0% found this document useful (0 votes)
39 views65 pages

Nursing Exam Prep: Fluid & Electrolytes

The document consists of 175 multiple-choice questions related to nursing assessments and interventions for various medical conditions, particularly focusing on fluid and electrolyte imbalances. It covers topics such as the effects of diuretics, the management of potassium and sodium levels, and the implications of specific patient conditions on fluid balance. Each question presents a clinical scenario requiring knowledge of nursing practices and patient care.

Uploaded by

Ella Magistrado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
39 views65 pages

Nursing Exam Prep: Fluid & Electrolytes

The document consists of 175 multiple-choice questions related to nursing assessments and interventions for various medical conditions, particularly focusing on fluid and electrolyte imbalances. It covers topics such as the effects of diuretics, the management of potassium and sodium levels, and the implications of specific patient conditions on fluid balance. Each question presents a clinical scenario requiring knowledge of nursing practices and patient care.

Uploaded by

Ella Magistrado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Name: Score:

175 Multiple choice questions

Definition 1 of 175
Congestive heart failure managed with loop diuretics puts you at risk for?

Potassium

Hypokalemia

Magnesium

Sodium

Definition 2 of 175

Whish statement best explains how antidiuretic hormone (ADH) affects urine output?

It increases permeability to water in the tubules causing a decrease in urine output.

It increases urine output as a result of water being absorbed by the tubules.

Urine output is reduced as the posterior pituitary decreases ADH production.

Increased urine output results from increased osmolarity and fluid in the extracellular
space.

Definition 3 of 175
Diabetes insipidus puts you at risk for?

Sodium

Potassium

Hypokalemia

Magnesium
Definition 4 of 175

The nurse is assisting a community group to plan a family sports day. In order to prevent
dehydration, what beverage does the nurse suggest be supplied?

Iced tea

Light beer

Diet soda

Bottled water

Definition 5 of 175
The patient has a low potassium level and the physician has ordered an IV infusion. Before
starting an IV potassium infusion, what does the nurse assess?

Adequate urine output

Oxygen saturation level

Baseline mental status

Apical pulse

Definition 6 of 175
The older adult patient needs an oral potassium solution, but is refusing it because it has a
strong and unpleasant taste. What is the best strategy the nurse uses to administer the
drug?

Tell the patient that failure to take the drug could result in serious heart problem

Ask the patient's preference of juice and mix the drug with a small amount

Mix the solution into food on the patient's meal tray and encourage the patient to eat
everything

Offer the drug to the patient several times and then document the patient's refusal.
Definition 7 of 175

High in magnesium content

Interstitial fluid

Hydrostatic pressure

Plasma

Intracellular compartment

Definition 8 of 175

Normal value is 1.3 to 2.1 mg/dL

a. U waves

Hypokalemia

Phosphorus

Magnesium

Definition 9 of 175

The nurse is assessing skin turgor in the 65-year-old patient. What is the correct technique
to use with this patient?

Pinch the skin over the sternum and observe for tenting and resumption of skin to its
normal position after release.

Observe the skin for a dry, scaly appearance and compare it to a previous
assessment.

Pinch the skin over the back of the hand and observe for tenting; count the number of
seconds for the skin to recover position.

Observe the mucous membranes and tongue for cracks, fissures, or a pasty coating.
Definition 10 of 175

The nurse and an unlicensed assitive personnel (UAP) are caring for a group of clients.
Which nursing intervention should the nurse perform?

Measure the client's output from the indwelling catheter

Record the client's intake and output on the I & O sheet

Instruct the client on appropriate fluid restriction

Provide water for a client diagnosed with diabetes insipidus

Definition 11 of 175
Early stage of severe burns puts you at risk for?

A. Bradycardia And Hypotension

Hyperkalemia

Hypernatremia

Potassium

Definition 12 of 175
What is the consequence and clinical manifestation for the patient who does not meet the
obligatory urine output?

Increased salivation and alkalosis

Increased thirst with dry mucous membranes

Lethal electrolyte imbalance and acidosis

Bradycardia and decreased nitrogen level.


Definition 13 of 175

Trauma patient with crushed extremities puts them at risk for?

Potassium

A. Bradycardia And Hypotension

Hypernatremia

Hyperkalemia

Definition 14 of 175

The nurse is assessing the patient's urine specific gravity. The value is 1.035. How does the
nurse interpret this result?

Overhydration

Dehydration

Normal value for an adult

Renal disease

Definition 15 of 175
The movement of water only (the solvent) through a selectively permeable membrane

Filtration

Hydrostatic Pressure

Osmosis

Diffusion
Definition 16 of 175

On admission, the patient with pulmonary edema weighed 151 lbs; now the patient's weight
is 149 lbs. Assuming the patient was weighed both times with the same clothing, same scale,
and same time of day, how many milliliters of fluid does the nurse estimate the patient has
lost?

500

1000

2000

2500

Definition 17 of 175

Which nursing interventions does the nurse include for the patient with hypophosphatemia?

Aggressive treatment with parenteral p;hosphorous

Administration of oral vitamin D and phosphorus supplements

Concurrent administration of calcium supplements

Elimination of beef, pork, and legumes from the diet

Definition 18 of 175

The patient has a magnesium level of 0.8 mg/dL. Which treatment does the nurse expect to
be ordered for this patient?

Intramuscular magnesium sulfate

Increased intake of fruits and vegetables

Oral preparations of magnesium sulfate

IV magnesium sulfate and discontinuation of diuretic therapy


Definition 19 of 175

The physician orders magnesium sulfate (MgSO4) for the patient with severe
hypomagnesemia. What is the preferred route of administration for this drug?

Oral

Subcutaneous

Intramuscular

Intravenous

Definition 20 of 175
The nurse is reviewing orders for several patients who have risk for fluid volume excess. For
which patient condition does the nurse question an order for diuretics?

Pulmonary edema

Congestive heart failure

End-stage renal disease

Ascites

Definition 21 of 175
What is the minimum amount of urine per day needed to excrete toxic waste products?

200 to 300 mL

400 to 600 mL

500 to 1000 mL

1000 to 1500 mL
Definition 22 of 175

The nurse is reviewing the laboratory calcium level results for the patient. Which value
indicates mild hypocalcemia?

5.0 mg/dL

8.0 mg/dL

10.0 mg/dL

12.0 mg/dL

Definition 23 of 175
Multiple transfusions of packed red blood cells can put you at risk for?

Hyperkalemia

A. Bradycardia And Hypotension

Potassium

Hypernatremia

Definition 24 of 175
Normal value is 9.0 - 10.5 mg/dL

Potassium

Sodium

Magnesium

Calcium
Definition 25 of 175

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is
3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a
result of the laboratory value?

U waves

Absent P waves

Elevated T waves

Elevated ST segment

Definition 26 of 175

The client who has undergone an exploratory laparotomy and subsequent removal of a
large intestinal tumor has a nasogastric tube (NGT) in place an an IV running at 150 mL/hr
via an IV pump. Which data should be reported to the HCP?

The pump keeps sounding an alarm indicating the high pressure has been reached.

Intake is 1800 mL, NGT output is 550 mL, and Foley output is 950 mL

On auscultation, crackles and rhonchi in all lung fields are noted

Client has negative pedal edema and an increasing level of consciousness


Definition 27 of 175

The patients with which conditions are at great risk for deficient fluid volume? (Select all
that apply)
a. Fever of 103 degrees F
b. Extensive burns
c. Thyroid crisis
d. Water intoxication
e. Continuous fistula drainage
f. Diabetes insipidus

a. Pinch the skin over the sternum and observe for tenting and resumption of skin to
its normal position after release.

a. Egg roll with soy sauce


d. Bacon and eggs
e. Cottage cheese and tomato
g. Soup with saltine crackers

a. Fever of 103 degrees F


b. Extensive burns
d. Thyroid crisis
e. Continuous fistula drainage
f. Diabetes insipidus

a. Greater than 3 lbs gained in a week or greater than 1 to 2 lbs gained in a 24-hour
period.

Definition 28 of 175

The patient's potassium level is 2.5 mEq/L. Which clinical findings does the nurse expect to
see when assessing this patient?

Hypertension, bounding pulses, and bradycardia

Moist crackles, tachypnea, and diminished breath sounds

General skeletal muscle weakness, lethargy, and weak hand grasps

Increased specific gravity and decreased urine output


Definition 29 of 175

Which assessment findings are related to hypercalcemia? (Select all that apply)
a. Bradycardia
b. Paresthesia
c. Leg cramping
d. Hyperactive bowel sounds
e. Ineffective respiratory movements
f. Shortened QT interval
g. Impaired blood flow
h. Profound muscle weakness

a. Game with four players on one side and eight on the other; two move over to
create six per side.

a. Place the solution on an IV pump at the prescribed rate


b. Monitor blood glucose every six hours
e. Monitor intake and output every shift

a. Bradycardia
e. Ineffective respiratory movements
f. Shortened QT interval
g. Impaired blood flow
h. Profound muscle weakness

a. Fever of 103 degrees F


b. Extensive burns
d. Thyroid crisis
e. Continuous fistula drainage
f. Diabetes insipidus
Definition 30 of 175

High in sodium and chloride content

Extracellular compartment

Hypokalemia

Phosphorus

Calcium

Definition 31 of 175

Functions include contraction of skeletal and cardiac muscles

Magnesium

Sodium

Potassium

Calcium

Definition 32 of 175

The nurse is caring for the older adult patient whose serum sodium level is 150 mEq/L. The
nurse assesses the patient for which common manifestation associated with this sodium
result?

Gastrointestinal disorders

Altered urinary elimination

Impaired skin integrity

Altered cerebral functioning


Definition 33 of 175

A nurse is reading a physician's progress notes in the client's record and reads that the
physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse
interprets that this type of fluid loss can occur through:

The skin

Urinary output

Wound drainage

The gastrointestinal tract

Definition 34 of 175

Which food provides both calcium and vitamin D for the patient in need of supplemental
diet therapy for hypocalcemia?

Eggs

Broccoli

Milk

Tofu

Definition 35 of 175

the nurse is caring for several patients at risk for fluid and electrolyte imbalances. Which
patient problem or condition can result in a relative hypernatremia?

Use of salt substitute

Diarrhea

Drinking too much water

NPO status for a prolonged period


Definition 36 of 175

The patient who has undergone which surgical procedure is at risk for hypocalcemia?

Thyroidectomy

Adrenalectomy

Pancreatectomy

Gastrectomy

Definition 37 of 175

What is the intervention of choice for the patient with mild hypernatremia caused by
excessive fluid loss?

IV infusion of 10 units of insulin in 50 mL of 10% dextrose.

Replacement of table salt with salt substitute

Furosemide (Lasix) 20 mg IV

Increased oral water intake

Definition 38 of 175
A nursing student needs to administer potassium chloride intravenously as prescribed to a
client with hypokalemia. The nursing instructor determines that the student is unprepared
for this procedure if the student states that which of the following is part of the plan for
preparation and administration of the potassium?

Obtaining a controlled intravenous (IV) infusion pump

Monitoring urine output during administration

Preparing the medication for bolus administration

Diluting the medication in appropriate amount of normal saline


Definition 39 of 175

the patient's potassium level is low. What change in the cardiovascular system does the
nurse expect to see related to hypokalemia?

Tall, peaked T waves

Weak, thready pulse

Malignant hypertension

Distended neck veins

Definition 40 of 175
Metabolic alkalosis puts you at risk for?

Magnesium

Hypokalemia

Sodium

Potassium

Definition 41 of 175
Short bowel syndrome with use of total parentaeral nutrition can put you at risk for?

Hypokalemia

A. Bradycardia And Hypotension

Magnesium

Sodium
Definition 42 of 175

The nurse is caring for a patient who takes potassium and digoxin. For what reason does the
nurse monitor both laboratory results?

Digoxin increases potassium loss through the kidneys.

Digoxin toxicity can result if hypokalemia is present.

Digoxin may cause potassium levels to rise to toxic levels

Hypokalemia causes the cardiac muscle to be less sensitive to digoxin

Definition 43 of 175
The nurse instructs the UAP to use precautions with moving and use of a lifting sheet for
which patient with an electrolyte imbalance?

Young diabetic woman with hyperkalemia

Psychiatric patient with hyponatremia

Older woman with hypocalcemia

Child with severe diarrhea and hypomagnesemia

Definition 44 of 175
The nurse is assessing the patient with a mild increase in sodium level. What early
manifestation does the nurse observe in this patient?

Muscle twitching and irregular muscle contractions.

Inability of muscles and nerves to respond to a stimulus

Muscle weakness occurring bilaterally with no specific pattern.

Reduced or absent deep tendon reflexes.


Definition 45 of 175

The patient's serum potassium value is below 2.8 mEq/L. The patient is also on digoxin. The
nurse quickly assesses the patient for which cardiac problem before notifying the
physician?

Cardiac murmur

Cardiac dysrhythmia

Congestive heart failure

Cardiac tamponade

Definition 46 of 175

Hypertension managed with Aldactone puts you at risk for?

Hypernatremia

A. Bradycardia And Hypotension

Hyperkalemia

Potassium

Definition 47 of 175
The 65-year-old patient has a potassium laboratory value of 5.0 mEq/L. How does the nurse
interpret this value?

High for the patient's age

Low for the patient's age

Normal for the patient's age

Dependent upon the medical diagnosis


Definition 48 of 175

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a
sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that
which client is at highest risk for the development of a sodium value at this level?

The client with Cushing's syndrome

The client who is taking diuretics

The client with hyperaldosteronism

The client who is taking corticosteroids

Definition 49 of 175

The nurse caring for the patient with hypercalcemia anticipates orders for which
medications? (Select all that apply)
a. Magnesium sulfate
b. Calcitonin (Calcimar)
c. Furosemide (Lasix)
d. Plicamycin (Mithracin)
e. Calcium gluconate
f. Aluminum hydroxide

b. Calcitonin (Calcimar)
c. Furosemide (Lasix)
d. Plicamycin (Mithracin)

b. Restrict the sodium in the client's diet

c. Help the incontinent patient to toilet every 1 to 2 hours.

b. Tachycardia with weak peripheral pulses


Definition 50 of 175

The nurse is caring for the patient with hypovolemia secondary to severe diarrhea and
vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to
assess?

No changes, because the respiratory system is not involved.

Hypoventilation, because the respiratory system is trying to compensate for low pH

Increased respiratory rate, because the body perceives hypovolemia as hypoxia

Normal respiratory rate, but a decreased oxygen saturation

Definition 51 of 175

Contains the largest amount of body fluid

Plasma

Diffusion

Intracellular compartment

Interstitial fluid

Definition 52 of 175
Which serum laboratory value indicates the patient has hypernatremia?

Chloride greater than 95 mEq/L

Sodium greater than 135 mEq/L

Chloride greater than 103 mEq/L

Sodium greater than 145 mEq/L


Definition 53 of 175

The nurse writes the client problem of "fluid volume excess" (FVE). Which intervention
should be included in the plan of care?

Change the IV fluid from 0.9% NS to D5W

Restrict the sodium in the client's diet

Monitor blood glucose levels

Prepare the client for hemodialysis

Definition 54 of 175
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line.
Which precautions should the nurse implement? (Select all that apply)
a. Place the solution on an IV pump at the prescribed rate
b. Monitor blood glucose every six hours
c. Weigh the client weekly, first thing in the morning
d. Change the IV tubing every three days
e. Monitor intake and output every shift

a. Place the solution on an IV pump at the prescribed rate


b. Monitor blood glucose every six hours
e. Monitor intake and output every shift

a. Increased, bounding pulse


b. Jugular venous distention
d. Presence of crackles
f. Elevated blood pressure
h. Skin pale and cool to touch

a. Game with four players on one side and eight on the other; two move over to
create six per side.

d. Assist the patient to change position every 2 hours.


Definition 55 of 175

The unit of measure in a liter of solution that reflects the concentration of solutes

Hyperkalemia

Osmosis

Diffusion

Osmolality

Definition 56 of 175

The patient with low potassium must have an IV potassium infusion. The pharmacy sends a
250 mL IV bag of dextrose in water with 40 mEq of potassium. The label is marked "to infuse
over 1 hour." What does the nurse do?

Obtain a pump and administer the solution

Double-check the physician's order and call the pharmacy

Hold the infusion because there is an error in labeling

Recalculate the rate so that it is safe for the patient

Definition 57 of 175
Which patient in the medical surgical unit is most likely to have increased aldosterone
secretion?

Patient who has excessive salt ingestion

Patient who drinks a lot of water

Patient who loses a lot of fluid and sodium

Patient who loses potassium and water


Definition 58 of 175

A nurse caring for a client who has been receiving IV diuretics suspects that the client is
experiencing a fluid volume deficit. Which assessment finding would the nurse note in a
client with this condition?

Lung congestion

Decreased hematocrit

Increased blood pressure

Decreased central venous pressure (CVP)

Definition 59 of 175

Which changes on the patient's electrocardiogram (ECG) reflect hyperkalemia?

Tall peaked T waves

Narrow QRS complex

Tall P waves

Normal P-R interval

Definition 60 of 175
The emergency department (ED) nurse is caring for the patient who was brought in for
significant alcohol intoxication and minor trauma to the wrist. What will serial hematocrits
for this patient likely show?

Hemoconcentration

Normal and stable hematocrits

Progressively lower hematocrits

Decreasing osmolality
Definition 61 of 175

Contains plasma

Diffusion

Calcium

Extracellular compartment

Hypokalemia

Definition 62 of 175

A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the
client's record and determines that the client was at risk for developing the potassium
deficit because the client:

Sustained tissue damage

Requires nasogastric suction

Has a history of Addison's disease

Is taking a potassium-sparing diuretic

Definition 63 of 175
Which serum value does the nurse expect to see in the patient with hyponatremia?

Sodium less than 136 mEq/L

Chloride less than 95 mEq/L

Sodium less than 145 mEq/L

Chloride less than 103 mEq/L


Definition 64 of 175

The older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by
the nurse for the first indication of a fluid balance problem. What is this indication?

Fever

Mental status change

Poor skin turgor

Dry mucous membranes

Definition 65 of 175
Works in balance with calcium

Phosphorus

Calcium

Sodium

Potassium

Definition 66 of 175
Which intake-output record represents the norm for the average adult?

500 mL of fluid per day, ingesting an additional 200 mL of fluid from food.

1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.

3000 mL of fluid per day, ingesting an additional 500 mL of fluid from food.

5000 mL of fluid per day, ingesting an additional 100 mL of fluid from food.
Definition 67 of 175

The nurse is caring for the child at risk for dehydration secondary to diarrhea, vomiting, and
fever. The child is alert, quiet, and clinging to the parent. What is the best nursing
intervention to rehydrate this patient?

Give an oral rehydration solution such as oralyte or rehydralyte.

Have the parent give small sips of preferred diluted fluids every 5 to 10 minutes.

Obtain an order for IV access and an isotonic solution such as normal saline.

Encourage the child to take as much water as possible and offer popsicles.

Definition 68 of 175

Normal value is 98 to 106 mEq/L

Sodium

Calcium

Chloride

Potassium

Definition 69 of 175
A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150
mEq/L. The nurse reports the serum sodium level to the physician and the physician
prescribes dietary instructions based on the sodium level. Which food item does the nurse
instruct the client to avoid?

Peas

Nuts

Cauliflower

Processed oat cereals


Definition 70 of 175

The patient has chronic renal failure (CRF). Which electrolyte imbalance often associated
with hypocalcemia and CRF does the nurse monitor for?

Hypophosphatemia

Hyperphosphatemia

Hyperkalemia

Hyponatremia

Definition 71 of 175
Which is a preventive nursing intervention for patients at risk for developing hypercalcemia?

Ensure adequate hydration

Discourage weight-bearing activity such as walking

Monitor the patient for fluid volume excess

Administer multivitamin tablets twice per day

Definition 72 of 175
The nurse is caring for the patient with hypernatremia caused by fluid and sodium losses.
What type of IV solution is best for treating this patient?

Hypotonic 0.225% sodium chloride.

Small-volume infusions of hypertonic (2% to 3%) saline.

Isotonic sodium chloride (NaCl)

Isotonic Ringer's lactate


Definition 73 of 175

A patient will be sent home on diuretic therapy and will need to increase the amount of
potassium in the diet. What food choices would the nurse suggest be added?

Liver, red meats, lettuce

Apples, pears, celery, onions

Bananas, tomatoes, beans, fresh meats

Potato chips, licorice, rice, corn

Definition 74 of 175
Which serum laboratory value does the nurse expect to see in the patient with
hyperkalemia?

Calcium greater than 8.0 mg/dL

Potassium greater than 3.5 mEq/L

Calcium greater than 11.0 mg/dL

Potassium greater than 5.0 mEq/L

Definition 75 of 175
Main cation in ECF of the cell that maintains ECF osmolarity

Calcium

Sodium

Chloride

Potassium
Definition 76 of 175

The client admitted with a serum sodium level of 110 mEq/L. Which nursing intervention
should be implemented?

Encourage fluids orally

Administer 10% saline solution IVPB

Administer antidiuretic hormone intranasally

Place on seizure precautions

Definition 77 of 175
The patient's laboratory results show a decrease in serum phosphorus level. The nurse
expects to see a reciprocal increased change in which serum level?

Calcium

Potassium

Sodium

Magnesium

Definition 78 of 175
A nurse reviews a client's laboratory report and notes that the client's serum phosphorus
level is 2 mg/dL. Which condition most likely caused this serum phosphorus level?

Alcoholism

Renal insufficiency

Hypoparathyroidism

Tumor lysis syndrome


Definition 79 of 175

Which serum level of phosphorus represents hypophosphatemia?

2.5 mg/dL

3.5 mg/dL

4.5 mg/dL

5.5 mg/dL

Definition 80 of 175

The physician has ordered therapy for the patient with low sodium and signs of fluid volume
excess. Which diuretic is best for this patient?

Conivaptan (Vaprisol)

Furosemide (Lasix)

Hydrochlorothiazide (HydroDiuril)

Bumetanide (Bumex)

Definition 81 of 175
The patient on the medical-surgical unit suddenly has a severely elevated magnesium level.
What does the nurse anticipate will happen next with the patient's care?

Immediate transfer to the intensive care unit

Discontinuation of magnesium sources so the patient can recover

Administration of diuretics such as furosemide

Administration of IV magnesium binder


Definition 82 of 175

The nurse is working in a long-term care facility where there are numerous patients who are
immobile and at risk for dehydration. Which task is best to delegate to the unlicensed
assistive personnel (UAP)?

Offer patients a choice of fluids every 1 to 2 hours.

Check patients at the beginning of the shift to see who is thirsty.

Give patients extra fluids around medication times.

Evaluate oral intake and urinary output.

Definition 83 of 175

Major intracellular anion

Sodium

Calcium

Phosphorus

Potassium

Definition 84 of 175
The patient has hyperkalemia resulting from dehydration. Which additional laboratory
findings does the nurse anticipate for this patient?

Increased hematocrit and hemoglobin levels

Decreased serum electrolyte levels

Increased urine potassium levels

Decreased serum creatinine


Definition 85 of 175

The nurse assessing the patient notes a bounding pulse quality, neck vein distention when
supine, presence of crackles in the lungs, and increasing peripheral edema. What condition
does the nurse suspect?

Fluid excess

Fluid deficit

Electrolyte imbalance

Serum protein increase

Definition 86 of 175

Which patient is most at risk for developing hypernatremia?

Patient who dislikes drinking milk and lacks calcium in the diet.

Patient who is receiving total parenteral nutrition related to gastrointestinal surgery

Patient with excessive diarrhea and vomiting from food poisoning

Older adult patient with decreased sensitivity to thirst

Definition 87 of 175
The nurse is caring for several patients at risk for falls because of fluid and electrolyte
imbalances. Which task related to patient safety and fall prevention does the nurse delegate
to the UAP?

Assess for orthostatic hypotension

Orient the patient to the environment.

Help the incontinent patient to toilet every 1 to 2 hours.

Encourage family members or significant other to stay with the patient.


Definition 88 of 175

Maintains action potentials in excitable membranes

Magnesium

Calcium

Sodium

Potassium

Definition 89 of 175

The patient is talking to the nurse about sodium intake. Which statement by the patient
indicates an understanding of high sodium food sources?

"I have bacon and eggs every morning for breakfast."

"We never eat seafood because of the salt water."

"I love Chinese food, but I gave it up because of the soy sauce."

"Pickled herring is a fish and my doctor told me to eat alot of fish.

Definition 90 of 175
Which serum laboratory value does the nurse expect to see in the patient with
hypokalemia?

Calcium less than 8.0 mg/dL

Potassium less than 5.0 mEq/L

Calcium less than 11.0 mg/dL

Potassium less than 3.5 mEq/L


Definition 91 of 175

Which analogy best approximates the principles of diffusion and concentration gradient?

Game with four players on one side and eight on the other; two move over to create
six per side

Community fun run where 2000 participants move across the line in a mass start.

Basketball game of five players per side; all players move across the court.

Concert where 1000 people are trying to enter through a single gate.

Definition 92 of 175
Which of the following nursing interventions is most important when caring for a patient
receiving a plasma volume expander?

Assess the patient for deep vein thrombosis

Observe for signs of fluid overload

Encourage fluid intake

Monitor arterial blood gases

Definition 93 of 175

The nurse weighs the patient and finds that there has been a weight gain of 1.5 kg since the
previous day. What would be the nurse's next highest priority?

Check with the patient to see if there have been any dietary changes in the last few
days

Assess the patient for signs of edema and BP for possible hypertension

Contact dietary to change the patient's diet to reduced sodium

Request a diuretic from the patient's provider


Definition 94 of 175

The nurse monitors the effectiveness of magnesium sulfate by assessing which factor every
hour?

Deep tendon reflexes

Vital signs

Serum laboratory values

Urine output

Definition 95 of 175
The nurse is teaching the patient to recognize food sthat are high in sodium. Which food
items does the nurse use as examples? (Select all that apply)
a. Egg roll with soy sauce
b. Whate rice
c. Salad with oil and vinegar dressing
d. Bacon and eggs
e. Cottage cheese and tomato
f. Steak
g. Soup with saltine crackers
h. Steamed vegetable

a. Increased, bounding pulse


b. Jugular venous distention
d. Presence of crackles
f. Elevated blood pressure
h. Skin pale and cool to touch

c. Stay with patients while they drink and note the exact amount ingested.

a. Egg roll with soy sauce


d. Bacon and eggs
e. Cottage cheese and tomato
g. Soup with saltine crackers

c. Help the incontinent patient to toilet every 1 to 2 hours.


Definition 96 of 175

The nurse is giving discharge instructions to the patient with advanced congestive heart
failure who is at continued risk for fluid volume excess. For which physical change does the
nurse instruct the patient to call the health care provider?

Greater than 3 lbs gained in a week or greater than 1 to 2 lbs gained in a 24-hour
period.

Greater than 5 lbs gained in a week or greater than 1 to 2 lbs gained in a 24-hour
period.

Greater than 15 lbs gained in a month or greater than 5 lbs gained in a week.

Greater than 20 lbs gained in a month or greater than 5 lbs gained in a week.

Definition 97 of 175

Which medication order does the nurse clarify before administering the drug to the patient
with hypocalcemia?

Magnesium sulfate 1 g IM every 6 hours for four doses

Aluminum hydroxide (AlternaGEL) 15 mL orally three times a day and at bedtime

Calcium carbonate 1000 mg orally after meals and at bedtime

Calcium gluconate 5 mEq IV PRN for tetany

Definition 98 of 175

Which of the following mechanisms is the most important regulator of fluid intake?

Thirst

Electrolytes

Renin-angiotensin

Kidneys
Definition 99 of 175

Which clinical condition can result from hypocalcemia?

Stimulated cardiac muscle contraction

Increased intestinal and gastric motility

Decreased peripheral nerve excitability

Increased bone density

Definition 100 of 175

The advanced practice nurse is assessing the patient with a risk for hypocalcemia. What is
the correct technique to test for Chvostek's sign?

Patient flexes arms against the chest and examiner attempts to pull the arms away
from the chest.

Place a blood pressure cuff around the upper arm and inflate the cuff to greater than
the patient's systolic pressure

Tap the face just below and in front of the ear to trigger facial twitching of one side of
the mouth, nose, and cheek

Lightly tap the patellar and Achilles tendons with a reflex hammer and measure the
movement.

Definition 101 of 175


The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory
test should the nurse monitor?

Serum calcium

Serum phosphorus

Serum potassium

Serum sodium
Definition 102 of 175

Which statements about the function of the lymphatic system are true? (Select all that
apply)
a. Lymph fluid contains more protein than plasma.
b. Lymph flow is slower than blood flow
c. Lymph flow is enhanced by a pump system
d. Lymphatic vessels carry lymph fluid toward the heart
e. Lymph fluid is filtered by lymph nodes.
f. The lymphatic system takes lymph to the kidneys for excretion.

b. Lymph flow is slower than blood flow.


d. Lymphatic vessels carry lympth fluid toward the heart
e. Lymph fluid is filtered by lymph nodes

d. Provide adequate intake of vitamin D and calcium rich foods

b. 1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.

d. Older adult patient with decreased sensitivity to thirst

Definition 103 of 175


A nurse is assigned to care for a group of clients. On review of the clients' medical records,
the nurse determines that which client is at risk for fluid volume excess?

The client taking diuretics

The client with renal failure

The client with an ileostomy

The client who requires gastrointestinal suctioning


Definition 104 of 175

The nurse provides instructions to a client with a low potassium level about the foods that
are high in potassium and tells the client to consume which foods? (Select all that apply)

Peas

Raisins

Potatoes

Cauliflower

Cantaloupe

Strawberries

Definition 105 of 175


What is a typical nursing assessment finding for the patient with hypocalcemia?

Paresthesias and tingling followed by numbness

Shortened ST segment, tachycardia, and hypertension

Constipation and hypoactive bowel sounds

Severe muscle weakness


Definition 106 of 175

The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate that
the patient has fluid volume excess? (Select all that apply)
a. Increased, bounding pulse
b. Jugular venous distention
c. Diminished peripheral pulses
d. Presence of crackles
e. Excessive thirst
f. Elevated blood pressure
g. Orthostatic hypotension
h. Skin pale and cool to touch

a. Increased hematocrit and hemoglobin levels

a. Increased, bounding pulse


b. Jugular venous distention
d. Presence of crackles
f. Elevated blood pressure
h. Skin pale and cool to touch

c. Stay with patients while they drink and note the exact amount ingested.

a. Egg roll with soy sauce


d. Bacon and eggs
e. Cottage cheese and tomato
g. Soup with saltine crackers

Definition 107 of 175

Severe malnutrition in an older adult man can make him at risk for?

Hypokalemia

Potassium

Sodium

Magnesium
Definition 108 of 175

The patient has an elevated potassium level. Which assessment findings are associated with
hyperkalemia? (Select all that apply)
a. Wheezing on exhalation
b. Numbness in hands, feet, and around the mouth
c. Frequent, explosive diarrhea stools
d. Irregular heart rate and hypotension
e. Circumoral cyanosis

d. IV magnesium sulfate and discontinuation of diuretic therapy

a. Administer IV normal saline (0.9% sodium chloride)


c. Measure the abdominal girth
e. Monitor for ECG changes
g. During treatment, monitor for tetany

b. Numbness in hands, feet, and around the mouth


c. Frequent, explosive diarrhea stools
d. Irregular heart rate and hypotension

a. Immediate transfer to the intensive care unit

Definition 109 of 175

The movement of electrolytes into or out of a cell

Osmosis

Diffusion

Filtration

Hydrostatic Pressure
Definition 110 of 175

The patient complains of muscle cramping in the calves, paresthesia of the toes, and the
sensation of the heart skipping a beat. These symptoms may indicate which one of the
following imbalances?

Hypernatremia

Hypercalcemia

Hypoglycemia

Hyperkalemia

Definition 111 of 175

The client who is post-thyroidectomy complains of numbness and tingling around the
mouth and the tips of the fingers. Which intervention should the nurse implement first?

Notify the health-care provider immediately

Tap the cheek about two cm anterior to the earlobe

Check the serum calcium and magnesium levels

Prepare to administer calcium gluconate IVP

Definition 112 of 175

Which intervention does the nurse implement for the patient with hypocalcemia?

Encourage activitiy by thepatient as tolerated, including weight-lifting

Encourage socialization and active participation in stimulating activities

Include a tracheostomy tray at the bedside for emergency use

Provide adequate intake of vitamin D and calcium rich foods


Definition 113 of 175

Which precaution or intervention does the nurse teach the patient at continued risk for
hypernatremia?

Avoid salt substitutes

Avoid aspirin and aspirin-containing products

Read labels on canned or packaged foods to determine sodium content

Increase daily intake of caffeine-containing foods and beverages

Definition 114 of 175


The patient with a recent history of anterior neck injury reports muscle twitching and spasms
with tingling in the lips, nose, and ears. The nurse suspects these symptoms may be caused
by which condition?

Hypocalcemia

Hypokalemia

Hyponatremia

Hypomagnesemia

Definition 115 of 175

The patient's serum sodium value is 149 mEq/L. Which of the following nursing interventions
is most appropriate for this patient? (Select all that apply)

Encourage the patient to eat a low-salt diet

Administer a 0.45% NaCl IV solution

Hold all doses of glucocorticoids

Notify the health care provider

Have patient drink as much water as possible


Definition 116 of 175

Based on the factors of age, gender, and body type, which patient has the smallest
percentage of total body water?

Thin 78-year-old adult man

Obese 35-year-old man

Thin 25-year-old woman

Obese 68-year-old woman

Definition 117 of 175


Respiratory acidosis puts you at risk for?

Hypernatremia

Hyperkalemia

Potassium

A. Bradycardia And Hypotension

Definition 118 of 175


Which patient is at greatest risk of developing hypocalcemia?

30-year-old Asian woman with breast cancer

45-year-old Caucasian man with hypertension and diuretic therapy

60-year-old Aftrican American woman with a recent ileostomy

70-year-old Caucasian man on long-term lithium therapy


Definition 119 of 175

The patient's blood osmolality is 302 mOsm/L. What manifestation does the nurse expect to
see in the patient?

Increased urine output

Thirst

Peripheral edema

Nausea

Definition 120 of 175


The patient has a serum sodium level of 126 mEq/L. What assessment findings does the
nurse expect to see in this patient?

Constipation and paralytic ileus

Watery diarrhea with abdominal cramping

Muscle cramping and spasticity

Tachypnea and diminished breath sounds

Definition 121 of 175


Which is a preventive measure for patients at risk for developing hypocalcemia?

Increase daily dietary calcium intake to 1000 mg

Increase intake of phosphorus

Apply sunblock and wear protective clothing whenever outdoors

Administer calcium-containing IV fluids to patients receiving multiple blood


transfusions
Definition 122 of 175

The nurse is assessing the weight of the patient with chronic renal failure. The patient shows
a 2 kg weight gain since the last clinic appointment. This is equivalent to how many liters of
fluid?

0.5

Definition 123 of 175

The nurse administering potassium to the patient carefully monitors the infusion because of
the risk for which condition?

Pulmonary edema

Cardiac dysrhythmia

Postural hypotension

Renal failure

Definition 124 of 175

The patient is at risk for fluid volume excess. For self-management at home, what does the
nurse teach the patient to do?

Increase diuretic dose if swelling occurs.

Limit the amount of free water in relation to sodium intake.

Monitor his or her skin turgor.

Weigh self each day on the same scale.


Definition 125 of 175

the patient shows a positive Trousseau's or Chvostek's sign. The nurse prepares to give the
patient which urgent treatment?

IV calcium

Calcitonin (Calcimar)

IV potassium chloride

Large doses of oral calcium

Definition 126 of 175


Which conditions cause the patient to be at risk for hypernatremia? (Select all that apply)
a. Renal failure
b. Immobility
c. Use of corticosteroids
d. Watery diarrhea
e. Cushing's syndrome

a. Renal failure
c. Use of corticosteroids
d. Watery diarrhea
e. Cushing's syndrome

a. Ensure adequate hydration

c. Lethal electrolyte imbalance and acidosis

b. 3.5 mmol/L
c. 4.5 mmol/L
d. 5.0 mmol/L
Definition 127 of 175

The client has received IV solutions for three days through a 20-gauge IV catheter placed in
the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation
and a red streak has formed. Which intervention should the nurse implement first?

Start a new IV in the right hand

Discontinue the intravenous line

Complete an incident record

Place a warm washrag over the site

Definition 128 of 175

The patient with congestive heart failure is receiving a loop diuretic. The nurse monitors for
which electrolyte imbalances? (Select all that apply)
a. Hypocalcemia
b. Hypokalemia
c. Hyponatremia
d. Hypercalcemia
e. Hyperkalemia
f. Hypernatremia

a. Hypocalcemia
b. Hypokalemia
c. Hyponatremia

c. Bananas, tomatoes, beans, fresh meats

b. Hypocalcemia

a. Hypocalcemia
Definition 129 of 175

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the


following clinical manifestations would the nurse expect to note in the client?

Twitching

Hypoactive bowel sounds

Negative Trousseau's sign

Hypoactive deep tendon reflexes

Definition 130 of 175


Which patient conditions cause the patient to be at risk for hypocalcemia? (Select all that
apply)
a. Crohn's disease
b. Acute pancreatitis
c. Removal or destruction of parathyroid glands
d. Immobility
e. Use of digitalis

b. Numbness in hands, feet, and around the mouth


c. Frequent, explosive diarrhea stools
d. Irregular heart rate and hypotension

d. Provide adequate intake of vitamin D and calcium rich foods

a. Crohn's disease
b. Acute pancreatitis
c. Removal of destruction of parathyroid glands
d. Immobility

a. Encourage the patient to eat a low-salt diet, d. Notify the health care provider
Definition 131 of 175

Normal value is 3.0 to 4.5 mg/dL

Phosphorus

Chloride

Hypokalemia

a. U waves

Definition 132 of 175

A nurse caring for a client with hypocalcemia would expect to note which of the following
changes on the electrocardiogram?

Widened T wave

Prominent U wave

Prolonged QT interval

Shortened ST segment

Definition 133 of 175


The UAP reports to the nurse that the patient being evaluated for kidney problems has
produced a large amount of pale yellow urine. What does the nurse do next?

Instruct the UAP to measure the amount carefully and then discard the urine.

Instruct the UAP to save the urine in a large bottle for a 24-hour urine specimen.

Assess the patient for signs of fluid imbalance and check the specific gravity of the
urine.

Compare the amount of urine output to the fluid intake for the previous 8 hours.
Definition 134 of 175

Major cation of intracellular fluid (ICF) in the cell

Sodium

Calcium

Magnesium

Potassium

Definition 135 of 175

Contains interstitial fluid

Phosphorus

Extracellular compartment

Hypokalemia

Calcium

Definition 136 of 175

A nurse reviews the electrolyte results of an assigned client and notes that the potassium
level is 5.4 mEq/L. Which of the following would the nurse expect to note on the
electrocardiogram as a result of the laboratory value?

ST depression

Inverted T wave

Prominent U wave

Tall peaked T waves


Definition 137 of 175

The nurse is evaluating the hydration status of the older adult patient. If the patient is
dehydrated, the nurse expects to observe which type of cardiovascular change?

Hypertension with bounding peripheral pulses

Tachycardia with weak peripheral pulses

Bradycardia and distended neck veins

Increase in pulse pressure and systolic pressure

Definition 138 of 175


"Water-pushing" pressure

Filtration

Diffusion

Hydrostatic pressure

Osmosis

Definition 139 of 175


Hyperkalemia can cause severe problems in which body system?

Neuromuscular

Cardiovascular

Intestinal

Respiratory
Definition 140 of 175

Which patient condition places the patient at risk for hypocalcemia, hyperkalemia, and
hypernatremia?

Hypothyroidism

Diabetes mellitus

Chronic renal failure

Adrenal insufficiency

Definition 141 of 175


The nurse is teaching the patient about foods high in potassium. Which food item does the
nurse use as the best example?

Bread

Eggs

Cereal grains

Meat

Definition 142 of 175


High in potassium and phosphorous content

Hydrostatic pressure

Interstitial fluid

Intracellular compartment

Plasma
Definition 143 of 175

Chronic obstructive pulmonary disease (COPD) managed with prednisone can make you at
risk for?

B. The Client With Renal Failure

Hypokalemia

Sodium

Magnesium

Definition 144 of 175


The nurse is caring for several older adult patients who are at risk for dehydration. Which
task can be delegated to the UAP?

Withhold fluids if patients are incontinent of bowels or bladder.

Assess for and report any difficulties that patients are having in swallowing.

Stay with patients while they drink and note the exact amount ingested.

Divide the total amount of fluids needed over a 24-hour period and post a note.

Definition 145 of 175


Normal plasma value is 3.5 to 5.0 mEq/L

Chloride

Potassium

Magnesium

Hypokalemia
Definition 146 of 175

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes
that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects
excess fluid volume. What addition signs would the nurse expect to note in this client if
excess fluid volume is present?

Weight loss

Flat neck and hand veins

An increase in blood pressure

A decreased central venous pressure (CVP)

Definition 147 of 175

Has more activity in the cell than in the blood

Magnesium

Potassium

Sodium

Calcium

Definition 148 of 175

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a
potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that
which client is at highest risk for the development of a potassium value at this level?

The client with colitis

The client with Cushing's syndrome

The client who has been overusing laxatives

The client who has sustained a traumatic burn


Definition 149 of 175

The movement of fluid through a membrane; usually occurs from capillaries to the
interstitial space

Diffusion

Filtration

Hydrostatic Pressure

Osmosis

Definition 150 of 175


Which potassium levels are within normal limits? (Select all that apply)
a. 2.0 mmol/L
b. 3.5 mmol/L
c. 4.5 mmol/L
d. 5.0 mmol/L
e. 6.0 mmol/L

a. Renal failure
c. Use of corticosteroids
d. Watery diarrhea
e. Cushing's syndrome

a. Increase daily dietary calcium intake to 1000 mg

b. Observe for signs of fluid overload

b. 3.5 mmol/L
c. 4.5 mmol/L
d. 5.0 mmol/L
Definition 151 of 175

The patient is at risk for fluid volume excess and dependent edema. Which task does the
nurse delegate to the UAP?

Massage the legs and heels to stimulate circulation.

Evaluate the effectiveness of a pressure-reducing-mattress.

Assess the coccyx, elbows, and hips daily for signs of redness.

Assist the patient to change position every 2 hours.

Definition 152 of 175


The nurse is teaching the patient about hypokalemia. Which statement by the patient
indicates a correct understanding of the treatment of hypokalemia?

"My wife does all the cooking. She shops for food high in calcium."

"When I take the liquid potassium in the evening, I'll eat a snack beforehand."

"I will avoid bananas, orange juice, and salt substitutes."

"I hate being stuck with needles all the time to monitor how much sugar I can eat."

Definition 153 of 175


The patient has hyperphosphatemia. Which accompanying and potentially life-threatening
electrolyte imbalance does the nurse monitor for?

Hypercalcemia

Hypocalcemia

Hyponatremia

Hyperkalemia
Definition 154 of 175

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of
56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?

Overhydration

Anemia

Dehydration

Renal failure

Definition 155 of 175


Which person is most likely to have symptoms related to poor lymph circulation?

Person with carpal tunnel syndrome

Marathon runner

Person with a history of myocardial infarction

Frequent overseas flyer

Definition 156 of 175


The nurse is assessing the patient with severe hypermagnesemia. Which assessment findings
are associated with this electrolyte imbalance?

Bradycardia and hypotension

Tachycardia and weak palpable pulse

Hypertension and irritability

Irregular pulse and deep respirations


Definition 157 of 175

Ileostomy puts you at risk for?

Sodium

Potassium

Magnesium

Hypokalemia

Definition 158 of 175

The nurse is caring for the psychiatric patient who is continuously drinking water. The nurse
monitors for which complication related to potential hyponatremia?

Proteinuria/prerenal failure

Change in mental status/increased intracranial pressure

Pitting edema/circulatory failure

Possible stool for occult blood/gastrointestinal bleeding

Definition 159 of 175


The telemetry monitor technician notifies the nurse of the morning telemetry readings.
Which client should the nurse assess first?

The client in normal sinus rhythm with a peaked T wave

The client diagnosed with atrial fibrillation with a rate of 100

The client diagnosed with a myocardial infarction who has occasional PVCs

The client with a first-degree atrioventricular block and a rate of 92


Definition 160 of 175

Free form is physiologically active in the body

Magnesium

Potassium

Sodium

Calcium

Definition 161 of 175

A nurse is caring for a client with acute congestive heart failure who is receiving high doses
of a diuretic. On assessment, the nurse notes tha tthe client has flat neck veins, generalized
muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia.
What additional signs would the nurse expect to note in a client with hyponatremia?

Exstreme thirst

Decreased urinary output

Hyperactive bowel sounds

Increased specific gravity of the urine

Definition 162 of 175

Major anion of extracellular fluid (ECF)

Chloride

Calcium

Potassium

Sodium
Definition 163 of 175

The unit of measure in a kilogram of solution that reflects the concentration of solutes

Diffusion

Hyperkalemia

Osmosis

Osmolarity

Definition 164 of 175

Which nursing interventions apply to patients with hypercalcemia? (Select all that apply)
a. Administer IV normal saline (0.9% sodium chloride)
b. Assess the patient for a positive Homan's sign.
c. Measure the abdominal girth.
d. Massage calves to encourage blood return to the heart.
e. Monitor for ECG changes
f. Provide adequate intake of vitamin D
g. During treatment, monitor for tetany

d. Assist the patient to change position every 2 hours.

a. Renal failure
c. Use of corticosteroids
d. Watery diarrhea
e. Cushing's syndrome

b. Calcitonin (Calcimar)
c. Furosemide (Lasix)
d. Plicamycin (Mithracin)

a. Administer IV normal saline (0.9% sodium chloride)


c. Measure the abdominal girth
e. Monitor for ECG changes
g. During treatment, monitor for tetany
Definition 165 of 175

Normal plasma value is 136 to 145 mEq

Calcium

Chloride

Potassium

Sodium

Definition 166 of 175

Which patients are at risk for developing hyponatremia? (Select all that apply)
a. Postoperative patient who has been NPO for 24 hours.
b. Patient with decreased fluid intake for several days
c. Patient with excessive intake of 5% dextrose solution
d. Diabetic patient with blood glucose of 250 mg/dL
e. Patient with overactive adrenal glands
f. Tennis player in 100 degree F weather

a. Postoperative patient who has been NPO for 24 hours.


c. Patient with excessive intake of 5% dextrose solution
d. Diabetic patient with blood glucose of 250 mg/dL
f. Tennis player in 100 degree F weather

d. The client who has sustained a traumatic burn

b. 1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.

a. Muscle twitching and irregular muscle contractions.


Definition 167 of 175

The nurse is caring for several patients with electrolyte imbalances. Which condition may
require the patient to be put on seizure precautions?

Hypercalcemia

Hyperphosphatemia

Hypocalcemia

Hypokalemia

Definition 168 of 175


The nurse is assessing the patient's neuromuscular status to obtain a baseline because the
patient is at risk for electrolyte imbalances. What technique does the nurse use to assess
muscle strength in the legs?

Ask the patient to push the feet against a flat surface and apply resistance to the
opposite side of the flat surface.

Ask the patient to walk around the room and observe for stride, gait, balance, and
endurance.

Instruct the patient to stand at the side of the bed and abduct each leg as high as
possible.

Support the patient's lower leg with the palm and move the knee through flexion and
extension.
Definition 169 of 175

A nurse is assigned to care for a group of clients. On review of the client's medical records,
the nurse determines that which client is at risk for a fluid volume deficit?

A client with a colostomy

A client with congestive heart failure

A client on long-term corticosteroid therapy

A client receiving frequent wound irrigations

Definition 170 of 175


The nurse identifies the nursing diagnosis of Risk for Injury for the patient with
hyponatremia. What is the etiology of this diagnosis?

Altered mental capabilities

Fragility of bones

Immobility

Altered senses

Definition 171 of 175


During the shift report, the nurse discovers that the patient has low sodium. What
gastrointestinal change does the nurse expect to find during the physical assessment?

Minimal bowel sounds with frequent episodes of vomitting.

Absent bowel sounds with pronounced abdominal distention.

Hypoactive bowel sounds and complaints of constipation.

Hyperactive bowel sounds and abdominal cramps.


Definition 172 of 175

The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement
best explains the scientific rationale for the client's Kussmaul's respirations?

The kidneys produce excess urine and the lungs try to compensate

The respirations increase the amount of carbon dioxide in the bloodstream

The lungs speed up to release carbon dioxide and increase the pH

The shallow and slow respirations will increase the HCO3 in the serum.

Definition 173 of 175


The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight
was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs
approximately 2.2 pounds. How much fluid has the client lost?

1,250 ml

1,995 ml

3,500 ml

2,000 mL

Definition 174 of 175

Uncontrolled diabetes mellitus puts you at risk for?

Hyperkalemia

A. Bradycardia And Hypotension

Potassium

Hypernatremia
Definition 175 of 175

End - stage renal disease puts you at risk for?

Hypernatremia

Potassium

A. Bradycardia And Hypotension

Hyperkalemia

Privacy Terms English (UK)

You might also like