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complete solution Updated I I I
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral
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mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the
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nurse identify as manifestations of fluid volume deficit? (Select all that apply.)
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A. Decreased skin turgor I I II
B. Concentrated urine I I
C. Bradycardia I
D. Low-grade fever I I
E. Tachypnea - A; Decreased skin turgor is a manifestation present with fluid volume deficit. Skin I I I I I I I I I I I I I I
turgor is decreased due to the lack of fluid within the body and results in dryness of the skin.
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B; Concentrated urine is a manifestation present with fluid volume deficit. Urine is concentrated due
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to lack of fluid in the vascular system, causing a decreased profusion of the kidneys resulting in an
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increased urine specific gravity.
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D; Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is one of
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the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E;
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Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are the
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body's way to obtain oxygen due to the lack of fluid volume within the body.
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A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr. Which of
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the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.)
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A. Dyspnea I
B. Edema I
C. Bradycardia I
D. Hypertension I
E. Weakness - A; Dyspnea is a manifestation present with fluid volume excess. Dyspnea is due to an
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excess of fluids within the body and lungs, and the client is struggling to breathe to obtain oxygen.
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B; Weight gain can be a result of edema.
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D; Blood pressure rises as the heart must work harder due to the excess fluid.
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E; Weakness is due to the excess fluid that is retained, which depletes energy and increases the
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workload for the body.
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A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse
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expect?
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A. Moist skin I I
B. Distended neck veins I I I
C. Increased urinary output I I I
D. Tachycardia - D; Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid I I I I I I I I I I I I I I
volume deficit.
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A nurse is caring for a client in a long-term facility who has become weak, confused, and experienced
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dizziness when standing. The client's temperature is 38.3 degrees C (100.9 degrees F), pulse 92/min,
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, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the
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nurse take?
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A. Initiate fluid restrictions to limit intake I I I I I I
B. Check for peripheral edema I I I I
C. Encourage the client to ambulate to promote oxygenation I I I I I I I II
D. Monitor for orthostatic hypotension - D; Monitor for orthostatic hypotension because they have
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manifestations of dehydration due to decreased circulatory volume.
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A nurse is caring for a client who has a blood sodium level 133 mEg/L and blood potassium level 3.4
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mEq/L. The nurse should recognize that which of the following treatments can result in these
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laboratory findings?
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A. Three tap water enemas I I I I
B. 0.9% NaCl solution IV at 50 ml/hr I I I I I I I
C. 5% dextrose with 0.45% NaCl solution with 20 mEq of K+ IV at 80 mL/hr
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D. Antibiotic therapy - A; Three tap water enemas can result in a decrease in blood sodium and I I I I I I I I I I I I I I I I
potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an
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imbalance and solute dilution.
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A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for
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which of the following manifestations?
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A. ECG changes I I
B. Constipation C. I
Polyuria I I
D. Paresthesia - A; Assess for ECG changes. Potassium levels can affect the heart and result in
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arrhythmias.
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A nurse is caring for a client who has a NGT attached to low intermittent suctioning. The nurse
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should monitor for which of the following electrolyte imbalances?
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A. Hypercalcemia I
B. Hyponatremia I
C. Hyperphosphatemia I
D. Hyperkalemia - B; Monitor the client for hyponatremia. Nasogastric losses are isotonic and I I I I I I I I I I I I
contain sodium.
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A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the
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following conditions as being associated with this electrolyte imbalance?
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A. Diabetic Ketoacidosis I I
B. heart failure I I
C. Cushing's syndrome I I
D. Thyroidectomy - A; Hyperkalemia is a lab finding associated with DKA. I I I I I I I I I I I
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A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the
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nurse use to perform this test?
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A. Apply a blood pressure cuff to the client's arm I I I I I I I I II
B. Place the stethoscope bell over the client's carotid artery
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