Deck 6: Fluids and Electrolytes

Question 1

During an assessment,the nurse learns that a client seeking emergency treatment for a headache and nausea works in a mill without air conditioning.The air temperature is 88 degrees and the client states that water has been ingested several times throughout the day because of heavy sweating.Based on this data,which suggestion by the nurse is the most appropriate?

A) Eat something sweet when drinking water.
B) Eat something salty when drinking water.
C) Double the amount of water being ingested.
D) Drink juices and carbonated sodas.

Answer 1

Eat something salty when drinking water.

Question 2

The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting.What should the nurse explain to the client about the purpose of this medication?

A) It is vital in regulating muscle contraction and relaxation.
B) It is needed to maintain skeletal, cardiac, and neuromuscular activity.
C) It controls and regulates water balance in the body.
D) It is used in the body to synthesize ingested protein.

Answer 2

It is needed to maintain skeletal, cardiac, and neuromuscular activity.

Question 3

An older adult client is admitted to the hospital after a fall.The client appears intermittently confused.Based on age and current data,which is the client at an increased risk for developing?

A) Kidney damage
B) Dehydration
C) Stroke
D) Bleeding

Answer 3

Dehydration

Question 4

An older adult client is brought to the emergency department from a long-term care facility.The client has been experiencing fever,nausea,and vomiting for the past 2 days.The client denies thirst.Urine dipstick indicates a decreased urine specific gravity.Based on this data,which diagnosis does the nurse anticipate?

A) Congestive heart failure
B) Dehydration
C) Fluid overload
D) Normal changes of aging

Question 5

A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days.The client's current weight is 154 pounds.The health care provider has diagnosed the client with a viral infection.The nurse has been monitoring intravenous fluids and urine output.Which urinary output indicates the efforts to rehydrate this client have been successful?

A) 40 mL per hour
B) 20 mL per hour
C) 25 mL per hour
D) 30 mL per hour

Question 6

The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance.Which laboratory value evaluated by the nurse supports the diagnosis of dehydration?

A) Serum osmolality 230 mOsm/kg
B) Hematocrit 30%
C) Hematocrit 53%
D) Serum potassium 3.8 mEq/L

Question 7

The nurse is analyzing the intake and output record for a client being treated for dehydration.The client weighs 176 lbs.and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL.Based on this data,which conclusion by the nurse is the most appropriate?

A) Treatment needs to include a diuretic.
B) Treatment has not been effective.
C) Treatment is effective and should continue.
D) Treatment has been effective and should end.

Question 8

The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise.Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session?

A) "It is important for my child to wear dark clothing while exercising in the heat."
B) "Water is the drink of choice to replenish fluids that are lost during exercise."
C) "My child only needs to hydrate at the end of an exercise session."
D) "I will have my child stop every 15-20 minutes during the activity for fluids."

Question 9

During an assessment,the nurse becomes concerned that an older adult client is at risk for dehydration.Which did the nurse assess to come to this conclusion?

A) Poor skin turgor
B) Ingests 2 glasses of water each day.
C) Blood pressure 140/98 mmHg
D) Body mass index 20.5

Question 10

The nurse is concerned that a client with a fluid imbalance is at risk for an alteration in perfusion.Which assessment data indicates that the client is experiencing an alteration in perfusion? Select all that apply.

A) Skin turgor 20 seconds
B) Peripheral pulses present and full
C) Capillary refill of nail beds 3 seconds
D) Oriented to person, place, and time
E) Bowel sounds sluggish in all four quadrants

Question 11

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr.Upon assessment,the nurse notes crackles,shortness of breath,and jugular vein distention.Based on this data,which complication of IV fluid therapy does the nurse anticipate?

A) Speed shock
B) Fluid volume excess
C) Pulmonary embolism
D) An allergic reaction

Question 12

The nurse is caring for a client receiving a blood transfusion.Ten minutes after the transfusion of a unit of packed red blood cells was initiated,the client complains of a headache.The nurse assesses that the client has slight shortness of breath and feels warm to the touch.Based on this data,which is the priority intervention for this client?

A) Decrease the rate of the transfusion.
B) Notify the client's health care provider.
C) Prepare to resuscitate the client.
D) Discontinue the transfusion.

Question 13

The nurse receives shift report on a pediatric medical-surgical unit.The nurse has been assigned four clients for the shift.Which client does the nurse plan to assessment first based on the increased risk for dehydration?

A) A 4-year-old child with a broken leg
B) A 15-month-old child with tachypnea
C) A 16-year-old child with migraine headaches
D) A 10-year-old child with cellulitis of the left leg

Question 14

A client's serum sodium level is 150 mg/dL.Based on this data,which interventions should the nurse plan for this client? Select all that apply.

A) Monitor heart rate and rhythm.
B) Elevate the head of the bed.
C) Instruct on a low-sodium diet.
D) Administer diuretics as prescribed.
E) Administer potassium supplement as prescribed.

Question 15

The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy.The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before surgery.Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia?

A) Measure vital signs every 8 hours.
B) Assist the client to ambulate around the room at least three times daily.
C) Irrigate the client's Foley catheter daily.
D) Assist the client to turn, cough, and deep breathe every 2 hours.

Question 16

The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit and documents that the client is experiencing the following symptoms: tachycardia; pale,cool skin; and a decreased urine output.The nurse anticipates which as the cause of the client's current symptoms?

A) Natural compensatory mechanisms
B) Cardiac failure
C) Pharmacological effects of a diuretic
D) Rapidly infused intravenous fluids

Question 17

A pediatric nurse is assigned phone triage for the shift.The nurse takes a call from the mother of a 3-month-old infant.The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days.Which response by the nurse is the most appropriate?

A) "You should bring the infant in to be seen by the doctor."
B) "Give your baby at least 2 ounces of juice every 2 hours."
C) "Give your baby 50 mL of glucose water every hour."
D) "Measure your baby's urine output for 24 hours and call back tomorrow."

Question 18

The nurse is reviewing the lab values for a client being cared for on the unit.The client's phosphorus level is 2.0 mg/dL.Based on this data,which nursing intervention would address this client's phosphorus level?

A) Enforce contact precautions.
B) Encourage consumption of a high-calorie carbohydrate diet.
C) Strain all urine.
D) Encourage consumption of milk and yogurt.

Question 19

The nurse is providing care to a client who is exhibiting clinical manifestations of a severe fluid and electrolyte imbalance.Based on this data,which health care provider prescriptions does the nurse prepare to implement? Select all that apply.

A) Initiate intravenous therapy
B) Initiate hypodermoclysis
C) Administer antibiotics
D) Administer diuretics
E) Administer red blood cells

Question 20

A home health nurse is providing care for a client with congestive heart failure.The client is taking furosemide (Lasix).The nurse reviews the client's most recent serum potassium,which was 3.4 mEq/L.Based on this data,which food will the nurse encourage the client to consume?

A) Baked fish
B) Iced tea
C) Banana
D) Peas

Question 21

A client in the emergency department is being admitted for fluid volume deficit.When preparing to assess this client,on which body system should the nurse focus to determine the cause of the imbalance?

A) Cardiovascular
B) Genitourinary
C) Gastrointestinal
D) Musculoskeletal

Question 22

The nurse is instructing a client with heart failure about a prescribed sodium-restricted diet.Which client statement indicates that additional teaching is required?

A) "I can use as much salt substitute as I want."
B) "I have to read the labels on foods to find out the sodium content."
C) "I have to limit the intake of food with baking soda or baking powder."
D) "I can use spices and lemon juice to add flavor to food when cooking."

Question 23

A child weighing 33 lbs.who is diagnosed with dehydration is prescribed to receive 50 mL/kg of oral fluids for the next 4 hours.How many total mL of fluid should the nurse provide to the client? Calculate to the nearest whole number.

Question 24

A client with renal failure is receiving peritoneal dialysis.The nurse is explaining the process to the client.Which statement would the nurse include in a discussion with the client and family?

A) "The peritoneum is more permeable because of the presence of excess metabolites."
B) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration."
C) "The peritoneum acts as a semi-permeable membrane through which wastes move by diffusion and osmosis."
D) "The solutes in the dialysate will enter the bloodstream through the peritoneum."

Question 25

The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery.The nurse is aware that this client is at risk for fluid volume excess.The family asks why the client is at risk for this condition.Which response by the nurse is the most appropriate?

A) "Fluid volume excess is caused by new onset liver failure caused by the surgery."
B) "Fluid volume excess is caused by the intravenous fluids."
C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."
D) "Fluid volume excess is caused by inactivity."

Question 26

The nurse is administering peritoneal dialysis to a client with acute renal failure.The nurse notes the presence of a cloudy dialysate return.After notifying the health care provider,which action by the nurse is the most appropriate?

A) Measure abdominal girth.
B) Document the cloudy dialysate.
C) Culture the dialysate return.
D) Increase dialysate instillation.

Question 27

The nurse is caring for a client with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia.Which medication on the client's medication administration record may have contributed to the client's current hypokalemic state?

A) Demerol
B) Cortisol
C) Hydrochlorothiazide
D) Skelaxin

Question 28

A client with frequent urinary tract infections in seen in the urology clinic and is at risk for acute renal failure.The nurse reviews the client's medical history.Which item support the client's being at risk for acute renal failure? Select all that apply.

A) Dehydration
B) Renal calculi
C) Ineffective would healing
D) Low serum albumin
E) Hypertension

Question 29

The nurse is caring for a client following hemodialysis.The nursing assessment reveals the client is tachycardic; has pale,cool skin; and has a decreased urine output.Based on this data,the nurse determines that the client has not met which expected outcome associated with hemodialysis?

A) Cardiac decompensation
B) The pharmacological effects of a diuretic infused in the dialysate
C) The effects of rapidly infused intravenous fluids
D) A reduction of extracellular fluid

Question 30

A young school-age client is in the hospital with acute renal failure following a streptococcus infection.The parents are Spanish-speaking and speak little English.The parents,through an interpreter,ask the nurse what mistake they made that caused the child to be so sick.Which response by the nurse is the most appropriate?

A) "Your child does not have enough dietary protein."
B) "Your child has a congenital defect that led to renal failure."
C) "Your child's renal failure has been caused by a low calcium level."
D) "Your child's recent infection may have caused the renal failure."

Question 31

The nurse is caring for a client with a potassium level of 5.9 mEq/L.The health care provider prescribes both glucose and insulin for the client.The client's spouse asks,"Why is insulin needed?" Which response by the nurse is the most appropriate?

A) "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood."
B) "Insulin is safer than other medications that can lower potassium levels."
C) "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted."
D) "The insulin will help his kidneys excrete the extra potassium."

Question 32

A client with heart failure is prescribed an oral fluid restriction of 1,200 mL per day.How many ounces of fluid should the nurse teach the client is permitted during the daylight shift?

A) 200 mL
B) 300 mL
C) 400 mL
D) 600 mL

Question 33

The nurse is planning care for a client admitted to the unit with dehydration.The client's lab values indicate a low level of serum sodium.Based on the assessment finding,the nurse determines an appropriate nursing diagnosis to be electrolyte imbalance.Which medical condition supports this nursing diagnosis?

A) Isotonic dehydration
B) Hydrostatic pressure
C) Hypotonic dehydration
D) Osmotic pressure

Question 34

The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client with heart failure.Which assessment finding supports the use of this diagnosis for the client?

A) Shortness of breath with ambulation
B) Productive cough
C) + 3 pitting edema both feet
D) Heart rate 104 and regular

Question 35

The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months.Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply.

A) Drink diet soda.
B) Drink more fluids during hot weather.
C) Drink flat cola or ginger ale if vomiting.
D) Reduce the intake of coffee and tea.
E) Exercise during the hours of 10 am and 2 pm.

Question 36

The nurse is caring for a client who is diagnosed with acute renal failure.When reviewing the client's laboratory data,which findings indicate that a client has met the expected outcomes? Select all that apply.

A) Decreasing serum creatinine
B) Decreasing blood urea nitrogen (BUN) levels
C) Decreasing neutrophil count
D) Decreasing lymphocyte count
E) Decreasing erythrocyte count

Question 37

The nurse is planning care for a client admitted with heart failure.Based on this diagnosis,which type of renal failure is the client at an increased risk for experiencing?

A) Prerenal hypovolemia
B) Intrarenal glomerular injury
C) Intrarenal acute tubular necrosis
D) Prerenal low cardiac output

Question 38

A client with renal failure will be discharged to home in the next few days.When conducting dietary instruction,the nurse teaches the client to choose proteins that are high in biological value.Which client statement indicates that teaching has been effective?

A) "I will be sure to include eggs in my diet."
B) "I should include vegetables at every meal."
C) "Legumes should be included in my diet, as they are complete proteins."
D) "I will eat nuts daily because they are high in protein."

Question 39

The nurse is caring for a client admitted with a diagnosis of acute renal failure.The client asks the nurse,"Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate?

A) "No, don't think that. You're going to be fine."
B) "Your condition can be reversed with prompt treatment and usually will not destroy the kidney."
C) "Kidney transplantation is highly likely, and it would be a good idea to start talking to family members."
D) "When the doctor comes to see you, we can talk about whether you will need a transplant."

Question 40

The nurse is planning care for the client with acute renal failure.The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume.Which assessment data supports this nursing diagnosis?

A) Pitting edema in the lower extremities
B) Bowel sounds positive in 4 quadrants
C) Wheezing in the lungs
D) Generalized weakness

Question 41

A client with acute renal failure has jugular vein distention,lower extremity edema,and elevated blood pressure.Based on this data,which nursing diagnosis is the most appropriate?

A) Ineffective Renal Tissue Perfusion
B) Excess Fluid Volume
C) Risk for Altered Cardiac Perfusion
D) Risk for Infection

Question 42

The nurse is concerned that an older adult client is at risk for developing acute renal failure.Which information in the client's history support the nurse's concern? Select all that apply.

A) Diagnosed with hypotension
B) Recent aortic valve replacement surgery
C) Prescribed high doses of intravenous antibiotics
D) Total hip replacement surgery 5 years ago
E) Taking medication for type 2 diabetes mellitus

Question 43

A client with a history of hypertension,is diagnosed with chronic renal disease.When the client asks the nurse how this occurred,which response by the nurse is the most appropriate?

A) "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis."
B) "Cysts compress renal tissue that destroys the kidneys causing this diagnosis."
C) "High blood pressure reduces renal blood flow and harms the kidney tissue causing this diagnosis."
D) "Immune complexes form in the kidney tissue that causes inflammation causing this diagnosis."

Question 44

A client with acute renal failure is complaining of a metallic taste in the mouth and has no appetite.Based on this data,which intervention by the nurse is the most appropriate?

A) Provide mouth care before meals.
B) Administer an antiemetic as prescribed.
C) Restrict fluids.
D) Encourage the intake of protein, salt, and potassium.

Question 45

The nurse is providing care for a child diagnosed with renal failure who is experiencing hyperkalemia.When planning meals for this child,which choice would be most appropriate for this client?

A) Hamburger on a bun, banana
B) Cold cuts with bun with fresh pears
C) Spaghetti and meat sauce, breadsticks
D) Carrots and green, leafy vegetables

Question 46

While caring for a client with end-stage renal disease,the nurse tracks the client's serum albumin level.For which nursing diagnosis is the action most indicated?

A) Excess Fluid Volume
B) Imbalanced Nutrition: Less Than Body Requirements
C) Risk for Ineffective Perfusion
D) Risk for Infection

Question 47

A nurse evaluating the therapeutic effect of the drug sodium polystyrene sulfonate (Kayexalate)for a client diagnosed with chronic renal failure.Which therapeutic effect from the medication does the nurse anticipate?

A) Increased serum sodium
B) Increased stool excretion
C) Decreased urine specific gravity
D) Decreased serum potassium

Question 48

The nurse is preparing to administer a hemodialysis treatment for a client with chronic kidney disease.Which laboratory values does the nurse anticipate prior to the client's treatment? Select all that apply.

A) Increased blood urea nitrogen (BUN)
B) Decreased potassium
C) Decreased phosphorus
D) Increased urine osmolality
E) Increased creatinine

Question 49

The nurse is caring for a client from another country who was admitted with hypertension and chronic renal failure.The client is receiving hemodialysis three times a week.The nurse is assessing the client's diet and the client reports the use of salt substitutes.When teaching the client to avoid salt substitute,which rationale supports this teaching point?

A) They will increase the risk of AV fistula infection.
B) They will cause the client to retain fluid.
C) They will interact with the client's antihypertensive medications.
D) They can potentiate hyperkalemia.

Question 50

The nurse is caring for a client with chronic renal disease who is pale and experiencing fatigue.The nurse attributes these symptoms to anemia secondary to chronic renal disease.The client's spouse asks why the client is anemic.Which response by the nurse is the most appropriate?

A) "Your spouse has a genetic tendency for the development of anemia."
B) "The increased metabolic waste products in the body depress the bone marrow and cause anemia."
C) "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of anemia."
D) "The client is not eating enough iron-rich foods which is causing anemia."

Question 51

The nurse is planning care for a client with chronic kidney disease and osteoporosis.After reviewing the client's medical record,which is the priority nursing diagnosis for this client?

A) Anxiety
B) Disturbed Body Image
C) Risk for Injury
D) Risk for Bleeding

Question 52

A client with chronic renal disease is experiencing manifestations of anemia.Based on this data,which treatment does the nurse anticipate for this client?

A) Begin a fluid restriction.
B) Administer intravenous glucose and insulin.
C) Begin a low-sodium diet.
D) Epoetin injections

Question 53

The nurse is planning a seminar to instruct community members on ways to reduce the development of chronic kidney disease.Which topics should the nurse include in the seminar? Select all that apply.

A) Avoid eating red meat.
B) Control blood glucose levels in diabetes mellitus.
C) Adhere to medication regimen to control hypertension.
D) Participate in regular exercise.
E) Avoid smoking.

Question 54

A client agrees to receive long-term hemodialysis to treat acute renal failure.For which surgical procedure should the nurse instruct this client?

A) Insertion of a double-lumen catheter into the subclavian artery
B) Placement of a peritoneal catheter
C) Insertion of a subarachnoid-peritoneal shunt
D) Placement of an arteriovenous fistula

Question 55

The nurse is caring for an older adult client diagnosed with chronic kidney disease.The client reports no bowel movement in the past 2 days.Based on this data,which condition is the client at an increased risk for developing?

A) Metabolic acidosis
B) Hypercalcemia
C) Increased serum creatinine levels
D) Hyperkalemia

Question 56

The nurse is preparing to discharge a client with chronic kidney disease.The nurse is teaching the client and family about administering calcium acetate tablets by mouth with each meal at home.Which explanation about this medication is the most appropriate?

A) "The calcium acetate will lower your serum phosphate levels."
B) "The calcium acetate helps to neutralize your gastric acids."
C) "The calcium acetate will help to stimulate your appetite."
D) "The calcium acetate will decrease your serum creatinine levels."

Question 57

During a home visit,the nurse is concerned that an older adult client is developing renal failure.The client has no history of cardiovascular disease.Which data in the client's assessment caused the nurse to have this concern? Select all that apply.

A) Progressive edema
B) Complaints of hip joint pain
C) New onset of hypertension
D) Recent increase in hunger and thirst
E) Warm moist skin

Question 58

The community nurse visits the home of a young child who is home from school because of sudden onset of nausea,vomiting,and lethargy.The nurse suspects acute renal failure.Which clinical manifestations support the nurse's suspicions? Select all that apply.

A) Elevated blood pressure
B) Postural hypotension
C) Wheezing
D) Edema
E) Hematuria

Question 59

The nurse instructs a client with chronic renal disease on the prescribed medication furosemide (Lasix).Which client statement indicates that teaching has been effective?

A) "I will take this medication to keep my calcium balance normal."
B) "This medication will make sure I have enough red blood cells in my body."
C) "I will take this pill to keep my protein level in my body stable."
D) "This pill will reduce the swelling in my body and get rid of the extra potassium."