Show
Terms in this set (70)A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl. The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50-year-old with pneumonia, diaphoresis, and high fevers A. 50-year-old with pneumonia, diaphoresis, and high fevers Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules. A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A. Request a physical therapy consult from the physician B. Ensure the client is safe from falls and check the most recent potassium level In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium. A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A. urine output. C. bowel movements. Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L. The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? A. Absent patellar reflex A. Absent patellar reflex
A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A. Assess for depressed deep tendon reflexes D. Check to see if a serum albumin level is available A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin C. Call the physician The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A. Provide passive ROM exercises and encourage fluid intake A. Provide passive ROM exercises and encourage fluid intake An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." C. "The sodium level is low, and the confusion will resolve as the levels normalize." A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion C. Assess for signs of fluid overload A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A. Bisacodyl (Dulcolax) suppository D. Milk of magnesia A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? A. Encourage the client to increase fluid intake D. Notify the physician of the urine output and hold the dose The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A. A client with osteoporosis taking vitamin D and calcium supplements B. A client who is alcoholic receiving total parenteral nutrition A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. A. Eggs B. Broccoli A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? A. Sodium D. Magnesium The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? A. Increase intake of dairy products and nuts B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A. Administer a sedative C. Place client in high-Fowler's position A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? A. Call the physician and report the change in client's condition D. Encourage the client to rest and to use pursed-lip breathing technique A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A. D5.45 NS at 50 ml/hr B. 0.9 NS at an open rate
A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? A. pH of 7.43, PCO2 of 36, HCO3 of 26 C. pH of 7.33, PCO2 of 35, HCO3 of 17 A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? A. Respiratory alkalosis C. Metabolic alkalosis A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? A. Monitor intake and output D. Provide reassurance to the client and administer sedatives Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A. Deep tendon reflexes decreasing from +2 to +1 A. Deep tendon reflexes decreasing from +2 to +1 A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? A. "The fluid is an adverse reaction to chemotherapy." C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain C. Positive Chvostek's sign A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A. Deficient
fluid volume related to decreased fluid intake B. Excess fluid volume related to increased water retention The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse? A. Assess a client for metabolic acidosis C. Obtain a glucose level on a client admitted with diabetes mellitus A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A. Withhold furosemide (Lasix) B. Notify the physician The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of A. acute renal failure. A. acute renal failure. Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L? A.
Pretzels B. Baked chicken The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following? A. Hypokalemia D. Hypocalcemia Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? A. Sodium is essential to maintain intracellular fluid water balance D. Chloride is lost in hydrochloride acid The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A. Baked cod A. Baked cod The nurse evaluates which of the following clients to have hypermagnesemia? A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A. A client with osteoporosis and a calcium level of 10.6 mg/dl D. A client with dehydration and a sodium level of 149 mEq/L The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? A. A client who has been experiencing diarrhea
and has a serum chloride level of 100 mEq/L A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. C. Dehydration. The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A. The pump keeps sounding an alarm that the high pressure has been reached. C. On auscultation, crackles and rales in all lung fields are noted. The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A. 500 mL C. 2000 mL The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? A. Change the IV fluid from 0.9% NS to D5W. B. Restrict the client's sodium in the diet. The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. D. Place on seizure precautions. The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A. The client in normal sinus rhythm with a peaked T wave. A. The client in normal sinus rhythm with a peaked T wave. The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A. Notify the health care provider immediately. B. Tap the cheek about two (2) centimeters anterior to the ear lobe. Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? A. The kidneys produce excess urine and the lungs try to compensate. C. The lungs speed up to release carbon dioxide and increase the pH. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A. Place the solution on an IV pump at the prescribed rate. A. Place the solution on an IV pump
at the prescribed rate. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first? A. Start a new IV in the right hand. B. Discontinue the intravenous line. The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform? A. Measure the client's output from the indwelling catheter. C. Instruct the client on appropriate fluid restrictions. The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A. Serum calcium. C. Serum potassium. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: A. The skin A. The skin A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? A. A client with a colostomy A. A client with a colostomy A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A. Lung congestion D. Decreased central venous pressure (CVP) A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A. The client taking diuretics B. The client with renal failure The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss C. An increase in blood pressure A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: A. Has renal failure. B. Requires nasogastric suction. A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? A. U waves A. U waves A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? A. Obtaining a controlled IV infusion pump D. Preparing the medication for bolus administration A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: A. Apples A. Apples A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? A. The client with colitis D. The client who has sustained a traumatic burn A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? A. ST depression D. Tall peaked T waves A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? A. The client with renal failure B. The client who is taking diuretics A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? A. Dry skin C. Hyperactive bowel sounds A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? A. Tap water C. Sodium chloride A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? A. Peas D. Processed oat cereals A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A. Prolonged bed rest A. Prolonged bed rest A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A. Twitching A. Twitching A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? A. Widened T wave C. Prolonged QT interval A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A. Prominent U waves C. Depressed ST segment A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? A. Alcoholism
A. Alcoholism The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. A. Peas A. Peas
Sets with similar termsFluid & Electrolyte Nclex Questions96 terms GoddlydaughterPLUS Fluid & Electrolyte Nclex Questions96 terms kalicokat21 Fluid and Electrolytes70 terms stephanie_daprai Sets found in the same folderF&E NCLEX43 terms Diana_Pemberton Fluid and Electrolytes NCLEX Questions19 terms rose_roman Fluid, Electrolyte, and Acid-Base Balance NCLEX40 terms john29649 Chapter 16: Fluid, Electrolyte, and Acid-Base Imba…27 terms RN1NP2CRNA3 Other sets by this creatorMed-Surg: Lewis: Chapter 61: Peripheral Nerve and…40 terms coopercec Lewis Ch. 4739 terms coopercec Med-Surg: Lewis: Chapter 57: Acute Intracranial Pr…68 terms coopercec Chapter 2552 terms coopercec Recommended textbook solutions The Human Body in Health and Disease7th EditionGary A. Thibodeau, Kevin T. Patton 1,505 solutions
Clinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions Mathematics for Health Sciences1st EditionJoel Helms 1,674 solutions Nutrition: Concepts and Controversies15th EditionEleanor Noss Whitney, Ellie Whitney, Frances Sizer 342 solutions Other Quizlet setsMKG 400 Exam 1 Ch. 123 terms TARNL ENTM 105 Week 4 Test17 terms keagls2 social research methods exam 113 terms hankthegoat Respiratory Physiology Unit 1121 terms jdodoo Related questionsQUESTION Who is at risk for arterial insufficiency? 14 answers QUESTION what is a nontunneled triple lumen cvad used for? 11 answers QUESTION Nurse in antepartum unit is performing shift assessment of several pregnant patient. Which patient assessment is the priority to report to PCP 3 answers QUESTION What does a full thickness wound look like? 8 answers |
Managing a sodium level of 120 in a client with diabetic ketoacidosis is correctly accomplished with
zusammenhängende Posts
Urheberrechte © © 2024 decemle Inc.
