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Fluids&Electrolytes
| Question | Answer |
|---|---|
| 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. | Ileostomy output of 650 mL in 4 hours Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute |
| 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. | "Water and electrolytes are lost in approximately the same proportion as they exist in the body." "A client who has a large blood loss due to an accident will initially have an isotonic dehydration." |
| 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. Which sign/symptom would be noted in the client if hyperkalemia? | Muscle weakness |
| 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. | Weakness in all extremities Confusion with garbled speech Diarrhea with abdominal cramping |
| Which fluids are identified as insensible fluid losses? Select all that apply. | Sweat Sputum |
| The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply. | A client with pneumonia A client with an ileostomy A client with a temperature of 102.5° F (39.2° C) |
| The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use? | Increased specific gravity of the urine |
| A client 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? | Obtain orthostatic vital signs. |
| Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information would the nurse reinforce when instructing the client about taking this medication? | Take 2 hours before meals. |
| A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply. | Hypokalemia Hyponatremia Hypomagnesemia |
| A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply. | Positive Trousseau's sign Fine tremors noted in hands |
| The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium? | Butter |
| The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value? | Narrow, peaked T waves |
| The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. include which strategies to avoid foods high in potassium? Select all that apply. | Use eggs as a source for protein. Avoid eating lunch meats and bolognas. Eat salads with cabbage and lettuce and avoid spinach. |
| The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? | Generalized muscle weakness |
| diagnosis of severe nausea and vomiting. serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which IV fluids would provide free water, sodium, and chloride to the client? Select all that apply. | 0.45% sodium chloride in water solution Dextrose 5% in 0.225% sodium chloride solution |
| 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? | Left foot has 4+ pitting edema. |
| 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. | Flat neck veins Weakly palpable peripheral pulses Heart rate of 104 beats per minute |
| 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. | Decreasing body weight Decreasing abdominal girth |
| The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing? | The client with diabetes mellitus |
| The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply. | Hypotension Loss of deep tendon reflexes |
| A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply. | Is the same solution as sodium chloride 0.9% Is used to administer red blood cell transfusion Is used to treat hypotension due to fluid volume deficit |
| A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient? | Vitamin D |
| 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 would take which action? | Inform the registered nurse of the laboratory value. |
| A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply. | Restrict fluid intake. Monitor electrolytes every 24 hours. |
| A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply. | Restrict fluid intake. Monitor electrolytes every 24 hours. |
| The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The gastroenterologist prescribes to have the tube irrigated once every 8 hours. nurse would utilize in performing this procedure. Select all that apply. | Utilize 30 mL of 0.9% normal saline for the irrigating solution. After injecting the irrigating solution, pull back on the irrigation syringe. |
| A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply. | Cabbage Mushrooms Strawberries |
| 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? | The skin when pinched immediately fell back to normal when released. |
| 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 would include which instructions? Select all that apply. | Take the calcium carbonate with or just after meals. Avoid foods such as beets, spinach, and bran in the diet. Take the medication with a full glass of water (8 oz/240 mL). |
| The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit? | The client with an ileostomy |
| 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. | The client with renal failure The client with chronic cirrhosis |
| The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? | The client with the syndrome of inappropriate secretion of antidiuretic hormone |
| The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse would determine that this is an expected finding if the client had which health problems? Select all that apply. | Severe burn injury Untreated ketoacidosis |
| 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, which action will provide a reliable indicator of fluid balance? | Monitoring for decreased urine output and hypotension |
| 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. | A client with a new burn injury A client diagnosed with acute kidney injury (AKI) |
| 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? | Hypertension |
| A client enters the emergency department confused, twitching, and having seizures. flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. serum sodium level is 172 mEq/L (172 mmol/L)PHCP likely prescribe? Select all that apply. | Monitor vital signs. Monitor intake and output. Increase water intake orally. Monitor electrolyte levels. Provide a sodium-reduced diet. |
| The nurse admits a client with a diagnosis of dehydration and history of cancer to the nursing unit. The client is weak and irregular heart pulse rhythm. absent bowel sounds last BM 4 days earlier. client is at high risk for which electrolyte imbalance? | Hypercalcemia |
| The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider? | Administer hypertonic normal saline solution intravenously. |
| 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? | Prolonged bed rest |
| 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)? | A client with a history of alcoholism |
| The nurse is caring for a client with leukemia, client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom would the nurse expect to note in this client if hyponatremia is present? | Postural blood pressure changes |
| The nurse is told in a report that the client has hypocalcemia. Which signs would the nurse expect to note during the data collection? Select all that apply. | Tetany A positive Chvostek sign A positive Trousseau sign |
| Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. | A premature infant A 101-year-old man A client with heart failure A client receiving renal dialysis |
| 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)? | U waves |
| The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication would the nurse plan to assist in administering to the client? | Calcitonin |
| 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 would the nurse expect to note in the client, based on this magnesium level? | Loss of deep tendon reflexes |
| The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply. | The client with renal failure The client with chronic congestive heart failure (CHF) |
| 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 would the nurse collect? Select all that apply. | Presence of Chvostek's sign Presence of electrocardiogram abnormalities Presence of tingling in the fingertips and around the mouth Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes |
| The client consumed (8 oz), (8 oz), (6 oz) for breakfast; (4 oz) (8 oz) for lunch; (10 oz), (8 oz),(8 oz) for dinner. 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. | 2520 |
Created by:
ceangel