NCLEX Practice Questions: Fluid & Electrolytes, Urinary & Bowel Elimination, and Nutrition

NCLEX Practice Questions: Fluid & Electrolytes, Urinary &

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53 terms vannasaytPreview Skin Int 21 terms P45 A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply.a.) "Try to drink at least six to eight glasses of water each day." b.) "Try to limit your fluid intake to 1 quart of water daily." c.) "Limit sugar, salt, and alcohol in your diet." d.) "Report side effects of medications you are taking, especially diarrhea." e.) "Temporarily increase foods containing caffeine for their diuretic effect." f.) "Weigh yourself daily and report any changes in your weight." a.) "Try to drink at least six to eight glasses of water each day." c.) "Limit sugar, salt, and alcohol in your diet." d.) "Report side effects of medications you are taking, especially diarrhea." f.) "Weigh yourself daily and report any changes in your weight." -In general, fluid intake and output averages 2,600 mL per day.-This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.a.) 5?xtrose in 0.9% NaCl b.) 0.9% NaCl (normal saline) c.) Lactated Ringer's solution d.) 0.33% NaCl (⅓-strength normal saline) e.) 0.45% NaCl (½-strength normal saline) f.) 5?xtrose in Lactated Ringer's solution d.) 0.33% NaCl (⅓-strength normal saline) e.) 0.45% NaCl (½-strength normal saline) -0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia.-5?xtrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available.-0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia.-Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources.-5?xtrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?a.) Recording intake and output.b.) Testing skin turgor.c.) Reviewing the complete blood count.d.) Measuring weight daily.d.) Measuring weight daily.-Daily weight is the most reliable indicator of a person's fluid balance status.-Intake and output are not always as accurate and may involve a subjective component.-Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.A patient has been encouraged to increase fluid intake.Which measure would be most effective for the nurse to implement?a.) Explaining the mechanisms involved in transporting fluids to and from intracellular compartments.b.) Keeping fluids readily available for the patient.c.) Emphasizing the long-term outcome of increasing fluids when the patient returns home.d.) Planning to offer most daily fluids in the evening.b.) Keeping fluids readily available for the patient.-Having fluids readily available helps promote intake.-Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake.-Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation?a.) Remove the IV from the site and start at another location.b.) Immediately notify the primary care provider.c.) Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes.d.) Aspirate the catheter and attempt to flush again.a.) Remove the IV from the site and start at another location.-If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location.-The primary care provider does not need to be notified first.-The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?a.) Encourage foods and fluids with high sodium content.b.) Administer oral K supplements as ordered.c.) Caution the patient about eating foods high in potassium content.d.) Discuss calcium-losing aspects of nicotine and alcohol use.b.) Administer oral K supplements as ordered.-Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered.-Encouraging foods with high sodium content is appropriate for a patient with hyponatremia.-Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?a.) A pinched and drawn facial expression b.) Deep, rapid respirations.c.) Moist crackles heard upon auscultation d.) Tachycardia c.) Moist crackles heard upon auscultation -Moist crackles may indicate fluid volume excess.-A person with a severe fluid volume deficit may have a pinched and drawn facial expression.-Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis.-Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply.a.) The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis.b.) The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up.c.) The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter.d.) The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture.e.) The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma.f.) The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient d.) The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture.e.) The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma.f.) The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient -A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine.-The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma.-For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours.-A sterile urine specimen is not required for a routine urinalysis.-Urine chemistry is altered after urine stands at room temperature for a long period of time.-A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply.a.) A 78-year-old male patient diagnosed with an enlarged prostate b.) An 83-year-old female patient who is on bedrest c.) A 75-year-old female patient who is diagnosed with vaginal prolapse d.) An 89-year-old male patient who has dementia e.) A 73-year-old female patient who is taking antihistamines to treat allergies f.) A 90-year-old male patient who has difficulty walking to the bathroom a.) A 78-year-old male patient diagnosed with an enlarged prostate c.) A 75-year-old female patient who is diagnosed with vaginal prolapse e.) A 73-year-old female patient who is taking antihistamines to treat allergies -Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder.-Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse.-Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.A patient who has pneumonia has had a fever for 3 days.What characteristics would the nurse anticipate related to the patient's urine output?a.) Decreased and highly concentrated b.) Decreased and highly dilute c.) Increased and concentrated d.) Increased and dilute a.) Decreased and highly concentrated -Fever and diaphoresis cause the kidneys to conserve body fluids.-Thus, the urine is concentrated and decreased in amount The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure?a.) The male urethra is more vulnerable to injury during insertion.b.) In the hospital, a clean technique is used for catheter insertion.c.) The catheter is inserted 2 to 3 in into the meatus.d.) Since it uses a closed system, the risk for UTI is absent.a.) The male urethra is more vulnerable to injury during insertion.-Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in.-This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract.-The presence of an indwelling catheter places the patient at risk for a UTI.A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply.a.) Measure the patient's fluid intake and output.b.) Keep the skin around the stoma moist.c.) Empty the appliance frequently.d.) Report any mucus in the urine to the primary care provider.e.) Encourage the patient to look away when changing the appliance.f.) Monitor the return of intestinal function and peristalsis.a.) Measure the patient's fluid intake and output.c.) Empty the appliance frequently.f.) Monitor the return of intestinal function and peristalsis.-When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.