Med Surg Ch 8 Fluid and Electrolyte nclex questions

Med Surg Ch 8 Fluid and Electrolyte nclex questions ScienceMedicineNursing hornet0330 Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview Fluid and Electrolytes NCLEX Quest...96 terms daniela_alldredge Preview NCLEX 83 terms kat The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit. The patient is currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. The patient has a decreased urine output. Which probable cause to the patient's symptoms should the nurse include when educating the family?1) Congestive heart failure 2) Rapidly infused intravenous fluids 3) Natural compensatory mechanisms 4) Pharmacological effects of a diuretic

ANS: 3

The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart.The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure performed three days prior.Which intervention should the nurse implement to decrease the risk for the development of hypercalcemia?1) Monitor vital signs every eight hours 2) Encourage ambulation three times a day 3) Irrigate the Foley catheter one time a day 4) Recommend turning, coughing, and deep breathing every two hours

ANS: 2

Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.

Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL?1) Enforce contact precautions 2) Strain all urine for kidney stones 3) Encourage consumption of milk and yogurt 4) Discourage the consumption of a high-calorie diet

ANS: 3

A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus.The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive heart failure (CHF). The patient's serum potassium level is 3.4 mEq/L. Which food should the nurse encourage the patient to eat based on this data?1) Peas 2) Iced tea 3) Bananas 4) Baked fish

ANS: 3

A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is banana.A patient is admitted to the emergency department (ED) for dehydration. The patient is 154 lbs. Which urine output indicate the rehydration efforts for this patient have been effective?1) 20 mL/hr 2) 25 mL/hr 3) 30 mL/hr 4) 35 mL/hr

ANS: 4

Expected urine output for an adult patient is 0.5 mL/kg/hr. The patient currently weighs 70 kg; therefore, adequate urine output would be at least 35 mL/hr.An older adult patient, who appears intermittently confused, is admitted to the hospital after a fall. Based on the current data, which is the patient at an increased risk for developing?1) Brain attack 2) Dehydration 3) Hemorrhage 4) Kidney damage

ANS: 2

During the aging process, the thirst mechanism declines. In a patient with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality.

The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hr. The patient is currently exhibiting crackles in the lungs, shortness of breath, and jugular vein distention. Which complication of IV fluid therapy does the nurse suspect the patient is experiencing?1) Speed shock 2) Fluid volume excess 3) Anaphylactic reaction 4) Pulmonary embolism

ANS: 2

Fluid volume excess may occur when older adult patients receive intravenous fluids rapidly.A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for this drug the nurse should provide to the patient?1) It controls and regulates water balance in the body.2) It is used in the body to synthesize ingested protein.3) It is vital in regulating muscle contraction and relaxation.4) It is needed to maintain skeletal, cardiac, and neuromuscular activity.

ANS: 4

Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity.Which data collected by the nurse during the assessment process places the older adult patient at risk for dehydration?1) Poor skin turgor 2) Body mass index of 20.5 3) Blood pressure of 140/98 mmHg 4) Water intake of 2 glasses per day

ANS: 4

A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the patient only ingests two glasses of water each day, this could indicate a reduction in the normal thirst response.The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance. Which laboratory value evaluated by the nurse supports the diagnosis of dehydration?1) Hematocrit 30% 2) Hematocrit 53% 3) Serum potassium 3.8 mEq/L 4) Serum osmolality 230 mOsm/kg

ANS: 2

The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration.

The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data, which conclusion by the nurse is the most appropriate?1) Treatment has not been effective.2) Treatment needs to include a diuretic.3) Treatment is effective and should continue.4) Treatment has been effective and should end.

ANS: 3

Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Patients whose intake substantially exceeds output are at risk for fluid volume excess; however, the patient is dehydrated. The extra fluid intake is being used to improve body fluid balance. The patient's output is 40 mL/hr, which is within the normal range.The nurse is providing care to a patient who seeks emergency treatment for headache and nausea. The patient works in a mill without air conditioning. The patient states, "I drink water several times each day but I seem to sweat more than I am able to replace." Which suggestions should the nurse provide to this patient?1) Drink juices and carbonated sodas.2) Eat something salty when drinking water.3) Eat something sweet when drinking water.4) Double the amount of water being ingested.

ANS: 2

Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium.An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for this patient?1) Dehydration 2) Hypertension 3) Fluid overload 4) Congestive heart failure

ANS: 1

Older adult patients are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The patient's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration.The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four patients for the shift. Which child does the nurse plan to assess first based on the increased risk for dehydration?1) A 4-year-old child with a broken leg 2) A 15-month-old child with tachypnea 3) A 16-year-old child with migraine headaches 4) A 10-year-old child with cellulitis of the left leg

ANS: 2

The pediatric patient with the greatest risk for dehydration is the child who is under 2 years of age experiencing tachypnea which increases insensible fluid loss.