QUESTIONS AND CORRECT

NCLEX -silversteri -physiological integrity COMPLETE REVISION

QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED

ANSWERS) ALREADY GRADED A+

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? - Answer: 1. Potassium-rich gastrointestinal (GI) fluids are lost through --GI suction, which places the client at risk for hypokalemia.

• The client with intestinal obstruction,

i) Addison's disease, and

ii) metabolic acidosis is at risk for hyperkalemia.The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L).The nurse understands that a potassium value at this level would be noted with which condition?

K+ = ACID - Answer: 1. Diarrhea

2.Traumatic burn 3.Cushing's syndrome

4. 1 / 3

Overuse of laxatives

ans: 2

• A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) is indicative of hyperkalemia.
• Clients who experience the cellular shifting of potassium, as in the early stages of massive cell

destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia.

• The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at

risk for hypokalemia.The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value? -

Answer: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia.

Cardiac changes include a

• wide, flat P wave;
• a prolonged PR interval;
• a widened QRS complex;
• narrow, peaked T waves.

third spacing - Answer: Fluid that shifts into the interstitial space 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 include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age. 2 / 3

Fluid volume deficit - Answer: Causes of a fluid volume deficit include

• vomiting,
• diarrhea,
• conditions that cause increased respirations or increased urinary output,
• insufficient intravenous fluid replacement,
• draining fistulas,
• ileostomy, and ileostomy.

FV Excess

• A client with cirrhosis,
• heart failure (HF), or
• decreased kidney function is at risk for fluid volume excess.

The nurse is caring for a client who has been taking *diuretics* on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? - Answer: Gurgling respirations 2.Increased blood pressure 3.Decreased hematocrit level 4.Increased specific gravity of the urine

ans: 4

Fl.vol deficit ? - Answer: Clients taking diuretics on a long-term basis are at risk for fluid volume deficit.

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