Fluid

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Question 1
Free
Multiple Choice

The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?

Choose correct answer/s
A

The blood pressure is 90/40 mm Hg.

B

Urine output is 30 mL over the last hour.

C

Oral fluid intake is 100 mL for the last 8 hours.

D

There is prolonged skin tenting over the sternum.

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Question 2
Free
Multiple Choice

The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments should the nurse carefully monitor?

Choose correct answer/s
A

Increased total urinary output

B

Elevation of serum hematocrit

C

Decreased serum sodium level

D

Rapid and unexpected weight loss

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Question 3
Free
Multiple Choice

The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this client?

Choose correct answer/s
A

Skin turgor

B

Daily weight

C

Presence of edema

D

Hourly urine output

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Question 4
Free
Multiple Choice

The nurse is caring for an alert and oriented older-adult client with a history of dehydration. Which of the following information should the home health nurse teach the client as to when to increase fluid intake?

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A

In the late evening hours

B

If the oral mucosa feels dry

C

When the client feels thirsty

D

As soon as changes in level of consciousness (LOC) occur

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Question 5
Free
Multiple Choice

The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan?

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A

Personality changes

B

Frequent loose stools

C

Facial muscle spasms

D

Lower extremity weakness

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Question 6
Multiple Choice

The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client indicates that the teaching about this medication has been effective?

Choose correct answer/s
A
"I will try to drink at least eight glasses of water every day."
B
"I will use a salt substitute to decrease my sodium intake."
C
"I will increase my intake of potassium-containing foods."
D
"I will drink apple juice instead of orange juice for breakfast."
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Question 7
Multiple Choice

The nurse is caring for a client admitted with hyponatremia. Which of the following actions should the nurse anticipate implementing?

Choose correct answer/s
A
Restrict client's oral free water intake.
B
Avoid use of electrolyte-containing drinks.
C
Infuse a solution of 5% dextrose in 0.45% saline.
D
Administer vasopressin (antidiuretic hormone, [ADH]).
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Question 8
Multiple Choice

The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following actions should the nurse take?

Choose correct answer/s
A
Administer the KCl as a rapid IV bolus.
B
Infuse the KCl at a rate of 20 mEq/hour.
C
Give the KCl only through a central venous line.
D
Add no more than 40 mEq/L to a litre of IV fluid.
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Question 9
Multiple Choice

The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG) report. Which of the following ECG changes would the nurse expect to assess in this client?

Choose correct answer/s
A
Ventricular dysrhythmias
B
Bradycardia
C
Flatten T wave
D
Prolonged P-R interval
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Question 10
Multiple Choice

The nurse is caring for a client who has required prolonged mechanical ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following interpretations would the nurse document?

Choose correct answer/s
A
Metabolic acidosis
B
Metabolic alkalosis
C
Respiratory acidosis
D
Respiratory alkalosis
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Question 11
Multiple Choice

The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep respirations. Which of the following actions should the nurse implement?

Choose correct answer/s
A
Notify the client's health care provider.
B
Give the prescribed PRN lorazepam.
C
Start the prescribed PRN oxygen at 2-4 L/minute.
D
Encourage the client to take deep, slow breaths.
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Question 12
Multiple Choice

The home health nurse is visiting an older-adult client who has a low serum protein level. Which of the following assessment areas should the nurse assess?

Choose correct answer/s
A
Pallor
B
Edema
C
Confusion
D
Restlessness
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Question 13
Multiple Choice

The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, which of the following assessments is a priority for the nurse to monitor?

Choose correct answer/s
A
Lung sounds
B
Urinary output
C
Peripheral pulses
D
Peripheral edema
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Question 14
Multiple Choice

The nurse is caring for a client who has a low serum total protein level and is taking protein supplements. Which of the following data indicate that the client's condition has improved?

Choose correct answer/s
A
Hematocrit 28%
B
Good skin turgor
C
Absence of peripheral edema
D
Blood pressure 110/72 mm Hg
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Question 15
Multiple Choice

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would the nurse document?

Choose correct answer/s
A
Metabolic acidosis
B
Metabolic alkalosis
C
Respiratory acidosis
D
Respiratory alkalosis
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Question 16
Multiple Choice

The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications that the client has been taking at home, which of the followingwouldbe of most concern to the nurse?

Choose correct answer/s
A
Oral digoxin 0.25 mg daily
B
Ibuprofen 400 mg every 6 hours
C
Metoprolol 12.5 mg orally daily
D
Lantus insulin 24 U subcutaneously every evening
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Question 17
Multiple Choice

The nurse is caring for a client with hypercalcemia. Which of the following actions would be included in the client's nursing care plan?

Choose correct answer/s
A
Maintain the client on bed rest.
B
Auscultate lung sounds every 4 hours.
C
Monitor for Trousseau's and Chvostek's signs.
D
Encourage fluid intake up to 3 000 mL every day.
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Question 18
Multiple Choice

The nurse is teaching a client with renal failure about a low phosphate diet. Which of the following foods would the nurse teach the client to restrict?

Choose correct answer/s
A
Dairy products
B
High-fat foods
C
Fruits and juices
D
Green, leafy vegetables
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Question 19
Multiple Choice

The nurse is caring for a client in the outpatient clinic who has a decreased serum magnesium level. Which of the following assessment areas should the nurse include in the health history?

Choose correct answer/s
A
Daily alcohol intake
B
Intake of dietary protein
C
Multivitamin/mineral use
D
Use of over-the-counter (OTC) laxatives
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Question 20
Multiple Choice

The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client asks the nurse why a peripherally inserted central catheter must be inserted. Which of the following explanations is the basis for the nurse's response?

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A
The prescribed infusion can be given much more rapidly when the client has a central line.
B
There is a decreased risk for infection when 50% dextrose is infused through a central line.
C
The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
D
The required blood glucose monitoring is more accurate when samples are obtained from a central line.
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