Deck 19: Fluid

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?

A)Oral digoxin 0.25 mg daily
B)Ibuprofen 400 mg every 6 hours
C)Metoprolol 12.5 mg orally daily
D)Lantus insulin 24 U subcutaneously every evening

Answer 1

Oral digoxin 0.25 mg daily

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?

A)In the late evening hours
B)If the oral mucosa feels dry
C)When the client feels thirsty
D)As soon as changes in level of consciousness (LOC) occur

Answer 2

If the oral mucosa feels dry

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?

A)Increased total urinary output
B)Elevation of serum hematocrit
C)Decreased serum sodium level
D)Rapid and unexpected weight loss

Answer 3

Decreased serum sodium level

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?

A)Pallor
B)Edema
C)Confusion
D)Restlessness

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?

A)Hematocrit 28%
B)Good skin turgor
C)Absence of peripheral edema
D)Blood pressure 110/72 mm Hg

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?

A)The blood pressure is 90/40 mm Hg.
B)Urine output is 30 mL over the last hour.
C)Oral fluid intake is 100 mL for the last 8 hours.
D)There is prolonged skin tenting over the sternum.

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?

A)Daily alcohol intake
B)Intake of dietary protein
C)Multivitamin/mineral use
D)Use of over-the-counter (OTC) laxatives

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?

A)Maintain the client on bed rest.
B)Auscultate lung sounds every 4 hours.
C)Monitor for Trousseau's and Chvostek's signs.
D)Encourage fluid intake up to 3 000 mL every day.

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, PaO? 85 mm Hg, PaCO? 32 mm Hg, and HCO? 25 mmol/L. Which of the following interpretations would the nurse document?

A)Metabolic acidosis
B)Metabolic alkalosis
C)Respiratory acidosis
D)Respiratory alkalosis

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?

A)Dairy products
B)High-fat foods
C)Fruits and juices
D)Green, leafy vegetables

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?

A)The prescribed infusion can be given much more rapidly when the client has a central line.
B)There is a decreased risk for infection when 50% dextrose is infused through a central line.
C)The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
D)The required blood glucose monitoring is more accurate when samples are obtained from a central line.

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?

A)Ventricular dysrhythmias
B)Bradycardia
C)Flatten T wave
D)Prolonged P-R interval

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?

A)Personality changes
B)Frequent loose stools
C)Facial muscle spasms
D)Lower extremity weakness

Question 14

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

A)Metabolic acidosis
B)Metabolic alkalosis
C)Respiratory acidosis
D)Respiratory alkalosis

Question 15

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

A)Restrict client's oral free water intake.
B)Avoid use of electrolyte-containing drinks.
C)Infuse a solution of 5% dextrose in 0.45% saline.
D)Administer vasopressin (antidiuretic hormone, [ADH]).

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?

A)Notify the client's health care provider.
B)Give the prescribed PRN lorazepam.
C)Start the prescribed PRN oxygen at 2-4 L/minute.
D)Encourage the client to take deep, slow breaths.

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?

A)Administer the KCl as a rapid IV bolus.
B)Infuse the KCl at a rate of 20 mEq/hour.
C)Give the KCl only through a central venous line.
D)Add no more than 40 mEq/L to a litre of IV fluid.

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?

A)Lung sounds
B)Urinary output
C)Peripheral pulses
D)Peripheral edema

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?

A)"I will try to drink at least eight glasses of water every day."
B)"I will use a salt substitute to decrease my sodium intake."
C)"I will increase my intake of potassium-containing foods."
D)"I will drink apple juice instead of orange juice for breakfast."

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?

A)Skin turgor
B)Daily weight
C)Presence of edema
D)Hourly urine output

Question 21

The nurse is caring for a client who is receiving iso-osmolar continuous tube feedings who has developed nausea, vomiting, and tachycardia. Which of the following laboratory results is most important for the nurse to report to the health care provider?

A)K+ 3.4 mmol/L
B)Ca+² 1.95 mmol/L
C)Na+ 128 mmol/L
D)PO?-³ 1.55 mmol/L

Question 22

The nurse has administered 3% saline to a client with hyponatremia. Which of the following assessment data will require the most rapid response by the nurse?

A)The client's radial pulse is 105 beats/minute.
B)There is sediment and blood in the client's urine.
C)The blood pressure increases from 120/80 to 142/94.
D)There are crackles audible throughout both lung fields.

Question 23

The nurse obtains the following data when assessing a pregnant client with eclampsia who is receiving IV magnesium sulphate. Which of the following findings is most important to report to the health care provider immediately?

A)The bibasilar breath sounds are decreased.
B)The patellar and triceps reflexes are absent.
C)The client has been sleeping most of the day.
D)The client reports feeling "sick to my stomach."

Question 24

The nurse is caring for a client postoperative after a thyroidectomy and the client states "I have a tingling feeling around my mouth." Which of the following data is priority for the nurse to assess?

A)An elevated serum potassium level
B)The presence of Chvostek's sign
C)A decreased thyroid hormone level
D)Bleeding on the client's dressing

Question 25

The nurse is caring for a client who is postoperative and has been receiving nasogastric suction for 3 days. The client's serum sodium level is 123 mmol/L. Which of the following prescribed therapies would the nurse implement? (Select all that apply.)

A)Infuse 5% dextrose in water at 125 mL/hour.
B)Administer IV morphine sulphate 4 mg every 4 hours PRN.
C)Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
D)Administer 3% saline if serum sodium drops to less than 128 mmol/L.
E)Withhold opioid prescription related to adverse events with low sodium level.

Question 26

The nurse is caring for a client who has been hospitalized for 2 days and is receiving normal saline IV at 100 mL/hour, has a nasogastric tube to low suction, and is NPO. Which of the following assessment findings by the nurse is the priority to reporttothehealth care provider?

A)Serum sodium level of 138 mmol/L
B)Gradually decreasing level of consciousness (LOC)
C)Oral temperature of 37.8°C (100°F) with bibasilar lung crackles
D)Weight gain of 1 kg above the admission weight

Question 27

The nurse is caring for a client with advanced lung cancer who has been admitted to the emergency department with urinary retention caused by renal calculi. Which of the following laboratory values will require the most immediate action by the nurse?

A)Arterial blood pH is 7.32.
B)Serum calcium is 3.45 mmol/L.
C)Serum potassium is 5.1 mmol/L.
D)Arterial oxygen saturation is 91%.

Question 28

Which assessment finding about a client who has a serum calcium level of 1.58 mmol/L is most important for the nurse to immediately report to the health care provider?

A)The client is experiencing laryngeal stridor.
B)The client complains of generalized fatigue.
C)The client's bowels have not moved for 4 days.
D)The client has numbness and tingling of the lips.

Question 29

Which of the following actions would the nurse include in the plan of care for a client who has a central venous access device (CVAD)?

A)Avoid using friction when cleaning around the CVAD insertion site.
B)Use the push-pause method to flush the CVAD after giving medications.
C)Obtain an order from the health care provider to change CVAD dressing.
D)Have the client turn the head toward the CAVD during injection cap changes.

Question 30

The nurse is caring for a client with renal failure and has been taking magnesium hydroxide suspension at home for indigestion. The client is somnolent and has decreased deep tendon reflexes. Which of the following actions should the nurse take first?

A)Notify the client's health care provider.
B)Withhold the next scheduled dose of magnesium hydroxide.
C)Review the magnesium level on the client's chart.
D)Check the chart for the most recent potassium level.

Question 31

The nurse is assessing a client with increased extracellular fluid (ECF) osmolality. Which of the following assessment areas is the priority assessment for the nurse to obtain?

A)Skin turgor
B)Heart sounds
C)Mental status
D)Capillary refill

Question 32

The nurse is caring for a client with a CVAD who suddenly develops chest pain, hypotension, and tachycardia. Which of the following positions should the nurse immediately put the client in?

A)Prone
B)High Fowler's
C)Left lateral with head down
D)Sims

Question 33

The nurse is caring for a postoperative client who is receiving nasogastric suction and is anxious with incisional pain. The client's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which of thefollowing actions should the nurse take first?

A)Discontinue the nasogastric suctions for a few hours.
B)Notify the health care provider about the ABG results.
C)Teach the client about the need to take slow, deep breaths.
D)Give the client the PRN morphine sulphate 4 mg intravenously.