NCLEX questions PN electrolyte balance(56)

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? 1.U waves 2.Flat P waves 3.Elevated T waves 4.Prolonged PR interval

1. U waves Rationale:A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life-threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1.Prolonged bed rest 2.Adrenal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D

1. Prolonged bed rest Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply. 1.Increasing pulse 2.Decreasing body weight 3.Decreasing urine output 4.Decreasing abdominal girth 5.Increasing central venous pressure

2.Decreasing body weight 4.Decreasing abdominal girth Rationale:A sign that fluid overload is resolving is loss of body weight and a decrease in the abdominal girth. The client with cirrhosis with resolving fluid overload will have less ascites. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, decreased urine output, and a decreased hematocrit. These symptoms must reverse if the fluid overload is to be resolved

Which fluids are identified as insensible fluid losses? Select all that apply 1.Sweat 2.Sputum 3.Nasogastric tube output 4.Output from Jackson-Pratt drain 5.Urine output from indwelling catheter

1.Sweat 2.Sputum Rationale:Insensible fluid losses are those that cannot be perceived by the senses or measured because they occur through the skin, such as sweat, and the lungs, such as sputum. They occur on a daily basis without the client's awareness. Sensible losses are those that are perceivable and measurable and include wound drainage, including output from wound drains such as a Jackson-Pratt drain; gastrointestinal tract losses, such as output from a nasogastric tube;and urine output.

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.1.Lung crackles 2.Flat neck veins 3.Weakly palpable peripheral pulses 4.Heart rate of 104 beats per minute 5.Blood pressure (BP) of 136/86 mmHg

2.Flat neck veins 3.Weakly palpable peripheral pulses 4.Heart rate of 104 beats per minute Rationale:A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins, a slightly tachycardic pulse rate (104 beats per minute), and weakly palpable peripheral pulses. Other findings are increased respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The lung crackles are consistent with consolidation in the lungs occurring with pneumonia and the borderline elevated BP may relate to pain associated with breathing.

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present? 1.Muscle pain 2.Mental confusion 3.Muscle weakness 4.Depressed deep tendon reflexes

3. Muscle weakness Rationale:Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness not muscle pain. Mental status changes and confusion are most likely noted in the client experiencing hypocalcemia hyponatremia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance? 1.Checking for moistness of the skin 2.Checking for skin turgor with tenting 3.Monitoring for decreased urine output and hypotension 4.Precisely measuring vomitus and diarrhea

3.Monitoring for decreased urine output and hypotension Rationale:With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid and chronic illness in clients with HIV.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data as a baseline and then checks the client's skin turgor by doing which action? Refer to video. Click on the Question Video button to view a video showing preparation procedures. 1.Pinching the skin on the thigh 2.Pushing on the skin in the ankle area 3.Assessing the skin in the radial pulse area 4.Pulling up and releasing the skin on the sternal area

4. Pulling up and releasing the skin on the sternal area Rationale:Click on the Rationale Video button. When preparing to place a client on I&O measurement, the nurse explains the procedure to the client. This will provide the client with information about the purpose and procedure and allow client participation, if feasible, such as contacting the nurse when oral intake is consumed or if the bathroom is used. The nurse also performs a baseline assessment for later comparison and checks for signs of fluid imbalance, including measuring the client's vital signs, weight, and skin turgor. Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor. The actions in manipulating the skin near the thigh, ankle, or wrist are not approved interventions to assess turgor.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1.Rapid weight loss 2.Flat hand and neck veins 3.A weak and thready pulse 4.An increase in blood pressure

4.An increase in blood pressure Rationale:Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level? 1.Twitching 2.Irritability 3.Hyperactive reflexes 4.Loss of deep tendon reflexes

4.Loss of deep tendon reflexes Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability, and hyperactive reflexes should be noted in a client with hypomagnesemia.

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply. 1."The loss of electrolytes is greater than the loss of water." 2."The loss of water is greater than the loss of electrolytes." 3."Serum sodium level rises above 150 mEq/L (150 mmol/L)." 4."The client is likely to have impaired mental status due to low sodium levels." 5."Water and electrolytes are lost in approximately the same proportion as they exist in the body." 6."A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

5."Water and electrolytes are lost in approximately the same proportion as they exist in the body." 6."A client who has a large blood loss due to an accident will initially have an isotonic dehydration." Rationale:Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal (135 to 145 mEq/L [135 to 145 mmol/L]). A client who loses a large amount of blood initially is dehydrated, but the electrolytes are lost proportionately. Options 1 and 4 describe hypotonic dehydration in which the serum sodium level is less than 130 mEq/L (130 mmol/L). Options 2 and 3 describe hypertonic dehydration.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take? 1.Obtain orthostatic vital signs. 2.Prepare to insert a nasogastric tube feeding. 3.Prepare to insert a parenteral nutrition infusion. 4.Check the client's skin for irritation caused by diarrhea.

1.Obtain orthostatic vital signs. Rationale:The initial nursing action is to determine the client's level of dehydration. Orthostatic vital signs (blood pressures and pulses, lying, sitting, standing) are actions to determine the probability of fluid losses. A drop of more than 10 to 20 mm Hg and an increased pulse rate of 10 to 20 beats per minute probably indicate a significant intravascular fluid volume deficit. With a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is facing a life-threatening problem. Generally, the fluid levels must be increased quickly with lactated Ringer's or normal saline intravenous solutions as prescribed. Option 4 may be an intervention, but it is not the initial action. Options 2 and 3 are not initial measures to treat dehydration.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action? 1.Document the value in the client's record. 2.Inform the registered nurse of the laboratory value. 3.Place the laboratory result form in the client's record. 4.Reassure the client that the laboratory result is normal.

2.Inform the registered nurse of the laboratory value. Rationale:The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The primary health care provider (PHCP) prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse should utilize in performing this procedure. Select all that apply. 1.Follow strict sterile technique. 2.Utilize 30 mL of 0.9% normal saline for the irrigating solution. 3.Inject the irrigating solution through the air vent of the Salem sump tube. 4.After injecting the irrigating solution, pull back on the irrigation syringe. 5.Check client's electrolyte lab results to determine correct irrigating solution.

2.Utilize 30 mL of 0.9% normal saline for the irrigating solution. 4.After injecting the irrigating solution, pull back on the irrigation syringe. Rationale:A nasogastric tube is usually a Salem sump tube that is inserted through the nare with the end of the tube in the stomach. The tube is connected to low suction to remove gastric secretions and rest the bowel. Irrigation is done to maintain patency of the tube. Normal saline is used to limit loss of electrolytes. The usual amount is 30 mL injected through the tube, not the air vent, and then aspirated back into the syringe. The nurse should follow aseptic technique wearing clean gloves, not sterile technique. The client's serum electrolyte results do not need to be monitored since normal saline is the correct solution f

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

2530ml The client consumed a total of 84 oz of fluid. Because 1 oz is equal to 30 mL, multiply 84 oz by 30 mL/oz. This yields 2520 mL.

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)? 1.A client receiving chemotherapy 2.A client with hypoparathyroidism 3.A client with a history of alcoholism 4.A client admitted with vitamin D intoxication

3.A client with a history of alcoholism Rationale:The normal serum phosphorus level is 3.0 to 4.5 mg/dL (0.97-1.45 mmol/L) so a value of 2.0 mg/dL (0.64 mmol/L) is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply. 1.Dry flaky skin 2.Bleeding from the gums 3.Weakness in all extremities 4.Confusion with garbled speech 5.Diarrhea with abdominal cramping

3.Weakness in all extremities 4.Confusion with garbled speech 5.Diarrhea with abdominal cramping Rationale:The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Thus the client is experiencing low sodium, or hyponatremia, as evidenced by the weakness in extremities, confusion, and diarrhea with abdominal cramping. Signs of hyponatremia include rapid and thready pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion, and apprehension. The neurological functioning of the client relates to the swollen brain cells that impair functioning. The gastrointestinal system is stimulated and hyperactive bowel sounds often occur. Dry skin and bleeding gums are not related to the low sodium level.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1.Twitching 2.Positive Trousseau's sign 3.Hyperactive bowel sounds 4.Generalized muscle weakness

4.Generalized muscle weakness Rationale:Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present? 1.Intense thirst 2.Slow bounding pulse 3.Dry mucous membranes 4.Postural blood pressure changes

4.Postural blood pressure changes Rationale:Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication? 1.Take with milk. 2.Take with meals. 3.Take with an antacid. 4.Take 2 hours before meals.

4.Take 2 hours before meals. Rationale:Etidronate is a bisphosphonate that works by slowing the resorption of bone and allowing new bone to be formed. Etidronate should be taken on an empty stomach 2 hours before meals. It should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron, or albumin.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1.The client with Addison's disease 2.The client with metabolic acidosis 3.The client with intestinal obstruction 4.The client receiving nasogastric suction

4.The client receiving nasogastric suction Rationale:Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply. 1.Take the calcium carbonate with or just after meals. 2.Avoid foods such as beets, spinach, and bran in the diet. 3.Take the medication with a full glass of water (8 oz/240 mL). 4.It is permissible to swallow whole and not chew the chewable tablets. 5.It is permissible to take an extra calcium pill if the client develops tremors.

1.Take the calcium carbonate with or just after meals. 2.Avoid foods such as beets, spinach, and bran in the diet. 3.Take the medication with a full glass of water (8 oz/240 mL). Rationale:Calcium carbonate is best absorbed with or just after meals. Foods that are high in oxalate, such as beets and spinach, or insoluble fiber, such as bran, may interfere with calcium absorption if eaten in excess. The medication should be taken with a full glass of water (8 oz/240 mL). Chewable tablets should be chewed and taken with a full glass of water to improve absorption of the calcium. The client should follow the prescribed dose and contact the PHCP if symptoms such as tremors occur.

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply. 1.Pulse oximetry reading 92% 2.Ileostomy output of 650 mL in 4 hours 3.Skin returns to position after being pinched up 4.Fine inspiratory crackles that clear with coughing 5.Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute

2.Ileostomy output of 650 mL in 4 hours 5.Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute Rationale:The client with an ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses. An output of 650 mL in 4 hours would amount to a loss of over 3500 mL in 24 hours. Vital signs indicate a risk with the slightly low BP (104/66 mmHg) and a slight tachycardia (106 beats per minute). The borderline normal pulse oximetry reading with crackles that clear with coughing indicates the client may be breathing shallowly and developing atelectasis. The normal skin turgor is not indicative of risk for fluid volume deficit.

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids? 1.Major burn 2.Renal failure 3.Hypertension 4.Laënnec's cirrhosis

3.Hypertension Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as "third-space fluid." This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include body tissues, the pleural and peritoneal cavities and the pericardial sac. In clients with severe burns, fluid shifts out to the tissues in the area of the burn as sometimes evidenced by blistering. In clients with renal failure, there is a loss of protein due to failure of the kidney to retain protein, and fluid shifts from the blood out into the tissues causing the client to have edema in extremities and face. In Laënnec's cirrhosis the liver becomes fibrotic because of insufficient protein intake, alcoholism, and other conditions. The liver normally produces protein as albumin. With the loss of sufficient levels of albumin in clients with cirrhosis, the fluid shifts out into the abdomen (ascites) or tissues. Hypertension, elevated blood pressure, by itself is not a mechanism leading to fluid shifts. Risk factors for third spacing of fluids include the older client, and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition.

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply. 1.Presence of Chvostek's sign 2.Presence of muscle weakness 3.Presence of decreased deep tendon reflexes 4.Presence of electrocardiogram abnormalities 5.Presence of tingling in the fingertips and around the mouth 6.Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

1.Presence of Chvostek's sign 4.Presence of electrocardiogram abnormalities 5.Presence of tingling in the fingertips and around the mouth 6.Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes Rationale:The laboratory result reveals hypocalcemia, a lower than normal calcium level. The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Tetany, electrocardiogram abnormalities, and tingling can be present in hypocalcemia. To test for tetany, the nurse should check for a positive Chvostek's sign (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) and Trousseau's sign (checking for a carpal spasm induced by inflating a blood pressure cuff over the systolic blood pressure for a few minutes). Muscle weakness is commonly associated with potassium abnormalities. Decreased deep tendon reflexes are associated with both hypercalcemia and hypermagnesemia.

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation? 1.Blood pressure (BP) is 138/74. 2.Left foot has 4+ pitting edema. 3.Skin instantly returns to position after being pinched up. 4.Abdomen is slightly distended with active bowel sounds.

2.Left foot has 4+ pitting edema. Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include tissues where an injury or burn occurred, the pleural and peritoneal cavities, and the pericardial sac. Clients at high risk for third spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The left foot that was crushed and is grossly edematous is an example of third spacing of body fluid. The blood pressure represents intravascular fluid status. Normal skin turgor and slight abdominal distention are not examples of third-spacing of fluids.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply. 1.The client with renal failure 2.The client with an ileostomy 3.The client with chronic cirrhosis 4.The client with a draining abdominal wound 5.The client with a nasogastric tube to low suction

1.The client with renal failure 3.The client with chronic cirrhosis Rationale:The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. The client with chronic cirrhosis is at risk for fluid volume excess due to fluid retention secondary to portal hypertension and low levels of protein. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube attached to suction is at risk for deficient fluid volume.

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.1.A client with ulcerative colitis 2.A client with a new burn injury 3.A client with Cushing's syndrome 4.A client diagnosed with acute kidney injury (AKI) 5.A client who has a history of long-term laxative abuse

2.A client with a new burn injury 4.A client diagnosed with acute kidney injury (AKI) Rationale:Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium (from intracellular to extracellular) from early massive cell destruction such as in trauma or burns. Clients with altered kidney function, such as those with AKI, are at risk because the normally functioning kidney excretes potassium. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1.A premature infant 2.A 101-year-old man 3.A client with heart failure 4.A client with diabetes mellitus 5.A client receiving renal dialysis 6.A 29-year-old client with pneumonia

1.A premature infant 2.A 101-year-old man 3.A client with heart failure 5.A client receiving renal dialysis Rationale:Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply. 1.Monitor vital signs. 2.Monitor electrolyte levels. 3.Monitor intake and output. 4.Increase water intake orally. 5.Maintain sodium-reduced diet. 6.Administer hypertonic saline intravenously.

1.Monitor vital signs. 2.Monitor electrolyte levels. 3.Monitor intake and output. 4.Increase water intake orally. 5.Maintain sodium-reduced diet. Rationale:Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. Hypertonic saline is prescribed for severe hyponatremia.

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented? 1.The skin when pinched remained elevated when released. 2.The skin when pinched failed to return to normal when released. 3.The skin when pinched immediately fell back to normal when released. 4.The skin when pinched remained tented for several seconds when released.

3. The skin when pinched immediately fell back to normal when released. Rationale:Turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch.