CH 25 Fluid

Question 1

6) A client has a serum sodium level of 125 mEq/L. Which prescription should the nurse anticipate?
1. Encourage the patient to drink fluids.
2. Administer normal saline intravenous (IV).
3. Administer 0.45% NaCl.
4. Provide a diet high in NaCl.

Answer 1

2. Administer normal saline intravenous (IV).

Question 2

7) A client with a potassium level of 5.9 mEq/L is prescribed glucose and insulin. Which statement should the nurse include in the client’s education?
1. “Insulin will cause extra potassium to go into cells and lower the blood level.”
2. “Insulin lowers blood sugar levels and this is how the extra potassium is excreted.”
3. “Insulin is safer than giving laxatives such as Kayexalate.”
4. “Insulin will help kidneys excrete the extra potassium.”

Answer 2

1. “Insulin will cause extra potassium to go into cells and lower the blood level.”

Question 3

19) Which serum sodium level should the nurse recognize as hyponatremia?
1. 137 mEq/mL
2. 140 mEq/mL
3. 133 mEq/mL
4. 145 mEq/mL

Answer 3

3. 133 mEq/mL

Question 4

17) Which information should the nurse provide a client with hyperkalemia experiencing constipation?
Select all that apply.
1. Increase fluid intake.
2. Include prune juice in your daily fluids.
3. Add fruits and vegetables to the diet.
4. Increase activity such as walking.
5. Use salt substitutes to reduce the sodium level.

Answer 4

1. Increase fluid intake.

4. Increase activity such as walking.

Question 5

18) Which action should the nurse take when initiating a prescription of intravenous dextran 40 (Gentran 40)?
Select all that apply.
1. Start the infusion no faster than 240 mg/min.
2. Monitor the patient’s vital signs continuously during administration.
3. Monitor for signs of anaphylaxis.
4. Monitor the client for deep vein thrombosis.
5. Discard any unused portion of the infusion.

Answer 5

1. Start the infusion no faster than 240 mg/min.
2. Monitor the patient’s vital signs continuously during administration.
3. Monitor for signs of anaphylaxis.
4. Discard any unused portion of the infusion.

Question 6

20) Which condition is a symptom of hypokalemia?
1. Constipation
2. Hypertension
3. Muscle weakness
4. Weight gain

Answer 6

3. Muscle weakness

Question 7

28) Which nursing interventions should the nurse implement when administering oral potassium chloride (KCl)?
Select all that apply.
1. Instruct the client to sit straight up to swallow the pill.
2. Crush the tablet and put it in a soft food.
3. Instruct the client to chew the tablet.
4. Administer the prescription with an antacid.
5. Instruct the client to take the prescription prior to eating a meal.

Answer 7

1. Instruct the client to sit straight up to swallow the pill.
2. Administer the prescription with an antacid.
3. Instruct the client to take the prescription prior to eating a meal.

Question 8

29) The nurse reviewing a client’s records notes the client has received polystyrene sulfonate (Kayexalate). Which condition should the nurse associate with the treatment?
1. Hyperphosphatemia
2. Hyperkalemia
3. Hypernatremia
4. Hypercalcemia

Answer 8

2. Hyperkalemia

Question 9

30) Which nursing actions are appropriate for a client prescribed oral polystyrene sulfonate (Kayexalate)?
Select all that apply.
1. Monitor for onset of action of this drug in an hour.
2. Administer sorbitol concurrently.
3. Repeat the dose in 4 hours if needed.
4. Mix the dose with a liquid high in glucose.
5. Administer with sodium bicarbonate.

Answer 9

1. Monitor for onset of action of this drug in an hour.
2. Administer sorbitol concurrently.
3. Repeat the dose in 4 hours if needed.

Question 10

13) Which are the nurse’s priority assessments of a client who has received normal serum albumin?
1. Blood pressure and urinary output
2. Urinary output and pupil response
3. Blood pressure and level of pain
4. Urinary output and nausea or vomiting

Answer 10

1. Blood pressure and urinary output