Adult 2

Question 1

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?

a. Hyperactive deep-tendon reflexes
b. Orthostatic hypotension
c. Rapid, deep respirations
d. Strong, bounding pulse

Answer 1

Orthostatic hypotension

Hypokalemia can lead to hypotension. The nurse should monitor the client for orthostatic hypotension.

Question 1

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

a. Decreased muscle strength
b. Decreased gastric motility
c. Increased heart rate
d. Increased blood pressure

Answer 1

Decreased muscle strength

Hyperkalemia can cause muscle weakness. The nurse should monitor the client’s muscle strength.

Question 2

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?

a. Hemoglobin 20 g/dL
b. Hematocrit 34%
c. BUN 25 mg/dL
d. Urine specific gravity 1.050

Answer 2

Hematocrit 34%

This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.
for men is 40 to 54%; for women it is 36 to 48%.

Question 3

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care?

a. Administer IV fluids to the client evenly over 24 hr.
b. Provide the client with a salt substitute.
c. Assess the client for pitting edema.
d. Encourage the client to rise slowly when standing up.
e. Weigh the client every 8 hr.

Answer 3

-Administer IV fluids to the client evenly over 24 hr
-Encourage the client to rise slowly when standing up
-Weigh the client every 8 hr

Administer IV fluids to the client evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload.

Provide the client with a salt substitute is incorrect. There is no reason to limit the client’s sodium intake. The client might require electrolyte replacement, depending on the cause of fluid loss.

Assess for pitting edema is incorrect. This action is appropriate for a client who has fluid overload.

Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension.

Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.

Question 4

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding?

a. Sodium 152 mEq/L
b. Chloride 102 mEq/L
c. Magnesium 1.8 mEq/L
d. Potassium 6.1 mEq/L

Answer 4

Potassium 6.1 mEq/L

Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.