MedSurg Exam 1- Fluid and Electrolytes- Test
Which clinical manifestation would indicate that a patient with heart failure is at risk for developing a fluid volume excess? 1. A full, bounding pulse 2. Flattened neck veins 3. Low blood pressure 4. Easily obliterated pulse
1. A full, bounding pulse
Which clinical manifestation would the nurse observe when assessing cardiovascular changes in a patient suspected of having a medical diagnosis of fluid volume excess? Select all that apply. 1. A full, bounding pulse 2. Orthostatic hypotension 3. An increased heart rate 4. The presence of an S3 heart sound 5. Distended neck veins
1. A full, bounding pulse 4. The presence of an S3 heart sound 5. Distended neck veins
Which over-the-counter medication would the nurse advise a renal patient to avoid? 1. Magnesium containing laxatives 2. Bulk-forming laxatives 3. Ibuprofen 4. Robitussin
1. Magnesium containing laxatives
Which intervention would the nurse include in the patient's plan of care if the patient has been admitted with dehydration? 1. Perform daily weights. 2. Reorient the patient hourly. 3. Restrict the patient's sodium intake to 2 grams per day. 4. Provide continuous oxygen saturation monitoring.
1. Perform daily weights.
When assessing a patient's skin turgor, the nurse pinched a fold of skin over the sternum and released the fold. Return of the skin to the original position required 22 seconds. Which term would the nurse use to document this finding? 1. Poor 2. Lagged 3. Normal 4. Decreased
1. Poor
Which intervention will the nurse make when monitoring a patient at risk for fluid volume changes? 1. Reposition frequently. 2. Obtain weekly weights. 3. Implement fluid restriction. 4. Dangle edematous extremities.
1. Reposition frequently.
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia? (Select all that apply.) 1. Weakness 2. Paresthesia 3. Facial spasms 4. Muscle tremors 5. Depressed reflexes
1. Weakness 5. Depressed reflexes
Which IV solution may be used to pull fluid into the intravascular space after removing 5 liters of fluid during a patient's paracentesis? 1. 0.9% sodium chloride 2. 25% albumin solution 3. Lactated Ringer solution 4. 5% dextrose in 0.45% saline
2. 25% albumin solution
Which laboratory finding is consistent with a diagnosis of milk-alkali syndrome? 1. Calcium level of 7 mg/dL 2. Calcium level of 15 mg/dL 3. Magnesium level of 1 mEq/dL 4. Magnesium level of 3 mEq/dL
2. Calcium level of 15 mg/dL
Which indicator is the most accurate when assessing the fluid balance of a patient being treated for heart failure? 1. Skin turgor 2. Daily weights 3. Intake and output 4. Blood urea nitrogen (BUN), sodium, and hematocrit levels
2. Daily weights
The morning laboratory results of a patient admitted with heart failure reveal a serum potassium level of 2.9 mEq/L. Which classification of medications would be withheld until the nurse consults with the health care provider? 1. Antibiotics 2. Loop diuretics 3. Bronchodilators 4. Antihypertensives
2. Loop diuretics
Which patient cue is associated with an extracellular fluid volume deficit? 1. Edema 2. Muscle spasms 3. Cold, clammy skin 4. Elevated blood pressure
3. Cold, clammy skin
Which foods would the nurse encourage the patient to consume in greater quantities in order to prevent a recurrence of hypocalcemia? 1. Fish 2. Lean meat 3. Dairy products 4. Potatoes and starches
3. Dairy products
A family member inquires as to the meaning of "third spacing," which the nurse used when assessing their loved one, who has acute pancreatitis. Which explanation would the nurse provide to explain the process? 1. "Third spacing refers to how the fluids are distributed in the cells and vessels." 2. "This is just a term that we use to describe generalized edema." 3. "Third spacing describes potential fluid locations, such as the cells, blood vessels, and lymph system." 4. "Fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells.
4. "Fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells.
Which condition is associated with extracellular fluid volume excess? 1. Vomiting 2. Hemorrhage 3. Diabetes insipidus 4. Cushing syndrome
4. Cushing syndrome
The nurse reports to the healthcare provider her assessment and lab findings. Which laboratory result is critical and should the nurse have the HCP repeat back? 1. Sodium 140 mEq/L (140 mmol/L). 2. Chloride 105 mEq/L (105 mmol/L). 3. Magnesium 2 mg/dL (0.82 mmol/L). 4. Potassium 3 mEq/L (3 mmol/L).
4. Potassium 3 mEq/L (3 mmol/L).
Which patient has the highest percentage of body water? 1. Child 2. Neonate 3. Older adult 4. Preterm infant
4. Preterm infant
A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which condition results from this imbalance? 1. Hemorrhage with subsequent anemia 2. Diminished resistance to bacterial insult 3. Malnutrition of cells, especially hepatic cells 4. Reduction of colloidal oncotic pressure in the blood
4. Reduction of colloidal oncotic pressure in the blood
A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline
A. 3% Saline
________ fluids remove water from the extracellular space into the intracellular space. A. Hypotonic B. Hypertonic C. Isotonic D. Colloids
A. Hypotonic
Which patient below would NOT be a candidate for a hypotonic solution? A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct
A. Patient with increased intracranial pressure
D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution. A. True B. False
A. True
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline
C. 0.45% Saline
Which condition below could lead to cell lysis, if not properly monitored? A. Isotonicity B. Hypertonicity C. Hypotonicity D. None of the options are correct
C. Hypotonicity
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline
D. 0.9% Normal Saline
_______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic
D. Hypertonic
The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.
b. calcium supplements.
Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
c. 42-year-old woman with systemic lupus erythematosus and renal failure
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. try to force 10 mL of normal saline into the device. c. place the patient on the left side with the head down. d. have the patient change positions, raise arm, and cough.
d. have the patient change positions, raise arm, and cough.
Which instruction regarding the importance of obtaining daily weights would the nurse provide to a patient with heart failure? 1. "Weigh yourself on the same calibrated scale." 2. "Wear clothes when weighing yourself, and subtract weight if you are wearing heavy clothes or shoes." 3. "Consistently measure your weight after your first intake of food every day." 4. "Weigh yourself along with drainage fluid in the catheter bag."
1. "Weigh yourself on the same calibrated scale."
A patient is admitted to the emergency department with a stab wound to the abdomen. Vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9°F (36.6°C). Which fluid, if ordered by the health care provider, would the nurse question? 1. 0.45% saline 2. 0.9% saline 3. Packed red blood cells 4. Lactated Ringer's solution
1. 0.45% saline
The nurse admits a patient who reports severe diarrhea for several days from a Clostridium difficile infection. Which IV fluid would the nurse associate with the need to rapidly replace the patient's fluid volume? 1. 0.9% sodium chloride 2. 0.45% sodium chloride 3. 5% dextrose in 0.45% sodium chloride 4. 5% dextrose in 0.9% sodium chloride
1. 0.9% sodium chloride
Which grade of edema would the nurse document if the patient has cool, taut skin that yields a 2-mm indentation when pressure is applied with a thumb? 1. 1+ 2. 2+ 3. 3+ 4. 4+
1. 1+
A patient has a prescription to receive D5W with 20 mEq KCl/L at 100 mL/hour. The nurse would select which solution from the IV supply cart? 1. 1000 mL of 5% dextrose in water with 20 mEq of KCl 2. 100 mL of 5% dextrose in 0.9% sodium chloride with 20 mEq of KCl 3. 250 mL of 5% dextrose in 0.45% sodium chloride with 20 mEq of KCl 4. 200 mL of 5% dextrose in lactated Ringer solution with 20 mEq of KCl
1. 1000 mL of 5% dextrose in water with 20 mEq of KCl
Which serum potassium result best supports the need for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 1. 3.0 mEq/L 2. 3.5 mEq/L 3. 4.6 mEq/L 4. 5.3 mEq/L
1. 3.0 mEq/L
The nurse determines that a patient's multilumen central venous access device (CAVD) is missing one of the injection caps, and the patient is exhibiting clinical manifestations of respiratory distress, hypotension, and tachycardia. Which action would the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Notify the health care provider. 3. Reposition patient to left side, head down. 4. Adjust the IV fluids via the CAVD.
1. Administer oxygen via nasal cannula.
Which clinical finding would the nurse expect to find in a patient with chronic heart failure at risk of developing excess extracellular fluid volume (ECV)? Select all that apply. 1. Ankle edema 2. Postural hypotension 3. Overnight weight loss 4. Overnight weight gain 5. Neck veins full when upright
1. Ankle edema 4. Overnight weight gain 5. Neck veins full when upright
Which clinical manifestation would the nurse look for when assessing a patient with primary hyperparathyroidism? Select all that apply. 1. Anorexia 2. Easy fatigability 3. Depressed reflexes 4. Circumoral numbness 5. Positive Trousseau sign
1. Anorexia 3. Depressed reflexes
Which assessment would the nurse perform routinely when an older-adult patient is receiving intravenous 0.9% NaCl? 1. Auscultate dependent portions of lungs. 2. Check color of urine. 3. Assess muscle strength. 4. Check skin turgor over sternum or shin.
1. Auscultate dependent portions of lungs.
The nurse is concerned that the client may develop fluid volume excess because the client's intake is greater than her output and both ankles and feet are swollen. Which assessment is important for the nurse to perform? 1. Auscultate the client's breath sounds. 2. Measure the client's tympanic temperature. 3. Compare the client's muscle strength bilaterally. 4. Ask the client if she is experiencing any syncope.
1. Auscultate the client's breath sounds.
While obtaining a patient's BP, the nurse notices that the patient's arm has a carpal spasm. Which serum laboratory test would the nurse review after assessing this finding? 1. Calcium 2. Sodium 3. Potassium 4. Magnesium
1. Calcium
Which signs and symptoms of fluid volume deficit should the nurse include when educating the client and her daughter prior to discharge? 1. Changes in mental status. 2. Change in urine output. 3. Presence of tachycardia. 4. Tenting on arm when checking skin turgor. 5. Longitudinal furrows on the tongue.
1. Changes in mental status. 2. Change in urine output. 3. Presence of tachycardia. 5. Longitudinal furrows on the tongue.
Which disease may cause excessive extracellular fluid volume? Select all that apply. 1. Cirrhosis 2. Heart failure 3. Hemorrhage 4. Adrenal insufficiency 5. Acute oliguric renal disease
1. Cirrhosis 2. Heart failure 5. Acute oliguric renal disease
The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? 1. Count the client's radial pulse rate. 2. Remove the blood pressure cuff. 3. Help the client change positions. 4. Assess for an auscultatory gap.
1. Count the client's radial pulse rate.
Which laboratory findings would the nurse expect when providing care for a patient with low levels of parathyroid hormone? 1. Decreased calcium levels 2. Increased potassium levels 3. Decreased phosphate levels 4. Increased magnesium levels
1. Decreased calcium levels
Which problem often occurs in older clients and may have contributed to the fluid volume deficit the client is experiencing? 1. Decreased hepatic blood flow. 2. Decreased drug absorption. 3. Decreased drug half-life. 4. Decreased GI acidity
1. Decreased hepatic blood flow.
The nurse administers regular IV insulin to a patient with hyperkalemia. Which additional IV medication would the nurse administer along with the insulin to prevent complications from this treatment? 1. Dextrose 2. Furosemide 3. Pamidronate 4. Calcium gluconate
1. Dextrose
Which factor causing extracellular fluid volume (ECV) deficit would the nurse evaluate? Select all that apply. 1. Diarrhea 2. Vomiting 3. Heart failure 4. Sodium-rich diet 5. Nasogastric suctioning
1. Diarrhea 2. Vomiting 5. Nasogastric suctioning
Which clinical manifestation would the nurse expect to observe when assessing a patient with Cushing syndrome? 1. Dyspnea 2. Hypoglycemia 3. Weight loss 4. Hypotension
1. Dyspnea
Which patient cue is associated with extracellular fluid volume excess? 1. Dyspnea 2. Tachycardia 3. Postural hypotension 4. Decreased capillary refill
1. Dyspnea
Which adverse effect would the nurse monitor for if a patient's serum potassium level is 2.8 mEq/L? 1. Dysrhythmias 2. Acute renal failure 3. Metabolic acidosis 4. Malignant hypertension
1. Dysrhythmias
What precautions would the nurse initate for a patient with a NA of 119? Select all that apply. 1. Fall precautions 2. Have them closer to the nurses station 3. Seizure precautions 4. Fluid restriction
1. Fall precautions 2. Have them closer to the nurses station 3. Seizure precautions 4. Fluid restriction
Which intervention would the nurse implement when providing care for a patient with hypercalcemia? Select all that apply. 1. Give isotonic saline infusions. 2. Administer a bisphosphonate. 3. Administer calcitonin. 4. Restrict oral fluid intake to 1000 mL. 5. Encourage the patient to breathe into a paper bag.
1. Give isotonic saline infusions. 2. Administer a bisphosphonate. 3. Administer calcitonin.
Which condition places a patient at risk for extracellular fluid volume deficit? 1. High fever 2. Heart failure 3. Renal failure 4. Primary polydipsia
1. High fever
An inadvertent removal of the parathyroid glands occurred during a patient's scheduled thyroidectomy. Which electrolyte disturbance would the nurse assess for using the presence of the Trousseau sign? 1. Hypocalcemia 2. Hyperkalemia 3. Hypermagnesemia 4. Hypophosphatemia
1. Hypocalcemia
Which electrolyte abnormality is least likely to be caused by the use of laxatives? 1. Hyponatremia 2. Hypokalemia 3. Hypocalcemia 4. Hypomagnesemia
1. Hyponatremia
A nurse is caring for a client who had an adrenalectomy. Which clinical response would the nurse monitor while steroid therapy is being regulated? 1. Hypotension 2. Hyperglycemia 3. Sodium Retention 4. Potassium Excretion
1. Hypotension
Which medication would the nurse administer to counter the signs of toxicity when infusing IV magnesium sulfate into a patient with preeclampsia? 1. IV calcium gluconate 2. Magnesium hydroxide 3. IV potassium chloride 4. 3% sodium chloride solution
1. IV calcium gluconate
Which intervention would the nurse implement first when providing care for a patient who is being treated for hypernatremia that developed slowly over several days? 1. Initiate seizure precautions. 2. Monitor the patient's weight each day. 3. Restrict the patient's dietary sodium intake. 4. Administer prescribed diuretics.
1. Initiate seizure precautions.
Which food item would the nurse include in the patient's diet to help correct hypokalemia? Select all that apply. 1. Instant coffee 2. Milk 3. Potatoes 4. Processed foods 5. Canned fish with bones
1. Instant coffee 3. Potatoes
Which term would the nurse use when extracellular fluid and intracellular fluid have the same osmolality? 1. Isotonic 2. Hypotonic 3. Hypertonic 4. Oncotic pressure
1. Isotonic
For which possible cause will the nurse associate in a patient with a fluid volume deficit experiencing hypotension? Select all that apply. 1. Low calcium 2. Decreased sodium 3. Below normal chloride 4. Low potassium 5. Elevated magnesium
1. Low calcium 5. Elevated magnesium
A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply.) 1. Lung sounds 2. Bowel sounds 3. Blood pressure 4. Serum sodium level 5. Serum potassium level
1. Lung sounds 3. Blood pressure 4. Serum sodium level
Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehyrdation, a heart rate of 100 beats/ mins, and blood pressure of 104/62 mm Hg? 1. Offer frequent oral fluids for several hours 2. Administer 1 liter of normal saline over 2 hours 3. Give fluid and electrolytes per nasogastric tube 4 Infuse 500 mL of lactated Ringer's solution over 30 minutes
1. Offer frequent oral fluids for several hours
Which client would a nurse recognize as having an age-related impairment of the thirst mechanism when reviewing the laboratory reports of a group of older adult clients? 1. Patient A with a sodium of 167 mEq/l 2. Patient B with a sodium of 143 mEq/l 3. Patient C with a sodium of 118 mEq/l 4. Patient D with a sodium of 101 mEq/l
1. Patient A with a sodium of 167 mEq/l
For which reason would the nurse promote a potassium-rich diet? 1. Potassium improves smooth, skeletal, and cardiac muscle function. 2. Potassium is necessary for production of adenosine triphosphate (ATP). 3. Potassium decreases muscle wasting. 4. Potassium acts as a cofactor for various enzymes.
1. Potassium improves smooth, skeletal, and cardiac muscle function.
Which interventions would the nurse implement in caring for a client with diabetes insipidus (DI) after a head injury? 1. Provide adequate fluids within easy reach 2. Report an increasing urine specific gravity 3. Administer diuretics 4. Assess for and report changes in neurological status 5. Monitor for constipation, weight loss, hypotension, and tachycardia
1. Provide adequate fluids within easy reach 4. Assess for and report changes in neurological status 5. Monitor for constipation, weight loss, hypotension, and tachycardia
A patient presents with muscle twitching and cramping. On examination, the health care provider diagnoses the patient with calcium deficiency. Which dietary instruction would the nurse give to this patient? Select all that apply. 1. Supplement with vitamin D. 2. Avoid broccoli and oranges. 3. Increase the intake of dairy products. 4. Increase the intake of canned fish with bones. 5. Increase consumption of dark green vegetables.
1. Supplement with vitamin D. 3. Increase the intake of dairy products. 4. Increase the intake of canned fish with bones.
The nurse is caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) 1. The potassium level may be increased if the patient has nephropathy. 2. The patient has been eating excessive amounts of foods that increase potassium levels. 3. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. 4. There may be excess potassium being released into the blood as a result of massive blood transfusion. 5. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.
1. The potassium level may be increased if the patient has nephropathy. 3. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. 5. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.
Since the client is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which foods selected by the client indicate an understanding of potassium-rich foods? 1. Whole grains. 2. Canned Green beans. 3. Peanut butter 4. Apple. 5. Tuna
1. Whole grains. 3. Peanut butter 5. Tuna
Which statement indicates that the patient understood the nurse's teaching regarding potassium supplementation for the treatment of hypokalemia? Select all that apply. 1. "I will chew my tablets." 2. "I will eat a banana every day." 3. "I will include licorice in my diet." 4. "I will take my medication with a glass of water." 5. "I will tell my doctor if I begin to develop constipation."
2. "I will eat a banana every day." 4. "I will take my medication with a glass of water." 5. "I will tell my doctor if I begin to develop constipation."
Which fluid replacement therapy would the nurse prepare to administer for a patient who is exhibiting clinical manifestations of hypovolemic shock? 1. 0.45% saline 2. 0.9% NaCl 3. 5% dextrose in 0.45% saline 4. Dextran
2. 0.9% NaCl
Which intravenous solution would the nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration? 1. 3% sodium chloride 2. 0.9% sodium chloride 3. 5% dextrose and 0.9% sodium chloride 4. 5% dextrose and lactated ringer solution
2. 0.9% sodium chloride
A patient was admitted for a paracentesis to remove ascite fluid. Five liters of fluid were removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 1. 0.9 sodium chloride 2. 25% albumin solution 3. Lactated Ringers solution 4. 5% dextrose in 0.45% saline
2. 25% albumin solution
The nurse finds that a patient with renal disease is irritable and has an irregular pulse. Electrocardiogram (ECG) changes suggest severe hyperkalemia. Which intervention would the nurse implement first? 1. Stop all sources of dietary potassium. 2. Administer IV calcium gluconate immediately. 3. Locate and administer sodium polystyrene sulfonate. 4. Obtain and administer IV insulin with glucose.
2. Administer IV calcium gluconate immediately.
Upon reviewing the morning laboratory reports, the nurse would conclude that which patient is at greatest risk of developing hypomagnesemia? 1. An 83-year-old man with lung cancer and hypertension 2. An unhoused 65-year-old woman with a history of chronic alcohol use disorder 3. A 32-year-old pregnant woman who has been treated for eclampsia 4. A 63-year-old man with benign prostatic hyperplasia (BPH) and a urinary tract infection (UTI)
2. An unhoused 65-year-old woman with a history of chronic alcohol use disorder
The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply.) 1. Apple 2. Banana 3. Orange juice 4. Chocolate milk 5. Cooked broccoli
2. Banana 3. Orange juice 4. Chocolate milk 5. Cooked broccoli
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when she changes position? 1. Respiratory rate. 2. Blood pressure. 3. Temperature. 4. Pulse rate.
2. Blood pressure.
Which clinical manifestation would the nurse look for when assessing a patient with primary hypoparathyroidism? Select all that apply. 1. Anorexia 2. Easy fatigability 3. Depressed reflexes 4. Circumoral numbness 5. Positive Trousseau sign
2. Easy fatigability 4. Circumoral numbness 5. Positive Trousseau sign
A patient is experiencing the syndrome of inappropriate antidiuretic hormone (SIADH). For which electrolyte disturbance would the nurse evaluate the patient? 1. Hypernatremia 2. Hyponatremia 3. Hemoconcentration 4. Increased serum osmolality
2. Hyponatremia
For which metabolic alteration would the nurse prepare to administer IV albumin in a 5% solution? 1. Alkalosis 2. Hypovolemia 3. Hyperkalemia 4. Mixed acid-base disorder
2. Hypovolemia
Which prescription from the health care provider would the nurse anticipate when admitting a patient with a fluid volume deficit due to severe diarrhea? 1. Restrict the patient's dietary sodium intake. 2. Insert an IV access and infuse lactated Ringer's solution. 3. Transfuse packed red blood cells as soon as they are available. 4. Initiate hypertonic IV sodium chloride fluids.
2. Insert an IV access and infuse lactated Ringer's solution.
A patient is admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medication would the nurse hold until the health care provider is consulted? 1. Antibiotics 2. Loop diuretics 3. Bronchodilators 4. Antihypertensives
2. Loop diuretics
Which clinical manifestations is indicative of the fluid and electrolyte imbalance associated with a parathyroidectomy? 1. Constipation 2. Muscle spasms 3. Hypoactive reflexes 4. Increased specific gravity
2. Muscle spasms
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypocalcemia? (Select all that apply.) 1. Weakness 2. Paresthesia 3. Facial spasms 4. Muscle tremors 5. Depressed reflexes
2. Paresthesia 3. Facial spasms 4. Muscle tremors
The nurse plans to assess the client for orthostatic vital sign changes. Which action will the nurse take first? 1. Assist the client to a standing position. 2. Position the client in a supine position. 3. Elevate the head of the client's bed. 4. Dangle the client's feet at the bedside.
2. Position the client in a supine position.
Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply.) 1. Have patient restrict fluid intake to less than 2000 mL/day. 2. Renal calculi may occur as a complication of hypercalcemia. 3. Weight-bearing exercises can help keep calcium in the bones. 4. The patient should increase daily fluid intake of 3000 to 4000 mL. 5. Any heartburn can be managed with an as needed calcium-containing antacid.
2. Renal calculi may occur as a complication of hypercalcemia. 3. Weight-bearing exercises can help keep calcium in the bones. 4. The patient should increase daily fluid intake of 3000 to 4000 mL.
Which condition would the nurse associate with the patient being monitored for clinical manifestations of hyperkalemia? Select all that apply. 1. Alkalosis 2. Renal failure 3. Low blood volume 4. Large urine volume 5. Adrenal insufficiency
2. Renal failure 5. Adrenal insufficiency
Which intervention would the nurse implement when a patient reports headaches and shortness of breath and the nurse auscultates crackles and a bounding pulse? 1. Apply hot and cold compresses. 2. Restrict the patient's intake of dietary sodium. 3. Ask the patient to sit and then stand. 4. Provide ice chips to hydrate the patient.
2. Restrict the patient's intake of dietary sodium.
When a client in the emergency department has a blood pressure of 90/60mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? 1. Complete a head-to-toe assessment 2. Start infusion of normal saline 500 mL 3. Ask the client about current medications 4. Obtain blood samples for laboratory testing
2. Start infusion of normal saline 500 mL
Which physical finding can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply. 1. Edema 2. Thready pulse 3. Crackles in lungs 4. Postural hypotension 5. Dry mucous membranes
2. Thready pulse 4. Postural hypotension 5. Dry mucous membranes
The nurse provides postoperative care 1 hour after a patient underwent surgery. The nurse assesses the patient and recognizes the need to carefully monitor which parameter? 1. Temperature of 37.6° C (99.7° F) 2. Urine output of 0.4 mL/kg/hr 3. Blood pressure of 114/70 mm Hg 4. Serous drainage on the surgical dressing
2. Urine output of 0.4 mL/kg/hr
Which patient statement about hypercalcemia indicates an understanding of content taught by the nurse? Select all that apply. 1. "I can use antacids as needed for heartburn." 2. "I should restrict my fluid intake to less than 2000 mL/day." 3. "Increasing my daily fluid intake to 3000 to 4000 mL is good." 4. "Renal calculi may occur as a complication of hypercalcemia." 5. "Weight-bearing exercises can help keep calcium in my bones."
3. "Increasing my daily fluid intake to 3000 to 4000 mL is good." 4. "Renal calculi may occur as a complication of hypercalcemia." 5. "Weight-bearing exercises can help keep calcium in my bones."
When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is 1. 500 to 1500 mL. 2. 1200 to 2200 mL. 3. 2000 to 3000 mL. 4. 3000 to 4000 mL.
3. 2000 to 3000 mL.
For ongoing evaluation of the client's fluid volume status, which assessment data is most important to obtain? 1. Urine color. 2. Capillary refill. 3. Body weight. 4. Skin turgor.
3. Body weight.
Which condition may be observed due to incorrect fluid replacement with hypotonic crystalloids in patients with DKA? 1. Polyuria 2. Hypokalemia 3. Cerebral edema 4. Metabolic acidosis.
3. Cerebral edema
Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign or dehydration? 1. Sunken eyes 2. Dry flaky skin 3. Change in mental status 4. Decreased bowel sounds
3. Change in mental status
Which condition can lead to a high hematocrit value? 1. Infection 2. Increased risk of a blood clot 3. Dehydration 4. Polycythemia
3. Dehydration
Which defining characteristics are consistent with fluid volume deficit? 1. A weight loss of 1 pound (0.5 kg) in 1 week, pale yellow urine 2. Engorged neck veins when upright, bradycardia 3. Dry mucous membranes, thready pulse, tachycardia 4. Bounding radial pulse, flat neck veins when supine
3. Dry mucous membranes, thready pulse, tachycardia
The patient has an Na+ level of 132 mEq/L, a BUN level of 5 mg/dL, and a hematocrit level of 33%. Which fluid and electrolyte imbalance would the nurse associate with the patient's laboratory data? 1. Hyperkalemia 2. Hypernatremia 3. Excessive fluid volume 4. Deficient fluid volume
3. Excessive fluid volume
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? 1. Fluid movement from the blood vessels into the cells 2. Fluid movement from the interstitial space into the cells 3. Fluid movement from the interstitial spaces into the plasma 4. Fluid movement from the blood vessels into interstitial spaces
3. Fluid movement from the interstitial spaces into the plasma
A patient with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which provider prescription would the nurse question? 1. Limit foods high in potassium. 2. Calcium gluconate IV piggyback. 3. Give a potassium-sparing diuretic daily. 4. Administer intravenous insulin and glucos
3. Give a potassium-sparing diuretic daily.
A patient reports intense thirst, decreased alertness, and has a serum sodium level of 170 mEq/L. Which condition would the nurse document in the patient's medical chart? 1. Hyperkalemia 2. Hypercalcemia 3. Hypernatremia 4. Hypermagnesemia
3. Hypernatremia
Based on the blood pressure (BP) readings below, which action would the nurse take for a patient with overuse of diuretics? Lying----132/84 mm Hg Sitting----110/78 mm Hg Standing----92/62 mm Hg 1. Administer oxygen. 2. Apply a pulse oximeter. 3. Implement fall precautions. 4. Auscultate the lungs for crackles.
3. Implement fall precautions.
A patient with heart failure accidentally overused the prescribed diuretics. Which respiratory manifestation would the nurse anticipate finding in the patient? 1. Shortness of breath 2. Pulmonary congestion 3. Increased respiratory rate 4. Moist crackles on inspiration
3. Increased respiratory rate
A patient with diabetes mellitus has a urinary output of 4000 mL/day. Which intervention would the nurse implement? 1. Transfuse 2 units of blood. 2. Generously apply skin moisturizer regularly. 3. Initiate infusion of lactated Ringer's solution. 4. Provide supplementary water through enteral feedings.
3. Initiate infusion of lactated Ringer's solution.
An older patient is receiving IV fluids postoperatively. During the 8:00 am assessment, the nurse notes that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 am. What is the priority nursing intervention? 1. Slow the rate to keep vein open until next bag is due at noon. 2. Notify the health care provider and complete an incident report. 3. Listen to the patient's lung sounds and assess respiratory status. 4. Assess the patient's cardiovascular status by checking pulse and blood pressure.
3. Listen to the patient's lung sounds and assess respiratory status.
Which rationale supports the nurse's assessment of a patient's magnesium level? 1. The electrolyte is the most abundant intracellular cation present in the body. 2. The electrolyte may cause extracellular fluid overload. 3. Magnesium may affect neuromuscular excitability and contractility. 4. The patient is at risk for hypotension when the levels of magnesium decrease.
3. Magnesium may affect neuromuscular excitability and contractility.
Which nursing intervention is most appropriate when caring for a patient with dehydration? 1. Monitor skin turgor every shift. 2. Auscultate lung sounds every 2 hours. 3. Monitor daily weight and intake and output. 4. Encourage the patient to reduce sodium intake.
3. Monitor daily weight and intake and output.
Which statement describes diffusion? 1. Involves using a protein carrier in the cell membrane 2. Process in which molecules move against the concentration gradient 3. Movement of molecules from an area of high concentration to an area of low concentration 4. Movement of water "down" a concentration gradient from a region of low solute concentration to one of high solute concentration across a semipermeable membrane
3. Movement of molecules from an area of high concentration to an area of low concentration
Which physical assessment finding is consistent with a patient's total serum calcium level of 6.4 mg/dL? 1. Polyuria 2. Bone pain 3. Paresthesias 4. Diminished deep tendon reflexes
3. Paresthesias
Which patient disorder has a potential complication of developing increased extracellular fluids? 1. Drainage from a rectal fistula 2. Osmotic diuresis 3. Renal impairment 4. Heatstroke
3. Renal impairment
When assessing a patient admitted with nausea and vomiting, which finding best supports the patient problem of deficient fluid volume? 1. Polyuria 2. Bradycardia 3. Restlessness 4. Difficulty breathing
3. Restlessness
Which rationale supports the nurse's instruction that a client with chronic kidney disease is to avoid all salt substitutes? 1. A person's body tends to retain fluid when a salt substitute is included in the diet. 2. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood 3. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats 4. The salt substitute substances interfere with capillary membrane transfer, resulting in anasarca
3. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats
A healthcare provider prescribes Hydrochlorothiazide, a potassium-wasting diuretic, to treat a hyperkalemic client, which lab values are most important for the nurse to monitor? 1. Hemoglobin 2. White blood cell count 3. Serum potassium 4. Prothrombin Time (PT/INR) 5. Magnesium.
3. Serum potassium 5. Magnesium.
The nurse receives a provider's prescription to change an IV from 5% dextrose in 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the indication for this change? 1. Sodium, 136 mEq/L; potassium, 3.6 mEq/L 2. Sodium, 145 mEq/L; potassium, 4.8 mEq/L 3. Sodium, 133 mEq/L; potassium, 4.5 mEq/L 4. Sodium, 144 mEq/L; potassium, 3.7 mEq/
3. Sodium, 133 mEq/L; potassium, 4.5 mEq/L
Which clinical manifestation would the nurse look for to detect the presence of dehydration in an older adult patient who has been admitted with nausea and vomiting? Select all that apply. 1. Hypertension 2. Bradypnea 3. Tachycardia 4. Restlessness 5. Urinary output of 10 mL/hour
3. Tachycardia 4. Restlessness 5. Urinary output of 10 mL/hour
Which mechanism would the nurse describe to explain a patient's insensible water loss of an estimated 900 mL/day? 1. Excreted via urine 2. Lost through feces 3. Vaporized by the lungs and skin 4. Secreted into the digestive tract
3. Vaporized by the lungs and skin
When planning the care of a patient with dehydration, what urine output would the nurse instruct the assistive personnel (AP) to report? 1. 60 mL in 90 minutes 2. 1200 mL in 24 hours 3. 300 mL per 8-hour shift 4. 20 mL for 2 consecutive hours
4. 20 mL for 2 consecutive hours
The patient presents with a one-time prescription for 20 mEq of potassium chloride in 250 mL of IV normal saline, to be given immediately. Which serum potassium level would prompt the nurse to seek clarification regarding the patient's prescription? 1. 1.7 mEq/L 2. 2.9 mEq/L 3. 3.6 mEq/L 4. 4.5 mEq/L
4. 4.5 mEq/L
Which solution would the nurse select as the most effective means of killing harmful bacteria when preparing to cleanse the skin around a central venous access device? 1. Sterile saline solution 2. Povidone-alcohol solution 3. Isopropyl alcohol solution 4. Chlorhexidine-based solution
4. Chlorhexidine-based solution
Which food item would the nurse include in the diet plan of a patient with a magnesium deficiency? 1. Milk 2. Broccoli 3. Brazil nuts 4. Dark-green leafy vegetables
4. Dark-green leafy vegetables
Which type of imbalance would the nurse attribute to a patient who has second-degree (partial-thickness) burns over 30% of the total body surface area, poor skin turgor, restlessness, a urinary output of <50 mL over the past 2 hours, and a rapid, thready pulse? 1. Hyperkalemia 2. Metabolic acidosis 3. Hyperphosphatemia 4. Extracellular fluid volume deficit
4. Extracellular fluid volume deficit
Which clinical manifestation would the nurse associate with the patient's admitting problem of deficient fluid volume related to nausea and vomiting? 1. Polyuria 2. Decreased pulse 3. Difficulty breathing 4. General restlessness
4. General restlessness
Which action would the nurse perform to ensure a patient's safety when preparing to administer IV potassium chloride (KCl) to the patient? 1. Administer the KCl via IV push. 2. Add the KCl to the hanging (existing) IV bag. 3. Administer the IV KCl in concentrated amounts. 4. Invert the IV fluid with KCl several times prior to hanging.
4. Invert the IV fluid with KCl several times prior to hanging.
A patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would the nurse identify as an adverse effect related to this therapy? 1. Sodium falling to 138 mEq/L 2. Potassium rising to 4.1 mEq/L 3. Magnesium rising to 2.9 mg/dL 4. Phosphorus falling to 2.1 mg/dL
4. Phosphorus falling to 2.1 mg/dL
Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's
B. D5W
Isotonic fluids cause shifting of water from the extracellular space to the intracellular space. A. True B. False
B. False
What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Hypertonic C. Isotonic D. Colloid
B. Hypertonic
When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B. Pulmonary Edema
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis
C. Isotonic
Which solution below is NOT a hypertonic solution? A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS
D. 0.33% saline (1/3 NS
It is important for the nurse to assess for which manifestation(s) in a patient who has just undergone a total thyroidectomy. (select all that apply) a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek sign
a. Confusion d. Circumoral numbness e. Positive Chvostek sign
The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.
a. fluid restriction.
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is (recognize) a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.
a. osmosis.
An older adult is admitted to the medical unit with GI bleeding. Assessment findings that occur with fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. orthostatic hypotension. f. increased central venous pressure.
a. weight loss. b. dry oral mucosa. e. orthostatic hypotension.
The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c. Weak, irregular pulse and poor muscle tone
The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's solution. d. 5% dextrose in 0.45% saline.
c. lactated Ringer's solution.
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. older adults are more likely than younger adults to lose extracellular fluid during surgeries. c. water accounts for a greater percentage of body weight in the older adult than in younger adults. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.
d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.