F&E NCLEX GRADE A QUESTION AND ANSWER
FULLY ANSWERED
B.
Hypocalcemia
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. - (correct answer)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
A.
50-year-old with pneumonia, diaphoresis, and high fevers
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. - (correct answer)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)
B.
Ensure the client is safe from falls and check the most recent potassium level
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. - (correct answer)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.
C.
Bowel movements.
,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. - (correct answer)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.
B.
Question the results and redraw the specimen
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. -
(correct answer)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
D. Check to see if a serum albumin level is available
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. - (correct answer)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
C. Call the physician
D. Report the urine output
E. Report indications of nausea
FULLY ANSWERED
B.
Hypocalcemia
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. - (correct answer)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
A.
50-year-old with pneumonia, diaphoresis, and high fevers
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. - (correct answer)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)
B.
Ensure the client is safe from falls and check the most recent potassium level
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. - (correct answer)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.
C.
Bowel movements.
,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. - (correct answer)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.
B.
Question the results and redraw the specimen
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. -
(correct answer)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
D. Check to see if a serum albumin level is available
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. - (correct answer)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
C. Call the physician
D. Report the urine output
E. Report indications of nausea
