Fluid, Electrolyte, Acid-Base Transition

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The clients nursing diagnosis is Deficient Fluid volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant
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The clients nursing diagnosis is Deficient Fluid volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant
Provide straws and offer fluids between meals
The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports the is nursing diagnosis?
Flattended neck veins when the client is in the supine position
The nursing care plan for the client with dehydration includes interventions for oral health., Which intervention are within the scope of practice for an LPN being supervised be a nurse?
1. Remind the client to avoid commercial mouthwash
2. Encourage mouth rising with warm saline
3. Observe the lips, tongue, and mucous, membranes
4. Provide mouth care every 2 hours while the client is awake
The physician has written all of these orders a client with a diagnosis of Excess Fluid Volume. The clients morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankles edema, and moist crackles bilaterally. Which order takes priority at this time?
Administer furosemide (lasix) 40mg IV push
You have been pulled to the telemetry unit for the day. The monitor watcher informs you that the client developed prominent U waves. Which laboratory value should you check immediately?
Potassium
The clients potassium level is 6.7 mEq. Which intervention should you delegate to the first year student nurse whom you supervising
Administer sodium polystyrene sulfonate ( kayexalate)
A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuertic hormone secretion. For which electrolyte abnormality would you be sure to monitor
Hyponatremia
The charge nurse assisgned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegated to the nursing assistant?
Provide oral care every 3 - 4 hours
An experienced LPN reports to you that a clients blood pressure and heart rate have decreased and when his fave is assessed one side twitches. What action should you take at this time?
Review the clients morning calcium level
You are preparing to discharge a client whose calcium level was low but is now just barley within the normal range (9-10.5) Which statement by the client indicates to you the need for additional teaching?
I will avoid diary products broccoli and spinach
The nursing assistant asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is you best responseThe clients skeletal muscle are weak because of the low phosphorusYour are reviewing the clients morning laboratory results, Which of these results is of most concern to you?Serum magnesium level of 0.8As the charge nurse you would assign which client to the step down unit nurse pulled to the intensive care unit for the day?A 72 year old with COPD and normal blood gas values who is ventilator dependentThe client with respiratory failure is receiving mechanical ventilation and continue to produce arterial blood gas result indicating respiratory acidosis, Which change in ventilator setting should you expect to correct this problemIncrease in the ventilator rate from 6 to 10 breathes/ minWhich action should you delegate to the nursing assistant for the client with diabetic ketoacidosisRecord Intake and Output every hour Measure vital signs every 15 minutesYou are admitting an older adult client to the medical unit. Which factors alerts you that this client has a risk for acid-base imbalances?The client has chronic renal insufficiencyA client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain, When the student nurse assesses the client, which finding would you instruct the student to report immediately?Respiratory rate or 8-10 breathsThe nursing assistant reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/ min. Which acid-base imbalance should you suspected?Respiratory alkalosisA client is admitted to your unit for chemotherapy To prevent an acid-base problem, which of these would you instruct the nursing to report?Repeated episodes of nausea and vomitingThe client has a nasogastric tube connected to intermittent wall suction. The student nurse ask why the clients respiratory rate has decreased. What is your best response?The client may have a metabolic alkalosis due to the nasogastric suction and the decreased respiratory rate is compensatory mechanismThe client has an order for hydrochlororhiazide (HCTZ, Microzide) 10 mg orally every day. What should you be use to include in a teaching plan for this drug?1. Take this medication in the morning 2. Inform your prescriber if you notice weight gain or increased swelling 3. You should expect your urine output to increaseWhich blood test result would you be sure to monitor for the patient taking HCTZ?Potassium