chapter 13 AD 2 Flashcards


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1

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired
d. An 83-year-old with congestive heart failure

C. A 76 year old who is cognitively impaired

2

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler's position.

b. Apply oxygen by mask or nasal cannula.

3

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates the client correctly understood the teaching?
a. "I must drink a quart of water or other liquid each day."
b. "I will weigh myself each morning before I eat or drink."
c. "I will use a salt substitute when making and eating my meals."
d. "I will not drink liquids after 6 PM so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink."

4

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

5

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain

b. Anxious client who has tachypnea

6

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the client's posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic light-headedness and dizziness

d. Decreased orthostatic light-headedness and dizziness

7

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole wheat crackers
d. Grilled chicken breast with glazed carrots

d. Grilled chicken breast with glazed carrots

8

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a. A 34-year-old on NPO status who is receiving intravenous D5W
b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

a. A 34-year-old on NPO status who is receiving intravenous D5W

9

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching?
a. "Weigh yourself every morning and every night."
b. "Check your radial pulse twice a day."
c. "Read food labels to determine sodium content."
d. "Bake or grill the meat rather than frying it."

c. "Read food labels to determine sodium content."

10

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?

A. Have your spouse watch you for irritability and anxiety

B. Notify the clinic if you notice muscle twitching

C. Call your primary health care provider for diarrhea

D. Bake or grill your meat rather than frying it.

C. Call your primary health care provider for diarrhea

11

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography

a. Depth of respirations

12

A nurse cares for a client who has the following laboratory results: Potassium 2.4, Magnesium 1.8, calcium 8.5, and sodium 144. Which assessment does the nurse complete first?

A. Depth of respirations

B. Bowel sounds

C. Grip strength

D. Electrocardiography

A. Depth of respirations

13

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

14

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a. Client with pancreatitis who has continuous nasogastric suctioning
b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d. Client with uncontrolled diabetes and a serum pH level of 7.33

a. Client with pancreatitis who has continuous nasogastric suctioning

15

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

A. Administer high-ceiling loop diuretics

B. Assess the client's lung sounds ever 2 hours

C. Place a pressure-relieving overlay on the mattress

D. Weigh the client daily at the same time on the same scale.

B. Assess the client's lung sounds ever 2 hours

16

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
a. Assess the client's respiratory rate, rhythm, and depth.
b. Measure the client's pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care provider.

a. Assess the client's respiratory rate, rhythm, and depth.

17

After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
a. Toasted English muffin with butter and blueberry jam, and tea with sugar
b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

18

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond?
a. "Potatoes and avocados can be substituted for fruit."
b. "If you cook the fruit, the amount of potassium will be lower."
c. "Berries, cherries, apples, and peaches are low in potassium."
d. "You are correct. Fruit is very high in potassium."

c. "Berries, cherries, apples, and peaches are low in potassium."

19

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

A. Notifies the pharmacy of the IV potassium order

B. Asses the client's IV site every hour during infusion

C. Sets the IV pump to deliver 30 mEq of potassium an hour

D. Double checks the IV bag against the order with the precepting nurse

C. Sets the IV pump to deliver 30 mEq of potassium an hour

20

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin (Calcimar).

b. Connect the client to a cardiac monitor.

21

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 liter of fluids each shift.
d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating.

22

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness

a. Increased pulse rate
b. Distended neck veins

e. Skeletal muscle weakness

23

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
a. A 36-year-old who is malnourished
b. A 42-year-old with uncontrolled diabetes
c. A 50-year-old with hyperparathyroidism
d. A 58-year-old with chronic renal failure
e. A 76-year-old who is prescribed antacids

a. A 36-year-old who is malnourished
b. A 42-year-old with uncontrolled diabetes

e. A 76-year-old who is prescribed antacids

24

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L
e. Blood osmolality of 250 mOsm/L

b. Serum potassium level of 5.4 mEq/L

e. Blood osmolality of 250 mOsm/L

25

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
a. Electrocardiogram changes
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness

a. Electrocardiogram changes

d. Paralytic ileus
e. Skeletal muscle weakness

26

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
a. Hypokalemia - Flaccid paralysis with respiratory depression
b. Hyperphosphatemia - Paresthesia with sensations of tingling and numbness

c. Hyponatremia - Decreased level of consciousness
d. Hypercalcemia - Positive Trousseau's and Chvostek's signs
e. Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension

a. Hypokalemia - Flaccid paralysis with respiratory depression

c. Hyponatremia - Decreased level of consciousness

27

After administering 40 mEq of potassium chloride, a nurse evaluates the client's response. Which manifestations indicate that treatment is improving the client's hypokalemia? (Select all that apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)

c. Strong productive cough

d. Active bowel sounds

28

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this client's care plan? (Select all that apply.)
a. Encourage oral fluid intake of at least 2 L/day.
b. Use a draw sheet to reposition the client in bed.
c. Strain all urine output and assess for urinary stones.
d. Provide nonslip footwear for the client to use when out of bed.
e. Rotate the client from side to side every 2 hours.

b. Use a draw sheet to reposition the client in bed.

d. Provide nonslip footwear for the client to use when out of bed.

29

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?

A. Assesses the client's Chvostek and Trousseau sign.

B. Keeps the client's room quiet and dimly lit

C. Moves the client carefully to avoid fracturing bones.

D. Administers bisphosphonates as prescribed.

D. Administers bisphosphonates as prescribed.

30

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (select all that apply)

A. Increased pulse rate

B. distended neck veines

C. Decreased Blood pressure

D. Warm and pink skin

E. Skeletal muscle weakness

F. Visual disturbances.

A. Increased pulse rate

B. distended neck veines

E. Skeletal muscle weakness

F. Visual disturbances.

31

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretions and release. For which potential complications will the nurse assess? Select all that apply

A. Urine output of 25 mL/ hr

B. Serum potassium level of 5.4 mEq/L

C. Urine specific gravity of 1.02 g/mL

D. Serum sodium level of of 128 mEq/L

E. Blood osmolarity of 250 mOsm/kg

B. Serum potassium level of 5.4 mEq/L

E. Blood osmolarity of 250 mOsm/kg

32

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For Which potential complications of this electrolyte imbalance does the nurse assess? Select all that apply

A. Reports of palpitations

B. Slow, shallow respirations

C. Orthostatic hypotension

D. Paralytic ileus

E. Skeletal muscle weakness

F. Tall, peaked T waves on ECG

A. Reports of palpitations

E. Skeletal muscle weakness

F. Tall, peaked T waves on ECG

33

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

A. Hypokalemia- muscle weakness with respiratory depression

B. Hypermagnesemia- Bradycardia and hypotension

C. Hyponatremia - Decreased level of consciousness

D. Hypercalcemia- positive Trousseau and chveostek signs

E. Hypomagnesemia - Hyperactive deep tendon reflexes

F. Hypernartemia- Weak peripheral pulses

A. Hypokalemia- muscle weakness with respiratory depression

B. Hypermagnesemia- Bradycardia and hypotension

C. Hyponatremia - Decreased level of consciousness

E. Hypomagnesemia - Hyperactive deep tendon reflexes

F. Hypernartemia- Weak peripheral pulses

34

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? Select all that apply

A. Respiratory rate of 8 Breaths/ min

B. Absent deep tendon reflexes

C. Strong productive cough

D. Active bowel sounds

E. U waves present on the Electrocardiogram

C. Strong productive cough

D. Active bowel sounds

35

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? Select all that apply

A. Calculate pulse pressure with each blood pressure reading

B. Assess skin tumor using the back of the client's hand

C. Assess for pitting edema in dependent body areas.

D. Monitor trends in the client's daily weights.

E. Assist the client to change positions frequently

F. Teach client and family how to read food labels for sodium

A. Calculate pulse pressure with each blood pressure reading

C. Assess for pitting edema in dependent body areas.

D. Monitor trends in the client's daily weights.

E. Assist the client to change positions frequently

F. Teach client and family how to read food labels for sodium

36

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? Select all that apply

A. Sodium 160 mEq Over hydration

B. Potassium 5.4 Dehydration

C. Osmolarity 250 Overhydration

D. Hematocrit 68% Dehydration

E. BUN 39 mg/dL. Overhydration

F. Magnesium 0.8 mg/dL Dehydration

B. Potassium 5.4 Dehydration

C. Osmolarity 250 Overhydration

D. Hematocrit 68% Dehydration

F. Magnesium 0.8 mg/dL Dehydration