Test 1 Flashcards
adult client c/o cough, fever, nausea, and vomiting x 3d. Examination reveals dry tongue and oral mucosa and concentrated urine. The client also reports feeling weak, dizzy. Which vital signs measurement would provide the best indicator of current fluid status?
a. temperature
b. respiratory rate and depth
c. BP and pulse in lying and standing position
d. pulse oximetry reading at rest.
c. BP and pulse lying and standing position
A 70 year old client with a past medical history of hypertension and myocardial infarction is in the hospital following stomach surgery. Vital signs have been stable and an IV of D51/2 NS is infusing at 100 ml/hr. The client now complains of trouble breathing, has a moist cough, and pulse oximetry reading has fallen to 92%. What action should the nurse take first?
A. Measure blood pressure and heart rate
B. Assess legs and arms for pitting edema
C. Telephone and notify the physician
D. Slow the IV rate to 10 to 20 ml/hr
D. slow the IV rate to 10-20 mL/hr
A 45 year old client diagnosed with fluid volume overload due to acute kidney dysfunction is placed on 1,000 mL fluid restriction per 24 hour period. The client asks the nurse, “Why is there such a severe fluid restriction when I already have dry lips and mouth?” What is the nurses best response?
A. “The doctor ordered the fluid restriction, so you must comply with those orders.”
B. “Your kidneys are not able to eliminate extra fluid right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid.”
C. “You probably drank too much fluid before you got sick, so you can’t compare your usual intake to your limitations now that your kidneys are working.”
D. “Too much fluid will cause your heart to fail and your lungs to fill with water, which could be fatal.”
B. “Your kidney are not able to eliminate extra fluid right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid”
The nurse is helping a client who was recently placed on a low-sodium diet to choose foods for lunch. Which lunch menu would be best for this client?
A. Grilled chicken sandwich on white bread, apple, salad, and iced tea
B. Bologna sandwich on wheat bread, canned fruit cocktail, salad, and a soda
C. Canned ham and bean soup, fresh fruit salad, pickles, and a diet soda
D. Fast food cheeseburger, grapes, fresh pineapple, and tomato juice
A. Grilled chicken sandwich on white bread, apple, salad, and iced tea
During intershift report, the nurse is told that a client who has suffered a stroke has also developed diabetes insipidus. The nurse concludes that this client is now at risk for:
A. Severe fluid volume deficit due to excess urine output
B. Severe fluid volume excess due to inadequate urine output
C. Hyperglycemia due to poor insulin production
D. Hypoglycemia due to excess insulin production
A. Severe fluid volume deficit due to excess urine output
The nurse is monitoring IV fluid therapy for a client with hyponatremia. The nurse knows that which of the following types of solutions exerts the same osmotic pressure as the fluid on the other side of the cell membrane and thus maintains equilibrium and minimizes fluid shifts?
A. Hypertonic
B. Hyperosmolar
C. Hypotonic
D. Isotonic
D. Isotonic
Which of the following interventions is not warranted in planning care for a client admitted with hypernatremia?
A. Monitoring intake and output
B. Observing for possible increase in temperature
C. Observing and preparing for possible seizures
D. Restricting fluids to 1200 mL per day
B. Observing for possible increase in temperature
Which of the following interventions should be utilized in a client who is experiencing hyponatremia in a hypervolemic state?
A. Use normal saline IV to correct extracellular fluid deficit
B. Restrict additional fluids
C. Remove sources of salt excess
D. Replace deficit with free water
B. Restrict additional fluids
Which of the following statements made by the nurse is correct when performing client education regarding oral potassium supplementation?
A. “When you take your potassium pill, if you can’t swallow it,you can crush it up and put in orange juice.”
B. “Potassium should only be taken in the morning on an empty stomach.”
C. “Take your potassium tablet after you have eaten breakfast.”
D. “You can continue to use salt substitute while you are taking your potassium supplement.”
C. “Take your potassium tablet after you have eaten breakfast.”
A client in renal failure has an abnormally high potassium level. Which of the following is a priority nursing intervention?
A. Obtain an EKG
B. Evaluate level of consciousness
C. Measure urinary output
D. Draw arterial blood gases
A. Obtain an EKG
A client with hypokalemia must be assessed carefully for which of the following that can occur because of this electrolyte imbalance?
A. Perforated bowel
B. Paralytic ileus
C. Renal failure
D. Diabetes
B. Paralytic ileus
Which of the following is the best response by the nurse to the daughter of a 46 year old client who was admitted with hypokalemia and is complaining of being dizzy upon standing?
A. “Your mother has just stayed in bed too long and when she stands up she will get dizzy.”
B. “The level of your mother’s potassium is making her dizzy.”
C. “Your mother is probably dizzy because her heart is not pumping as effectively, making her blood pressure low.”
D. “Your mother is dizzy because her nervous system isn’t functioning correctly: once her potassium level goes up she will improve.”
D. “Your mother is dizzy because her nervous system isn’t functioning correctly: once her potassium level goes up she will improve.”
Trousseau Sign
involuntary contractions of the muscles in the hand and wrist (when a BP cuff is inflated on the upper arm; sign of latent tetany)
caused by HYPOcalcemia
The nurse us assessing a client with HYPERcalcemia. The nurse expects neuromuscular examination to show:
A. Tetany
B. A positive Trousseau’s sign
C. Muscle weakness
D. Hyperactive deep tendon reflexes
C. Muscle weakness
The nurse evaluates that discharge teaching has been effective when the client with hypocalcemia states:
A. “I shouldn’t take antacids such as TUMS”
B. “I should notify my healthcare provider if I start to feel tingling or numbness around my mouth.”
C. “I’ll need to cut down on the protein in my diet.”
D. “I will watch my urine for signs of kidney stones.”
B. “I should notify my healthcare provider if I start to feel tingling or numbness around my mouth.”
The nurse would expect a client to have a high serum level of magnesium after seeing which of the following health problems listed in the medical history?
A. Malabsorption
B. Anemia
C. Overuse of laxatives
D. Alcoholism
C. Overuse of laxatives
The nurse would assess for which of the following classic manifestations in a client suspected of having hypermagnesemia?
A. Diarrhea
B. Hyperreflexia
C. Hypertension
D. Diminished deep tendon reflexes
D. Diminished deep tendon reflexes
The nurse would interpret that a magnesium level of 3.2 indicates which of the following?
A. Hypomagnesemia
B. Concurrent hypokalemia
C. Hypermagnesemia
D. Concurrent hypocalcemia
C. Hypermagnesemia
normal range is 1.7-2.2 mg/dL
Which of the following activities would be least acceptable for a client diagnosed with hypochloremia?
A. Decrease salt in the diet
B. Use soy sauce sparingly in the diet
C. Decrease canned soups
D. Decrease bananas and dates
A. Decrease salt in the diet
The physician orders a high phosphorus diet for the client with hypophosphatemia. You would expect to see which of the following dietary items on the meal tray?
A. Fresh fruits
B. Dairy products
C. Non-carbonated soft drinks
D. White bread
B. Dairy products
Which of the following concurrent electrolyte imbalances should the nurse anticipate while working with a client who has hyperphosphatemia?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
C. Hypocalcemia
phosphor binds to calcium which means less free flowing calcium in the blood
The nurse evaluate the lab reports on electrolyte values are fully to assess the balance between positive and negative ions. Which is regulated by the process of:
A. Adaptation
B. Diffusion
C. Filtration
D. Osmosis
B. Diffusion
The nurse is aware that ECF osmolarity is primarily maintained by:
A. Chloride
B. Magnesium
C. Potassium
D. Sodium
D. Sodium
The pt is frequently thirsty. The nurse assess this symptom as:
A. Too much sodium and too much water in body
B. Too little sodium and too much water in body
C. Too much sodium and too little water in body
D. Too little sodium and too little water in body
C. Too much sodium and too little water in body
In an assessment of a pt who has been receiving IV fluids for the last 6 hours, the nurse finds that the pulse is now bounding, the BP is more than 15 mmHg higher than the last reading, and there is pedal edema. The nurse evaluates these signs as associated with:
A. Infiltration of IV site
B. Vascular fluid volume excess
C. Pulmonary air embolism
D. Phlebitis of the leg veins
B. Vascular fluid volume excess
The physician orders an infusion of 1000 mL of 5% dextrose in 0.45 NS to be completed in 8 hours. The IV delivery system’s drop factor is 20. The nurse should set the electronic infusion pump to deliver how many mL/hour?
A. 125
B. 100
C. 85
D. 42
A. 125
1000/8 =125
