Question 1

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?

Accepted Answer

The low serum sodium level is consistent with hyponatremia and the client's symptoms of nausea, vomiting and tachycardia and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

Question 2

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?

Accepted Answer

Crackles throughout both lungs suggest that the client may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

Question 3

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?

Accepted Answer

The loss of the deep tendon reflexes indicates that the client's magnesium level may be reaching toxic levels. Nausea and lethargy also are adverse effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the client needs to cough and deep breathe to prevent atelectasis.

Question 4

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?

Accepted Answer

The client's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

Question 5

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.)

Accepted Answer

It is appropriate to provide pain relief for the postoperative client and treatment for nausea as required. The serum sodium is low; therefore, serum sodium drops are appropriate for this client. Because the client's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement, not dextrose. Solutions such as lactated Ringer's solution would usually be ordered for this client. The postoperative pain medication order would not be withheld.

Question 6

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?

Accepted Answer

The client's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

Question 7

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?

Accepted Answer

The serum calcium is well above the normal level and puts the client at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

Question 8

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?

Accepted Answer

Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the client's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action.

Question 9

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)?

Accepted Answer

The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the client should turn away from the CVAD during cap changes.

Question 10

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?

Accepted Answer

The client has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The magnesium hydroxide should be held, but more immediate action is needed to correct the client's decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for clients with renal failure, but the client's current symptoms are not consistent with hyperkalemia.

Question 11

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?

Accepted Answer

Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on client outcomes.

Question 12

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?

Accepted Answer

A client with a CVAD that suddenly develops chest pain, hypotension, and tachycardia is experiencing an air embolism and the nurse needs to immediately place the client in left lateral with their head down. Prone is not the correct position in a client with suspected air emboli. Sims is not the correct position in a client with suspected air emboli. High Fowler's is not the correct position in a client with suspected air emboli.

Question 13

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?

Accepted Answer

The client's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the client for pain.
Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the client needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The client will not be able to take slow, deep breaths when experiencing pain.

Quiz 19: Fluid