Question 1

What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance?

Accepted Answer

A)Aldosterone is the principal mineralocorticoid that assists in regulating serum sodium balance. It does this by stimulating the kidneys to conserve sodium and to excrete potassium when serum sodium levels fall below normal. Water follows the sodium, and blood volume rises. When extracellular fluid (ECF)osmolality increases, antidiuretic hormone is secreted, leading to additional water reabsorption. The atria detect this rise in ECF volume and secrete atrial natriuretic peptide (ANP)to reverse the aldosterone process and promote sodium and water excretion to return the ECF to balance.
B)Aldosterone is the principal mineralocorticoid that assists in regulating serum sodium balance. It does this by stimulating the kidneys to conserve sodium and to excrete potassium when serum sodium levels fall below normal. Water follows the sodium, and blood volume rises. When extracellular fluid (ECF)osmolality increases, antidiuretic hormone is secreted, leading to additional water reabsorption. The atria detect this rise in ECF volume and secrete atrial natriuretic peptide (ANP)to reverse the aldosterone process and promote sodium and water excretion to return the ECF to balance.
C)Aldosterone is the principal mineralocorticoid that assists in regulating serum sodium balance. It does this by stimulating the kidneys to conserve sodium and to excrete potassium when serum sodium levels fall below normal. Water follows the sodium, and blood volume rises. When extracellular fluid (ECF)osmolality increases, antidiuretic hormone is secreted, leading to additional water reabsorption. The atria detect this rise in ECF volume and secrete atrial natriuretic peptide (ANP)to reverse the aldosterone process and promote sodium and water excretion to return the ECF to balance.
D)Aldosterone is the principal mineralocorticoid that assists in regulating serum sodium balance. It does this by stimulating the kidneys to conserve sodium and to excrete potassium when serum sodium levels fall below normal. Water follows the sodium, and blood volume rises. When extracellular fluid (ECF)osmolality increases, antidiuretic hormone is secreted, leading to additional water reabsorption. The atria detect this rise in ECF volume and secrete atrial natriuretic peptide (ANP)to reverse the aldosterone process and promote sodium and water excretion to return the ECF to balance.

Question 2

A client diagnosed with frequent urinary tract infections is seen in the urology clinic. The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury. Which items in the client's history support this conclusion? Select all that apply.

Accepted Answer

A)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
B)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
C)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
D)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
E)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.

Question 3

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

Accepted Answer

A)Acute kidney injury (AKI)is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.
B)AKI is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.
C)AKI is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.
D)AKI is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.

Question 4

The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare 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?

Accepted Answer

A)Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.
B)Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.
C)Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.
D)Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.

Question 5

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

Accepted Answer

A)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
B)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
C)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
D)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.

Question 6

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

Accepted Answer

A)Low-sodium salt substitutes are not really sodium-free; they may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should also be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium, so intake should be limited when on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
B)Low-sodium salt substitutes are not really sodium-free; they may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should also be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium, so intake should be limited when on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
C)Low-sodium salt substitutes are not really sodium-free; they may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should also be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium, so intake should be limited when on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
D)Low-sodium salt substitutes are not really sodium-free; they may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should also be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium, so intake should be limited when on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.

Question 7

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

Accepted Answer

A)Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.
B)Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.
C)Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.
D)Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.

Question 8

________ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure.

Accepted Answer

A)Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Active transport is the process by which substances move across cell membranes from a less concentrated solution to a more concentrated one.
B)Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Active transport is the process by which substances move across cell membranes from a less concentrated solution to a more concentrated one.
C)Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Active transport is the process by which substances move across cell membranes from a less concentrated solution to a more concentrated one.
D)Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Active transport is the process by which substances move across cell membranes from a less concentrated solution to a more concentrated one.

Question 9

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

Accepted Answer

A)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
B)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
C)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
D)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.

Question 10

An older adult client is brought to the emergency department. 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 should the nurse most anticipate for this client?

Accepted Answer

A)Older adult clients are less able to concentrate their urine, and they have a blunted perception of thirst. Both of these characteristics make them susceptible to dehydration. However, fever, nausea, and vomiting are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing this client at even higher risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.
B)Older adult clients are less able to concentrate their urine, and they have a blunted perception of thirst. Both of these characteristics make them susceptible to dehydration. However, fever, nausea, and vomiting are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing this client at even higher risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.
C)Older adult clients are less able to concentrate their urine, and they have a blunted perception of thirst. Both of these characteristics make them susceptible to dehydration. However, fever, nausea, and vomiting are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing this client at even higher risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.
D)Older adult clients are less able to concentrate their urine, and they have a blunted perception of thirst. Both of these characteristics make them susceptible to dehydration. However, fever, nausea, and vomiting are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing this client at even higher risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.

Question 11

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?

Accepted Answer

A)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
B)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
C)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
D)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.

Question 12

The nurse is caring for a child who weighs 33 lb and has been diagnosed with dehydration. The healthcare provider's orders state that the child is 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.
________ mL

Accepted Answer

The answer of The nurse is caring for a child...

Question 13

A client diagnosed with heart failure is prescribed an oral fluid restriction of 1200 mL per day. How many ounces of fluid would the client be permitted during the day shift?

Accepted Answer

A)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
B)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
C)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
D)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.

Question 14

Which of the following terms refers to severe, generalized edema, which may occur as a result of fluid volume excess?

Accepted Answer

A)Anasarca refers to severe, generalized edema, which may occur due to fluid volume excess. Ascites refers to excess fluid in the peritoneal cavity. Hypervolemia is an excess of intravascular fluid. Orthopnea is difficulty breathing when supine.
B)Anasarca refers to severe, generalized edema, which may occur due to fluid volume excess. Ascites refers to excess fluid in the peritoneal cavity. Hypervolemia is an excess of intravascular fluid. Orthopnea is difficulty breathing when supine.
C)Anasarca refers to severe, generalized edema, which may occur due to fluid volume excess. Ascites refers to excess fluid in the peritoneal cavity. Hypervolemia is an excess of intravascular fluid. Orthopnea is difficulty breathing when supine.
D)Anasarca refers to severe, generalized edema, which may occur due to fluid volume excess. Ascites refers to excess fluid in the peritoneal cavity. Hypervolemia is an excess of intravascular fluid. Orthopnea is difficulty breathing when supine.

Question 15

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 session?

Accepted Answer

A)During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids lost during exercise. Light-colored, lightweight clothing is preferable; wearing dark colors can increase sweating.
B)During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids lost during exercise. Light-colored, lightweight clothing is preferable; wearing dark colors can increase sweating.
C)During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids lost during exercise. Light-colored, lightweight clothing is preferable; wearing dark colors can increase sweating.
D)During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids lost during exercise. Light-colored, lightweight clothing is preferable; wearing dark colors can increase sweating.

Question 16

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

Accepted Answer

A)Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Ineffective Peripheral Tissue Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.
B)Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Ineffective Peripheral Tissue Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.
C)Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Ineffective Peripheral Tissue Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.
D)Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Ineffective Peripheral Tissue Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.

Question 17

An increase in blood hydrostatic pressure would result in which fluid volume disturbance?

Accepted Answer

A)When extracellular fluid volume excess occurs, the increased fluid volume in the vascular compartment congests the veins. This leads to an increase in blood hydrostatic pressure. In turn, as the pressure against the sides of the capillaries increases, more fluid enters the interstitial compartment, causing further fluid volume excess.
B)When extracellular fluid volume excess occurs, the increased fluid volume in the vascular compartment congests the veins. This leads to an increase in blood hydrostatic pressure. In turn, as the pressure against the sides of the capillaries increases, more fluid enters the interstitial compartment, causing further fluid volume excess.
C)When extracellular fluid volume excess occurs, the increased fluid volume in the vascular compartment congests the veins. This leads to an increase in blood hydrostatic pressure. In turn, as the pressure against the sides of the capillaries increases, more fluid enters the interstitial compartment, causing further fluid volume excess.
D)When extracellular fluid volume excess occurs, the increased fluid volume in the vascular compartment congests the veins. This leads to an increase in blood hydrostatic pressure. In turn, as the pressure against the sides of the capillaries increases, more fluid enters the interstitial compartment, causing further fluid volume excess.

Question 18

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

Accepted Answer

A)The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age and experiencing tachypnea, which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis)is at lower risk for dehydration than is a toddler with a condition that increases insensible water loss.
B)The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age and experiencing tachypnea, which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis)is at lower risk for dehydration than is a toddler with a condition that increases insensible water loss.
C)The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age and experiencing tachypnea, which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis)is at lower risk for dehydration than is a toddler with a condition that increases insensible water loss.
D)The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age and experiencing tachypnea, which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis)is at lower risk for dehydration than is a toddler with a condition that increases insensible water loss.

Question 19

Which of the following statements is correct with regard to hypercalcemia?

Accepted Answer

A)Calcium levels are controlled in part by parathyroid hormone; when levels of this hormone rise, so do serum calcium levels. Hyperparathyroidism is a condition characterized by an overactive parathyroid gland. Excessive activity of this gland leads to the secretion of abnormally high amounts of parathyroid hormone, which in turn may lead to hypercalcemia.
B)Calcium levels are controlled in part by parathyroid hormone; when levels of this hormone rise, so do serum calcium levels. Hyperparathyroidism is a condition characterized by an overactive parathyroid gland. Excessive activity of this gland leads to the secretion of abnormally high amounts of parathyroid hormone, which in turn may lead to hypercalcemia.
C)Calcium levels are controlled in part by parathyroid hormone; when levels of this hormone rise, so do serum calcium levels. Hyperparathyroidism is a condition characterized by an overactive parathyroid gland. Excessive activity of this gland leads to the secretion of abnormally high amounts of parathyroid hormone, which in turn may lead to hypercalcemia.
D)Calcium levels are controlled in part by parathyroid hormone; when levels of this hormone rise, so do serum calcium levels. Hyperparathyroidism is a condition characterized by an overactive parathyroid gland. Excessive activity of this gland leads to the secretion of abnormally high amounts of parathyroid hormone, which in turn may lead to hypercalcemia.

Question 20

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.

Accepted Answer

A)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
B)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
C)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
D)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
E)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.

Quiz 6: Fluids and Electrolytes