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28 Cards in this Set
- Front
- Back
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Nurse would be most concerned about which lab values obtained fro ma client receiving furosemide (Lasix) therapy?
a. BUN 20 b. K 3.4 c. Creatinine 1.1 d. K 3.2 |
d. K = 3.2
Furosemide inhibits reabsorption of sodium, water, and K leading to diuresis. ** The most common electrolyte disturbance associated with furosemde admin is hypokalemia |
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Nurse inserts a nasogastric tube, and it immediately drains 1000 mL of fluid. Which of the follwoing electrolyte level is of greatest concern at this time?
a. Na b. K c. Cl d. CO2 |
K
Hypokalemia is almost universal complication of loss of gastric hydrochloric acid. Metabolic alkalosis results. Other electrolytes may be affected, but not to the degree of potassium homeostasis is altered. |
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The nurse should observe for a Trousseau sign in the client with which of the following electrolyte abnormalities?
a. Hypokalemia b. Hyponatremia c. Hypochloremia d. Hypocalcemia |
d. Hypocalcemia
Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of this is seen in the Trousseau sign, a carpopedal spasm. |
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The WBC count of a client is 18,000. the nurse attributes this value to which of the following health problems of this client?
a. arthritis b. alcoholism c. viral infection d. wound dehisience |
d. wound dehisience
Tissue injury can cause an increase in WBC |
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The majority of the body’s water is contained in which of the following fluid compartments?
A. interstitial B. intracellular C. extracellular D. intravascular |
B. intracellular
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If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is
A. osmosis. B. diffusion. C. active transport. D. facilitated diffusion. |
A. osmosis.
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An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is
A. weight loss. B. full bounding pulse. C. engorged neck veins. D. Kussmaul respiration. |
A. weight loss.
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Implementation of nursing care for the patient with hyponatremia includes
A. fluid restriction. B. administration of hypotonic IV fluids. C. administration of a cation exchange resin. D. increased water intake for patients on nasogastric suction. |
A. fluid restriction.
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A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms?
A. restlessness and agitation B. paresthesias and irritability C. weak, irregular pulse and poor muscle tone D. increased blood pressure and muscle spasms |
C. weak, irregular pulse and poor muscle tone
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Which of the following patients would be at greatest risk for the potential development of hypermagnesemia?
A. 83-year-old man with lung cancer and hypertension B. 65-year-old woman with hypertension taking -adrenergic blockers C. 42-year-old woman with systemic lupus erythematosus and renal failure D. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection |
C. 42-year-old woman with systemic lupus erythematosus and renal failu
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It is especially important for the nurse to assess for which of the following in a patient who has just undergone a total thyroidectomy? A. weight gain B. depressed reflexes C. positive Chvostek’s sign D. confusion and personality changes |
C. positive Chvostek’s sign
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The nurse anticipates that the patient with hyperphosphatemia secondary to renal failure will require
A. calcium supplements. B. potassium supplements. C. magnesium supplements. D. fluid replacement therapy. |
A. calcium supplements.
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The lungs act as an acid-base buffer by
A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. B. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. C. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. D. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load. |
A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
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The typical fluid replacement for the patient with an ICF fluid volume deficit is
A. isotonic. B. hypotonic. C. hypertonic. D. a plasma expander. |
B. hypotonic.
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A client with a history of cardiac disease is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. The nurse expects to evaluate which laboratory values?
A. Albumin and protein levels B. Sodium and chloride levels C. Potassium and blood glucose levels D. Hemoglobin level and hematocrit |
C. Potassium and blood glucose levels
Individuals taking potassium-wasting diuretics are at risk for hypokalemia. Evaluating blood glucose level when the client reports weakness is important to ensure that low blood glucose level is not an issue. Levels of the other substances would not be affected by a potassium-wasting diuretic. |
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The following four clients are all at risk for fluid volume excess. Which of the clients should the nurse see first?
A. 88-year-old client with a fractured femur scheduled for surgery B. 20-year-old client with a 5-year history of type 1 diabetes mellitus C. 65-year-old client recently diagnosed with congestive heart failure D. 50-year-old client with second-degree burns on the ankles and feet |
C. 65-year-old client recently diagnosed with congestive heart failure
The 65-year-old client with congestive heart failure is at the greatest risk for problems from fluid volume excess. Fluid overload in this client could quickly cause life-threatening problems. The 50-year-old client with second degree burns is at risk for fluid volume deficit. |
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The nurse assesses four clients. Which client is at greatest risk for the development of hypocalcemia?
A. 56-year-old client with acute renal failure B. 40-year-old client with systemic lupus erythematosus C. 28-year-old client who has just undergone a total thyroidectomy D. 65-year-old client with hypertension taking beta-adrenergic blockers |
A. 56-year-old client with acute renal failure
The client with acute renal failure is at the highest risk of hypocalcemia. While the patient who underwent a thyroidectomy is at risk, the client with acute renal failure is at a higher risk. |
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Clinical assessment of dehydration would be confirmed if the nurse identified:
A. 1-lb weight loss B. Engorged neck vessels C. Dry mucous membranes D. Full bounding radial pulse |
C. Dry mucous membranes
Dry mucous membranes are a clinical sign of dehydration. Weight loss can be associated with dehydration but is not a confirming sign. Engorged neck vessels and bounding pulse are signs of fluid overload. |
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The nurse anticipates that the physician will order which intravenous (IV) fluid for a client who is dehydrated?
A. Ringer's lactate B. 3% Sodium chloride C. 0.9% Sodium chloride D. 0.45% Sodium chloride |
D. 0.45% Sodium chloride
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The physician has ordered that a client with hypertension begin receiving a thiazide diuretic. The nurse will now closely monitor the client for:
A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hypermagnesemia |
A. Hypokalemia
Thiazide diuretics cause the loss of water and potassium through the kidneys. Thus, if the client is not consuming sufficient potassium in the diet, a hypokalemic state could occur. Hypokalemia can cause muscle weakness and dysrhythmias. Hyponatremia is not usually a problem because there is an abundance of sodium in the body and the additional regulation of sodium by aldosterone would compensate for sodium loss due to diuretics Calcium level would be unaffected by thiazide diuretics. If magnesium were to be affected by thiazide diuretics, it would be excreted along with potassium, but the imbalance would be hypomagnesemia, not hypermagnesemia. |
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The nurse is assisting a physician in obtaining a sample for blood gas analysis from a client's left wrist. After drawing the sample into the syringe, the nurse:
A. Adds a drop of heparin to the sample to prevent clotting B. Seals the end of the syringe and places it in a cup of crushed ice water C. Places the syringe of blood in a dark bag to protect the specimen from light D. Seals the syringe in a zip-lock bag and places the specimen in the out box for laboratory pickup |
B. Seals the end of the syringe and places it in a cup of crushed ice water
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The nurse is conducting an assessment of a client receiving intravenous (IV) fluids via a central line. Today is March 9. The tubing is dated March 5. The nurse determines that the tubing:
A. Is good for 3 more days, for a total of 7 days B. Can remain in place as long as there is not a disconnection C. Needs changing because it is beyond the 3-day recommended limit D. Needs changing, along with the IV port, because they have been in place for 4 days |
C. Needs changing because it is beyond the 3-day recommended limit
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One of the most common electrolyte imbalances is:
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Hypokalemia
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The client most at risk for fluid volume defecit (FVD) is:
a. Elder adult b. Adult c. Child d. Infant |
4. Infant
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One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they:
a. Eat poor quality foods b. Have a decreased thirst sensation c. have more stress response d. have an overly active thirst response |
b. Have a decreased thirst sensation
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Output recorded on an I/O sheet would be all of these:
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Urine
Diarrhea Vomit Gastric suction Wound drainage |
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Health promotion activities in the area of fluid and electrolyte imbalance focus primarily on:
a. client teaching b. dietary intake c. medication d. physician involvement in care |
a. client teaching
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Many factors are intially controlled for the IV insertion procedure. This nurse understands this begins with:
a. hand washing b. checking sterility of supplies c. 6 med rights d. checking IV order |
a. hand washing
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