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Foundations Nursing
set 16
| Question | Answer |
|---|---|
| On assessment, the nurse notes that the patient is dyspneic and crackles are audible on lung auscultation, and that the patient has gained 1.8 kg over the past 24 hours. What nursing diagnostic label do these data suggest? | Excess fluid volume |
| A patient is preparing to undergo a major abdominal surgery. The nurse creates a care plan for this preoperative patient. Which is an appropriate nursing diagnosis related to fluid imbalance? | Risk for fluid imbalance |
| patient w/history of nausea, vomiting for 3 days, become lethargic, urine output less than 30 mL/hour, poor oral intake. RN performs assessment, finds cool pale skin, dry mucous membranes, low bp, tachycardia, lethargy. appropriate RN diagnosis? | Deficient Fluid Volume related to loss of fluids through nausea and vomiting as evidenced by dry mucous membranes, low blood pressure, tachycardia, and decreased urine output |
| Mrs. Ellis exhibits clinical manifestations of fluid volume excess (FVE). In addition to the nursing diagnosis of Excess Fluid Volume, what other nursing diagnoses related to FVE could be selected for her, based on her clinical data? | Decreased cardiac output |
| After completing the nursing assessment, the nurse writes the nursing diagnosis label, Readiness for Enhanced Fluid Balance. What are the defining characteristics of this diagnostic label? | Stable daily weights Moist mucous membranes Intake equals output No manifestations of fluid volume deficit |
| patient has diagnosis of Deficient Fluid Volume related to decreased circulating volume as evidenced by low blood pressure, thready pulse, tachycardia, decreased urine output, and thirst. Which statement represents a measurable, patient-centered goal? | The patient will consume at least 100 mL of fluids every hour for a 12-hour shift. |
| patient has diagnosis of Excess Fluid Volume related to increased fluid retention as evidenced by edema, decreased urine output, dyspnea, and activity intolerance. Which goals would be appropriate for the nurse to add to the patient’s plan of care? | The patient will consume no more than 1500 mg of sodium in a 24-hour period. The patient will maintain a urinary output of greater than 30mL per hour for 24 hours. The patient will be able to walk 50 feet without dyspnea by the end of a 12-hour shift. |
| nurse writes the nursing diagnosis of Excess Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient's intake and output will be approximately equal during a 24-hour day. |
| nurse writes the nursing diagnosis of Deficient Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient's intake will approximately equal output during a 12-hour shift. |
| The nurse identifies hypokalemia in a patient. Which findings on the nursing assessment may be associated with this electrolyte imbalance? | Bradycardia Hypertension Poor muscle tone Poor skin turgor |
| nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance should the nurse use as the “as evidenced by” portion for this nursing diagnostic statement? | Hypercalcemia |
| The nurse is providing care to a patient with electrolyte imbalance showing edema and shortness of breath. Which nursing diagnosis should the nurse include in the updated patient plan of care? | Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath |
| The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal statement for the nurse to include in the patient’s plan of care? | Patient’s serum potassium level will be within the normal range of 3.5–5.0 mEq/L during the hospitalization. |
| RN planning care for patient whose diagnosis is Decreased cardiac output related to electrolyte imbalance. The NOC for this diagnosis is Cardiac pump effectiveness. Which indicators should RN monitor to determine effectiveness of current plan of care? | Blood pressure Heart sounds |
| Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by muscle cramping? | Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment. |
| Mr. Johnson continues to exhibit poor skin turgor and reports redness and irritation to the skin. The nurse adds Risk for impaired skin integrity to the plan of care. Which is an accurate goal that the nurse should include for the new nursing diagnosis? | Patient will report altered sensation or pain at risk areas as soon as noted |
| The nurse has become concerned that a patient may be developing a fluid volume imbalance. Which data reflect the priority assessments that the nurse should monitor on this patient? | The patient's pulse and blood pressure The patient's weight changes over the past day The patient's intake and output balance over the past 48 hours |
| The nurse is preparing to tally up a patient’s fluid intake at the end of the shift. Which substances should be included in the fluid intake tally? | Nasogastric tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications |
| The nurse is tallying up a patient’s intake and output at the end of the shift. Which patient-related data would require entry of fluid output information on the EHR? | The patient has a nasogastric tube attached to wall suction. The patient has a Foley catheter in place. The patient has a surgical wound drain on his abdomen. |
| Which of Mrs. Walters’ assessments will Julie, her nurse, need to closely monitor as indicators of changes in her fluid volume status? | Vital signs Daily weights Intake and output |
| The nurse has received a “force fluids” order for a patient with a fluid volume deficit. Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs? | Ensuring the pitcher of water at the patient bedside is refilled as required Providing ways to record intake of fluids to meet required levels |
| The nurse has received a “force fluids” order for a patient with a fluid volume deficit. Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs? | Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day |
| The nurse is developing a 24-hour fluid budget for a patient with 1000 mL fluid restriction. The fluid budget will need to include which set of factors? | Medications IV fluids Between meal fluid sipping Breakfast, lunch, and dinner |
| A patient is on a 1000 mL per day fluid restriction. At 3 pm, the patient has consumed 700 mL. What is the best plan for the remainder of the day to maintain that fluid restriction? | Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep. |
| When addressing fluid restriction in a patient with fluid volume excess, what actions should the nurse take to ensure the patient is responsible and comfortable meeting the fluid restriction goals? | Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day. |
| nurse suspects that a patient receiving an IV infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. The nurse is aware that this IV solution can cause these complications due to what tonicity? | It is a hypertonic solution. |
| The nurse is inspecting an infant to identify a suitable IV site. In infants, the most common location for an IV site is which vein location? | The vein in the middle of the scalp |
| What are the nurse’s responsibilities regarding IV fluid administration? | Verify that the fluid is appropriate for the patient. Evaluate the effectiveness of IV therapy. Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration. |
| The nurse is assigned to a patient who is receiving 0.9% Normal Saline IV fluid. The nurse will need to monitor the patient for what IV solution-related complication? | Hypernatremia |
| The nurse is preparing to administer a blood product. The nurse will prime the IV tubing with what IV solution? | 0.9% normal saline |
| The nurse is preparing to start a blood transfusion. The nurse is aware that the most common cause of adverse blood transfusion events is what procedural step failure? | Inappropriate identification prior to blood administration |
| When administering blood to a patient, the nurse knows that the most vigilant monitoring of the patient must take place. When must this monitoring happen? | As the transfusion is started and within the first 15 minutes |
| The nurse is monitoring a patient for possible adverse effects while receiving a unit of blood. What common manifestations does the nurse assess the patient for? | Itching Hypotension Dyspnea Fever |
| Which patient would benefit from ECG monitoring due to an electrolyte imbalance? | Hypokalemia Hypocalcemia Hypomagnesemia |
| Which is the priority consideration for a nurse who is administering IV potassium to a patient who is experiencing acute hypokalemia? | Administering the solution slowly |
| What should the nurse monitor when providing care to a patient who is prescribed the prolonged use of IV normal saline (NS)? | Fluid volume excess |
| The nurse is caring for a patient with known hyponatremia. Which are appropriate nursing interventions for the nurse to implement for this patient? | Assist the patient to adhere to fluid restriction requirements. Monitor intake and output. |
| Which foods should the nurse teach the patient to avoid when prescribed a low sodium diet for hypernatremia? | Canned soup Sports drinks Table salt |
| The nurse is providing education to a patient diagnosed with hypermagnesemia. Which food should the nurse teach the patient to avoid? | Green, leafy vegetables |
| Which would be an appropriate instruction for a patient experiencing hypermagnesemia? | Avoid taking antacids |
| Which foods should the nurse teach patients to avoid when diagnosed with hyperkalemia? | Broccoli Cabbage Bananas |
| Which patient potassium level would require the nurse to prepare for cardiac monitoring? | 2.4 mEq/L |
| Which electrolyte excess or deficit will the nurse pay special attention to, given its critical role in maintaining appropriate cardiac functioning? | Sodium Potassium |
| Which advantage of cardiac telemetry should the nurse include in the teaching session for a patient diagnosed with an electrolyte imbalance who requires cardiac monitoring? | Allows the patient's cardiac activity to be monitored remotely without affecting the patient's mobility |
| What purpose of cardiac monitoring should the nurse include in a teaching session for patients diagnosed with electrolyte imbalances? | To monitor for cardiac dysrhythmias |
| What nursing actions should be implemented prior to a patient receiving a dialysis treatment? | Obtaining vital signs Assessing lab data Providing instruction about what the patient should expect |
| A patient has a serum potassium level of 7.0 mEq/L and dialysis is ordered. Which should the nurse expect after the dialysis treatment? | The serum potassium concentration will decrease. |
| nurse completes education for a patient who will receive dialysis to treat an electrolyte imbalance. Which patient statement indicates the correct understanding of the information presented? | "Dialysis removes excess wastes and electrolytes from my body." |
| Which concept should the nurse include in a teaching session for a patient requiring dialysis for the treatment of an electrolyte imbalance? | Dialysis may be needed as a result of decreased renal function. Blood is drawn from the body and processed through a series of filters to remove wastes. Dialysis helps maintain normal fluid and electrolyte balance. |
| Which statements by the nursing student regarding an isotonic fluid deficit demonstrate correct understanding of the condition? | -Water and sodium are lost together equally. -Serum osmolality does not change. |
| A patient has just returned from surgery. Which patient factors, if present, increases the risk for fluid volume deficit? | -A draining wound. -Dressing changes for severe burns. -Nausea and vomiting. |
| patient was admitted, her baseline weight has decreased from 160 pounds to 152 pounds, a 5% total body weight loss. The nurse is aware that on the dehydration severity scale, the patient falls into which category? | Moderate dehydration. |
| A patient with heart failure has developed the clinical manifestations of fluid volume excess. What features of FVE would the nurse expect to be present? | -No change in serum osmolality. -Equal gain of water and sodium |
| patient has been admitted to the hospital for treatment of severe fluid volume excess related to syndrome of inappropriate antidiuretic hormone (SIADH). What unique features of fluid volume excess will the nurse expect? | -Water gain in excess of sodium. -Decreased serum osmolality. -Signs of cerebral edema. |
| student nurse is studying fluid imbalances, including unique and common features. The student would include what information regarding the feature that hypotonic and isotonic FVE have in common? | Increased circulating volume. |
| RN asked to assess patient for fluid volume deficit. patient reports he has lost 10 kg of total body weight in the last 48 hours due to vomiting and diarrhea. Based on the relationship between volume and weight, about how much fluid has this patient lost? | 10 liters of fluid |
| nurse has been assigned to an adult patient with isotonic fluid volume deficit and performing her shift assessment on the patient. The nurse can anticipate which clinical findings? | Hypotension, flat neck veins when supine, low urine output |
| A patient has developed neurologic manifestations related to hypertonic fluid volume deficit. The nurse is aware that these manifestations are caused by what underlying problem? | Increased serum osmolality causes water to shift out of brain cells by osmosis. |
| The nurse is assessing a patient with fluid volume deficit (FVD). Which clinical manifestation would suggest that the patient is experiencing hypertonic FVD? | The pt has become confused. |
| During the morning patient assessment the nurse finds bounding peripheral pulses and jugular venous distention. The nurse is aware that these are clinical manifestations caused by what type of fluid imbalance? | Increased circulating volume |
| A patient who received an excessive volume of hypotonic IV fluid has developed the signs and symptoms of hypotonic FVE. Which neurologic clinical manifestations are consistent with this fluid imbalance? | Seizures, confusion |
| A patient has developed edema as a result of fluid volume excess. The nurse is aware that the underlying cause of this fluid imbalance is which primary cause of edema? | Increased hydrostatic pressure |
| A patient has developed edema. Which descriptions are accurate regarding this manifestation? | - Caused by excessive fluid in the interstitial space - Dependent edema occurs in the sacral area of pt on bedrest - Edematous tissue is quite fragile |
| The nurse suspects that a patient has developed a hypertonic fluid volume deficit from receiving a large volume of hypertonic IV fluids. The nurse should expect to see which lab test result? | - Increased BUN and creatinine - Elevated serum osmolality |
| The nurse is admitting a patient with a fluid imbalance. During the patient interview, what questions would be appropriate for the nurse to ask to obtain fluid balance information? | - Have you lost or gained weight recently - Do you have a hx of renal dz or DM - Have you noticed swelling of your hands and feet |
| An acutely ill patient is brought into the urgent treatment center by a family member. Which patient assessments would suggest a significant fluid volume deficit? | - Elevated serum BUN and creatinine - Rapid, weak, thready pulse - Dry, cracked lips and furrows on the tongue |
| A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results? | - Elevated RBC - Increased BUN and Creatinine |
| Which serum sodium concentration should the nurse identify as hyponatremia? | 145 mEq/L |
| Which serum sodium concentration should the nurse identify as hypernatremia? | 150 mEq/L |
| Which factors should the nurse identify as increasing a patient’s risk for hypovolemic hyponatremia? | Diuretics Emesis Diarrhea |
| Which data should the nurse identify as placing a patient at risk for hypovolemic hyponatremia? | Profuse diaphoresis |
| Which disease process should the nurse identify as the cause of the patient’s serum potassium concentration of 5.3 mEq/L? | Severe infections |
| Which medical order should the nurse question for a patient experiencing hypokalemia? | Loop diuretic prescription |
| Which serum potassium concentrations would the nurse identify as hyperkalemia in the patient’s medical record? | 5.1 mEq/L 5.5 mEq/L |
| Which drug classification should the nurse identify as a cause of hyperkalemia? | ACE inhibitors |
| Which nursing statement is accurate when providing education to a post-menopausal patient who is at risk for hypercalcemia? | "It is important for us to monitor your serum parathyroid levels." |
| Which serum calcium concentrations should the nurse identify as abnormal? | 7.9 mg/dL 8.4 mg/dL 10.6 mg/dL |
| Which should the nurse identify as a primary cause of hypocalcemia? | Protein depletion |
| Which items found during the review of a medical history should the nurse identify as risk factors for hypocalcemia? | Inadequate dietary intake Hypomagnesemia Hypoparathyroidism |
| The nurse is providing care to a patient who is diagnosed with hypomagnesemia. Which cause for this condition should the nurse include in the patient teaching? | Loop diuretics |
| Which finding in the patient’s medical history necessitates the nurse to provide education related to hypermagnesemia? | Leukemia |
| A patient is diagnosed with hypermagnesemia related to an increased intake of magnesium. Which topic should the nurse include when providing patient education regarding the cause of the condition? | Antacid use Magnesium-containing laxatives |
| When conducting patient education related to the causes of hypermagnesemia, which cause should the nurse include in the teaching session? | Renal failure |
| patient is diagnosed with hypophosphatemia caused by an increased excretion of phosphate. Which probable cause for this condition should the nurse include in the teaching session with the patient? | Diabetic ketoacidosis |
| A patient is diagnosed with drug-related hyperphosphatemia. Which type of drug should the nurse include in the teaching session as the cause of the current diagnosis? | Cathartics |
| Which causes, related to poor intake of phosphate, should the nurse include in a teaching session for a patient who is diagnosed with hypophosphatemia? | Phosphate-binding antacids Alcoholism Malabsorption syndrome |
| Which should the nurse include in a patient-teaching session as the most common cause for hyperphosphatemia? | Poor kidney function |
Created by:
colby.caswell