Question 1

When taking the blood pressure of a very ill client,the nurse observes that the client's hand undergoes flexion contractions.Which intervention is most appropriate?

Accepted Answer

Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches,spasms,and tetany.Flexion contractions that occur during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign.Client safety is a priority,and the nurse must ensure that the client has a working intravenous line.Seizure precautions and decreasing environmental stimuli are also important.

Question 2

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?

Accepted Answer

The intestinal tract is relatively sensitive to decreasing potassium levels.Common manifestations of hypokalemia are decreased peristalsis and constipation.

Question 3

A client is admitted with hyponatremia.Four hours after the initial assessment,the nurse notes that the client has new hyperactive bowel sounds in all four quadrants.What analysis about the client's condition is correct?

Accepted Answer

Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy,decreased blood pressure,increased gastric motility,and diminished deep tendon reflexes.Bowel sounds that are more hyperactive than on a previous assessment indicate that the condition is worsening.

Question 4

A client has a calcium level of 14 mg/dL.Which intervention is the priority?

Accepted Answer

This client has hypercalcemia.Both forcing fluids and providing cardiac monitoring are appropriate,but because calcium has significant cardiac effects,placing the client on a cardiac monitor takes priority.Assessing for Chvostek's sign and administering calcium would be appropriate for the client with hypocalcemia.

Question 5

A client is taking furosemide (Lasix)and becomes confused.Which potassium level does the nurse correlate with this condition?

Accepted Answer

Hypokalemia decreases cerebral function and is manifested by lethargy,confusion,inability to perform problem-solving tasks,disorientation,and coma.Normal potassium levels are 3.5 to 5.0 mEq/L.At 2.9 mEq/L,potassium is too low,and this could lead to neurologic manifestations.

Question 6

A client has the following laboratory values: Ca²⁺ 8.7 mg/dL; K⁺ 4.2 mEq/L; Na⁺ 142 mEq/L.Which intervention by the nurse is most appropriate?

Accepted Answer

The client's calcium is low.Treatment for hypocalcemia includes calcium replacement,administering drugs that increase calcium absorption,and giving medications to control bothersome neuromuscular effects.Aluminum hydroxide helps the body absorb calcium.The client's potassium is normal,so giving potassium is not warranted.Asking the laboratory to rerun the tests will not help the client's problem,although if this seems contradictory to the client's condition,it might be an option.Documenting findings and performing ongoing assessments will not help the client's problem.

Question 7

A client is being discharged and needs to self-monitor for the development of hyperkalemia.Which intervention is most important for the nurse to teach the client?

Accepted Answer

As potassium levels rise,dysrhythmias can develop.By being vigilant for changes in pulse rate,rhythm,and quality,the client can seek medical attention before hyperkalemia becomes severe.Taking a daily weight will help determine fluid retention,but this is not an accurate indicator of potassium increase or decrease.Fluid intake should be based on body weight.Sodium restriction may not be necessary.

Question 8

A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day.Which response by the nurse is best?

Accepted Answer

Not all fruit is potassium rich.Fruits that are relatively low in potassium and can be included in the diet include apples,apricots,berries,cherries,grapefruit,peaches,and pineapples.Fruits high in potassium include bananas,kiwi,cantaloupe,oranges,and dried fruit.Cooking fruit does not alter its potassium content.

Question 9

A client has a history of hypocalcemia.What intervention is most important for the nurse to add to this client's care plan?

Accepted Answer

Clients with long-standing hypocalcemia have brittle bones that may fracture easily.Safety needs are a priority.Having the client wear nonslip footwear to get out of bed can help prevent falls.The other interventions would not provide safety for this client.

Question 10

A nurse is caring for several clients.Which client does the nurse assess most carefully for hyperkalemia?

Accepted Answer

Many salt substitutes are composed of potassium chloride.Heavy use can contribute to the development of hyperkalemia.The client should be taught to read labels and to choose a salt substitute that does not contain potassium.NSAIDs promote the retention of sodium but not potassium.

Question 11

A client in the emergency department has potassium of 2.9 mEq/L.For which disease process or condition does the nurse assess the client?

Accepted Answer

Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing excretion of potassium.Therefore,any client with this condition is at high risk for the development of hypokalemia.

Question 12

A client has hypokalemia.Which question by the nurse obtains the most information on a possible cause?

Accepted Answer

Misuse and overuse of diuretics,especially high-ceiling (loop)and thiazide diuretics,and laxatives are common causes of hypokalemia in older adults and in clients with eating disorders.Sugar substitutes and bowel habits are not related to hypokalemia.The client with kidney disease would be more likely to have hyperkalemia.

Question 13

A client has been treated for hypokalemia.Which clinical manifestation or condition indicates that treatment has been effective?

Accepted Answer

Hypokalemia depresses all excitable tissues,including gastrointestinal smooth muscle.Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.The other answer options are not applicable to hypokalemia.

Question 14

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago.Which intervention by the nurse is the priority?

Accepted Answer

In a client with hypokalemia,progressive skeletal muscle weakness is associated with increasing severity of hypokalemia.The most life-threatening complication of hypokalemia is respiratory insufficiency.It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy.Next,the nurse would call the health care provider to obtain orders for potassium replacement.

Question 15

A client has been taught to increase potassium in the diet.What dietary meal selection indicates to the nurse that teaching has been effective?

Accepted Answer

Meat,dairy products,and dried fruit have high concentrations of potassium.Eggs,breads,cereals,sugar,and some fruits (berries,peaches)are low in potassium.The menu selection of sausage,toast,raisins,and milk has the greatest number of items with higher potassium content.

Question 16

A nurse is assessing clients for fluid and electrolyte imbalances.Which client is at greatest risk for developing hyponatremia?

Accepted Answer

D₅W contains no electrolytes.Because the client is not taking any food or fluids by mouth,normal sodium excretion can lead to hyponatremia.The antibiotic,Motrin,and digoxin will not put a client at risk for hyponatremia.

Question 17

A client has a history of hypothyroidism.Which laboratory value is the nurse most concerned about?

Accepted Answer

A common cause of hypocalcemia is hypothyroidism.The calcium value is low,correlating with this condition.The sodium level is only slightly high,and hypothyroidism is not related to sodium imbalances.The potassium level is normal.The magnesium level is low,but hypothyroidism can cause hypermagnesemia.

Question 18

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia.What action is most important for the nurse to teach the client?

Accepted Answer

Most prepackaged foods have high sodium content.Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia.Daily self-weighing and checking the pulse are methods of identifying manifestations of hypernatremia,but they do not prevent it.The addition of substances during cooking increases the sodium content of a meal,not the method of cooking.

Question 19

Which client is at greatest risk for developing hypercalcemia?

Accepted Answer

The parathyroid glands secrete parathyroid hormone.The actions of parathyroid hormone include increasing intestinal absorption of calcium,decreasing renal excretion of calcium,and increasing calcium resorption from the bones.All these actions increase the serum calcium level.

Question 20

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline.The client states that the area around the IV site burns.What intervention does the nurse perform first?

Accepted Answer

Potassium is a severe tissue irritant.The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether,in which case the client would need another site started.Assessing for a blood return may or may not be successful.The solution could be diluted (less potassium)and the rate could be slowed once it is determined that the needle is in the vein.

Quiz 13: Assessment and Care of Patients With Fluid and Electrolyte Imbalances

When taking the blood pressure of a very ill client,the nurse observes that the client's hand undergoes flexion contractions.Which intervention is most appropriate?

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?

A client is admitted with hyponatremia.Four hours after the initial assessment,the nurse notes that the client has new hyperactive bowel sounds in all four quadrants.What analysis about the client's condition is correct?

A client has a calcium level of 14 mg/dL.Which intervention is the priority?

A client is taking furosemide (Lasix) and becomes confused.Which potassium level does the nurse correlate with this condition?

A client has the following laboratory values: Ca²⁺ 8.7 mg/dL; K⁺ 4.2 mEq/L; Na⁺ 142 mEq/L.Which intervention by the nurse is most appropriate?

A client is being discharged and needs to self-monitor for the development of hyperkalemia.Which intervention is most important for the nurse to teach the client?

A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day.Which response by the nurse is best?

A client has a history of hypocalcemia.What intervention is most important for the nurse to add to this client's care plan?

A nurse is caring for several clients.Which client does the nurse assess most carefully for hyperkalemia?

A client in the emergency department has potassium of 2.9 mEq/L.For which disease process or condition does the nurse assess the client?

A client has hypokalemia.Which question by the nurse obtains the most information on a possible cause?

A client has been treated for hypokalemia.Which clinical manifestation or condition indicates that treatment has been effective?

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago.Which intervention by the nurse is the priority?

A client has been taught to increase potassium in the diet.What dietary meal selection indicates to the nurse that teaching has been effective?

A nurse is assessing clients for fluid and electrolyte imbalances.Which client is at greatest risk for developing hyponatremia?

A client has a history of hypothyroidism.Which laboratory value is the nurse most concerned about?

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia.What action is most important for the nurse to teach the client?

Which client is at greatest risk for developing hypercalcemia?

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline.The client states that the area around the IV site burns.What intervention does the nurse perform first?

Quiz 13: Assessment and Care of Patients With Fluid and Electrolyte Imbalances

When taking the blood pressure of a very ill client,the nurse observes that the client's hand undergoes flexion contractions.Which intervention is most appropriate?

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?

A client is admitted with hyponatremia.Four hours after the initial assessment,the nurse notes that the client has new hyperactive bowel sounds in all four quadrants.What analysis about the client's condition is correct?

A client has a calcium level of 14 mg/dL.Which intervention is the priority?

A client is taking furosemide (Lasix) and becomes confused.Which potassium level does the nurse correlate with this condition?

A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L.Which intervention by the nurse is most appropriate?

A client is being discharged and needs to self-monitor for the development of hyperkalemia.Which intervention is most important for the nurse to teach the client?

A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day.Which response by the nurse is best?

A client has a history of hypocalcemia.What intervention is most important for the nurse to add to this client's care plan?

A nurse is caring for several clients.Which client does the nurse assess most carefully for hyperkalemia?

A client in the emergency department has potassium of 2.9 mEq/L.For which disease process or condition does the nurse assess the client?

A client has hypokalemia.Which question by the nurse obtains the most information on a possible cause?

A client has been treated for hypokalemia.Which clinical manifestation or condition indicates that treatment has been effective?

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago.Which intervention by the nurse is the priority?

A client has been taught to increase potassium in the diet.What dietary meal selection indicates to the nurse that teaching has been effective?

A nurse is assessing clients for fluid and electrolyte imbalances.Which client is at greatest risk for developing hyponatremia?

A client has a history of hypothyroidism.Which laboratory value is the nurse most concerned about?

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia.What action is most important for the nurse to teach the client?

Which client is at greatest risk for developing hypercalcemia?

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline.The client states that the area around the IV site burns.What intervention does the nurse perform first?

A client has the following laboratory values: Ca²⁺ 8.7 mg/dL; K⁺ 4.2 mEq/L; Na⁺ 142 mEq/L.Which intervention by the nurse is most appropriate?