Question 1

A client diagnosed with hypokalemia should have which of the following electrolytes also assessed?&#10;A) Sodium&#10;B) Calcium&#10;C) Bicarbonate&#10;D) Magnesium&#10;

Accepted Answer

Hypokalemia is often accompanied by hypomagnesemia, so it is important to assess magnesium levels in these cases. Sodium, calcium, and bicarbonate levels may also be affected, but magnesium is the best choice to assess in this scenario.

Question 2

An elderly client is demonstrating new signs of confusion. Which of the following should the nurse consider when caring for this client?&#10;A) Assess for signs of elevated sodium level.&#10;B) Restrict fluids.&#10;C) Administer prescribed diuretic medication.&#10;D) Monitor daily weights.&#10;

Accepted Answer

Confusion in an elderly client can be a symptom of hyponatremia or low sodium levels in the blood. Therefore, assessing for signs of elevated sodium levels would be important in identifying the cause of the confusion. Restricting fluids or administering diuretic medication would not be appropriate without identifying the underlying cause of the confusion. Monitoring daily weights would not be specifically helpful in identifying the cause of the confusion.

Question 3

A client is diagnosed with fluid volume excess. Which of the following will the nurse most likely assess in this client?&#10;A) Poor skin turgor&#10;B) Jugular vein distention&#10;C) Dry mouth&#10;D) Increased heart rate&#10;

Accepted Answer

Jugular vein distention is a classic sign of fluid volume excess as it indicates an increase in blood volume and pressure within the heart and venous system. Poor skin turgor, dry mouth, and increased heart rate are more commonly associated with fluid volume deficit.

Question 4

Which of the following components of the arterial blood gas will the nurse focus when on determining a client's acid-base status? (Select all that apply.) A) pH B) PO₂ C) PCO₂ D) HCO₃^- E) O₂ Sat F) Hgb

Accepted Answer

The nurse will focus on pH, PCO₂, and HCO₃^- to determine a client's acid-base status. pH indicates the acidity or alkalinity, PCO₂ reflects respiratory contribution, and HCO₃^- represents metabolic contribution to the acid-base balance.

Question 5

A client had a 2 kg weight loss in one day. The nurse realizes this change in weight is due to:&#10;A) fluid loss.&#10;B) poor appetite.&#10;C) medications.&#10;D) bed rest.&#10;

Accepted Answer

A 2 kg weight loss in one day is a significant amount and is more likely due to fluid loss rather than poor appetite, medications, or bed rest.

Question 6

After reviewing a client's most recent electrocardiogram, the nurse suspects the client is experiencing hyperkalemia. Which of the following did the nurse assess on the client's rhythm strip? (Select all that apply.)

A) Tall peaked T-waves
B) Short QRS complex
C) Dysrhythmias
D) Wide QRS complex
E) Bradycardia
F) Tachycardia

Accepted Answer

Tall peaked T-waves are a classic finding in hyperkalemia on an electrocardiogram. Dysrhythmias are also commonly seen, including ventricular tachycardia and bradycardia. Short QRS complex, Wide QRS complex, Bradycardia, and Tachycardia are not specific to hyperkalemia on an ECG.

Question 7

A client has lost a significant amount of blood. The nurse realizes that the fluid compartment most effected with the blood loss will be:&#10;A) intracellular.&#10;B) interstitial.&#10;C) intravascular.&#10;D) transcellular.&#10;

Accepted Answer

Intravascular compartment is the fluid compartment inside the blood vessels. Blood loss directly affects this compartment, causing a decrease in blood volume and blood pressure. Intracellular fluid is the fluid found within cells, while interstitial fluid is the fluid found between cells. Transcellular fluid refers to specific compartments such as cerebrospinal fluid or synovial fluid, and is not directly related to blood loss.

Question 8

Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia? (Select all that apply.)&#10;A) Allen test&#10;B) Chvostek's sign&#10;C) Percussion of the abdomen&#10;D) Auscultation of the lungs&#10;E) Trousseau's sign&#10;F) Palpation of the neck&#10;

Accepted Answer

Chvostek's sign and Trousseau's sign are both assessment techniques that can be used to determine if a client is experiencing hypocalcemia. Chvostek's sign involves tapping the client's facial nerve in front of the ear, which can cause twitching of the facial muscles in clients with hypocalcemia. Trousseau's sign involves inflating a blood pressure cuff around the client's arm and observing for spasms of the hand and forearm muscles, which can also indicate hypocalcemia. The other choices, such as the Allen test, percussion of the abdomen, auscultation of the lungs, and palpation of the neck, are not specific to assessing for hypocalcemia.

Question 9

A client is diagnosed with hypophosphatemia. The nurse realizes that this electrolyte imbalance is most likely associated with:&#10;A) diabetes mellitus.&#10;B) congestive heart failure.&#10;C) arthritis.&#10;D) chronic alcoholism.&#10;

Accepted Answer

Chronic alcoholism is a known cause of hypophosphatemia due to decreased intake and absorption of phosphorus from the diet, increased renal excretion of phosphorus, and shifts of phosphorus from the extracellular to the intracellular compartment. Diabetes mellitus, congestive heart failure, and arthritis are not typically associated with hypophosphatemia.

Question 10

A client begins rapid breathing and demonstrates anxiety after learning of a diagnosis of breast cancer. After a short while, the client complains of tingling lips and fingers. Which of the following should the nurse do to assist this client?

A) Provide oxygen.
B) Coach the client in the use of an incentive spirometer.
C) Help the client slow the respiratory rate or breathe into a paper bag.
D) Administer intravenous fluids.

Accepted Answer

The tingling lips and fingers indicate possible hyperventilation or respiratory alkalosis, which can be treated by helping the client slow their respiratory rate or breathing into a paper bag. Providing oxygen or administering intravenous fluids would not address the underlying issue of hyperventilation. Coaching the client in the use of an incentive spirometer may be helpful for promoting lung function, but it would not address the acute symptoms of anxiety and tingling.

Question 11

A client is demonstrating dizziness and lightheadedness upon standing. The nurse is concerned the client is experiencing postural hypotension when which of the following is assessed?&#10;A) Lying BP 120/70 mmHg, P 70; standing BP 116/78 mmHg, P 78&#10;B) Lying BP 116/64 mmHg, P 62; standing BP 94/58 mmHg, P 78&#10;C) Lying BP 130/80 mmHg, P 84; standing BP 118/72 mmHg, P 90&#10;D) Lying BP 126/74 mmHg, P 74; standing BP 108/62 mmHg, P 84&#10;

Accepted Answer

The answer of A client is demonstrating dizziness and lightheadedness...

Question 12

A client is diagnosed with chronic renal failure. Which of the following electrolytes should the nurse monitor for this client?&#10;A) Hydrogen&#10;B) Phosphorus&#10;C) Calcium&#10;D) Vitamin D&#10;

Accepted Answer

The answer of A client is diagnosed with chronic renal...

Question 13

A client diagnosed with chronic renal failure is experiencing muscle weakness, paresthesias, and depression. Which of the following do these assessment findings suggest to the nurse?&#10;A) Hyperkalemia&#10;B) Hyponatremia&#10;C) Hypocalcemia&#10;D) Hypermagnesemia&#10;

Accepted Answer

The answer of A client diagnosed with chronic renal failure...

Question 14

The nurse is concerned that a client can become dehydrated when which of the following is assessed?&#10;A) History of arthritis&#10;B) Appendicitis diagnosis 3 years ago&#10;C) Age 30&#10;D) Obese female&#10;

Accepted Answer

The answer of The nurse is concerned that a client...

Question 15

A client is diagnosed with hyponatremia. Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply.)&#10;A) Confusion&#10;B) Poor appetite&#10;C) Restlessness&#10;D) Lethargy&#10;E) Seizures&#10;F) Coma&#10;

Accepted Answer

The answer of A client is diagnosed with hyponatremia. Which...

Question 16

The nurse assesses a client to have mild pitting edema of the lower extremities. The nurse would document this finding as being:&#10;A) 0+.&#10;B) 1+.&#10;C) 2+.&#10;D) 3+.&#10;

Accepted Answer

The answer of The nurse assesses a client to have...

Deck 12: Fluid, Electrolyte, and Acid-Base Imbalances