 96/53 mm Hg c) Mild confusion d) Irregular heart rate
Irregular heart rate
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Irregular heart rate b) Weight loss of 4 lb c) Blood pressure 96/53 mm Hg d) Mild confusion
Irregular heart rate
Patients diagnosed with hypervolemia should avoid sweet or dry food because: a) It can cause dehydration. b) It can lead to weight gain. c) It obstructs water elimination. d) It increases the client's desire to consume fluid.
It increases the client's desire to consume fluid.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
Jugular vein distention
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? a) 10% dextrose in water b) 5% dextrose and normal saline solution c) Half-normal saline solution d) Lactated Ringer's solution
Lactated Ringer's solution
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? a) Lactated Ringer's solution b) Half-normal saline solution c) 5% dextrose and normal saline solution d) 10% dextrose in water
Lactated Ringer's solution
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? a) Limit sodium and water intake. b) Assess for dehydration. c) Teach client behaviors that decrease urination. d) Give medications that promote fluid retention.
Limit sodium and water intake.
The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Potassium b) Magnesium c) Calcium d) Phosphorus
Magnesium
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Metabolic alkalosis Explanation: A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 2 liters per day b) Minimal urine output of 10 mL per hour c) Minimal intake of 1.5 liters per day d) Minimal urine output of 50 mL per hour
Minimal intake of 1.5 liters per day
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? a) Gastrointestinal system b) Neurological system c) Musculoskeletal system d) Endocrine system
Neurological system
A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid? a) Hypotonic solution b) No intravenous solution c) Hypertonic solution d) Isotonic fluid
No intravenous solution
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client? a) Yes, this will correct the sodium deficit. b) No, start with the sodium chloride IV. c) No, sodium intake should be restricted. d) Yes, along with the hypotonic IV.
No, sodium intake should be restricted.
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? a) Yes, along with the hypotonic IV. b) Yes, this will correct the sodium deficit. c) No, start with the sodium chloride IV. d) No, sodium intake should be restricted.
No, sodium intake should be restricted.
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client? Yes, this will correct the sodium deficit. Yes, along with the hypotonic IV. No, start with the sodium chloride IV. No, sodium intake should be restricted.
No, sodium intake should be restricted. Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? a) Remove the Hemovac. b) Encourage oral fluids. c) Suggest a fluid restriction. d) Offer a prescribed antiemetic medication.
Offer a prescribed antiemetic medication.
Which of the following is a correct route of administration for potassium? a) IV (intravenous) push b) Subcutaneous c) Intramuscular d) Oral
Oral
Which of the following is a correct route of administration for potassium? a) Subcutaneous b) Intramuscular c) IV (intravenous) push d) Oral
Oral
Which of the following is a correct route of administration for potassium? Subcutaneous Intramuscular Oral IV (intravenous) push
Oral Explanation: Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.
Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid-electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? a) Diffusion b) Filtration c) Osmosis d) Active transport
Osmosis
The calcium level of the blood is regulated by which mechanism? a) Adrenal gland b) Parathyroid hormone (PTH) c) Thyroid hormone (TH) d) Androgens
Parathyroid hormone (PTH)
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? a) CO2 b) Potassium c) Chloride d) Sodium
Potassium
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? a) CO2 b) Sodium c) Potassium d) Chloride
Potassium
Which of the following electrolytes is a major cation in body fluid? a) Chloride b) Bicarbonate c) Phosphate d) Potassium
Potassium
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? a) Calcium: 10 mg/dL b) Sodium: 138 mEq/L c) Magnesium:2 mEq/L d) Potassium: 5.8 mEq/L
Potassium: 5.8 mEq/L
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? Potassium: 5.8 mEq/L Sodium: 138 mEq/L Magnesium:2 mEq/L Calcium: 10 mg/dL
Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Prolonged PR intervals b) Elevated ST segments c) Prolonged QT intervals d) Peaked T waves
Prolonged PR intervals
A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant? a) Monitor for signs and symptoms of dehydration. b) Assess the patient's daily weights for trends. c) Teach the patient about increased fluid intake. d) Provide oral care every 2-3 hours.
Provide oral care every 2-3 hours.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? a) Blood pressure b) Pulse c) Temperature d) Respirations
Pulse
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? a) Pulse b) Temperature c) Respirations d) Blood pressure
Pulse
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? a) Restricting fluids to 800 ml/day b) Elevating the head of the client's bed to 90 degrees c) Restricting sodium intake to 1 gm/day d) Administering vasopressin as ordered
Restricting fluids to 800 ml/day
The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Send the patient for a chest x-ray. b) Obtain written consent for the procedure. c) Administer the prescribed IV fluids. d) Assess the patient's blood pressure (BP) on the right arm.
Send the patient for a chest x-ray.
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? a) Serum sodium level of 132 mEq/L b) Urine specific gravity of 1.025 c) Serum potassium level of 3 mEq/L d) Blood urea nitrogen (BUN) level of 29 mg/dl
Serum potassium level of 3 mEq/L
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? a) Urine specific gravity of 1.025 b) Serum sodium level of 132 mEq/L c) Blood urea nitrogen (BUN) level of 29 mg/dl d) Serum potassium level of 3 mEq/L
Serum potassium level of 3 mEq/L
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? a) Serum creatinine level of 0.4 mg/dl b) Hematocrit of 52% c) Serum blood urea nitrogen (BUN) level of 8.6 mg/dl d) Serum sodium level of 124 mEq/L
Serum sodium level of 124 mEq/L
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? a) Calcium b) Sodium c) Potassium d) Magnesium
Sodium
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? a) Potassium b) Magnesium c) Sodium d) Calcium
Sodium
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? a) Tachycardia b) Bradycardia c) Increased urine output d) Vasodilation
Tachycardia
A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? a) patient's diet is lacking in calcium-rich food products. b) patient may be developing hyperaldosteronism. c) patient's malignancy causing the electrolyte imbalance. d) The patient has a history of alcohol abuse.
The patient's malignancy is causing the electrolyte imbalance.
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting? a) Third-spacing b) Hypovolemia c) Pitting edema d) Anasarca
Third-spacing
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting? a) Pitting edema b) Anasarca c) Third-spacing d) Hypovolemia
Third-spacing
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting? Third-spacing Pitting edema Anasarca Hypovolemia
Third-spacing Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. This occurs when indentations remain in the skin after compression. This is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid.
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? 1-Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad 2-Three ounces of sliced ham, beets, and a salad 3-A frozen, packaged low-fat dinner with a side salad 4-Tomato juice, low-fat cottage cheese, and three slices of bacon
Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Explanation: Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.
A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess: a) Hegar's sign. b) Goodell's sign. c) Homans' sign. d) Trousseau's sign.
Trousseau's sign.
A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess: a) Hegar's sign. b) Homans' sign. c) Trousseau's sign. d) Goodell's sign.
Trousseau's sign.
In a pre-nursing pathophysiology class the instructor is teaching about the regulation of fluid volume. How is fluid volume primarily regulated? a) Urine excretion b) Breathing c) Bowel elimination d) Perspiration
Urine excretion
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? a) Urine pH of 3.0 b) Absence of protein c) Specific gravity of 1.02 d) Absence of glucose
Urine pH of 3.0
The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? a) Intake and output b) Vital signs c) Edema d) Weight
Weight
ph < 7.35
acid
HCO3 < 22
acidic
PaCO2 > 45
acidic
PaCO2 < 35
alkaline/base
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: a) respiratory rate. b) electrocardiogram (ECG) results. c) neuromuscular function. d) bowel sounds.
electrocardiogram (ECG) results.
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: a) bowel sounds. b) electrocardiogram (ECG) results. c) respiratory rate. d) neuromuscular function.
electrocardiogram (ECG) results.
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: neuromuscular function. bowel sounds. respiratory rate. electrocardiogram (ECG) results.
electrocardiogram (ECG) results. Explanation: Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
Anasarca
generalized edema characterized by widespread swelling of the skin due to effusion of fluid into extracellular space.[
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: a) hypernatremia. b) hypokalemia. c) hypercalcemia. d) hyperkalemia.
hyperkalemia.
Early signs of hypervolemia include a) thirst. b) moist breath sounds. c) increased breathing effort and weight gain d) a decrease in blood pressure.
increased breathing effort and weight gain
Homans' sign
indication of incipient or established thrombosis in the leg veins in which slight pain occurs at the back of the knee or calf when, with the knee bent, the ankle is slowly and gently dorsiflexed.
Goodell's sign.
indication of pregnancy. It is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascularization is a result of hypertrophy and engorgement of the vessels below the growing uterus.
Patients diagnosed with hypervolemia should avoid sweet or dry food because a) it obstructs water elimination. b) it can cause dehydration. c) it increases the patient's desire to consume fluid. d) it can lead to weight gain.
it increases the patient's desire to consume fluid.
respiratory acidosis / alkalosis happens in
lungs
In alkalosis, to compensate, the lungs ___ / kidneys ___
lungs-keep CO2 + decrease respiration rate kidneys=excrete bicarbonate (HCO3) + retain H+
In acidosis, to compensate, the lungs ___ / kidneys ___
lungs=blow off CO2 + increase respiration rate kidneys=conserve bicarbonate (HCO3) + excrete H+
Hegar's sign.
non-sensitive indication of pregnancy in women — its absence does not exclude pregnancy. It pertains to the features of the cervix and the uterine isthmus. It is demonstrated as a softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions.
PaCO2 35 - 45
normal
ph 7.35 - 7.45
normal
compensation
opposite organ (lung/kidney) tries to adjust by adjusting pH
Oncotic pressure refers to the a) number of dissolved particles contained in unit of fluid. b) osmotic pressure exerted by proteins. c) amount pressure needed to stop flow water by osmosis d) excretion substances ex glucose thru inc urine output.
osmotic pressure exerted by proteins.
To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
pH PaCO2 HCO3
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.
metabolic alkalosis
ph ↑(up) HCO3 ↑(up)
metabolic acidosis
ph ↓(down) HCO3 ↓(down)
respiratory acidosis
ph ↓(down) PaCO2 ↑(up)
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Phlebitis b) Air embolism c) Extravasation d) Hematoma e) Infection
phlebitis extravasation hematoma
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. a) A low urine specific gravity b) Electrolyte imbalance c) Absence of ketones in urine d) An elevated hematocrit level e) Low protein level in the urine
• An elevated hematocrit level • Electrolyte imbalance
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Intake and output, urine volume, and color b) Skin assessment for edema and turgor c) Blood pressure, heart rate, and rhythm d) Nutritional status and diet e) Strength testing for muscle wasting
• Blood pressure, heart rate, and rhythm • Intake and output, urine volume, and color • Skin assessment for edema and turgor
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. a) Decreased blood pressure b) Crackles in the lung fields c) Distended neck veins d) Shortness of breath e) Bradycardia
• Crackles in the lung fields • Distended neck veins • Shortness of breath
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. a) Decreased blood pressure b) Shortness of breath c) Distended neck veins d) Bradycardia e) Crackles in the lung fields
• Distended neck veins • Crackles in the lung fields • Shortness of breath
In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply. a) Heart failure b) Severe hemorrhage c) Pulmonary edema d) Renal impairment e) Burns
• Heart failure • Pulmonary edema • Renal impairment
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. a) Monitor intake and output every shift. b) Administer the ordered potassium 40 mg IV push. c) Administer the ordered Kayexalate enema. d) Administer the ordered Furosemide (lasix) 60 mg po. e) Offer a diet with fruit juices and citrus fruits.
• Offer a diet with fruit juices and citrus fruits. • Monitor intake and output every shift.
Which of the following is a function of calcitonin? Select all that apply. a) Decreases deposition of phosphorous in bones b) Decreases urinary excretion of phospate c) Increases urinary excretion of calcium d) Increases deposition of calcium in bones e) Reduces bone resorption
• Reduces bone resorption • Increases urinary excretion of calcium • Increases deposition of calcium in bones
The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Dehydration b) Hypotension c) Tachypnea d) Lethargy e) Weakness
• Tachypnea • Weakness • Lethargy