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20 Cards in this Set
- Front
- Back
A nurse is reading 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: |
The skin |
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A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which clients is at risk for fluid volume deficit?
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A client with a colostomy. |
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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 a fluid volume excess?
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The client with renal failure. |
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The nurse is caring for a client with CHF. On assessment, the nurse notes that the client is dyspnea and that rales are heard on auscultation. The nurse suspects fluid volume excess. what additional signs would the nurse expect to note in this client if fluid volume excess is present?
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Increase in blood pressure. |
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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 is at risk for developing the potassium deficit because the client:
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Is on nasogastric (NG) suction. |
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A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2,Eq/L. Which of the following would the nurse note on the ECG as a result of the laboratory value?
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U waves
A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is a relatively common electrolyte imbalance and is potentially life threatening. ECG changes include inverted T waves, ST segment depression, heart block, and prominent U wave. |
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A nurse prepares to administer IV potassium chloride as prescribed to a client with hypokalemia. Which of the following would not be a part of the nurse's plan in regard to the preparation and administration of the potassium?
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Prepare the medication for bolus administration. |
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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?
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Apples |
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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 reports. The nurse understands that which client is at most risk for the development of a potassium value at this level?
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The client who has sustained a traumatic burn. |
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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 ECG as a result of the laboratory value?
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Tall T waves
A serum potassium level above 5.4 mEq.L is indicative of hyperkalemia. ECG changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall T waves. |
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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 reports. The nurse understands that which client is at most risk for the development of a sodium value at this level?
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The client who is taking diuretics. |
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A nurse is caring for a client with acute congestive heart failure who is receiving high doses of high-ceiling 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 sighs would the nurse expect to note in this client if hyponatremia is present?
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Hyperactive bowel sounds. |
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A nurse is caring for a client with a nasogastric (NG) tube. NG tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a p potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. On the basis of these laboratory findings, the nurse selects which solution to use for the NG tube irrigation?
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Normal saline. |
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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 dose the nurse instruct the client to avoid?
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Processed oat cereals. |
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A nurse is reviewing a client's laboratory reports 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?
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Prolonged bed rest. |
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A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following assessment sighs/symptoms would not be an indication of this diagnosis?
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Hypoactive bowel sounds. |
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A nurse caring for a client with hypocalcemia would expect to note which of the fowl lowing changes on the electrocardiogram (ECG)?
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Prolonged QT interval. |
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A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which ECG change would the nurse expect to note based on the magnesium level?
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Depressed ST segment.
The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. |
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A nurse reviews the serum phosphorus level and notes that the client's level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
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Alcoholism. |
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A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which assessment finding would be noted in a client with this condition?
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Decreased central venous pressure (CVP) |