Disease Questions

70 Questions | By Cclove15 | Updated: Mar 21, 2022 | Attempts: 235

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Practice questions for fluids and electrolytes

Questions and Answers

1.

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?
- A.
  
  Hyponatremia
- B.
  
  Hypocalcemia
- C.
  
  Hyperkalemia
- D.
  
  Hypermagnesemia
Correct Answer
B. Hypocalcemia

Explanation
Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.

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2.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?
- A.
  
  50-year-old with pneumonia, diaphoresis, and high fevers
- B.
  
  62-year-old with congestive heart failure taking loop diuretics
- C.
  
  39-year-old with diarrhea and vomiting
- D.
  
  60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)
Correct Answer
A. 50-year-old with pneumonia, diaphoresis, and high fevers

Explanation
Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

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3.

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?
- A.
  
  Request a physical therapy consult from the physician
- B.
  
  Ensure the client is safe from falls and check the most recent potassium level
- C.
  
  Allow uninterrupted rest periods throughout the day
- D.
  
  Encourage the client to increase intake of dairy products and green leafy vegetables.
Correct Answer
B. Ensure the client is safe from falls and check the most recent potassium level

Explanation
In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

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4.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor
- A.
  
  Urine output.
- B.
  
  Blood pressure.
- C.
  
  Bowel movements.
- D.
  
  ECG for tall, peaked T waves.
Correct Answer
C. Bowel movements.

Explanation
Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

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5.

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?
- A.
  
  Call the physician and report results
- B.
  
  Question the results and redraw the specimen
- C.
  
  Encourage the client to increase the intake of bananas
- D.
  
  Initiate seizure precautions
Correct Answer
B. Question the results and redraw the specimen

Explanation
A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

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6.

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?
- A.
  
  Absent patellar reflex
- B.
  
  Diarrhea
- C.
  
  Premature ventricular contractions
- D.
  
  Increase in blood pressure
Correct Answer
A. Absent patellar reflex

Explanation
An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.

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7.

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?
- A.
  
  Assess for depressed deep tendon reflexes
- B.
  
  Call the physician to report calcium level
- C.
  
  Place an intravenous catheter in anticipation of administering calcium gluconate
- D.
  
  Check to see if a serum albumin level is available
Correct Answer
D. Check to see if a serum albumin level is available

Explanation
A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.

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8.

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply.
- A.
  
  Administer an antiemetic prior to giving the digoxin
- B.
  
  Encourage the client to increase fluid intake
- C.
  
  Call the physician
- D.
  
  Report the urine output
- E.
  
  Report indications of nausea
Correct Answer(s)
C. Call the physician
D. Report the urine output
E. Report indications of nausea

Explanation
Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

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9.

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action?
- A.
  
  Provide passive ROM exercises and encourage fluid intake
- B.
  
  Teach the client to increase intake of whole grains and nuts
- C.
  
  Place a tracheostomy tray at the bedside
- D.
  
  Administer calcium gluconate IM as ordered
Correct Answer
A. Provide passive ROM exercises and encourage fluid intake

Explanation
A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

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10.

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating
- A.
  
  "The client may be suffering from dementia, and the hospitalization has worsened the confusion."
- B.
  
  "Most older adults get confused in the hospital."
- C.
  
  "The sodium level is low, and the confusion will resolve as the levels normalize."
- D.
  
  "The sodium level is high and the behavior is a result of dehydration."
Correct Answer
C. "The sodium level is low, and the confusion will resolve as the levels normalize."

Explanation
Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

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11.

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?
- A.
  
  Turn down the infusion
- B.
  
  Check the latest sodium level
- C.
  
  Assess for signs of fluid overload
- D.
  
  Place a call to the physician
Correct Answer
C. Assess for signs of fluid overload

Explanation
A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

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12.

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?
- A.
  
  Bisacodyl (Dulcolax) suppository
- B.
  
  Fiber supplements
- C.
  
  Docusate sodium
- D.
  
  Milk of magnesia
Correct Answer
D. Milk of magnesia

Explanation
Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

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13.

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?
- A.
  
  Encourage the client to increase fluid intake
- B.
  
  Administer the dose as ordered
- C.
  
  Draw a potassium level and administer the dose if the level is low or normal
- D.
  
  Notify the physician of the urine output and hold the dose
Correct Answer
D. Notify the physician of the urine output and hold the dose

Explanation
Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician order.

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14.

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?
- A.
  
  A client with osteoporosis taking vitamin D and calcium supplements
- B.
  
  A client who is alcoholic receiving total parenteral nutrition
- C.
  
  A client with chronic renal failure awaiting the first dialysis run
- D.
  
  A client with hypoparathyroidism secondary to thyroid surgery
Correct Answer
B. A client who is alcoholic receiving total parenteral nutrition

Explanation
A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving TPN are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.

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15.

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply.
- A.
  
  Eggs
- B.
  
  Broccoli
- C.
  
  Organ meats
- D.
  
  Nuts
- E.
  
  Canned salmon
Correct Answer(s)
B. Broccoli
D. Nuts
E. Canned salmon

Explanation
Fish, eggs, and organ meats are high in phosphorus. Broccoli, nuts, and canned salmon are high in calcium. Clients with lung or breast cancer often have elevated calcium levels due to tumor-induced hyperparathyroidism.

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16.

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment?
- A.
  
  Sodium
- B.
  
  Phosphorus
- C.
  
  Calcium
- D.
  
  Magnesium
Correct Answer
D. Magnesium

Explanation
Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.

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17.

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?
- A.
  
  Increase intake of dairy products and nuts
- B.
  
  Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals
- C.
  
  Reduce intake of chocolate, meats, and whole grains
- D.
  
  Avoid calcium supplements
Correct Answer
B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals

Explanation
Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.

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18.

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?
- A.
  
  Administer a sedative
- B.
  
  Place client in left lateral position
- C.
  
  Place client in high-Fowler's position
- D.
  
  Assist the client to breathe into a paper bag
Correct Answer
C. Place client in high-Fowler's position

Explanation
The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

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19.

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?
- A.
  
  Call the physician and report the change in client's condition
- B.
  
  Turn the client's O2 up to 4 liters nasal cannula
- C.
  
  Encourage the client to sit down and to take deep breaths
- D.
  
  Encourage the client to rest and to use pursed-lip breathing technique
Correct Answer
D. Encourage the client to rest and to use pursed-lip breathing technique

Explanation
Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

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20.

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?
- A.
  
  D5.45 NS at 50 ml/hr
- B.
  
  0.9 NS at an open rate
- C.
  
  D5W at 125 ml/hr
- D.
  
  0.45 NS at open rate
Correct Answer
B. 0.9 NS at an open rate

Explanation
A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

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21.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?
- A.
  
  PH of 7.43, PCO2 of 36, HCO3 of 26
- B.
  
  PH of 7.41, PCO2 of 49, HCO3 of 30
- C.
  
  PH of 7.33, PCO2 of 35, HCO3 of 17
- D.
  
  PH of 7.25, PCO2 of 56, HCO3 of 28
Correct Answer
C. PH of 7.33, PCO2 of 35, HCO3 of 17

Explanation
A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.

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22.

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?
- A.
  
  Respiratory alkalosis
- B.
  
  Respiratory acidosis
- C.
  
  Metabolic alkalosis
- D.
  
  Metabolic acidosis
Correct Answer
C. Metabolic alkalosis

Explanation
Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

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23.

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention?
- A.
  
  Monitor intake and output
- B.
  
  Encourage client to increase activity
- C.
  
  Institute deep breathing exercises every hour
- D.
  
  Provide reassurance to the client and administer sedatives
Correct Answer
D. Provide reassurance to the client and administer sedatives

Explanation
A client who is anxious and upset, gets lightheaded, and has tingling in the fingers is in respiratory alkalosis. The arterial blood gases include a pH of 7.48, PaCO2 of 29, and HCO3 of 24. Administering sedatives will assist the client to slow breathe and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

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24.

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating?
- A.
  
  Deep tendon reflexes decreasing from +2 to +1
- B.
  
  Bicarbonate rising from 20 mEq/L to 22 mEq/L
- C.
  
  Urine pH less than 6
- D.
  
  Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
Correct Answer
A. Deep tendon reflexes decreasing from +2 to +1

Explanation
A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.

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25.

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?
- A.
  
  "The fluid is an adverse reaction to chemotherapy."
- B.
  
  "A decrease in activity has allowed extra fluid to accumulate in the tissues."
- C.
  
  "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."
- D.
  
  "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."
Correct Answer
C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

Explanation
Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

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26.

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?
- A.
  
  Bone pain
- B.
  
  Depressed deep tendon reflexes
- C.
  
  Positive Chvostek's sign
- D.
  
  Nausea
Correct Answer
C. Positive Chvostek's sign

Explanation
Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.

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27.

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client?
- A.
  
  Deficient fluid volume related to decreased fluid intake
- B.
  
  Excess fluid volume related to increased water retention
- C.
  
  Deficient fluid volume related to excessive fluid loss
- D.
  
  Risk for injury related to fluid volume loss
Correct Answer
B. Excess fluid volume related to increased water retention

Explanation
The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

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28.

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse?
- A.
  
  Assess a client for metabolic acidosis
- B.
  
  Evaluate the blood gases of a client with respiratory alkalosis
- C.
  
  Obtain a glucose level on a client admitted with diabetes mellitus
- D.
  
  Perform a neurological assessment on a client suspected of having hypocalcemia
Correct Answer
C. Obtain a glucose level on a client admitted with diabetes mellitus

Explanation
A licensed practical nurse may obtain a finger-stick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological assessment on a client suspected of hypocalcemia.

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29.

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention?
- A.
  
  Withhold furosemide (Lasix)
- B.
  
  Notify the physician
- C.
  
  Administer the prescribed potassium supplement
- D.
  
  Instruct the client on foods high in potassium
Correct Answer
B. Notify the physician

Explanation
The priority intervention for a client who had gallbladder surgery, has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum potassium of 3.0 mEq/L would be to notify the physician that the potassium level is low. After notifying the physician, the furosemide (Lasix) may be withheld and potassium supplement should be administered as prescribed and may even be increased after talking with the physician. The client may also be instructed on foods high in potassium. These are all appropriate interventions but not the priority.

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30.

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of
- A.
  
  Acute renal failure.
- B.
  
  Malabsorption syndrome.
- C.
  
  Nasogastric drainage.
- D.
  
  Laxative abuse
Correct Answer
A. Acute renal failure.

Explanation
A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndrome, nasogastric drainage, and laxative abuse may result in a low serum potassium level, because output may be greater than input. Diarrhea results in malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L.

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31.

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L?
- A.
  
  Pretzels
- B.
  
  Baked chicken
- C.
  
  Chicken bouillon
- D.
  
  Baked potato
- E.
  
  Baked ham
Correct Answer(s)
B. Baked chicken
D. Baked potato

Explanation
Normal serum sodium is between 135 and 145 mEq/L. A sodium level of 158 mEq/L is elevated and a low sodium diet should be prescribed. A peanut butter sandwich, pretzels, chicken bouillon, and baked ham are all foods high in sodium content. Baked chicken and baked potato are low-sodium food choices.

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32.

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?
- A.
  
  Hypokalemia
- B.
  
  Hypernatremia
- C.
  
  Hypermagnesemia
- D.
  
  Hypocalcemia
Correct Answer
D. Hypocalcemia

Explanation
Normal serum calcium is 9 to 11 mg/dl. A client who has hypocalcemia would experience muscle cramps, numbness, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypothyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.

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33.

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?
- A.
  
  Sodium is essential to maintain intracellular fluid water balance
- B.
  
  Magnesium is essential to the function of muscle, red blood cells, and nervous system
- C.
  
  Less calcium is excreted with aging
- D.
  
  Chloride is lost in hydrochloride acid
Correct Answer
D. Chloride is lost in hydrochloride acid

Explanation
Sodium is essential to maintain extracellular fluid water balance. Phosphate is the major anion in intracellular fluid water balance that is essential in the function of muscle, red blood cells, and nervous system. A person tends to excrete more calcium with age. Chloride is lost through hydrochloride acid.

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34.

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply.
- A.
  
  Baked cod
- B.
  
  Ham and cheese omelet
- C.
  
  Fried eggs
- D.
  
  Baked potato
- E.
  
  Spinach
Correct Answer(s)
A. Baked cod
D. Baked potato
E. Spinach

Explanation
Normal serum potassium is 3.5 to 5.5 mEq/L. A client who has a potassium of 3.2 mEq/L would benefit from a diet high in potassium. Baked cod, baked potato, and spinach are all food selections high in potassium. A ham and cheese omelet is high in sodium. Fried eggs are high in cholesterol. A whole grain muffin is high in grains.

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35.

The nurse evaluates which of the following clients to have hypermagnesemia?
- A.
  
  A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L
- B.
  
  A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L
- C.
  
  A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L
- D.
  
  A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L
Correct Answer
C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L

Explanation
Normal serum magnesium is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.

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36.

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first?
- A.
  
  A client with osteoporosis and a calcium level of 10.6 mg/dl
- B.
  
  A client with renal failure and a magnesium level of 2.5 mEq/L
- C.
  
  A client with bulimia and a potassium level of 3.6 mEq/L
- D.
  
  A client with dehydration and a sodium level of 149 mEq/L
Correct Answer
D. A client with dehydration and a sodium level of 149 mEq/L

Explanation
Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dl is normal. Normal serum calcium is 9 to 11 mg/dl. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal. Normal serum potassium is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated.

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37.

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?
- A.
  
  A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L
- B.
  
  A client with renal failure who has a serum magnesium level of 3.0 mEq/L
- C.
  
  A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl
- D.
  
  A client with dehydration who has a serum sodium level of 128 mEq/L
Correct Answer
A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L

Explanation
Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience a low chloride level, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dl is elevated. Normal serum phosphate is 2.8 to 4.5 mg/dl. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium is 135 to 145 mEq/L.

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38.

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings?
- A.
  
  Overhydration.
- B.
  
  Anemia.
- C.
  
  Dehydration.
- D.
  
  Renal failure.
Correct Answer
C. Dehydration.

Explanation
A. (incorrect) Clients who are overhydrated or have fluid volume excess would experience dilutional values of sodium (135-145 mEq/L) and red blood cells (44% to 52%). The levels would be lower than normal, not higher.
B. (incorrect) Anemia is a low red blood cell count for a variety of reasons.
C. (correct) Dehydration results in concentrated serum that causes lab values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.
D. (incorrect) In renal failure, the kidneys cannot excrete, and this results in too much fluid in the body.

TEST-TAKING HINT: The test taker must decide first if the values are high or low and then determine what is happening with body fluids in each process. Overhydration and renal failure result in the same fluid shift, so these two options (A and D) could be excluded.

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39.

The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider?
- A.
  
  The pump keeps sounding an alarm that the high pressure has been reached.
- B.
  
  Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL.
- C.
  
  On auscultation, crackles and rales in all lung fields are noted.
- D.
  
  Client has negative pedal edema and an increasing level of consciousness.
Correct Answer
C. On auscultation, crackles and rales in all lung fields are noted.

Explanation
A. (incorrect) The pump is alerting the nurse that there is resistance distal to the pump; this does not require notifying the health care provider.
B. (incorrect) The client has an 1800 mL intake and total output of 1500 mL. The body has an insensible loss of approximately 400 mL per day through the skin, respirations, and other body functions. This would not warrant notifying the health care provider.
C. (correct) Crackles and rales in all lung fields indicate that the body is not able to process the amounts of fluids being infused. This should be brought to the health care provider's attention.
D. (incorrect) Negative pedal edema and an increasing level of consciousness indicate that the client is not experiencing a problem.

TEST-TAKING HINT: The question requires the test taker to distinguish nursing problems from client problems. Option A is a nursing problem and options B and D are expected results, so the health care provider does not need to be notified. Only one option, C, contains abnormal or life-threatening information.

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40.

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)?
- A.
  
  500 mL
- B.
  
  1000 mL
- C.
  
  2000 mL
- D.
  
  4400 mL
Correct Answer
C. 2000 mL

Explanation
First, determine how many pounds the client has lost:

180 - 175.6 = 4.4 pounds lost

Then, based on the fact that 1 liter of fluid weighs 2.2 pounds, determine how many liters of fluid have been lost.

4.4 / 2.2 = 2 liters lost

Then, because the question asks for the answer in milliliters, convert 2 liters into milliliters.

2 x 1000 = 2000 mL

TEST-TAKING HINT: The test taker must be able to work basic math problems. This problem has several steps. Sometimes it is helpful to write out what is occurring at each step, such as 4.4 divided by 2.2 kg per pound. This can help the test taker realize if a step has been overlooked.

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41.

The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care?
- A.
  
  Change the IV fluid from 0.9% NS to D5W.
- B.
  
  Restrict the client's sodium in the diet.
- C.
  
  Monitor blood glucose levels.
- D.
  
  Prepare the client for hemodialysis.
Correct Answer
B. Restrict the client's sodium in the diet.

Explanation
A. (incorrect) The nursing plan of care does not include changing the health care provider's orders.
B. (correct) Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume.
C. (incorrect) High blood glucose levels result in viscous blood and cause the kidneys to try and fix the problem by excreting the glucose through increasing the urine output, which results in fluid volume deficits.
D. (incorrect) If the FVE is the result of renal failure, then hemodialysis may be ordered, but this information was not provided in the stem of the question.

TEST-TAKING HINT: Option A is not a nursing prerogative. The test taker should not read into the question.

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42.

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A.
  
  Encourage fluids orally.
- B.
  
  Administer 10% saline solution IVPB.
- C.
  
  Administer antidiuretic hormone intranasally.
- D.
  
  Place on seizure precautions.
Correct Answer
D. Place on seizure precautions.

Explanation
A. (incorrect) The client probably will be placed on fluid restriction. Fluids should not be encouraged for a client with a low sodium level (135-145 mEq/L).
B. (incorrect) Hypertonic solutions of saline are 3% to 5%, not 10%, because of the extreme nature of hypertonic solutions. Hypertonic solutions of saline may be used but very cautiously because if the sodium levels are increased too rapidly, a massive fluid shift can occur in the body, resulting in neurological damage and heart failure.
C. (incorrect) THe antidiuretic hormone (vasopressin) would cause water retention in the body and increase the problem.
D. (correct) Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.

TEST-TAKING HINTS: The test taker must memorize certain common lab values and understand how deviations in the electrolytes affect the body.

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43.

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A.
  
  The client in normal sinus rhythm with a peaked T wave.
- B.
  
  The client diagnosed with atrial fibrillation with a rate of 100.
- C.
  
  The client diagnosed with a myocardial infarction who has occasional PVC.
- D.
  
  The client with a first-degree AV block and a rate of 92.
Correct Answer
A. The client in normal sinus rhythm with a peaked T wave.

Explanation
A. (correct) A client with a peaked wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability.
B. (incorrect) Fluctuations in rate are expected in clients diagnosed with atrial fibrillation, and a heart rate of 100 is at the edge of a normal rate.
C. (incorrect) Most people experience an occasional premature ventricular contraction (PVC); this would not warrant the nurse assessing this client first.
D. (incorrect) A first-degree block is not an immediate problem.

TEST-TAKING HINT: The test taker must know the normal data so that the abnormal will be apparent. Normal heart rate is 60-100. The nurse should assess the client who has an abnormal or life-threatening condition.

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44.

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first?
- A.
  
  Notify the health care provider immediately.
- B.
  
  Tap the cheek about two (2) centimeters anterior to the ear lobe.
- C.
  
  Check the serum calcium and magnesium levels.
- D.
  
  Prepare to administer calcium gluconate IVP.
Correct Answer
B. Tap the cheek about two (2) centimeters anterior to the ear lobe.

Explanation
A. (incorrect) The health care provider may need to be notified, but the nurse should perform assessment first.
B. (correct) These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency.
C. (incorrect) A positive Chvostek's sign can indicate a low calcium or magnesium level, but serum lab levels may have been drawn hours previously or may not be available.
D. (incorrect) If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment.

TEST-TAKING HINT: Assessment is the first step in the nursing process and is an appropriate option to select if the test taker has difficulty when trying to decide between two options.

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45.

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)?
- A.
  
  The kidneys produce excess urine and the lungs try to compensate.
- B.
  
  The respirations increase the amount of carbon dioxide in the bloodstream.
- C.
  
  The lungs speed up to release carbon dioxide and increase the pH.
- D.
  
  The shallow and slow respirations will increase the HCO3 in the serum.
Correct Answer
C. The lungs speed up to release carbon dioxide and increase the pH.

Explanation
A. (incorrect) Kussmaul's respirations are the lung's attempt to maintain the narrow range of pH that is compatible with human life. The respiratory system reacts rapidly to changes in pH.
B. (incorrect) Respiration is the act of moving oxygen and carbon dioxide. Kussmaul's respirations are rapid and deep and allow the client to exhale carbon dioxide.
C. (correct) The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).
D. (incorrect) HCO3 (sodium bicarbonate) is an alkaline (base) substance that is a metabolic buffer system, not a respiratory system buffer. The excretion and retention of sodium bicarbonate is regulated by the kidneys; therefore, it is a metabolic buffer system. The excretion and retention of carbon dioxide (CO2) are regulated by the lungs and therefore is a respiratory buffer system.

TEST-TAKING HINT: Homeostasis is a delicate balance between acids and bases. The test taker can discard option A by realizing that production of urine does not affect the respirations.

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46.

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.
- A.
  
  Place the solution on an IV pump at the prescribed rate.
- B.
  
  Monitor blood glucose every six (6) hours.
- C.
  
  Weigh the client weekly, first thing in the morning.
- D.
  
  Change the IV tubing every three (3) days.
- E.
  
  Monitor intake and output every shift.
Correct Answer(s)
A. Place the solution on an IV pump at the prescribed rate.
B. Monitor blood glucose every six (6) hours.
E. Monitor intake and output every shift.

Explanation
A. (correct) TPN is a hypertonic solution that has enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion.
B. (correct) TPN contains 50% dextrose solution; therefore, the client is monitored to ensure that the pancreas is adapting to the high glucose levels.
C. (incorrect) The client is weighed daily, not weekly, to monitor for fluid overload.
D. (incorrect) The IV tubing is changed with every bag because the high glucose level can cause bacterial growth.
E. (correct) Intake and output are monitored to observe for fluid balance.

TEST-TAKING HINT: Options C and E refer to the same factor--namely, fluid level. The test taker should then determine if the time factors are appropriate. Weekly weighing is not appropriate so C can be eliminated.

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47.

The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?
- A.
  
  Start a new IV in the right hand.
- B.
  
  Discontinue the intravenous line.
- C.
  
  Complete an incident record.
- D.
  
  Place a warm washrag over the site.
Correct Answer
B. Discontinue the intravenous line.

Explanation
A. (incorrect) A new IV will be started in the right hand after the IV is discontinued.
B. (correct) The client has signs of phlebitis and the IV must be removed to prevent further complications.
C. (incorrect) Depending on the health-care facility, this may or may not be done, but client care comes before documentation.
D. (incorrect) A warm washrag placed on an IV site sometimes provides comfort to the client. If this is done, it should be done for 20 minutes four (4) times a day.

TEST-TAKING HINT: The question is asking for a first action, which means all of the options may be actions the nurse would implement, but only one is priority. In general, priority actions are to stop the problem, continue treatment, treat the problem, and then document.

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48.

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?
- A.
  
  Measure the client's output from the indwelling catheter.
- B.
  
  Record the client's intake and output on the I & O sheet.
- C.
  
  Instruct the client on appropriate fluid restrictions.
- D.
  
  Provide water for a client diagnosed with diabetes insipidus.
Correct Answer
C. Instruct the client on appropriate fluid restrictions.

Explanation
A. (incorrect) An assistant can empty the catheter and measure the amount.
B. (incorrect) The assistant can record intake and output on the I & O sheet.
C. (correct) The nurse cannot delegate teaching.
D. (incorrect) The client has a disease, but all the assistant is being asked to do is take water to the client.

TEST-TAKING HINT: This is an example of an "except" question. Frequently questions ask which tasks can be assigned to the assistant, but this question asks which action the nurse should implement. If the test taker does not read carefully, it is easy to jump to the first option for actions that the assistant can perform.

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49.

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?
- A.
  
  Serum calcium.
- B.
  
  Serum phosphorus.
- C.
  
  Serum potassium.
- D.
  
  Serum sodium.
Correct Answer
C. Serum potassium.

Explanation
A. (incorrect) Serum calcium is decreased in conditions such as osteoporosis or post-thyroid surgery, but not in vomiting and diarrhea.
B. (incorrect) Serum phosphorus levels are altered in acute and chronic renal failure or diabetic ketoacidosis, among other conditions, but not with acute fluid losses from the gastrointestinal tract.
C. (correct) Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias.
D. (incorrect) The body is not at risk from losing sodium from these sources as it is with potassium.

TEST-TAKING HINT: The nurse must recognize basic fluids and electrolytes in the body and the implications of excess or loss. The body holds onto sodium and releases potassium.

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50.

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:
- A.
  
  The skin
- B.
  
  Urinary output
- C.
  
  Wound drainage
- D.
  
  The gastrointestinal tract
Correct Answer
A. The skin

Explanation
Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

Test-Taking Strategy: Note that the subject of the question is insensible fluid loss. Use the process of elimination, noting that options B, C, and D are comparative or alike. In options B, C, and D, these types of losses can be measured for accurate output. Fluid loss through the skin cannot be measured accurately, only approximated. If you had difficulty with this question, review the difference between sensible and insensible fluid loss.

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Mar 21, 2022

Quiz Edited by
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Nov 02, 2012

Quiz Created by
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Disease Questions

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action?

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply.

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating?

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client?

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse?

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L?

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply.

The nurse evaluates which of the following clients to have hypermagnesemia?

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first?

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings?

The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider?

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)?

The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care?

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first?

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)?

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.

The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: