Fundamental Skills - Fluids & Electrolytes

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nursedaisy98
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256719
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Fundamental Skills - Fluids & Electrolytes
Updated:
2014-04-20 10:23:07
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NCLEX RN
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Fundamental Skills
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Fluids & Electrolytes
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  1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
    1. Weight loss
    2. Flat neck and hand veins
    3. An increase in blood pressure
    4. Decreased central venous pressure (CVP)
    3. An increase in blood pressure
  2. The 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 of which situation?
    1. Sustained tissue damage
    2. Requires nasogastric suction
    3. Has a history of Addison's disease
    4. Is taking a potassium-retaining diuretic
    2. Requires nasogastric suction
  3. The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value?
    1. U waves
    2. Absent P waves
    3. Elevated T waves
    4. Elevated ST segment
    1. U waves
  4. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
    1. Peas
    2. Raisins
    3. Potatoes
    4. Cantaloupe
    5. Cauliflower
    6. Strawberries
    • 2. Raisins
    • 3. Potatoes
    • 4. Cantaloupe
    • 6. Strawberries
  5. The 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 health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?
    1. Peas
    2. Nuts
    3. Cauliflower
    4. Processed oat cereals
    4. Processed oat cereals
  6. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
    1. Twitching
    2. Hypoactive bowel sounds
    3. Negative Trousseau's sign
    4. Hypoactive deep tendon reflexes
    1. Twitching
  7. The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?
    1. Widened T wave
    2. Prominent U wave
    3. Prolonged QT interval
    4. Shortened ST segment
    3. Prolonged QT interval
  8. The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
    1. ST depression
    2. Inverted T wave
    3. Prominent U wave
    4. Tall peaked T waves
    4. Tall peaked T waves
  9. The 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?
    1. The client who is taking diuretics
    2. The client with hyperaldosteronism
    3. The client with Cushing's syndrome
    4. The client who is taking corticosteroids
    1. The client who is taking diuretics
  10. The nurse is caring for a client with 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 a client with hyponatremia?
    1. Muscle twitches
    2. Decreased urinary output
    3. Hyperactive bowel sounds
    4. Increased specific gravity of the urine
    3. Hyperactive bowel sounds
  11. The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level?
    1. Alcoholism
    2. Renal insufficiency
    3. Hypoparathyroidism
    4. Tumor lysis syndrome
    1. Alcoholism
  12. The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route?
    1. The skin
    2. Urinary output
    3. Wound drainage
    4. The gastrointestinal tract
    1. The skin
  13. The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
    1. A client with an ileostomy
    2. A client with heart failure
    3. A client on long-term corticosteroid therapy
    4. A client receiving frequent wound irrigations
    1. A client with an ileostomy
  14. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
    1. Lung congestion
    2. Decreased hematocrit
    3. Increased blood pressure
    4. Decreased central venous pressure (CVP)
    4. Decreased central venous pressure (CVP)
  15. The 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 fluid volume excess?
    1. The client taking diuretics
    2. The client with kidney disease
    3. The client with an ileostomy
    4. The client who requires gastrointestinal suctioning
    2. The client with kidney disease
  16. The 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 most at risk for the development of a potassium value at this level?
    1. The client with colitis
    2. The client with Cushing's syndrome
    3. The client who has been overusing laxatives
    4. The client who has sustained a traumatic burn
    4. The client who has sustained a traumatic burn
  17. Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure?
    1. 0.9% normal saline
    2. 0.45% normal saline
    3. Lactated Ringer's solution
    4. 5% dextrose in 0.9% normal saline
    4. 5% dextrose in 0.9% normal saline
  18. A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which intravenous solution would increase cellular swelling and cerebral edema?
    1. 0.9% normal saline
    2. 0.45% normal saline
    3. 5% dextrose in water
    4. Lactated Ringer's solution
    2. 0.45% normal saline
  19. The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?
    1. Bradycardia
    2. Elevated blood pressure
    3. Changes in mental status
    4. Bilateral crackles in the lungs
    3. Changes in mental status
  20. The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved?
    1. An oral temperature of 98.8° F
    2. A urine specific gravity of 1.043
    3. A urine output that is pale yellow
    4. A blood pressure of 120/80 mm Hg
    2. A urine specific gravity of 1.043
  21. A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?
    1. Increase fluid intake.
    2. Resume full activity level.
    3. Stay in a cool environment when possible.
    4. Monitor voiding for adequacy of urine output.
    2. Resume full activity level.
  22. The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?
    1. Daily weight
    2. Urinary output
    3. IV fluid intake
    4. NG tube intake
    1. Daily weight
  23. The nurse is reviewing the laboratory results of a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 7 mEq/L. On the basis of this laboratory result, the nurse should expect to note which in the client?
    1. Tremors
    2. Hyperactive reflexes
    3. Respiratory depression
    4. No specific signs or symptoms because this value is a normal level
    3. Respiratory depression
  24. A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do?
    1. Administer a Fleet enema.
    2. Administer an oil retention enema.
    3. Wait 30 minutes and then administer another enema.
    4. Stop administering the enemas until the health care provider (HCP) is notified.
    4. Stop administering the enemas until the health care provider (HCP) is notified.
  25. The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.
    1. Ensure adequate oxygenation.
    2. Provide assistance to prevent falls.
    3. Monitor medication administration of diuretics.
    4. Monitor for numbness and tingling around the mouth.
    5. Prevent complications during potassium administration.
    • 1. Ensure adequate oxygenation.
    • 2. Provide assistance to prevent falls.
    • 3. Monitor medication administration of diuretics.
    • 5. Prevent complications during potassium administration.
  26. A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?
    1. Confusion
    2. Muscle weakness
    3. Mental status changes
    4. Depressed deep tendon reflexes
    2. Muscle weakness
  27. The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?
    1. Urine pH of 6
    2. Urine that is pale yellow
    3. Urine output of 40 mL/hr
    4. Urine specific gravity of 1.032
    4. Urine specific gravity of 1.032
  28. A client becomes hypovolemic as a result of excess blood loss during surgery. The nurse plans care, knowing that which physiological response is needed to restore adequate circulating volume?
    1. Decreased production of angiotensin
    2. Decreased production of aldosterone
    3. Increased production of erythropoietin
    4. Increased production of antidiuretic hormone (ADH)
    4. Increased production of antidiuretic hormone (ADH)
  29. A client who had intracranial surgery is experiencing diabetes insipidus. The nurse plans care, knowing that the client is experiencing which problem?
    1. Water intoxication
    2. Excess production of dopamine
    3. Excess production of angiotensin II
    4. Insufficient production of antidiuretic hormone (ADH)
    4. Insufficient production of antidiuretic hormone (ADH)
  30. A client has a high potassium level. The nurse plans care, knowing that retention of potassium by the kidneys will be accompanied by which process?
    1. Increased sodium excretion
    2. Increased sodium retention
    3. Increased glucose retention
    4. Increased magnesium excretion
    1. Increased sodium excretion
  31. A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances?
    1. Calcium and chloride
    2. Chloride and bicarbonate
    3. Potassium and phosphates
    4. Aluminum and magnesium
    2. Chloride and bicarbonate
  32. A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.
    1. Dehydration
    2. Hypertension
    3. Physiological stress
    4. Decreased blood volume
    5. Decreased plasma osmolarity
    • 1. Dehydration
    • 3. Physiological stress
    • 4. Decreased blood volume
  33. A nurse is evaluating a client's serum creatinine level. On noting that the level is high, the nurse plans care, knowing that creatinine is not being adequately secreted by which part of the nephron?
    1. Distal tubule
    2. Loop of Henle
    3. Proximal tubule
    4. Collecting duct
    3. Proximal tubule
  34. The nurse is administering a dose of triamterene (Dyrenium) to an assigned client. The nurse monitors the client, expecting that the effect of this medication will result in retention of which substance?
    1. Water
    2. Sodium
    3. Chloride
    4. Potassium
    4. Potassium
  35. The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client?
    1. Monitor the client for dysrhythmias.
    2. Encourage increased intake of phosphate antacids.
    3. Discontinue any magnesium-containing medications.
    4. Encourage intake of foods such as ground beef, eggs, or chicken breast.
    1. Monitor the client for dysrhythmias.
  36. A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?
    1. Weighs athletes before, during, and after football practice
    2. Asks the athletes to take a salt tablet before football practice
    3. Schedules fluid breaks every 30 minutes throughout practice
    4. Tells the athletes to drink 16 oz of fluid per pound lost during practice
    2. Asks the athletes to take a salt tablet before football practice
  37. The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?
    1. Pour into the NG tube through a syringe with the plunger removed.
    2. Dilute with water and inject into the NG tube by putting pressure on the plunger.
    3. Discard properly and record as output on the client's intake and output (I&O) record.
    4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.
    1. Pour into the NG tube through a syringe with the plunger removed.
  38. A nurse is calculating a male client's fluid intake for an 8-hour period. The client drank 8 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 10:00 am and at 1:00 pm when taking his medications, and 6 oz of iced tea at lunch. At 8:00 am and again at 2:00 pm, the client received his intravenous antibiotics in 50 mL of normal saline. What is the client's total intake in mL? Fill in the blank.
    880 mL
  39. A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?
    1. Tetany
    2. Twitches
    3. Positive Trousseau's sign
    4. Loss of deep tendon reflexes
    4. Loss of deep tendon reflexes
  40. Which client is least likely to be at risk for the development of third spacing?
    1. The client with cirrhosis
    2. The client with liver failure
    3. The client with diabetes mellitus
    4. The client with chronic kidney disease
    3. The client with diabetes mellitus
  41. An intravenous (IV) Ringer's lactate solution is prescribed for the postoperative client. The nursing instructor asks the nursing student who is caring for the client about the tonicity of the prescribed IV solution. The nursing student responds correctly by stating that this solution is which type of solution?
    1. Isotonic
    2. Hypotonic
    3. Hypertonic
    4. Normotonic
    1. Isotonic
  42. A client is hypovolemic, and plasma expanders are not available. The nurse anticipates that which solution available on the nursing unit will be prescribed by the health care provider?
    1. 5% dextrose in water
    2. 0.9% sodium chloride
    3. 0.45% sodium chloride
    4. 5% dextrose in 0.45% sodium chloride
    4. 5% dextrose in 0.45% sodium chloride
  43. The nurse hears the attending health care provider ask an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which IV solution would the nurse expect the intern to prescribe?
    1. 5% dextrose in water
    2. 10% dextrose in water
    3. 0.45% sodium chloride
    4. 5% dextrose in 0.9% sodium chloride
    3. 0.45% sodium chloride
  44. The 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 result indicates a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?
    1. Tap water
    2. Sterile water
    3. Distilled water
    4. Sodium chloride
    4. Sodium chloride
  45. The 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?
    1. Prolonged bed rest
    2. Renal insufficiency
    3. Hyperparathyroidism
    4. Excessive ingestion of vitamin D
    1. Prolonged bed rest
  46. The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level?
    1. Prominent U waves
    2. Prolonged PR interval
    3. Depressed ST segment
    4. Widened QRS complexes
    3. Depressed ST segment
  47. During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?
    1. Document this assessment finding.
    2. Call another nurse to verify this finding.
    3. Check skin turgor over the client's sternum.
    4. Call the prescriber to obtain a prescription for fluid replacement.
    3. Check skin turgor over the client's sternum.
  48. During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?
    1. Dehydration
    2. Hypokalemia
    3. Fluid overload
    4. Hypernatremia
    1. Dehydration
  49. A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply.
    1. Ensure adequate fluid intake.
    2. Implement safety measures to prevent falls.
    3. Encourage low fiber foods to prevent diarrhea.
    4. Instruct the client about foods that contain potassium.
    5. Encourage the client to obtain assistance to ambulate.
    • 1. Ensure adequate fluid intake.
    • 2. Implement safety measures to prevent falls.
    • 4. Instruct the client about foods that contain potassium.
    • 5. Encourage the client to obtain assistance to ambulate.
  50. A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action?
    1. Pinching the skin on the thigh
    2. Pushing on the skin in the ankle area
    3. Assessing the skin in the radial pulse area
    4. Pulling up and releasing the skin on the sternal area
    4. Pulling up and releasing the skin on the sternal area
  51. The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?
    1. Sodium 135 mEq/L
    2. Sodium 140 mEq/L
    3. Potassium 3.0 mEq/L
    4. Potassium 5.0 mEq/L
    3. Potassium 3.0 mEq/L
  52. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?
    1. Hypotension
    2. Increased heart rate
    3. Bounding peripheral pulses
    4. Shortened QT interval on electrocardiography (ECG)
    1. Hypotension
  53. A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid?
    1. Client with a major burn
    2. Client with an ischemic stroke
    3. Client with Laënnec's cirrhosis
    4. Client with chronic kidney disease
    2. Client with an ischemic stroke
  54. A nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?
    1. Client in heart failure
    2. Client with an ileostomy
    3. Client in acute kidney injury
    4. Client with controlled hypertension
    2. Client with an ileostomy
  55. A nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?
    1. A client with ulcerative colitis
    2. A client with Cushing's syndrome
    3. A client admitted 6 hours ago with a 40% burn injury
    4. A client who has a history of long-term laxative abuse
    3. A client admitted 6 hours ago with a 40% burn injury
  56. A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT?
    1. Tap water
    2. Sterile water
    3. 0.9% sodium chloride
    4. 0.45% sodium chloride
    3. 0.9% sodium chloride
  57. A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?
    1. Tetany
    2. Tremors
    3. Areflexia
    4. Muscular excitability
    3. Areflexia

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