Nclex style questions fluids and electrolytes

Nclex style questions fluids and electrolytes 14 studiers today 5.0 (4 reviews) Students also studied Terms in this set (61) University of KentuckyANA 109 Save Module 2 Fluid & Electrolytes 38 terms saramirez123Preview Nclex electrolyte and acid/base 50 terms sierra_marie317 Preview Acid-Base balance 54 terms arielleflu92Preview NCLEX 67 terms kim The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?

1.A client with ulcerative colitis 2.A client with Cushing's syndrome 3.A client admitted 6 hours ago with a 40% burn injury 4.A client who has a history of long-term laxative abuse A client admitted 6 hours ago with a 40% burn injury

Rationale: Hyperkalemia is likely to occur in clients who experience cellular

shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.Which clients are most likely to be at risk for the development of third spacing? Select all that apply.

1.The client with cirrhosis 2.The client with liver failure 3.The client with diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic kidney disease 1.The client with cirrhosis 2.The client with liver failure 5.The client with chronic kidney disease Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

1.Urinary output 2.Wound drainage 3.Integumentary output 4.The gastrointestinal tract 3.Integumentary output Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes insipidus 4.Client with controlled hypertension 3.Client with diabetes insipidus Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Uric acid level of 9.4 mg/dL (557 mcmol/L) 2.Requires nasogastric suction

Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0

mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL (240 to 501 mcmol/L).The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

1.Hang the solution. 2.Contact the primary health care provider (PHCP). 3.Check the client's daily laboratory results. 4.Ask the client if any liver study tests have ever been done.

2.Contact the primary health care provider (PHCP).

Rationale: The nurse must contact the PHCP before administering the solution.

Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?

1.Tremors 2.Hyperactive reflexes 3.Respiratory depression 4.No specific signs or symptoms because this value is a normal level 3.Respiratory depression Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L).Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D 1.Prolonged bed rest

Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75

mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia.Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value?Select all that apply.

1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes 3.Tall peaked T waves 5.Widened QRS complexes Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level?

1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST segment 4.Widened QRS complexes 3.Depressed ST segment

Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05

mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.30 mL Rationale: The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and 4 oz at dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So if the client drank 820 mL and is allowed 850 mL, subtract 820 from 850.The client may drink 30 mL more fluid on this day.The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations 1.A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.

1.Tetany 2.Constipation 3.Renal calculi 4.Hypotension 5.Prolonged QT interval 6.Positive Chvostek's sign 1.Tetany 4.Hypotension 5.Prolonged QT interval 6.Positive Chvostek's sign Rationale: The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and the presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used.

1.Uncap the distal end of the tubing. 2.Close the roller clamp on the IV tubing. 3.Open the roller clamp and fill the tubing. 4.Attach the distal end of the tubing to the client. 5.Spike the IV bag and half-fill the drip chamber.

Correct Answer: 2, 5, 3, 1, 4

Rationale: The nurse should close the roller clamp on the IV tubing to prevent the solution from running freely through the tubing once it is attached to the IV bag.The nurse should next uncap the proximal (spike) end of the tubing, attach it to the IV bag, and then squeeze the drip chamber to half-fill it. Next, the roller clamp is opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing. Finally, the distal end of the tubing is uncapped and attached to the client.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?

1.Document this assessment finding. 2.Call another nurse to verify this finding. 3.Check skin turgor over the client's sternum. 4.Call the primary health care provider (PHCP) to obtain a prescription for fluid replacement.

3.Check skin turgor over the client's sternum.Rationale: In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

1.Confusion 2.Muscle weakness 3.Mental status changes 4.Depressed deep tendon reflexes 2.Muscle weakness

Rationale: Because potassium plays a major role in neuromuscular activity,

elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure 1.Weight loss and poor skin turgor Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.The nurse is caring for a client with heart failure who is receiving high doses of a 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 signs would the nurse expect to note in a client with hyponatremia?

1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine 3.Hyperactive bowel sounds Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L).Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

1.Tetany 2.Twitches 3.Positive Trousseau's sign 4.Loss of deep tendon reflexes 4.Loss of deep tendon reflexes

Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05

mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.