Med-Surg Chapter 11, 12, & 13

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Study Guide NCLX Style Questions Critical Thinking

A 68-kg 65-year-old woman was admitted to the hospital this morning with a medical diagnosis of dehydration. When taking the client's history, which information is most significant?
A. The client has noticed an increase in being thirsty over the last 2 weeks.
B. The client has lost 8 lb over 2 weeks using the same scale at home.
C. The client's urine has been dark, yellow, and clear.
D. The client has had trouble swallowing, stating she does not have enough saliva.

B

A loss of 2.2 lb is equivalent to losing 1 L of fluid; that is, an 8-lb loss equals a loss of 3.5 L of fluid. A 3-L loss of fluid equals moderate dehydration.

Options a, c, and d are all signs that the fluid volume is decreasing; however, option b is the most significant and needs to be addressed first.

It is time to administer morning medications for your assigned group of clients. After reviewing your group's medications and after assessment, you choose to begin administering medications. Your first client is a 78-year-old man who was admitted yesterday afternoon. After fainting in his front yard while gardening, he was brought to the emergency department by local paramedics. His wife states that he has six medications due to be taken at 0900. The working nursing diagnosis is Fluid Volume Deficit with a goal to restore normal fluid volume. Which intervention best assists the patient in reaching the goal?
A. Administer each medication separately with 3 oz of water between each medication.
B. Administer all six medications together and provide the client with 1 cup of water.
C. Administer each medication with the 120 mL of juice left over from the breakfast tray.
D. Administer all six medications with a cup of coffee, like the client takes them at home.

A.

When medications are given to dehydrated patients, it is helpful to give them one at a time with water in between to increase the amount of fluid consumption.

Even though the amount of fluid given to the client would be increased in option b (240 mL), the amount of water increase in option a is even greater (360 mL).

Options c and d still encourage fluid intake, but using the fluids from the tray will maintain fluid intake, not increase it. The use of caffeine to replace fluids is not in the best interest of the client because caffeine is a diuretic.

Your 65 year-old client is receiving intravenous (IV) fluid at 150 mL/hr for moderate dehydration. You note that the urine output has increased significantly and the serum sodium level is 148 mEq/L. What should you do next?
A. Nothing needs to be done at this time. The output has increased, which validates the improving fluid status, and the sodium is only slightly abnormal.
B. Contact the physician to reduce the rate of the IV flow. The increased urine output is overflow diuresis resulting in hypernatremia.
C. Contact the nursing assistant and request that the patient be weighed and then compare the weight with weight obtained earlier in the morning.
D. Document the hourly urine output and the serum sodium level as evaluation criteria on the client's plan of care.

B

The physician should be contacted for orders to decrease the IV rate because the client is experiencing overflow diuresis and not replenishing the cells.

The overflow diuresis leads to hypernatremia.

Option (a) does not take into account the client's age or the fact that an increase in serum sodium could lead to seizures. Options (c) and (d), although appropriate interventions for the management of fluid status, are not priorities in this situation.

Which statement if made by a 50-year-old active client on a daily diuretic indicates a correct understanding of dehydration prevention?
A. "I need to stop drinking water 1 hour before exercising so my diuretic does not begin to work during my exercise program."
B. "I need exercise in the early to mid afternoon because the diuretic will be at its peak and I will benefit the most."
C. "I need to drink water before I begin as well as during the exercise and then again after I am finished."
D. "I need to drink only when I feel thirsty regardless of my daily activity level or my exercise program."

C

Regardless of whether the client is taking a diuretic or not, in order to avoid dehydration, one must drink water before, during, and after exercise. Choice a is incorrect, reducing the amount of fluid consumed can lead to rebound fluid retention syndrome. Choice b is incorrect, because exercising during the hottest part of the day increases fluid loss and could lead to dehydration. Choice d is incorrect, in that usually by the time one begins to feel thirsty, dehydration has already begun.

A client has been diagnosed with dehydration. During the morning assessment the nurse notes that the client is confused and disoriented to place and time. What intervention should the nurse implement?
A. Reorient the client as needed.
B. Increase the IV fluid rate to 125 mL/hr.
C. Place the client in semi-Fowler's position.
D. Apply oxygen per nasal cannula.

D.

The client is confused most likely due to cellular dehydration. The nurse should apply oxygen to assist with the confusion and then proceed to additional interventions that would involve review of the IV flow rate, reorienting the client to protect the client from injury, and putting the client in semi-Fowler's position to increase lung expansion and thus increase the amount of oxygen brought into the body through respiration.

The nurse is providing care to a client with dehydration. The nurse notes that the morning laboratory values reveal an elevated blood urea nitrogen (BUN) and creatinine plus a decrease in the urine output. While discussing these results with the physician, the nurse should request which order?
A. Decrease IV fluids from 150 mL/hr.
B. Insert a 14-French indwelling catheter.
C. Initiate a 1500-mL fluid restriction.
D. Hold the furosemide (Lasix) dose.

A.

An increase in BUN and creatinine signifies a kidney problem and with the decrease in urine output the client may be at risk for fluid volume excess that could put the heart at risk for failure. A decrease in the IV fluid should be implemented first, stopping the influx of fluid that is causing additional stress of the system. Inserting an indwelling Foley catheter and possibly initiating fluid restriction could additionally assist in protecting the client from incurring failure. The catheter would allow more accurate measurement of urine output. The nurse should not hold the Lasix dose because it is a loop diuretic designed to remove fluid from the vascular system and excrete the extra fluid by way of the kidneys.

The nurse is completing an assessment on a client and notes distended neck veins while the client was in high Fowler's position. What should the nurse expect to find upon further examination?
A. Deviating trachea to the left from midline
B. Bounding pulse and an elevated blood pressure
C. Increasing respiratory rate and rhythm
D. Decreasing neck vein distention while supine

B.

Delayed emptying and filling of the right ventricle leads to venous engorgement. You would expect to find a bounding pulse and an elevated blood pressure. The respiratory rate would increase as venous engorgement continued. The neck veins, however, would not decrease in size and the trachea would not shift.

An 85-year-old client has a nursing diagnosis of Fluid Volume Excess. Which nursing diagnosis would be next in priority?
A. Risk for Fluid Volume Deficit
B. Risk for Impaired Physical Mobility
C. Risk for Impaired Skin Integrity
D. Risk for Imbalanced Nutrition

C.

The client already has fluid volume excess. With fluid volume excess, the client is most likely to have edema and edematous skin is more fragile. Furthermore, the skin in older adults is most at risk for integrity issues. The client could have all of the other nursing problems with the least likely being the volume deficit; however, the risk for impaired skin integrity would be the next diagnosis of priority.

The nurse is developing a plan of care for an older client with an admission diagnosis of exacerbation of congestive heart failure. Blood pressure is 170/85, pulse is 88 beats per minute and bounding, and respiration is 24 breaths per minute and shallow. The client is afebrile and has 3+ peripheral edema from ankles to toes. The nurse's goal is to decrease edema. Which intervention should the nurse implement with extreme caution?
A. Elevate the head of bed (HOB) 30 to 45 degrees.
B. Reposition the client every 2 hours.
C. Position the client flat in bed.
D. Elevate the client's legs above the level of the heart.

D

Caution must be used when working with older clients. The nurse must incorporate knowledge of the normal aging process, knowing that as the client ages so does the ability of the heart to pump and the kidneys to filter and excrete. The client in this scenario is both older and has a disease process that affects the ability of the heart to handle additional fluid in the vascular system. When the legs are elevated above the heart, the edema leaves the tissue and goes into the vascular system and then exerts pressure on an already overloaded circulatory system. Elevating the HOB improves respirations and increases venous return from the head. Changing the client's position every 2 hours may not assist in reducing the edema but will assist in respiratory function and prevention of skin breakdown. Positioning the client flat in bed may not assist with the respiratory expansion but will decrease the gravitational force and reduce edema.

The nurse is working with a student nurse who brings to the nurse the following information about a client. The client is a 43-year-old man admitted after exploratory laparotomy. He has an intravenous infusion of D5W at 150 mL/hr. On assessment, he was confused and disoriented, complained of a headache, and had a serum sodium (Na) level of 125 mmol/L. Which order should the nurse request from the physician?
A. Oxygen 2 L per nasal cannula
B. Repeat serum sodium level STAT
C. Change of IV fluids
D. Tylenol grain X

C.

The client is demonstrating clinical manifestations of water intoxication. Water intoxication is common when hypotonic IV fluids are administered for a long period of time. The best answer then is to have the IV solution changed. Oxygen may not assist in reducing the confusion because oxygenation is not the problem. The sodium is low because there is more fluid in the vascular space than sodium. Even though a repeat sodium level would clear any possibility of specimen error, the test would only prolong the manifestations, and providing Tylenol would assist with the headache but it would not correct the problem. The headache will disappear with the correction of the sodium balance.

An 82-year-old male client admitted 3 days ago for dehydration has the following orders: vital signs per floor routine, regular diet encourage fluids, IV fluids at 150 mL/hr, ambulate TID. Interpret the following assessment data: disoriented to time, BP 160/85, P 96 and bounding, hyperactive bowel sounds and complaints of cramping. What should the nurse suspect?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia

C.

In hypervolemic hyponatremia, the excess volume causes elevated blood pressure and a full, rapid pulse but continues with neurological issues such as confusion and disorientation. Dehydration can be a sodium balance issue but not a potassium balance issue. The nurse is not worried about potassium at the moment.

An older client is placed in soft restraints for medical purposes. What should the nurse instruct the nursing assistant to do?
A. Feed the client breakfast and lunch.
B. Ambulate the client in the hall TID.
C. Offer the client fluids every 2 hours.
D. Offer a total bed bath to the client.

C.

Even though all of the interventions listed are pertinent to the care of the client in some fashion, offering the client fluids every 2 hours takes priority. The older client by normal aging process may not drink enough to keep the body fluid status in homeostasis so the nursing assistant now has an important role to ensure adequate hydration. It is important for the client to eat, ambulate, and maintain clean skin.

A nurse is developing a plan of care of a client with overhydration. What is the priority nursing diagnosis?
A. Decreased Cardiac Output
B. Risk for Impaired Ventilation
C. Impaired Tissue Perfusion
D. Risk for Impaired Skin Integrity

B.

When a client has fluid volume excess, the vascular system is overloaded with fluid, challenging the respiratory system and the vascular system. Remember the ABCs (airway, breathing, circulation) when determining priority. In this instance, the nurse should focus on the respiratory aspect of the care then follow up with the circulatory. Options c and d are plausible but not a priority in this case.

What is the priority nursing intervention for a client with moderate to severe hypernatremia?
A. Maintaining a 1500-mL/day fluid restriction
B. Initiating seizure precautions by padding the side rails
C. Weighing the client every morning using the bed scale
D. Restricting the diet to a 2-g low-sodium diet

B.

When the serum sodium level is 155 mEq/L (hypernatremia is a sodium level greater than 145 mEq/L), more neurologic changes occur and seizures are a possibility. Therefore placing the client in seizure precautions is necessary. Fluid restriction and reducing the sodium in the diet will not return the sodium level to a normal level even though each would assist in preventing further complications. Weighing the client would assist in analyzing fluid volume status.

A 73-year-old male client admitted with uncontrolled diabetes mellitus is being discharged. He plans to live with his daughter. He is at risk for electrolyte imbalances. During client education, what point should the nurse ensure that the client understands?
A. Eat a banana every morning with breakfast to replace potassium.
B. Read the label on all packaged foods for sodium content.
C. Prepare food by baking or grilling instead of frying.
D. Use a sugar substitute instead of sugar while cooking.

B.

The client has uncontrolled diabetes mellitus, which increases the risk for hypernatremia through excessive fluid loss through urination. The client should get the diabetes under control and read all labels noting sodium content because high-sodium foods add to the potential hypernatremia.

The remaining options are great interventions that will assist the client; however, they will not assist the problem of hypernatremia.

A client reports having a temperature of 101 degrees F for 3 days and has lost 7 lb. Blood work is drawn and the serum osmolarity is 320 mOsm/L with a serum sodium level of 148 mEq/L. What does the analysis of these data indicate?
A. Hypotonic dehydration
B. Isotonic dehydration
C. Hypertonic dehydration
D. Iso-osmolar dehydration

A

The elevated osmolarity indicates that the client is dehydrated. The serum sodium is also elevated this indicates a fluid volume issue; rarely is elevated serum sodium the result of increase in sodium levels it is usually the result of decrease in serum plasma. With this in mind, the client is suffering from hypertonic dehydration. The remaining options are incorrect because the serum osmolarity and serum sodium would have different values to demonstrate that type of dehydration.

During the discharge process, the nurse reviews the plan of care for a client with chronic conditions that increase the risk for dehydration. Which intervention will assist in identifying the onset of dehydration?
A. Record all fluid intake while awake.
B. Convert fluids to ounces to milliliters.
C. Chart accurate weights daily in the morning.
D. Select foods with a high water content.

C.

Weighing the client at the same time, on the same scale, and wearing the same clothing is the gold standard for measuring fluid balance because an increase in weight can be translated as an increase in fluid (2.2 lb = 1 L). By weighing the client accurately and daily, the health care team can determine where the client stands regarding fluid balance. It is important that the fluid intake be measured, providing some control and responsibility to the client to maintain fluid balance. Converting the fluids from ounces to milliliters really just assists in accurate communication between the team members but does nothing regarding the client's status. Selecting foods high in water content would not be an accurate method to determine the risk for dehydration.

Which outcome criterion for fluid volume deficit related to vomiting and diarrhea would demonstrate the return to normal fluid status?
A. Overall weight loss of 3 lb since admission
B. Urine output greater than 0.5 mL/kg/hr
C. An increase in serum sodium to 145 mEq/L
D. Stable vital signs within baseline for client

B.

Urine output of 0.5 mL/kg/hr is the best choice because it provides support that the kidneys are functioning adequately, which comes from adequate tissue perfusion and adequate vascular volume. Vital signs being within baseline do not provide conclusive evidence that the fluid volume status is adequate because vital signs fluctuate for multiple reasons and are the last to change. Weight loss and increase in sodium provide data that the client is still in a volume deficit.

Which client is at risk for hypertonic dehydration?
A. 50-year-old woman with severe blood loss after surgery
B. 56-year-old man with diabetes mellitus in ketoacidosis
C. 84-year-old woman with syndrome of inappropriate antidiuretic hormone secretion
D. 70-year-old man with chronic congestive heart failure

B.

Hypertonic dehydration occurs when there is more fluid lost in the vascular space than electrolytes, leaving the solution hypertonic. The body starts a fluid shift to equal out the concentration and improve the circulatory volume. Ketoacidosis contributes to the excess fluid loss through increased respiratory effort and decreased electrolyte loss. When a client loses blood volume, the client loses fluid and electrolytes together, so the dehydration is more isotonic. In heart failure, there is more fluid in the vascular space and no electrolyte loss so there is no dehydration.

A client with a history of hypertension has recently started diuretic therapy. Today the client complains of muscle weakness and irritability. What should the nurse suspect is the cause of the muscle weakness and irritability?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperkalemia

C.

Muscle weakness from an imbalance of sodium and potassium occurs early and becomes worse as the deficit continues. Because the client is receiving a diuretic and most diuretics are potassium wasting, the symptoms are from a lack of potassium in the system.

What is the average daily fluid intake for adults?
A. 1000 to 1500 mL
B. 1500 to 2000 mL
C. 2000 to 2500 mL
D. 2500 to 3000 mL

B. 1500 to 2000 mL

The elderly are at risk for excessive fluid losses due to which of the following reasons?
A. Decreased renal concentration of urine
B. Increased body fat and a consequent decrease in water proportionate to body weight
C. An altered ADH response
D. All of the above are correct.

D. All of the above are correct

Which of the following is not a type of ECF deficit?
A. Hypotonic
B. Isotonic
C. Osmotonic
D. Hypertonic

C. Osmotonic is not a type of ECF deficit

Why is tenting not diagnostic of fluid deficit in older adults?
A. increased elastin in the skin.
B. Tenting results from decreased collagen in the skin.
C. Tenting results from increased collagen in the skin.
D. Tenting results from decreased elastin in the skin.

D. Tenting results from decreased elastin in the skin.

Which of the following is not a clinical manifestation of cellular dehydration?
A. Mucous membranes of the mouth and eyes become dry.
B. Lips crack.
C. Mucous membranes of the mouth become dry while the eyes remain moist.
D. Swallowing is difficult.

C. Mucous membranes of the mouth become dry while the eyes remain moist.

When fluid pressure increases in the interstitial area and tissues, a resistance to forward blood flow is created. This process is called:
A. increased peripheral vascular resistance.
B. decreased peripheral vascular resistance.
C. increased peripheral circulatory resistance.
D. decreased peripheral circulatory resistance.

A. Increased peripheral vascular resistance

With fluid overload, the excess fluid volume dilutes the concentration of solutes. Typical findings include all of the following except:
A. hematocrit less than 45%.
B. BUN less than 8 mg/dL.
C. specific gravity less than 0.1.
D. plasma sodium less than 135 mEq/L.

C. specific gravity less than 0.1

Which of the following is an indicator of adequate fluid volumes?
A. Absence of manifestations of ECFVE
B. BUN, plasma sodium, and hematocrit approaching normal levels within 72 hours
C. Absence of ICFVE
D. All of the above are correct.

D. All the above are correct

What is the term used to describe the accumulation of fluids in the interstitial spaces?
A. Interstitial volume
B. Vascular volume
C. Third spacing
D. Tissue-fluid overload

...

Typical manifestations of fluid shift include all of the following except:
A. pallor.
B. cold limbs.
C. hypotension.
D. polyuria.

...

When monitoring fluid replacement, if fluids are administered too rapidly, what might occur?
A. Hypovolemia
B. Hypervolemia
C. Hypernatremia
D. Hyponatremia

...

Which of the following is not a type of hyponatremic state?
A. Hypovolemic hyponatremia
B. Euvolemic hyponatremia
C. Hypervolemic hypernatremia
D. Redistributive hyponatremia

...

__________ is the most common fluid and electrolyte imbalance in the United States.

dehydration

Fluids are normally found in three spaces: __________, __________, and __________.

intracellularly; interstitially; intravascularly

People who are at risk for becoming dehydrated because they do not have the ability to concentrate urine are those who produce inadequate amounts of __________.

ADH

__________ __________ __________ may be used as an indirect measurement of osmolarity.

Urine Specific Gravity

If hydrostatic pressure continues to rise, fluid shifts into the pleural spaces as well. This is known as __________ __________.

Pleural Effusion

Match the examples with the correct etiologic factor.
1. Compromised regulation of fluid movement and excretion
2. Excessive ingestion of fluids or foods containing sodium
3. Increased ADH and aldosterone

A. Glucocorticoid use
B. Cirrhosis of the liver
C. Heart failure
D. Ingestion of high-sodium foods
E. Excessive use of enemas with sodium
F. Hyperaldosteronism
G. Renal disorders
H. Hypothyroidism
I. Cushing's syndrome
J. Lymphatic obstruction
K. General anesthesia
L. Syndrome of inappropriate ADH secretion

1. Compromised regulation of fluid movement and excretion
B. Cirrhosis of the liver
C. Heart Failure
G. Renal Disorders
H. Hypothyroidism
J. Lymphatic Obstruction

2. Excessive ingestion of fluids or foods containing sodium
D. Ingestion of High-Sodium foods
E. Excessive use of enemas with sodium

3. Increased ADH and aldosterone
A. Glucocorticoid use
F. Hyperaldosteronism
I. Cushing's Syndrome
K. General Anesthesia
L. Syndrome of inappropriate ADH secretion

Match each clinical condition or disorder with the correct type of hyponatremia.
1. Hypervolemic hyponatremia
2. Redistributive hyponatremia
3. Euvolemic hyponatremia
4. Hypovolemic hyponatremia


A. Edematous disorders resulting in sodium deficits
B. Pseudohyponatremia
C. Diabetic glycosuria
D. Severe hyperglycemia
E. Aldosterone deficiency
F. Cirrhosis of the liver
G. CNS disorders
H. Hyperlipidemia
I. Cancers
J. Diabetic glycosuria
K. Intrinsic renal disease
L. Nephrotic syndrome
M. Chronic renal failure

1. Hypervolemic hyponatremia
A. Edematous disorders resulting in sodium defitis
F. Cirrhosis of the liver
L. Nephrotic syndrome
M. Chronic Renal Failure

2. Redistributive hyponatremia
B. Pseudohyponatremia
D. Severe Hyperglycemia
H. Hyperlipidemia

3. Euvolemic hyponatremia
G. CNS Disorders
I. Cancers

4. Hypovolemic hyponatremia
C. Diabeteic Glycosuria
E. Aldosterone Dificiency
J. Diabetic Glycosuria
K. Intrinsic Renal Disease

A 68-year-old man is admitted with complaints of muscle weakness and paresthesia in his lower extremities. Which question should the nurse ask?
A. "Have you been diagnosed with a renal disease?"
B. "Do you currently use a sugar substitute?"
C. "Have you received a blood transfusion recently?"
D. "Do you use a diuretic or a laxative daily?"

D.

Most diuretics are not potassium sparing, so potassium is excreted with the sodium. Laxatives also remove potassium. The question about diuretic or laxative use provides the best and most information. Renal disease would lead to clinical manifestations of hyperkalemia.

A client with history of hypertension has been prescribed Lasix 40 mg by mouth twice a day. Upon assessment the nurse notes a diminished hand grasp. The nurse should:
A. document the finding as the client's baseline.
B. call the physician to alert him of the findings.
C. assess the client's rate, rhythm, and depth of respirations.
D. direct the nursing assistant to obtain the client's vital signs.

C.

Lasix removes potassium with the sodium. The client is experiencing hypokalemia, which slows skeletal muscles, leading to weakness. If the skeletal muscles are slowed, so are the respiratory muscles; therefore the nurse should assess the client's respiratory status. This is not a baseline measurement, in that the client has no other history to state that would diminish the hand grasp. Even though a PCA is capable of obtaining vital signs, the situation demands the RN's judgment. The physician should be notified immediately following the additional assessment.

A client with diabetes mellitus is having difficulties controlling his blood sugar. This client is also at risk for:
A. hypercalcemia.
B. hypocalcemia.
C. hyperkalemia.
D. hypokalemia.

D.

When diabetics have issues controlling their blood sugar, increased amounts of insulin are used. Insulin not only helps transport glucose into the cells but also transports potassium. When potassium is moved into the cells, there is reduced potassium in the serum, leading to hypokalemia. The other three options are not relevant to the question.

The morning laboratory results for a client are available. The nurse notes a high blood urea nitrogen (BUN) and creatinine. The nurse suspects a potential for:
A. change in pulse rate and rhythm.
B. an increase in urine output.
C. an elevation in serum osmolarity.
D. change in the mental status.

A.

The elevated creatinine and BUN suggest issues with decreased kidney function, which leads to retention of fluid, including potassium. Increase in potassium leads to changes in pulse rate and rhythm. Decreased kidney function could lead to decreased urine output and decrease in serum osmolarity. A change in mental status is possible but not before pulse changes.

A client is receiving intravenous (IV) fluids of D5.45 NS with 20 mEq of KCl at 125 mL/hr. The client complains of burning at the IV site. The nurse should:
A. slow the IV rate until the burning sensation stops.
B. check the IV site for a blood return.
C. obtain an order to discontinue the IV fluid.
D. change the IV fluid to D5.45 NS.

D.

Potassium is irritating to the veins and the irritation leads to the need to reinsert the IV access, so it is best to change the IV fluids until that can be done. A blood return will most likely be present even with an irritated vein. It is unlikely that the IV fluids would be discontinued, and slowing the rate defeats the purpose of infusing IV fluids.

Which clinical manifestation indicates that a client's treatment for hyperkalemia is effective?
A. Pulse rate is 80 and regular.
B. Respiratory rate is 22 and regular.
C. Trousseau's sign is negative.
D. Urine output is 0.5 mg/kg/hr.

A.

Mild to moderate hypokalemia can cause paresthesias, tachycardia, and intestinal colic and diarrhea. With this knowledge, the best method to evaluate whether treatment is working is to measure pulse rate and rhythm. Urine output is not an issue here. Trousseau's sign does not evaluate potassium, and even though respiratory muscles can be effective, measuring the heart rate is the best method of evaluation.

A client is receiving Lanoxin 0.125 mg and Lasix 40 mg by mouth daily for heart failure. Which statement validates the client's understanding of the medication and the potential side effects?
A. "I need to eat green leafy vegetables daily."
B. "I need to drink at least 8 glasses of water daily."
C. "I need to take my blood pressure every morning."
D. "I need to weigh myself every morning and every evening."

A.

Lasix is a diuretic that will reduce the potassium in the system. Lanoxin works best with adequate potassium. When a client takes both medications without a potassium supplement, then he needs to make sure he is getting enough potassium in the diet. Options b, c, and d are acceptable interventions but do not address the potassium issue.

Which nursing diagnosis is of priority for a 70-year-old client from a homeless shelter with a history of alcoholism and malnutrition?
A. Altered Nutrition
B. Impaired Mobility
C. Risk for Injury
D. Ineffective Coping

C.

The client is malnourished, which leads to a deficient intake of calcium and vitamin D. The client's history of alcoholism also puts the client at risk for deficient vitamin D. Without vitamin D, the body cannot absorb calcium. Calcium and vitamin D come from the diet. With this knowledge, the client is at risk for injury due to weakened bones. Nutrition is a factor but the client will suffer worse from an injury. The client has no issues with moving and, although alcoholism could be considered an ineffective coping mechanism, it is not a priority in this instance.

During morning care, the client relates the following symptoms. Which symptom should alert the nurse to the possibility of hypocalcemia?
A. "My wedding ring no longer spins on my finger."
B. "I have not had a bowel movement in 3 days."
C. "I have had a 'Charlie horse' every night for a week."
D. "My heart races after my morning cup of coffee."

C.

Calcium is necessary for regular normal muscle contractions. When calcium is low, muscle cramping is a clinical manifestation. Edematous fingers are not a sign of hypocalcemia and neither is constipation or palpitations after drinking coffee.

While taking the blood pressure on the right arm of a client, the nurse notes the right hand in flexion contraction. What action should the nurse take?
A. Take the blood pressure in the left arm and compare.
B. Document the finding as baseline in the client's chart.
C. Remove the blood pressure cuff and administer oxygen.
D. Notify the emergency response team on call.

C.

This is an example of Trousseau's sign signaling hypocalcemia. Oxygen is the appropriate intervention because hypocalcemia presents with neuromuscular symptoms and the respiratory muscles could be affected. It is not necessary to compare left arm to right arm. Trousseau's sign is not baseline, and although calling the emergency response team may be the next step, it is not the first step.

The nurse is developing a plan of care to protect a client with chronic hypocalcemia from injury during hospitalization. Which intervention would best assist in meeting the goal of injury prevention?
A. Consult physical therapy to teach the client weight-bearing exercises.
B. Teach the client to wear closed toe shoes while ambulating.
C. Keep the walkway to the bathroom clear and well lit.
D. Use a lift pad when repositioning the client in bed.

D.

When calcium level is low, the bone attempts to compensate for the plasma deficiency of calcium by increasing bone resorption, but the increased loss of calcium from the bone only makes the bone more brittle and easier to fracture. With the client being at risk for bone fracture, the best method of protection is to use the lift pad when repositioning the patient which prevents pathological fractures. Weight-bearing exercises will help but will not stop the cause of bone resorption. Walking with shoes on and keeping the walkway clear will also help prevent injury but the individual should not be ambulating without assistance and/or without the use of a gait belt.

What intervention should be included in a teaching plan to prevent complications at home for a client with chronic hypocalcemia?
A. Reduce exposure to the sun by covering all exposed body parts.
B. Drink at least eight 8-oz glasses of water daily.
C. Eat foods high in phosphorus twice a day.
D. Use an electric razor instead of a safety razor.

D.

Hypocalcemia impairs the intrinsic pathway and thus affects every phase of blood coagulation, leading to prolonged bleeding times and eventual hemorrhage. It is then in the client's best interest not to use a razor when shaving because any nick in the skin will have the tendency to bleed for an extended period of time. The best method to remove hair would be with an electric razor. The sun is necessary as a source of vitamin D, which is needed for calcium absorption. Drinking eight 8-oz glasses of water a day does not specifically affect the calcium levels but does provide the body with the water necessary for daily activities. Phosphorus and calcium have a reciprocal relationship: if the calcium is high, then the phosphorus is low; if the phosphorus is high, then the calcium is low. Therefore adding additional phosphorus to the diet would not help the client's situation.

A 73-year-old woman with a history of osteoporosis and who takes multiple calcium supplements was admitted yesterday morning for repair of a right fractured hip. During the afternoon assessment, the nurse notes the following: awakens to name but quickly drifts off to sleep, complains of pain in right hip at 8/10 on the pain scale, respirations easy and even, decrease in appetite with complaints of nausea, and hypoactive bowel sounds. What action should the nurse take?
A. Use nonpharmacological interventions for pain and hold the pain medications.
B. Document the assessment because the findings are typical after anesthesia.
C. Notify the surgeon of the findings and request a serum calcium level.
D. Encourage the client to drink liquids of choice to curb the nausea.

D.

The clinical manifestations demonstrate the possibility of an elevated calcium level. Increased calcium stimulates the release of hydrochloric acid, gastrin, and pancreatic enzymes and slows bowel transit time, leading to anorexia, nausea, and vomiting. The best action is to contact the physician and request a serum calcium level to be drawn. The neurological symptoms come from the potentially high calcium as well so withholding the pain medication though it will help the symptom will not help the problem. Even in older individuals, the anesthetic would be wearing off by more than 24 hours after surgery.

A client was admitted with multiple fractures from a motor vehicle accident. Which of the client's PMH is most likely to increase the risk of hypophosphatemia?
A. History of alcohol abuse for 10 years
B. History of tobacco abuse for 55 years
C. History of a myocardial infarction 1 year ago
D. History of Addison's disease for 10 years

A.

Risk for hypophosphatemia is the loss of or long-term lack of phosphorus intake, increased body growth or tissue repair, and recovery from malnourished states. Alcohol abuse places the client in a malnourished state. Tobacco use and myocardial infarction are not causes of hypophosphatemia, and Addison's disease usually reflects hyperphosphatemia.

What statement validates a client's correct understanding of how to prevent hypophosphatemia?
A. "I need to take two antacids tablets immediately before each meal."
B. "I need to take my radial pulse and record the rate daily."
C. "I need to weigh myself daily at 9 AM using the same scale."
D. "I need to eat foods high in phosphorus and low in calcium."

D.

Phosphorus and calcium have a reciprocal relationship, so eating food high in phosphorus and low in calcium should help correct the imbalance. Constant use or use of large amounts of antacids further reduces the phosphorus in the system. Having clients weigh themselves and monitor their pulse is not necessarily a part of this scenario.

A client with hypophosphatemia is receiving IV phosphorus to restore the body to normal levels. The client develops a positive Trousseau's sign. What is the correct interpretation?
A. The IV is leaking phosphorus into the tissues.
B. The serum phosphate level continues to drop.
C. Hypocalcemia is being caused by the phosphate replacement.
D. Overhydration is being caused by rapid rehydration.

C.

Phosphorus and calcium have a reciprocal relationship: when one is up, the other is down. So with the client receiving phosphorus, the calcium is shifted out of the serum and causes the client to exhibit Trousseau's sign. IV phosphorus leaking into the skin will not cause the symptom but will result in swelling from the infiltration. Phosphorus does not affect the hydration status of the client.

Which statement by the client with hypophosphatemia indicates a need for clarification of the electrolyte imbalance?
A. "I will eat more protein and avoid dairy products."
B. "I will use Tylenol instead of Advil for pain."
C. "I will drink at least eight glasses of water everyday."
D. "I will use Tums when I have indigestion."

C.

Phosphorus and calcium have a reciprocal relationship: when one is up, the other is down. If the client ingests Tums for indigestion, the client is taking in calcium as well that will continue to reduce the level of phosphorus. The client needs to build phosphorus stores without compromising the calcium, so a delicate balance is needed with reduction of medications that could cause problems with either the calcium or the phosphorus.

A client is receiving an aminoglycoside antibiotic for an infection. Which clinical manifestation is a potential response to an electrolyte imbalance induced by the antibiotic therapy?
A. Hyperactive bowel sounds
B. Decrease in systolic blood pressure
C. Loss of deep tendon reflexes
D. Positive Trousseau's and Chvostek's sign

D.

Some medications like aminoglycoside antibiotics interfere with how the kidneys handle magnesium, promoting loss. Trousseau's sign and Chvostek's sign are clinical signs that the client may be experiencing a deficit in magnesium. The other options are not specific to magnesium deficits.

Because the body does not conserve potassium, potassium deficit commonly results from:
A. inadequate potassium intake.
B. inadequate potassium metabolism.
C. inadequate dietary balance of sodium and magnesium.
D. inadequate dietary balance of phosphates and calcium.

A.

2.
Cushing's syndrome can be associated with:
A. hyperkalemia.
B. hypokalemia.
C. hypocalcemia.
D. hypophosphatemia.

B.

3.
Most of the clinical manifestations of hypocalcemia are related to:
A. skeletal disorders.
B. hormone deficiencies.
C. neuromuscular hyperexcitability.
D. neuromuscular atrophy.

C

4.
Which of the following is a common cause of hypercalcemia?
A. Metastatic malignancy
B. Hyperparathyroidism
C. Thiazide diuretic therapy
D. All are common causes.

D

5.
Overuse of antacids can increase the amount of phosphorus in the intestines, which may:
A. increase the intake of magnesium in the intestinal villi.
B. inhibit the intake of magnesium in the intestinal villi.
C. interfere with the intake of calcium in the intestinal villi.
D. all of these are correct.

B

6.
Magnesium deficits are often seen in:
A. infants.
B. critically ill.
C. alcoholics.
D. 2 and 3.

D

7.
Nursing management of electrolyte imbalance include which of the following?
A. Teaching clients and their families about positive health behaviors
B. Promoting nutritional maintenance
C. Assisting the physician in early detection of imbalances
D. Promoting balanced nutritional rehabilitation
E. All of these.

E

8.
The __________ work to keep the electrolyte concentrations in the blood constant despite changes in the body.

Kidneys

9.
Cells that require less stimulus to make them "fire" are called __________.

Hypopolarized

10.
Parathyroid disease decreases plasma __________ levels.

Calcium

11.
A plasma potassium level of less than 3.5 mEq/L is defined as __________.

Hypokalemia

12.
__________ __________ __________ is the consequence of rapid destruction of tumor cells by chemotherapy or irradiation.

Tumor Lysis Syndrome

13.
__________ is defined as a plasma calcium level less than 4.5 mEq/L.

Hypocalcemia

14.
__________ __________ is the occurrence of carpal spasm, or contraction of the fingers and hand, when a blood pressure cuff is kept inflated on the upper arm for 5 minutes at diastolic pressure.

Trousseaus Sign

15.
The occurrence of spasm of the muscles innervated by the facial nerve when the client's face is tapped lightly below the temple is __________ __________.

Chvostek's Sign

Match each electrolyte with the appropriate food source.
1. Calcium
2. Magnesium
3. Potassium
4. Sodium
A. Chips
B. Apricots
C. Pasta
D. Tofu
E. Cheeses
F. Halibut
G. Spinach
H. Prunes
I. Watermelon
J. Bacon
K. Rhubarb
L. Swiss chard

1. Calcium
C. Pasta
G. Spinach
K. Rhubarb

2. Magnesium
D. Tofu
F. Halibut
L. Swiss Chard

3. Potassium
B. Apricots
H. Prunes
I. Watermelon

4. Sodium
A. Chips
E. Cheeses
J. Bacon

1Anyone with decreased intake, decreased availability, or increased loss of electrolytes is at risk for _______

Electrolyte Deficiency

2Nursing Diagnoses that may apply to clients with electrolyte imbalances include:

Risk for Injury
Risk for activity intolerance
Risk for decreased cardiac output
Altered oral mucous membranes

3. The most ominous result of hypocalcemia is ______.

dysrhythmias

4. Hypokalemia is defined as a plasma K+ level less than ______.

3.5 mEq/L

5. Clinical manifestations of hypokalemia include: (Select all that apply)
1. Abnormal findings on EKG
2. GI abnormalities
3. Muscle weakness
4. Leg Cramps

1, 2, 3, 4

6. Dysrhythmias with hypokalemia are due to _____.

Excessive excitability of the myocardial cells

7. The underlying cause of hyperkalemia is often associated with ______ kidney function.

Decreased

Define Trousseau's sign

Carpal spasm when a blood pressure cuff is inflated on the arm for 5 minutes.

Define Chvostek's sign

Spasm of the facial muscle caused by lightly tapping the facial nurse below the temple regions in front of the ear.

10. The three most common causes of hyperclcemia are: (Select all that apply)
1. Metastatic malignancy.
2. hyperparathyroidism
3. thiazide diuretics
4. corticosteroid-induced

1, 2, 3

11. Normal calcium levels are ______ or ______.

4.5 mEq/L - 5.5 mEq/L
9 mg/dl - 11 mg/dL

12. Hypermagnesemia is a magnesium level above _____

2.5 mEq/L or 3 mg/dL

13. Manifestations of hypermagnesemia are related to the _________ which results in a decrease in _______.

...

14. Options for treating hypermagnesemia include what? List 5

...

15. Hypomagnesemia is a plasma level of ______.

...

16. Nursing interventions for the client with hypomagnesemia include: (select all that apply).
1. Monitoring vital signs every 4-8 hrs.
2. Reviewing ECG strip hourly.
3. Institute safety and seizure precautions.
4. Assess deep tendon reflexes for early changes.

...

17. Hypomagnesemia is implicated in treatment refractory ____ and ____.

...

18. Magnesium deficits are often seen in clients with, what? List 6

...

19. GI losses from several problems account for many cases of hypomagnesemia. What do these GI problems have in common?

...

20. The Normal Range of Phosphorus is _______.

...

21. Major Risk factors for hypophosphatemia are: List three

...

22. Hypophosphatemia can affect every body system because of _____.

...

23. Hyperphosphatemia is a serum phosphate level above ______.

...

24. Mild or moderate cases of hyperphosphatemia are managed by what? List three.

...

25. What EKG changes would a nurse expect to find in a client with hypokalemia? select all that apply.
1. Depressed and prolonged ST segment
2. Depressed and inverted T Waves
3. Prominent U Waves
4. Wide QRS complexes

...

26. Oral Potassium (Chloride and gluconate) is extremely irritating to gastric mucosa and must be administered with (SATA)
1. Juice
2. meals
3. milk
4. water

...

27. Self-care measures the nurse should teach a client being discharged after an episode of hypokalemia include: (SATA)
1. Eating a well-balanved dient with foods low in potassium.
2. Trying alternative cooking methods or eating vegetables raw.
3. drinking 30-60 ml/hr of an electrolyte containing solution when sick.
4. Manifestations of hypokalemia the client should report
5. Calling the health care provider if the client with chronic health problems is sick for more than 24 hours.

...

28. Medications that commonly cause hypokalemia include (SATA).
1. thiazide diuretics.
2. Osmotic diuretics.
3. steroids.
4. digitalis preparations.

...

29. Clients who have acute hypocalcemia and develop tetany will be treated with (SATA):
1. IV Calcium chloride.
2. IV calcium gluconate
3. Lasix
4. Vitamin D.

...

30. List the precautions the nurse takes when administering IV Potassium. 11 of them.

...

31. Mild Hyperkalemia can be treated with _____, _____, and _____.

...

32. Immediate treatment for sever hyperkalemia includes (SATA)
1. IV Calcium gluconate.
2. Sodium bicarbonate
3. albuterol
4. Insulin with glucose.
5. Kayexalate

...

33. Oral Calcium supplements are best given:
1. with a full glass of water.
2. On an empty stomach.
3. 30 minutes prior to other medications.
4. with a glass of milk

...

34. IV Calcium should be diluted with which IV slution?
1. D5W
2. 0.45% NS
3. NS
4. Sodium bicarbonate

...

35. Clients with severe hypophosphatemia are often treated with __________.

...

2a. Define Dehydration

...

2b. Define Cellular Dehydration

...

2c. Define Fluid overload

...

2d. Define water intoxication

...

2e. Define Third Spacing

...

2f. Hyponatremia

...

2g. Hypernatremia

...

3. Thirst is inhibited by _______.

...

4. List the two types of fluid shifts.

...

5. What hormone(s) is/are responsible for increasing water and sodium reabsorption? (SATA)
1. ADH
2. Estrogen
3. Thyroxin
4. Calcium
5. Aldosterone

...

6. Identify the three types of extracellular fluid (ECF) volume deficits.

...

7. Decreased urine output is a classic sign of ______.

...

8. Clinical signs that a client is dehydrated include: (SATA)
1. Dry mucous membranes
2. sunken eyes
3. decreased skin turgor.
4. Elevated alkaline level

...

9. Oral rehydration is inhibited by cola drinks because they contain ____ and ____.

...

10. The most common causes of hyponatremia are conditions that _____.

...

11. Common conditions that can lead to hypernatremia are:
1. Hypovolemic hypernatremia
2. euvolemic hypernatremia
3. Hypervolemic hypernatremia

...

12. A serum sodium of below ____ indicates hyponatremia; a serum sodium above ____ indicates hypernatremia.

...

13. Early manifestations of hyponatremia are _____ and _______ and are caused by ______

...

14. No matter the cause, clients with hypernatremia are at risk for dysrhythmias because _______

...

15. The most common fluid and electrolyte disturbance in the U.S. is:
1. hypokalemia
2. dehydration
3. sodium retention
4. obesity.

...

16. Physiologic regulators of fluid balance include: (SATA):
1. Thirst
2. Hormones
3. The lymphatic system
4. The kidneys

...

17. Clients with a high risk of developing fluid imbalances include clients with (SATA):
1. Dysphagia
2. Dementia
3. diabetes insipidus
4. Renal Failure

...

18. Dehydration can be caused by: (SATA)
1. unmonitored use of potent diuretics
2. severe vomiting
3. diarrhea
4. Excessive exercise

...

19. Older clients are at risk for excessive fluid loss for several reasons including: (SATA)
1. Decreased renal concentration of urine.
2. altered ADH response.
3. Increased Body Fat
4. Excessive exercise

...

20 A client with inadequate fluid volume would have which of the following clinical signs. (SATA).
1. Decreased BP
2. Weak Pulse
3. Decreased Central Venous Pressure
4. Elevated respirations

...

21. The nurse should notify the team leader if a client has not had at lease _______ of urine output for 8 consecutive hours.

...

22. Complications of too-rapid IV fluid infusion can result in _____ and ______.

...

23. In evaluating renal function in clients, which lab test is critical in maintaining adequate renal output?
1. Creatinine.
2. CBC
3. ADH level
4. Lipase

...

24. Which conditions predispose clients to fluid loss? (SATA)
1. Fever
2. Hyperglycemia
3. Gastrointestinal suctioning
4. Ileostomy.
5. Burns
6. Hyperventilation

...

25. A 78-y/o female is starting to experience cerebral anoxia due to fluid loss. What sign would indicate this and needs to be reported to the physician?
1. Restlessness
2. Apprehension
3. Headache
4. Confusion

...

26. Which of the following assessment criteria are critical when managing patients with fluid volume deficits? (SATA)
1. Urine output
2. Body weight
3. Sodium & Potassium lab value
4. Osmolality
5. BUN

...

27. Which of the following assessment criteria are critical when managing patients with fluid volume deficits? (SATA)
1. Urine output
2. Body Weight
3. Sodium and potassium lab value
4. Osmolality
5. BUN

...

28. When weighing a clieint, it is important to (SATA):
1. rely on what the client tells you his or her weight is.
2. weigh the client daily
3. use the same scale for each weight
4. weigh the client at the same time each day.
5. have the patient void prior to weighing.

...

29. Respiratory assessment that would indicate fluid volume excess are: (SATA)

1. Diminished lung sounds.
2. crackles, ronchi
3. coughing
4. Dyspnea

...

30. what intravenous fluid(s are considered hypotonic?

...

31. What intravenous fluid(s) are considered isotonic?

...

32. What intravenous fluid(s) are considered hypertonic?

...

37. List 7 teaching measures for self-care related to hypernatremia

...

38. Mild diuretics and digitalis promote _____ and improve _____.

...

39. Clients taking diuretics and digitalis need to be monitored for: (SATA)
1. plasma electrolytes
2. Digitalis toxicity
3. Hypokalemia
4. Hypernatremia

...

40. True or false, unmonitored use of potent diuretics can cause hyperkalemia

...

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