Fluid & Electrolyte Nclex Questions

Created by kalicokat21 

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d. K = 3.2

Nurse would be most concerned about which lab values obtained fro ma client receiving furosemide (Lasix) therapy?

a. BUN 20
b. K 3.4
c. Creatinine 1.1
d. K 3.2

b. K

Furosemide inhibits reabsorption of sodium, water, and K leading to diuresis. ** The most common electrolyte disturbance associated with furosemde admin is hypokalemia
Nurse inserts a nasogastric tube, and it immediately drains 1000 mL of fluid. Which of the follwoing electrolyte level is of greatest concern at this time?

a. Na
b. K
c. Cl
d. CO2

d. Hypocalcemia

Hypokalemia is almost universal complication of loss of gastric hydrochloric acid. Metabolic alkalosis results. Other electrolytes may be affected, but not to the degree of potassium homeostasis is altered.
The nurse should observe for a Trousseau sign in the client with which of the following electrolyte abnormalities?

a. Hypokalemia
b. Hyponatremia
c. Hypochloremia
d. Hypocalcemia

d. wound dehisience

Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of this is seen in the Trousseau sign, a carpopedal spasm.
The WBC count of a client is 18,000. the nurse attributes this value to which of the following health problems of this client?

a. arthritis
b. alcoholism
c. viral infection
d. wound dehisience

B. intracellular

Tissue injury can cause an increase in WBC
The majority of the body's water is contained in which of the following fluid compartments?

A. interstitial
B. intracellular
C. extracellular
D. intravascular

A. osmosis.

If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is

A. osmosis.
B. diffusion.
C. active transport.
D. facilitated diffusion.

A. weight loss.

An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is

A. weight loss.
B. full bounding pulse.
C. engorged neck veins.
D. Kussmaul respiration.

A. fluid

Implementation of nursing care for the patient with hyponatremia includes

A. fluid restriction.
B. administration of hypotonic IV fluids.
C. administration of a cation exchange resin.
D. increased water intake for patients on nasogastric suction.

C. weak, irregular pulse and poor muscle tone

A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms?

A. restlessness and agitation
B. paresthesias and irritability
C. weak, irregular pulse and poor muscle tone
D. increased blood pressure and muscle spasms

C. 42-year-old woman with systemic lupus erythematosus and renal failure

Which of the following patients would be at greatest risk for the potential development of hypermagnesemia?

A. 83-year-old man with lung cancer and hypertension

B. 65-year-old woman with hypertension taking -adrenergic blockers

C. 42-year-old woman with systemic lupus erythematosus and renal failure

D. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

C. positive Chvostek's sign

It is especially important for the nurse to assess for which of the following in a patient who has just undergone a total thyroidectomy?

A. weight gain
B. depressed reflexes
C. positive Chvostek's sign
D. confusion and personality changes

A. calcium supplements.

The nurse anticipates that the patient with hyperphosphatemia secondary to renal failure will require

A. calcium supplements.
B. potassium supplements.
C. magnesium supplements.
D. fluid replacement therapy.

A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

The lungs act as an acid-base buffer by

A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
B. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load.
C. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
D. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

B. hypotonic.

The typical fluid replacement for the patient with an ICF fluid volume deficit is

A. isotonic.
B. hypotonic.
C. hypertonic.
D. a plasma expander.

C. Potassium and blood glucose levels

A client with a history of cardiac disease is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. The nurse expects to evaluate which laboratory values?

A. Albumin and protein levels
B. Sodium and chloride levels
C. Potassium and blood glucose levels
D. Hemoglobin level and hematocrit

C. 65-year-old client recently diagnosed with congestive heart failure

Individuals taking potassium-wasting diuretics are at risk for hypokalemia. Evaluating blood glucose level when the client reports weakness is important to ensure that low blood glucose level is not an issue. Levels of the other substances would not be affected by a potassium-wasting diuretic.
The following four clients are all at risk for fluid volume excess. Which of the clients should the nurse see first?

A. 88-year-old client with a fractured femur scheduled for surgery
B. 20-year-old client with a 5-year history of type 1 diabetes mellitus
C. 65-year-old client recently diagnosed with congestive heart failure
D. 50-year-old client with second-degree burns on the ankles and feet

A. 56-year-old client with acute renal failure

The 65-year-old client with congestive heart failure is at the greatest risk for problems from fluid volume excess. Fluid overload in this client could quickly cause life-threatening problems. The 50-year-old client with second degree burns is at risk for fluid volume deficit.
The nurse assesses four clients. Which client is at greatest risk for the development of hypocalcemia?

A. 56-year-old client with acute renal failure
B. 40-year-old client with systemic lupus erythematosus
C. 28-year-old client who has just undergone a total thyroidectomy
D. 65-year-old client with hypertension taking beta-adrenergic blockers

C. Dry mucous membranes

The client with acute renal failure is at the highest risk of hypocalcemia. While the patient who underwent a thyroidectomy is at risk, the client with acute renal failure is at a higher risk.
Clinical assessment of dehydration would be confirmed if the nurse identified:

A. 1-lb weight loss
B. Engorged neck vessels
C. Dry mucous membranes
D. Full bounding radial pulse

D. 0.45% Sodium chloride

Dry mucous membranes are a clinical sign of dehydration. Weight loss can be associated with dehydration but is not a confirming sign. Engorged neck vessels and bounding pulse are signs of fluid overload.
The nurse anticipates that the physician will order which intravenous (IV) fluid for a client who is dehydrated?

A. Ringer's lactate
B. 3% Sodium chloride
C. 0.9% Sodium chloride
D. 0.45% Sodium chloride

A. Hypokalemia

The physician has ordered that a client with hypertension begin receiving a thiazide diuretic. The nurse will now closely monitor the client for:

A. Hypokalemia
B. Hyponatremia
C. Hypercalcemia
D. Hypermagnesemia

B. Seals the end of the syringe and places it in a cup of crushed ice water

Thiazide diuretics cause the loss of water and potassium through the kidneys. Thus, if the client is not consuming sufficient potassium in the diet, a hypokalemic state could occur. Hypokalemia can cause muscle weakness and dysrhythmias. Hyponatremia is not usually a problem because there is an abundance of sodium in the body and the additional regulation of sodium by aldosterone would compensate for sodium loss due to diuretics Calcium level would be unaffected by thiazide diuretics. If magnesium were to be affected by thiazide diuretics, it would be excreted along with potassium, but the imbalance would be hypomagnesemia, not hypermagnesemia.
The nurse is assisting a physician in obtaining a sample for blood gas analysis from a client's left wrist. After drawing the sample into the syringe, the nurse:

A. Adds a drop of heparin to the sample to prevent clotting
B. Seals the end of the syringe and places it in a cup of crushed ice water
C. Places the syringe of blood in a dark bag to protect the specimen from light
D. Seals the syringe in a zip-lock bag and places the specimen in the out box for laboratory pickup

C. Needs changing because it is beyond the 3-day recommended limit

The nurse is conducting an assessment of a client receiving intravenous (IV) fluids via a central line. Today is March 9. The tubing is dated March 5. The nurse determines that the tubing:

A. Is good for 3 more days, for a total of 7 days
B. Can remain in place as long as there is not a disconnection
C. Needs changing because it is beyond the 3-day recommended limit
D. Needs changing, along with the IV port, because they have been in place for 4 days

d. Infant

One of the most common electrolyte imbalances is: Hypokalemia
The client most at risk for fluid volume defecit (FVD) is:

a. Elder adult
b. Adult
c. Child
d. Infant

b. Have a decreased thirst sensation

One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they:

a. Eat poor quality foods
b. Have a decreased thirst sensation
c. have more stress response
d. have an overly active thirst response

a. client teaching

Output recorded on an I/O sheet would be all of these: Urine
Diarrhea
Vomit
Gastric suction
Wound drainage
Health promotion activities in the area of fluid and electrolyte imbalance focus primarily on:

a. client teaching
b. dietary intake
c. medication
d. physician involvement in care

a. hand washing

Many factors are intially controlled for the IV insertion procedure. This nurse understands this begins with:

a. hand washing
b. checking sterility of supplies
c. 6 med rights
d. checking IV order

B. Hypocalcemia

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?

A. Hyponatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypermagnesemia

A. 50-year-old with pneumonia, diaphoresis, and high fevers

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

A. 50-year-old with pneumonia, diaphoresis, and high fevers
B. 62-year-old with congestive heart failure taking loop diuretics
C. 39-year-old with diarrhea and vomiting
D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

B. Ensure the client is safe from falls and check the most recent potassium level

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?

A. Request a physical therapy consult from the physician
B. Ensure the client is safe from falls and check the most recent potassium level
C. Allow uninterrupted rest periods throughout the day
D. Encourage the client to increase intake of dairy products and green leafy vegetables.

C. bowel movements.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor

A. urine output.
B. blood pressure.
C. bowel movements.
C. ECG for tall, peaked T waves.\

B. Question the results and redraw the specimen

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?

A. Call the physician and report results
B. Question the results and redraw the specimen
C. Encourage the client to increase the intake of bananas
D. Initiate seizure precautions

A. Absent patellar reflex

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?

A. Absent patellar reflex
B. Diarrhea
C. Premature ventricular contractions
D. Increase in blood pressure

D. Check to see if a serum albumin level is available

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?

A. Assess for depressed deep tendon reflexes
B. Call the physician to report calcium level
C. Place an intravenous catheter in anticipation of administering calcium gluconate
D. Check to see if a serum albumin level is available

C. Call the physician
D. Report the urine output
E. Report indications of nausea

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply.

A. Administer an antiemetic prior to giving the digoxin
B. Encourage the client to increase fluid intake
C. Call the physician
D. Report the urine output
E. Report indications of nausea

A. Provide passive ROM exercises and encourage fluid intake

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action?

A. Provide passive ROM exercises and encourage fluid intake
B. Teach the client to increase intake of whole grains and nuts
C. Place a tracheostomy tray at the bedside
D. Administer calcium gluconate IM as ordered

C. "The sodium level is low, and the confusion will resolve as the levels normalize."

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating

A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion."
B. "Most older adults get confused in the hospital."
C. "The sodium level is low, and the confusion will resolve as the levels normalize."
D. "The sodium level is high and the behavior is a result of dehydration."

C. Assess for signs of fluid overload

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?

A. Turn down the infusion
B. Check the latest sodium level
C. Assess for signs of fluid overload
D. Place a call to the physician

D. Milk of magnesia

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?

A. Bisacodyl (Dulcolax) suppository
B. Fiber supplements
C. Docusate sodium
D. Milk of magnesia

D. Notify the physician of the urine output and hold the dose

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?

A. Encourage the client to increase fluid intake
B. Administer the dose as ordered
C. Draw a potassium level and administer the dose if the level is low or normal
D. Notify the physician of the urine output and hold the dose

B. A client who is alcoholic receiving total parenteral nutrition

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?

A. A client with osteoporosis taking vitamin D and calcium supplements
B. A client who is alcoholic receiving total parenteral nutrition
C. A client with chronic renal failure awaiting the first dialysis run
D. A client with hypoparathyroidism secondary to thyroid surgery

B. Broccoli
D. Nuts

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply.

A. Eggs
B. Broccoli
C. Organ meats
D. Nuts
E. Canned salmon

D. Magnesium

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment?

A. Sodium
B. Phosphorus
C. Calcium
D. Magnesium

B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?

A. Increase intake of dairy products and nuts
B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals
C. Reduce intake of chocolate, meats, and whole grains
D. Avoid calcium supplements

C. Place client in high-Fowler's position

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler's position
D. Assist the client to breathe into a paper bag

D. Encourage the client to rest and to use pursed-lip breathing technique

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?

A. Call the physician and report the change in client's condition
B. Turn the client's O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing technique

B. 0.9 NS at an open rate

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?

A. D5.45 NS at 50 ml/hr
B. 0.9 NS at an open rate
C. D5W at 125 ml/hr
D. 0.45 NS at open rate

C. pH of 7.33, PCO2 of 35, HCO3 of 17

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

A. pH of 7.43, PCO2 of 36, HCO3 of 26
B. pH of 7.41, PCO2 of 49, HCO3 of 30
C. pH of 7.33, PCO2 of 35, HCO3 of 17
D. pH of 7.25, PCO2 of 56, HCO3 of 28

C. Metabolic alkalosis (

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

D. Provide reassurance to the client and administer sedatives

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention?

A. Monitor intake and output
B. Encourage client to increase activity
C. Institute deep breathing exercises every hour
D. Provide reassurance to the client and administer sedatives

A. Deep tendon reflexes decreasing from +2 to +1

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating?

A. Deep tendon reflexes decreasing from +2 to +1
B. Bicarbonate rising from 20 mEq/L to 22 mEq/L
C. Urine pH less than 6
D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?

A. "The fluid is an adverse reaction to chemotherapy."
B. "A decrease in activity has allowed extra fluid to accumulate in the tissues."
C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."
D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

C. Positive Chvostek's sign

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?

A. Bone pain
B. Depressed deep tendon reflexes
C. Positive Chvostek's sign
D. Nausea

B. Excess fluid volume related to increased water retention

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client?

A. Deficient fluid volume related to decreased fluid intake
B. Excess fluid volume related to increased water retention
C. Deficient fluid volume related to excessive fluid loss
D. Risk for injury related to fluid volume loss

C. Obtain a glucose level on a client admitted with diabetes mellitus

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse?

A. Assess a client for metabolic acidosis
B. Evaluate the blood gases of a client with respiratory alkalosis
C. Obtain a glucose level on a client admitted with diabetes mellitus
D. Perform a neurological assessment on a client suspected of having hypocalcemia

B. Notify the physician

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention?

A. Withhold furosemide (Lasix)
B. Notify the physician
C. Administer the prescribed potassium supplement
D. Instruct the client on foods high in potassium

A. acute renal failure.

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of

A. acute renal failure.
B. malabsorption syndrome.
C. nasogastric drainage.
D. laxative abuse

B. Baked chicken
D. Baked potato

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L?

A. Pretzels
B. Baked chicken
C. Chicken bouillon
D. Baked potato
E. Baked ham

D. Hypocalcemia

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?

A. Hypokalemia
B. Hypernatremia
C. Hypermagnesemia
D. Hypocalcemia

D. Chloride is lost in hydrochloride acid

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?

A. Sodium is essential to maintain intracellular fluid water balance
B. Magnesium is essential to the function of muscle, red blood cells, and nervous system
C. Less calcium is excreted with aging
D. Chloride is lost in hydrochloride acid

A. Baked cod
D. Baked potato
E. Spinach

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply.

A. Baked cod
B. Ham and cheese omelet
C. Fried eggs
D. Baked potato
E. Spinach

C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L

The nurse evaluates which of the following clients to have hypermagnesemia?

A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L
B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L
C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L
D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L

D. A client with dehydration and a sodium level of 149 mEq/L

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first?

A. A client with osteoporosis and a calcium level of 10.6 mg/dl
B. A client with renal failure and a magnesium level of 2.5 mEq/L
C. A client with bulimia and a potassium level of 3.6 mEq/L
D. A client with dehydration and a sodium level of 149 mEq/L

A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?

A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L
B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L
C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl
D. A client with dehydration who has a serum sodium level of 128 mEq/L

C. Dehydration.

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 would be a cause for these findings?

A. Overhydration.
B. Anemia.
C. Dehydration.
D. Renal failure.

C. On auscultation, crackles and rales in all lung fields are noted.

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

A. The pump keeps sounding an alarm that the high pressure has been reached.
B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL.
C. On auscultation, crackles and rales in all lung fields are noted.
D. Client has negative pedal edema and an increasing level of consciousness.

C. 2000 mL

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 (in milliliters)?

A. 500 mL
B. 1000 mL
C. 2000 mL
D. 4400 mL

B. Restrict the client's sodium in the diet.

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

A. Change the IV fluid from 0.9% NS to D5W.
B. Restrict the client's sodium in the diet.
C. Monitor blood glucose levels.
D. Prepare the client for hemodialysis.

D. Place on seizure precautions.

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

A. Encourage fluids orally.
B. Administer 10% saline solution IVPB.
C. Administer antidiuretic hormone intranasally.
D. Place on seizure precautions.

A. The client in normal sinus rhythm with a peaked T wave.

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

A. The client in normal sinus rhythm with a peaked T wave.
B. The client diagnosed with atrial fibrillation with a rate of 100.
C. The client diagnosed with a myocardial infarction who has occasional PVC.
D. The client with a first-degree AV block and a rate of 92.

B. Tap the cheek about two (2) centimeters anterior to the ear lobe.

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first?

A. Notify the health care provider immediately.
B. Tap the cheek about two (2) centimeters anterior to the ear lobe.
C. Check the serum calcium and magnesium levels.
D. Prepare to administer calcium gluconate IVP.

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

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)?

A. The kidneys produce excess urine and the lungs try to compensate.
B. The respirations increase the amount of carbon dioxide in the bloodstream.
C. The lungs speed up to release carbon dioxide and increase the pH.
D. The shallow and slow respirations will increase the HCO3 in the serum.

A. Place the solution on an IV pump at the prescribed rate.
B. Monitor blood glucose every six (6) hours.
E. Monitor intake and output every shift.

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 (6) hours.
C. Weigh the client weekly, first thing in the morning.
D. Change the IV tubing every three (3) days.
E. Monitor intake and output every shift.

B. Discontinue the intravenous line.

The client has received IV solutions for three (3) 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 action should the nurse implement first?

A. Start a new IV in the right hand.
B. Discontinue the intravenous line.
C. Complete an incident record.
D. Place a warm washrag over the site.

C. Instruct the client on appropriate fluid restrictions.

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

A. Measure the client's output from the indwelling catheter.
B. Record the client's intake and output on the I & O sheet.
C. Instruct the client on appropriate fluid restrictions.
D. Provide water for a client diagnosed with diabetes insipidus.

C. Serum potassium.

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

A. Serum calcium.
B. Serum phosphorus.
C. Serum potassium.
D. Serum sodium.

A. The skin

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 understands that this type of fluid loss can occur through:

A. The skin
B. Urinary output
C. Wound drainage
D. The gastrointestinal tract

A. A client with a colostomy

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 deficient fluid volume?

A. A client with a colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigations

D. Decreased central venous pressure (CVP)

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

A. Lung congestion
B. Decreased hematocrit
C. Increased blood pressure
D. Decreased central venous pressure (CVP)

B. The client with renal failure

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 excess fluid volume?

A. The client taking diuretics
B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning

C. An increase in blood pressure

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 additional signs would the nurse expect to note in this client if excess fluid volume is present?

A. Weight loss
B. Flat neck and hand veins
C. An increase in blood pressure
D. A decreased central venous pressure (CVP)

B. Requires nasogastric suction.

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:

A. Has renal failure.
B. Requires nasogastric suction.
C. Has a history of Addison's disease.
D. Is taking a potassium-sparing diuretic.

A. U waves

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?

A. U waves
B. Absent P waves
C. Elevated T waves
D. Elevated ST segment

D. Preparing the medication for bolus administration

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?

A. Obtaining a controlled IV infusion pump
B. Monitoring urine output during administration
C. Diluting in appropriate amount of normal saline
D. Preparing the medication for bolus administration

A. Apples

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:

A. Apples
B. Carrots
C. Spinach
D. Avocado

D. The client who has sustained a traumatic burn

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?

A. The client with colitis
B. The client with Cushing's syndrome
C. The client who has been overusing laxatives
D. The client who has sustained a traumatic burn

D. Tall peaked T waves

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?

A. ST depression
B. Inverted T wave
C. Prominent U wave
D. Tall peaked T waves

B. The client who is taking diuretics

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?

A. The client with renal failure
B. The client who is taking diuretics
C. The client with hyperaldosteronism
D. The client who is taking corticosteroids

C. Hyperactive bowel sounds

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 that the 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 this client if hyponatremia were present?

A. Dry skin
B. Decreased urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine

C. Sodium chloride

A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation?

A. Tap water
B. Sterile water
C. Sodium chloride
D. Distilled water

D. Processed oat cereals

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?

A. Peas
B. Cauliflower
C. Low-fat yogurt
D. Processed oat cereals

A. Prolonged bed rest

A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?

A. Prolonged bed rest
B. Renal insufficiency
C. Hyperparathyroidism
D. Excessive ingestion of vitamin D

A. Twitching

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?

A. Twitching
B. Negative Trousseau's sign
C. Hypoactive bowel sounds
D. Hypoactive deep tendon reflexes

C. Prolonged QT interval

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

A. Widened T wave
B. Prominent U wave
C. Prolonged QT interval
D. Shortened ST segment

C. Depressed ST segment

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level?

A. Prominent U waves
B. Prolonged PR interval
C. Depressed ST segment
D. Widened QRS complexes

A. Alcoholism

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?

A. Alcoholism
B. Renal insufficiency
C. Hypoparathyroidism
D. Tumor lysis syndrome

A. Peas
C. Cauliflower
E. Canned white tuna

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

A. Peas
B. Oranges
C. Cauliflower
D. Peanut butter
E. Canned white tuna

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