Fluids And Electrolytes - Exam

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FLUIDS AND ELECTROLYTES; ACID-BASE BALANCE  June 01, 2015 2015 1. What is the nurse's primary concern regarding fuid & electrolytes when caring or an elderly pt who is intermittently conused? A. risk o dehydration B. risk o kidney damage C. risk o stroke . risk o !leeding ". #he nurse is planning care or a pt with se$ere !urns. Which o the ollowing is this pt at risk or de$eloping? A. intracellular fuid de%cit B. intracellular fuid o$erload C. etracellular fuid de%cit . interstitial fuid de%cit . A pt( eperiencing multisystem fuid $olume de%cit( has the symptoms o tachycardia( pale( cool skin( & decreased urine output. #he nurse reali)es these %ndings are most likely a direct result o which o the ollowing? A. the !ody's natural compensatory mechanisms B. pharmacological e*ects o a diuretic C. e*ects o rapidly inused intra$enous fuids . cardiac ailure +. A pregnant pt is admitted with ecessi$e thirst( increased urination( & has a medical diagnosis o dia!etes insipidus. #he nurse chooses which o the ollowing nursing diagnoses as most appropriate? A. ,isk or -m!alanced luid /olume B. 0cess luid /olume C. -m!alanced utrition . -ne*ecti$e #issue 2erusion 3. A pt reco$ering rom surgery has an indwelling urinary catheter. #he nurse would contact the pt's primary healthcare pro$ider with which o the ollowing "+4hour urine output $olumes? A. 566 m7 B. 836 m7 C. 1666 m7 . 1"66 m7 5. A pt is recei$ing intra$enous fuids postoperati$ely ollowing cardiac surgery. ursing assessments should ocus on which postoperati$e complication? A. fuid $olume ecess B. fuid $olume de%cit C. sei)ure acti$ity . li$er ailure 8. A pt is diagnosed with se$ere hyponatremia. #he nurse reali)es this pt will mostly likely need which o the ollowing precautions implemented? A. sei)ure C. neutropenic B. inection . high4risk all 9. A pt is diagnosed with hypokalemia. Ater re$iewing the pt's current medications( which o the ollowing might ha$e contri!uted to the pt's health pro!lem? A. corticosteroid C. narcotic B. thia)ide diuretic . muscle relaer :. A pt prescri!ed spironolactone is demonstrating 0C; changes & complaining o muscle weakness. #he nurse reali)es this pt is ehi!iting signs o which o the ollowing? A. hyperkalemia B. hypokalemia C. hypercalcemia . uest a dietitian consult or selecting oods high in phosphorous. B. 2ro$ide aluminum hydroide antacids as prescri!ed. C. -nstruct pt to a$oid poultry( peanuts( peanuts( & seeds. . -nstruct to a$oid the intake o sodium phosphate. 1. When analy)ing an arterial !lood gas report o a pt with C2 & respiratory acidosis( the nurse anticipates that compensation will de$elop through which o the ollowing mechanisms? A. #he kidneys retain !icar!onate. B. #he kidneys ecrete !icar!onate. C. #he lungs will retain car!on dioide. . #he lungs will ecrete car!on dioide. 1+. #he nurse is caring or a pt diagnosed with renal ailure. Which o the ollowing does the nurse recogni)e as compensation or the acid4!ase distur!ance ound in pts with renal ailure? A. #he pt !reathes rapidly to eliminate car!on dioide. B. #he pt will retain !icar!onate in ecess o normal. C. #he p< will decrease rom the present $alue. . #he pt's oygen saturation le$el will impro$e. 13. When caring or a group o pts( the nurse reali)es that which o the ollowing health pro!lems increases the risk or meta!olic alkalosis? A. !u !ulimia C. $e $enous st stasis ulcer B. dialysis . C2 15. #he nurse is caring or a pt who is anious & di))y ollowing a traumatic eperience. #he arterial !lood gas %ndings include@ p< 8.+9( 2a" 116( 2aC" "3( & o potassium chloride.  #he nurse reali)es reali)es that the the reason the pt is recei$ing recei$ing this replacement is 1 A. to sustain respiratory unction. B. to help regulate acid4!ase !alance. C. to keep a $ein open. . to encourage urine output. 19. An elderly pt does not complain o thirst. What should the nurse do to assess that this pt is not dehydrated? A. Ask the physician or an order to !egin intra$enous fuid replacement. B. Ask the physician to order a chest 4ray. C. Assess the urine or osmolality. . Ask the physician or an order or a !rain scan. 1:. An elderly pt who is !eing medicated or pain had an episode o incontinence. #he nurse reali)es that this pt is at risk or de$eloping A. dehydration. B. o$er4hydration. C. ecal incontinence. . a stroke. "6. #he nurse assesses a pt's weight loss as !eing "" l!s. uate fuid status. What can the nurse do to help this pt? A. Assist the pt to maintain a standing position or se$eral minutes. B. #his pt should !e on !ed rest. C. Assist the pt to mo$e into di*erent positions in stages. . Contact physical therapy to pro$ide a walker. "". A postoperati$e pt is diagnosed with fuid $olume o$erload. Which o the ollowing should the nurse assess in this pt? A. poor skin turgor B. decreased urine output C. distended neck $eins . concentrated hemoglo!in & hematocrit le$els ". An elderly pt is at home ater !eing diagnosed with fuid $olume o$erload. Which o the ollowing should the home care nurse instruct this pt to do? A. Wear support hose. B. =eep legs in a dependent position. C. A$oid wearing shoes while in the home. . #ry to sleep without etra pillows. "+. A pt with fuid retention related to renal pro!lems is admitted to the hospital. #he nurse reali)es that this pt could possi!ly ha$e which o the ollowing electrolyte im!alances? A. hypokalemia B. hypernatremia C. car!on dioide . agnesium "3. An elderly pt comes into the clinic with the complaint o watery diarrhea or se$eral days with a!dominal & muscle cramping. #he nurse reali)es that this pt is demonstrating which o the ollowing? A. hypernatremia B. hyponatremia C. fuid $olume ecess . potassium as a replacement. #he nurse reali)es that this replacement should !e administered A. directly into the $enous access line. B. mied in the prescri!ed intra$enous fuid. C. $ia a rectal suppository. . $ia intramuscular inDection. 6. An elderly pt with a history o sodium retention arri$es to the clinic with the complaints o Eheart skipping !eatsE & leg tremors. Which o the ollowing should the nurse ask this pt regarding these symptoms? A. Euate calcium intake. . ,ed meat is the protein source o choice. ". A pt is admitted or treatment o hypercalcemia.  #he nurse reali)es that this pt's intra$enous fuids will most likely !e which o the ollowing? A. detrose 3F & water B. detrose 3F & ? normal saline C. detrose 3F & ? normal saline . normal saline . A "94year4old male pt is admitted with dia!etic ketoacidosis. #he nurse reali)es that this pt will ha$e a need or which o the ollowing electrolytes? A. sodium C. calcium B. potassium . agnesium " +. An elderly pt with peripheral neuropathy has !een taking magnesium supplements. #he nurse reali)es that which o the ollowing symptoms can indicate hypomagnesaemia? A. hypotension( warmth( & sweating B. nausea & $omiting C. hyperrefeia . ecessi$e urination 3. A pt is admitted with !urns o$er 36F o his !ody.  #he nurse reali)es that this pt is at risk or which o the ollowing electrolyte im!alances? A. hypercalcemia B. hypophosphatemia C. hypernatremia . H7. #he nurse reali)es that the acid4!ase disorder this pt is demonstrating is which o the ollowing? A. respiratory acidosis C. respiratory alkalosis B. meta!olic acidosis . meta!olic alkalosis +1. An elderly postoperati$e pt is demonstrating lethargy( conusion( & a resp rate o 9 per minute. #he nurse sees that the last dose o pain medication administered $ia a pt controlled anesthesia 2CA pump was within 6 minutes. Which o the ollowing acid4 !ase disorders might this pt is eperiencing? A. respiratory acidosis C. respiratory alkalosis B. meta!olic acidosis . meta!olic alkalosis +". #he pt has !een placed on a 1"66 m7 daily fuid restriction. #he pt's -/ is inusing at a keep open rate o  16 m7Hhr. #he pt has no additional -/ medications. uired? Gelect all that apply. A. Administer the dose -/ push o$er  minutes. B. onitor the inDection site or redness. C. Add the ordered dose to the -/ hanging. . Ise an inusion controller or the -/. 0. onitor fuid intake & output. ++. Which pts are at risk or the de$elopment o hypercalcemia? Gelect all that apply. A. the pt with a malignancy B. the pt taking lithium C. the pt who uses sunscreen to ecess . the pt with hyperparathyroidism 0. the pt who o$eruses antacids +3. #he pt who has a serum magnesium le$el o 1.+ mgHd7 is !eing treated with dietary modi%cation. Which oods should the nurse suggest or this pt? Gelect all that apply. A. !ananas B. seaood C. white rice . lean red meat 0. Chocolate +5. #he pt has a serum phosphate le$el o +.8 mgHd7. Which interdisciplinary treatments would the nurse epect or this pt? Gelect all that apply. A. -/ normal saline B. calcium containing antacids C. -/ potassium phosphate . encouraging milk intake 0. increasing $itamin  intake +8. #he pt( newly diagnosed with dia!etes mellitus( is admitted to the emergency department with nausea( $omiting( & a!dominal pain. AB; results re$eal a p< o 8." & a !icar!onate le$el o "6 m0>H7. Which other assessment %ndings would the nurse anticipate in this pt? Gelect all that apply. A. tachycardia B. weakness C. dysrhythmias . =ussmaul's respirations 0. cold( clammy skin  +9. A clientJs nursing diagnosis is e%cient luid /olume related to ecessi$e fuid loss. Which action related to the fuid management should !e delegated to a nursing assistant? a. Administer -/ fuids as prescri!ed !y the physician. !. 2ro$ide straws and o*er fuids !etween meals. c. e$elop plan or added fuid intake o$er "+ hours d. #each amily mem!ers to assist client with fuid intake +:. #he client also has the nursing diagnosis ecreased Cardiac utput related to decrease plasma $olume. Which %nding on assessment supports this nursing diagnosis? a. lattened neck $eins when client is in supine position !. ull and !ounding pedal and post4ti!ial pulses c. 2itting edema located in eet( ankles( and cal$es d. Ghallow respirations with crackles on auscultation  36. #he nursing care plan or the client with dehydration includes inter$entions or oral health. Which inter$entions are within the scope o practice or the 72H7/ !eing super$ised !y the nurse? Choose all that apply. a. ,emind client to a$oid commercial mouthwashes. !. 0ncourage mouth rinsing with warm saline. c. Assess lips( tongue( and mucous mem!ranes d. 2ro$ide mouth care e$ery " hours while client is awake e. Geek dietary consult to increase fuids on meal trays. 39.A nursing assistant asks why the client with a chronically low phosphorus le$el needs so much assistance with acti$ities o daily li$ing. What is your !est response? a. L#he clientJs low phosphorus is pro!a!ly due to malnutrition.M !. L#he client is Dust worn out orm not getting enough rest.M c. L#he clientJs skeletal muscles are weak !ecause o the low phosphorus.M d. L#he client will do more or hersel when her phosphorus is normalM 31. #he physician has written the ollowing orders or the client with 0cess luid $olume. #he clientJs morning assessment includes !ounding peripheral pulses( weight gain o " pounds( pitting ankle edema( and moist crackles !ilaterally. Which order takes priority at this time? a. Weight client e$ery morning. !. aintain accurate intake and output. c. ,estrict fuid to 1366 m7 per day d. Administer urosemide 7asi +6 mg -/ push 3:.Kou are re$iewing a clientJs morning la!oratory results. Which o these results is o most concern? a. Gerum potassium 3." m0>H7 !. Gerum sodium 1+ m0>H7 c. Gerum calcium 16.5 mgHd7 d. Gerum magnesium 6.9 m0>H7 3". Kou ha$e !een pulled to the telemetry unit or the day. #he monitor inorms you that the client has de$eloped prominent I wa$es. Which la!oratory $alue should you check immediately? a. Godium !. 2otassium c. agnesium d. Calcium 3. #he clientJs potassium le$el is 5.8 m0>H7. Which inter$ention should you delegate to the student nurse under your super$ision? a. Administer =ayealate 13 g orally !. Administer spironolactone "3 mg orally c. Assess WC; strip or tall # wa$es d. Administer potassium 16 m0> orally 3+. A client is admitted to the unit with a diagnosis o syndrome o inappropriate antidiuretic hormone secretion G-A<. or which electrolyte a!normality will you !e sure to monitor? a. uest a neurologic consult today d. Check the clientJs papillary reaction to light 38.Kou are preparing to discharge a client whose calcium le$el was low !ut is now Dust slightly within the normal range :416.3 mgHd7. Which statement !y the client indicates the need or additional teaching? a. L- will call my doctor i - eperience muscle twitching or sei)ures.M !. L- will make sure to take my $itamin  with my calcium each day.M c. L- will take my calcium pill e$ery morning !eore !reakast.M d. L- will a$oid dairy products( !roccoli( and spinach when - eat.M 56. Kou are the charge nurse. Which client is most appropriate to assign to the step4down unit nurse pulled to the intensi$e care unit or the day? a. A 594year4old client on $entilator with acute respiratory ailure and respiratory acidosis !. A 8"4year4old client with C2 and normal arterial !lood gases AB;s who is $entilator4dependent c. A 354year4old new admission client with dia!etic ketoacidosis =A on a n insulin drip d. A 94year4old client on a $entilator with narcotic o$erdose and respiratory alkalosis 51.A client with respiratory ailure is recei$ing mechanical $entilation and continues to produce AB; results indicating respiratory acidosis. Which action should you epect to correct this pro!lem? a. -ncrease the $entilator rate rom 5 to 16 per minute !. ecrease the $entilator rate rom 16 to 5 per minute c. -ncrease the oygen concentration or 6F to +6F d. ecrease the oygen concentration or +6F to 6F 5".Which action should you delegate to the nursing assistant or the client with dia!etic ketoacidosis? Choose all that apply. a. Check %ngerstick glucose e$ery hour. !. ,ecord intake and output e$ery hour. c. Check $ital signs e$ery 13 minutes. d. Assess or indicators o fuid im!alance. 5.Kou are admitting an elderly client to the medical unit. Which actor indicates that this client has a risk or acid4!ase im!alances? a. yocardial inarction 1 year ago !. ccasional use o antacids c. Ghortness o !reath with etreme eertion d. Chronic renal insuNciency 5+.A client with lung cancer has recei$ed oycodone 16 mg orally or pain. When the student nurse assesses the client( which %nding should you instruct the student to report immediately? a. ,espiratory rate o 9 to 16 per minute !. 2ain le$el decreased rom 5H16 to "H16 c. Client re>uests room door !e closed. d. uet remaining on his arm. -n addressing the pro!lems( the nurse should@ A. inorm the nurse4super$isor right away. B. correct the pro!lems and su!mit a written report. C. speak to the coworker when she returns to the unit. . ask or a meeting with the coworker and a manager. :1. p< P 8.9 C" P 36