Question 1

The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications that the client has been taking at home, which of the followingwouldbe of most concern to the nurse?

Accepted Answer

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.

Question 2

The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake?

Accepted Answer

An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older clients prefer to restrict fluids slightly in the evening to improve sleep quality. The client will not be likely to notice and act appropriately when changes in LOC occur.

Question 3

The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments should the nurse carefully monitor?

Accepted Answer

SIADH causes water retention and hyponatremia-a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

Question 4

The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess?

Accepted Answer

Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

Question 5

The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client's condition has improved?

Accepted Answer

Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the client's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

Question 6

The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?

Accepted Answer

The blood pressure indicates that the client may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the client's fluid intake but not as urgently as the hypotension.

Question 7

The nurse is caring for a client in the outpatient clinic who has a decreased serum magnesium level. Which of the following assessment areas should the nurse include in the health history?

Accepted Answer

Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin or mineral supplements would tend to increase magnesium level.

Question 8

The nurse is caring for a client with hypercalcemia. Which of the following actions would be included in the client's nursing care plan?

Accepted Answer

To decrease the risk for renal calculi, the client should have an intake of 3 000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in clients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the client needs frequent assessment of lung sounds, although these would be assessed every shift.

Question 9

The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO₂ 85 mm Hg, PaCO₂ 32 mm Hg, and HCO₃ 25 mmol/L. Which of the following interpretations would the nurse document?

Accepted Answer

The pH indicates that the client has alkalosis and the low PaCO₂ indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO₃.

Question 10

The nurse is teaching a client with renal failure about a low phosphate diet. Which of the following foods would the nurse teach the client to restrict?

Accepted Answer

Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits or juices are not high in phosphate and are not restricted.

Question 11

The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client asks the nurse why a peripherally inserted central catheter must be inserted. Which of the following explanations is the basis for the nurse's response?

Accepted Answer

Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

Question 12

The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client?

Accepted Answer

ECG changes in a client with hypokalemia include a tall peaked T-wave, prolonged P-R interval, ST depression, loss of P wave, widening QRS complex, ventricular fibrillation and standstill. Ventricular dysrhythmias, bradycardia, and flatten T wave are all possible changes with hypokalemia.

Question 13

The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan?

Accepted Answer

Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

Question 14

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO₂ 88 mm Hg, PaCO₂ 37 mm Hg, and HCO₃ 16 mmol/L. Which of the following interpretations would the nurse document?

Accepted Answer

The pH and HCO₃ indicate that the client has a metabolic acidosis. The ABGs are inconsistent with the other responses.

Question 15

The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing?

Accepted Answer

To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the client's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further.

Question 16

The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement?

Accepted Answer

The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the client will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

Question 17

The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take?

Accepted Answer

Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mmol, concentrations up to 60 mmol may be used for some clients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

Question 18

The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor?

Accepted Answer

Hypertonic solutions cause water retention, so the client should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

Question 19

The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective?

Accepted Answer

Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which are high in potassium.

Question 20

The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client?

Accepted Answer

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

Quiz 19: Fluid

The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications that the client has been taking at home, which of the followingwouldbe of most concern to the nurse?

The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake?

The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH) . Which of the following assessments should the nurse carefully monitor?

The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess?

The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client's condition has improved?

The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?

The nurse is caring for a client in the outpatient clinic who has a decreased serum magnesium level. Which of the following assessment areas should the nurse include in the health history?

The nurse is caring for a client with hypercalcemia. Which of the following actions would be included in the client's nursing care plan?

The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO₂ 85 mm Hg, PaCO₂ 32 mm Hg, and HCO₃ 25 mmol/L. Which of the following interpretations would the nurse document?

The nurse is teaching a client with renal failure about a low phosphate diet. Which of the following foods would the nurse teach the client to restrict?

The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client asks the nurse why a peripherally inserted central catheter must be inserted. Which of the following explanations is the basis for the nurse's response?

The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client?

The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan?

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO₂ 88 mm Hg, PaCO₂ 37 mm Hg, and HCO₃ 16 mmol/L. Which of the following interpretations would the nurse document?

The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing?

The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement?

The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take?

The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor?

The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective?

The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client?

Quiz 19: Fluid

The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications that the client has been taking at home, which of the followingwouldbe of most concern to the nurse?

The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake?

The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH) . Which of the following assessments should the nurse carefully monitor?

The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess?

The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client's condition has improved?

The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?

The nurse is caring for a client in the outpatient clinic who has a decreased serum magnesium level. Which of the following assessment areas should the nurse include in the health history?

The nurse is caring for a client with hypercalcemia. Which of the following actions would be included in the client's nursing care plan?

The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following interpretations would the nurse document?

The nurse is teaching a client with renal failure about a low phosphate diet. Which of the following foods would the nurse teach the client to restrict?

The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client asks the nurse why a peripherally inserted central catheter must be inserted. Which of the following explanations is the basis for the nurse's response?

The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client?

The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan?

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would the nurse document?

The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing?

The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement?

The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take?

The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor?

The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective?

The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client?

The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO₂ 85 mm Hg, PaCO₂ 32 mm Hg, and HCO₃ 25 mmol/L. Which of the following interpretations would the nurse document?

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO₂ 88 mm Hg, PaCO₂ 37 mm Hg, and HCO₃ 16 mmol/L. Which of the following interpretations would the nurse document?