Deck 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances

Question 1

A nurse teaches clients at a community center about risks for dehydration.Which client is at greatest risk for dehydration?

A) A 36-year-old who is prescribed long-term steroid therapy
B) A 55-year-old receiving hypertonic intravenous fluids
C) A 76-year-old who is cognitively impaired
D) An 83-year-old with congestive heart failure

Answer 1

A 76-year-old who is cognitively impaired

Question 2

A nurse is assessing a client with hypokalemia,and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago.Which action should the nurse take first?

A) Assess the client's respiratory rate, rhythm, and depth.
B) Measure the client's pulse and blood pressure.
C) Document findings and monitor the client.
D) Call the health care provider.

Answer 2

Assess the client's respiratory rate, rhythm, and depth.

Question 3

A nurse is evaluating a client who is being treated for dehydration.Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?

A) Increased respiratory rate from 12 breaths/min to 22 breaths/min
B) Decreased skin turgor on the client's posterior hand and forehead
C) Increased urine specific gravity from 1.012 to 1.030 g/mL
D) Decreased orthostatic light-headedness and dizziness

Answer 3

Decreased orthostatic light-headedness and dizziness

Question 4

A nurse is caring for a client who has a serum calcium level of 14 mg/dL.Which provider order should the nurse implement first?

A) Encourage oral fluid intake.
B) Connect the client to a cardiac monitor.
C) Assess urinary output.
D) Administer oral calcitonin (Calcimar).

Question 5

After teaching a client who is prescribed a restricted sodium diet,a nurse assesses the client's understanding.Which food choice for lunch indicates the client correctly understood the teaching?

A) Slices of smoked ham with potato salad
B) Bowl of tomato soup with a grilled cheese sandwich
C) Salami and cheese on whole wheat crackers
D) Grilled chicken breast with glazed carrots

Question 6

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release.For which potential complications should the nurse assess? (Select all that apply.)

A) Urine output of 25 mL/hr
B) Serum potassium level of 5.4 mEq/L
C) Urine specific gravity of 1.02 g/mL
D) Serum sodium level of 128 mEq/L
E) Blood osmolality of 250 mOsm/L

Question 7

A nurse is caring for a client who exhibits dehydration-induced confusion.Which intervention should the nurse implement first?

A) Measure intake and output every 4 hours.
B) Apply oxygen by mask or nasal cannula.
C) Increase the IV flow rate to 250 mL/hr.
D) Place the client in a high-Fowler's position.

Question 8

A nurse assesses a client who is admitted for treatment of fluid overload.Which manifestations should the nurse expect to find? (Select all that apply.)

A) Increased pulse rate
B) Distended neck veins
C) Decreased blood pressure
D) Warm and pink skin
E) Skeletal muscle weakness

Question 9

After teaching a client to increase dietary potassium intake,a nurse assesses the client's understanding.Which dietary meal selection indicates the client correctly understands the teaching?

A) Toasted English muffin with butter and blueberry jam, and tea with sugar
B) Two scrambled eggs, a slice of white toast, and a half cup of strawberries
C) Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
D) Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Question 10

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L,magnesium 1.8 mEq/L,calcium 8.5 mEq/L,sodium 144 mEq/L.Which assessment should the nurse complete first?

A) Depth of respirations
B) Bowel sounds
C) Grip strength
D) Electrocardiography

Question 11

A nurse is caring for an older adult client who is admitted with moderate dehydration.Which intervention should the nurse implement to prevent injury while in the hospital?

A) Ask family members to speak quietly to keep the client calm.
B) Assess urine color, amount, and specific gravity each day.
C) Encourage the client to drink at least 1 liter of fluids each shift.
D) Dangle the client on the bedside before ambulating.

Question 12

A nurse is assessing clients on a medical-surgical unit.Which client is at risk for hypokalemia?

A) Client with pancreatitis who has continuous nasogastric suctioning
B) Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
C) Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
D) Client with uncontrolled diabetes and a serum pH level of 7.33

Question 13

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor).For which expected therapeutic effect should the nurse assess?

A) Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
B) Daily weight increase from 55 kg to 57 kg
C) Heart rate decrease from 100 beats/min to 82 beats/min
D) Respiratory rate increase from 12 breaths/min to 15 breaths/min

Question 14

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes.Which prescription should the nurse implement first?

A) Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
B) Provide a heart healthy, low-potassium diet.
C) Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
D) Prepare the client for hemodialysis treatment.

Question 15

A client at risk for developing hyperkalemia states,"I love fruit and usually eat it every day,but now I can't because of my high potassium level." How should the nurse respond?

A) "Potatoes and avocados can be substituted for fruit."
B) "If you cook the fruit, the amount of potassium will be lower."
C) "Berries, cherries, apples, and peaches are low in potassium."
D) "You are correct.Fruit is very high in potassium."

Question 16

A nurse is assessing clients for fluid and electrolyte imbalances.Which client should the nurse assess first for potential hyponatremia?

A) A 34-year-old on NPO status who is receiving intravenous D₅W
B) A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
C) A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
D) A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

Question 17

A nurse is assessing clients on a medical-surgical unit.Which clients are at increased risk for hypophosphatemia? (Select all that apply.)

A) A 36-year-old who is malnourished
B) A 42-year-old with uncontrolled diabetes
C) A 50-year-old with hyperparathyroidism
D) A 58-year-old with chronic renal failure
E) A 76-year-old who is prescribed antacids

Question 18

A nurse teaches a client who is at risk for mild hypernatremia.Which statement should the nurse include in this client's teaching?

A) "Weigh yourself every morning and every night."
B) "Check your radial pulse twice a day."
C) "Read food labels to determine sodium content."
D) "Bake or grill the meat rather than frying it."

Question 19

After teaching a client who is being treated for dehydration,a nurse assesses the client's understanding.Which statement indicates the client correctly understood the teaching?

A) "I must drink a quart of water or other liquid each day."
B) "I will weigh myself each morning before I eat or drink."
C) "I will use a salt substitute when making and eating my meals."
D) "I will not drink liquids after 6 PM so I won't have to get up at night."

Question 20

A nurse is assessing clients on a medical-surgical unit.Which adult client should the nurse identify as being at greatest risk for insensible water loss?

A) Client taking furosemide (Lasix)
B) Anxious client who has tachypnea
C) Client who is on fluid restrictions
D) Client who is constipated with abdominal pain

Question 21

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit.Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

A) Hypokalemia - Flaccid paralysis with respiratory depression
B) Hyperphosphatemia - Paresthesia with sensations of tingling and numbness
C) Hyponatremia - Decreased level of consciousness
D) Hypercalcemia - Positive Trousseau's and Chvostek's signs
E) Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension

Question 22

A nurse develops a plan of care for a client who has a history of hypocalcemia.What interventions should the nurse include in this client's care plan? (Select all that apply.)

A) Encourage oral fluid intake of at least 2 L/day.
B) Use a draw sheet to reposition the client in bed.
C) Strain all urine output and assess for urinary stones.
D) Provide nonslip footwear for the client to use when out of bed.
E) Rotate the client from side to side every 2 hours.

Question 23

A nurse is assessing a client who has an electrolyte imbalance related to renal failure.For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)

A) Electrocardiogram changes
B) Slow, shallow respirations
C) Orthostatic hypotension
D) Paralytic ileus
E) Skeletal muscle weakness

Question 24

After administering 40 mEq of potassium chloride,a nurse evaluates the client's response.Which manifestations indicate that treatment is improving the client's hypokalemia? (Select all that apply.)

A) Respiratory rate of 8 breaths/min
B) Absent deep tendon reflexes
C) Strong productive cough
D) Active bowel sounds
E) U waves present on the electrocardiogram (ECG)