FLUID & ELECTROLYTE PRACTICE
QUESTIONS WITH LEGIT AND EXPLAINED
ANSWERS
A bclient bwith bdiarrhea bfor b3 bdays band binability bto beat bor bdrink bwell bis bbrought bto
bthe bemergency bdepartment b(ED) bby bher bfamily. bShe bstates bshe bhas bbeen btaking
bher bdiuretics bfor bcongestive bheart bfailure b(CHF). bWhat bnursing bactions bare
bindicated bat bthis btime?
SELECT bALL bTHAT bAPPLY.
A. bPlace bthe bclient bon bbed brest.
B. bEvaluate bthe belectrolyte blevels.
C. bAdminister bthe bordered bdiuretic.
D. bAssess bfor borthostatic bhypotension
E. bInitiate bcardiac bmonitoring. b- bCORRECT✅✅A, bB, bD, bE
RATIONALE:
Nursing bactions bindicated bat bthis btime binclude: bplacing bthe bclient bon bbedrest band
bassisting bthe bclient bout bof bbed, bevaluating belectrolyte blevels, bassessing bfor
borthostatic bhypotension, band bapplying ba bcardiac bmonitor. bSafety bis brequired bto
bprevent bfalls bdue bto bweakness bfrom ba blikely bfluid bvolume bdeficit band belectrolyte
bimbalance. bThe bnurse bshould breview bthe blaboratory band bdiagnostic bresults bto
bdetect blikely bloss bof bsodium, bpotassium, band bmagnesium bsecondary bto bdiarrhea
band bdiuretic bus. bFluid bvolume bdeficit bis blikely bwith bdiarrhea band bdiuretic buse band
bleads bto bfluid band belectrolyte bimbalances, bespecially bhypokalemia. bAssessing bfor
borthostatic bchanges bwill bconfirm bpresence bof bvolume bdeficit. bMonitoring bfor
binverted bT bwave bor bpresence bof bU bwave bon bthe bECG bas bwell bas bdysrhythmias
bis bindicated bwhen bhypokalemia bis banticipated.Diuretics bincrease bloss bof bfluids band
belectrolytes. bThe bnurse bwould bquestion bthis border bin bthe bpresence bof bassessment
bdata bindicating bfluid bloss bfrom bthe bdiuretics band bdiarrhea.
A bclient bwith bhypokalemia bhas ba bprescription bfor bparenteral bpotassium bchloride
b(KCl). bWhich bof bthese binterventions bdoes bthe bnurse buse bto bsafely badminister
bKCl?
SELECT bALL bTHAT bAPPLY. b
A. bUse ba bpotassium binfusion bprepared bby ba bregistered bpharmacist.
B. bAssess bfor bburning bor bredness bduring binfusion.
C. bInfuse bat ba brate bof bno bmore bthan b10 bmEq bper bhour.
D. bAdminister bonly bthrough ba bcentral bvenous bcatheter.
E. bAdminister bby bIV bpush bonly bduring bcardiac barrest. b- bCORRECT✅✅A, bB, bC
RATIONALE:
,Interventions bto bsafely badminister bKCl bto ba bclient bwith bhypokalemia binclude: busing
ba bpharmacy bprepared bpotassium binfusion, bchecking bthe bclient bfor bany bburning bor
bredness bduring binfusion, band binfusing bthe bIV bat bnot bmore bthan b10 bmEq bper
bhour. bThe bJoint bCommission's bNational bClient bSafety bGoals bmandates bthat
bconcentrated bpotassium bbe bdiluted band badded bto bIV bsolutions bonly bin bthe
bpharmacy bby ba bregistered bpharmacist band bthat bvials bof bconcentrated bpotassium
bnot bbe bavailable bin bclient bcare bareas. bIV bpotassium bsolutions birritate bveins band
bcause bphlebitis. bAssess bthe bIV bsite bhourly, band bask bthe bclient bwhether bhe bor
bshe bfeels bburning bor bpain bat bthe bsite. bThe bpresence bof bpain bor bburning bat bthe
binsertion bsite bmay brequire ba bnew bintravenous bto bbe bstarted. bA bdose bof bKCl b5-10
bmEq/hour, bno bmore bthan b20 bmEq/hr bis brecommended.Potassium bmay bbe
badministered bby bperipheral bor bcentral bvein. bThere bis bno bcircumstance bwhere
bpotassium bis bgiven bby bIV bpush.
The bnurse bis bcaring bfor ba bclient bwho bis breceiving ba bloop bdiuretic bfor btreatment bof
bheart bfailure. bWhich bof bthese bactions bwill bbe bincluded bin bthe bplan bof bcare? b
SELECT bALL bTHAT bAPPLY. b
A. bAssess bdaily bweights.
B. bEncourage bconsumption bof bcitrus bfruits.
C. bWeigh bthe bclient bweekly.
D. bMonitor bserum bpotassium.
E. bDiscourage bintake bof bspinach.
F. bMonitor bfor bbradycardia. b- bCORRECT✅✅A, bB, bD
RATIONALE:
Actions bfor bthe bnurse bto binclude bwhen bcaring bfor ba bclient btaking ba bloop bdiuretic
bfor bheart bfailure binclude: bassessing bdaily bweights, bencouraging bconsumption bof
bcitrus bfruits, band bmonitoring bthe bclient's bserum bpotassium. bHigh-ceiling b(loop)
bdiuretics bremove bexcess bfluid band bare bpotassium-depleting bdrugs. bConsuming
bcitrus bfruit, bgreen bleafy bvegetables, bcantaloupe, btomato, band bother bfood bwith
bpotassium bis bindicated bwhile breceiving bthis btype bof bdiuretic bto bcompensate bfor
burinary bloss bof bpotassium. bThe bclient bmust bbe bweighed bat bthe bsame btime beach
bday, busing bthe bsame bscale band bwearing bapproximately bthe bsame bamount bof
bclothes. bGreen bleafy bvegetables bsuch bas bspinach bcontain bpotassium band bare
bencouraged. bThe bdiuretic bitself bhas bno beffect bon bthe bheart brate, bhowever
bpotassium bdepletion bcaused bby bthe bdiuretic bmay bcause bcardiac birritability bwith ba
bweak band bthready bpulse.
The bnurse bis bcaring bfor ba bclient bwho btakes bfurosemide b(Lasix) band bdigoxin
b(Lanoxin). bThe bclient's bpotassium b(K+) blevel bis b2.5 bmEq/L b(2.5 bmmol/L). bWhich
badditional bassessment bwill bthe bnurse bmake?
A. bHeart brate
B. bBlood bpressure b(BP)
C. bIncreases bin bedema b
D. bSodium blevel b- bCORRECT✅✅A. bHeart brate
,RATIONALE:
The bnurse bmust bassess bthe bheart brate bfor bbradycardia brelated bto bdigoxin band
birritability bor birregularity brelated bto bhypokalemia. bHypokalemia bincreases bthe
bsensitivity bof bcardiac bmuscle bto bdigoxin band bmay bresult bin bdigoxin btoxicity, beven
bwhen bthe bdigoxin blevel bis bwithin bthe btherapeutic brange. bThe bnurse balso bassesses
bfor bGI bsymptoms bsuch bas bdiarrhea, band bother bsymptoms bof btoxicity bto
bdigoxin.The bBP bmay bdecrease bwith blow bpotassium blevel bbut bmonitoring bthe bpulse
bis bessential. bThe bdiuretic bwould breduce bedema, btherefore bassessing bthe bheart
brate bis bthe bpriority. bHigh bserum bsodium blevels bwould bnot bbe bexpected bin bthis
bscenario bunless bfluid bvolume bdeficit bis bpresent.
Furosemide b(Lasix) bhas bbeen bordered bfor ba bclient bwith bheart bfailure, bshortness bof
bbreath, band b3+ bpitting bedema bof bthe blower bextremities. bWhich bassessment bfinding
bindicates bto bthe bnurse bthat bthe bmedication bhas bbeen beffective?
A. bThe bclient's bpotassium blevel bis b5.1 bmEq/L b(5.1 bmmol/L).
B. bThe bclient's bheart brate bis b101 bbeats bper bminute.
C. bThe bclient bis bfree bfrom badventitious bbreath bsounds.
D. bThe bclient bhas bexperienced ba bweight bgain bof b1 bpound b(0.5 bkg). b-
bCORRECT✅✅C. bThe bclient bis bfree bfrom badventitious bbreath bsounds.
RATIONALE:
The bnurse brecognizes bthat bFurosemide bis beffective bwhen bthe bclient bis bfree bfrom
badventitious bbreath bsounds bsuch bas bcrackles. bOther bpositive boutcomes bto bthe
bdiuretic binclude bnormal bheart brate, bweight bloss bwith bresolution bof bedema, band
bincreased burine boutput.A bpotassium bvalue bof b5.1 bmEq/L bor b(5.1 bmmol/L) bis
bnormal. bChanges bin bpotassium blevels bsuch bas bhypokalemia bare bside beffects bof
bfurosemide, bnot btherapeutic beffects. bAlthough ba bfall bin bthe bclient's bBP bmay boccur
bwith bthe bdecrease bin bbody bfluid, bthis bis bnot bthe bpriority. bTachycardia bmay boccur
bduring bepisodes bof bfluid bvolume bexcess bor bdeficit band bdoes bnot bdirectly bindicate
bthe bmedication bhas bbeen beffective. bWeight bloss, brather bthan bweight bgain, bis boften
bthe beffect bof bFurosemide, bcaused bby bthe bdiuresis.
The bnurse bis bdiscussing bsafety bwhen badministering bbumetanide bwith ba bnursing
bstudent. bThe bnurse brecognizes bthat bthe bstudent bunderstands bside beffects bof bthis
bmedication bwhen bthe bstudent bmakes bwhich bstatement?
A. b"The bclient's bPT band bINR bmay bbe bprolonged bwhile btaking bthis bmedication."
B. b"The bclient bmay bdevelop bhypoglycemia bduring btreatment."
C. b"Inverted bT bwaves band ba bU bwave bmay bappear bon bthe bECG."
D. b"I bneed bto btell bthe bclient bto bavoid bsalt bsubstitutes." b- bCORRECT✅✅C.
b"Inverted bT bwaves band ba bU bwave bmay bappear bon bthe bECG."
RATIONALE:
The bnursing bstudent bunderstands bthe bside beffects bof bBumex bwhen bcommenting
bthat binverted bT bwaves band ba bU bwave bmay bappear bon bthe bEKG. bHypokalemia
, bmay bcause bdepressed bST bsegments, bflat bor binverted bT bwaves bor bthe bpresence
bof ba bU bwave bon bthe bECG bas bwell bas bdysrhythmias. bHigh-ceiling b(loop) bdiuretics,
bsuch bas bfurosemide b(Lasix, bfurosemide), bpromote bloss bof bwater, bsodium, band
bpotassium.PT band bINR bare btypically bprolonged bwith btherapy bwith bwarfarin
b(Coumadin) bor bindividuals bwith bliver bdisease. bHypoglycemia bmay boccur bwith boral
bhypoglycemic bmedications bor binsulin. bSalt bsubstitutes bare btypically bavoided bwhen
bthe bclient bhas bhyperkalemia bor bis btaking ban bACE binhibitor bbecause bmany
bsubstitutes bcontain bpotassium bchloride.
The bnurse bis bteaching ba bclient bwho bis btaking ba bpotassium-sparing bdiuretic babout
bprecautions bwhile btaking bthis bmedication. bWhich bof bthese bdoes bthe bnurse bteach
bthe bclient bto bavoid bor buse bcautiously?
SELECT bALL bTHAT bAPPLY.
A. bApples
B. bBananas
C. bACE binhibitors
D. bGrapes
E. bSalt bsubstitute b- bCORRECT✅✅B, bC, bE b
RATIONALE: b
While btaking ba bpotassium-sparing bdiuretic, bthe bnurse bteaches bthe bclient bto bavoid
bbananas, bACE binhibitors, band bsalt bsubstitutes. bOther bfoods bhigh bin bpotassium
binclude bcantaloupe, bkiwi, boranges, bavocados, bbroccoli, bdried bbeans, blima bbeans,
bmushrooms, bpotatoes, bseaweed, bsoybeans, band bspinach. bSalt bsubstitutes bcontain
bpotassium band bmay bpredispose bthe bclient bto bhyperkalemia.Apples band bgrapes bare
bconsidered blower bpotassium-containing bfoods.
The bnurse bis bassessing ba bclient bwith ba bsodium blevel bof b118 bmEq/L b(118
bmmol/L). bWhich bactivity btakes bpriority?
A. bMonitoring burine boutput
B. bEncouraging bsodium brich bfluids band bfoods bthroughout bthe bday
C. bInstructing bthe bclient bnot bto bambulate bwithout bassistance
D. bAssessing bdeep btendon breflexes b- bCORRECT✅✅C. bInstructing bthe bclient bnot
bto bambulate bwithout bassistance
RATIONALE:
Safety bis bthe bpriority bin bthis binstance. bInstructing bthe bclient bnot bto bambulate
bwithout bassistance bis bthe bpriority bfor ba bclient bwith ba bsodium blevel bof b118 bmEq/L
b(118 bmmol/L). bThis bsodium blevel bdenotes bsevere bhyponatremia bwhich bmakes
bdepolarization bslower band bcell bmembranes bless bexcitable. bThis bis bmanifested bas
bgeneral bmuscle bweakness bwhich bis bworse bin bthe blegs band barms. bAdditionally,
bthis bclient bmay bhave bdeveloped bconfusion bfrom bcerebral bedema.Monitoring burine
boutput bneeds bto bbe bdone bbut bis bnot bthe bpriority baction bin bthis bsituation.
bGenerally, bfluid bis brestricted, brather bthan bsodium brich bfoods boffered, bto bminimize
QUESTIONS WITH LEGIT AND EXPLAINED
ANSWERS
A bclient bwith bdiarrhea bfor b3 bdays band binability bto beat bor bdrink bwell bis bbrought bto
bthe bemergency bdepartment b(ED) bby bher bfamily. bShe bstates bshe bhas bbeen btaking
bher bdiuretics bfor bcongestive bheart bfailure b(CHF). bWhat bnursing bactions bare
bindicated bat bthis btime?
SELECT bALL bTHAT bAPPLY.
A. bPlace bthe bclient bon bbed brest.
B. bEvaluate bthe belectrolyte blevels.
C. bAdminister bthe bordered bdiuretic.
D. bAssess bfor borthostatic bhypotension
E. bInitiate bcardiac bmonitoring. b- bCORRECT✅✅A, bB, bD, bE
RATIONALE:
Nursing bactions bindicated bat bthis btime binclude: bplacing bthe bclient bon bbedrest band
bassisting bthe bclient bout bof bbed, bevaluating belectrolyte blevels, bassessing bfor
borthostatic bhypotension, band bapplying ba bcardiac bmonitor. bSafety bis brequired bto
bprevent bfalls bdue bto bweakness bfrom ba blikely bfluid bvolume bdeficit band belectrolyte
bimbalance. bThe bnurse bshould breview bthe blaboratory band bdiagnostic bresults bto
bdetect blikely bloss bof bsodium, bpotassium, band bmagnesium bsecondary bto bdiarrhea
band bdiuretic bus. bFluid bvolume bdeficit bis blikely bwith bdiarrhea band bdiuretic buse band
bleads bto bfluid band belectrolyte bimbalances, bespecially bhypokalemia. bAssessing bfor
borthostatic bchanges bwill bconfirm bpresence bof bvolume bdeficit. bMonitoring bfor
binverted bT bwave bor bpresence bof bU bwave bon bthe bECG bas bwell bas bdysrhythmias
bis bindicated bwhen bhypokalemia bis banticipated.Diuretics bincrease bloss bof bfluids band
belectrolytes. bThe bnurse bwould bquestion bthis border bin bthe bpresence bof bassessment
bdata bindicating bfluid bloss bfrom bthe bdiuretics band bdiarrhea.
A bclient bwith bhypokalemia bhas ba bprescription bfor bparenteral bpotassium bchloride
b(KCl). bWhich bof bthese binterventions bdoes bthe bnurse buse bto bsafely badminister
bKCl?
SELECT bALL bTHAT bAPPLY. b
A. bUse ba bpotassium binfusion bprepared bby ba bregistered bpharmacist.
B. bAssess bfor bburning bor bredness bduring binfusion.
C. bInfuse bat ba brate bof bno bmore bthan b10 bmEq bper bhour.
D. bAdminister bonly bthrough ba bcentral bvenous bcatheter.
E. bAdminister bby bIV bpush bonly bduring bcardiac barrest. b- bCORRECT✅✅A, bB, bC
RATIONALE:
,Interventions bto bsafely badminister bKCl bto ba bclient bwith bhypokalemia binclude: busing
ba bpharmacy bprepared bpotassium binfusion, bchecking bthe bclient bfor bany bburning bor
bredness bduring binfusion, band binfusing bthe bIV bat bnot bmore bthan b10 bmEq bper
bhour. bThe bJoint bCommission's bNational bClient bSafety bGoals bmandates bthat
bconcentrated bpotassium bbe bdiluted band badded bto bIV bsolutions bonly bin bthe
bpharmacy bby ba bregistered bpharmacist band bthat bvials bof bconcentrated bpotassium
bnot bbe bavailable bin bclient bcare bareas. bIV bpotassium bsolutions birritate bveins band
bcause bphlebitis. bAssess bthe bIV bsite bhourly, band bask bthe bclient bwhether bhe bor
bshe bfeels bburning bor bpain bat bthe bsite. bThe bpresence bof bpain bor bburning bat bthe
binsertion bsite bmay brequire ba bnew bintravenous bto bbe bstarted. bA bdose bof bKCl b5-10
bmEq/hour, bno bmore bthan b20 bmEq/hr bis brecommended.Potassium bmay bbe
badministered bby bperipheral bor bcentral bvein. bThere bis bno bcircumstance bwhere
bpotassium bis bgiven bby bIV bpush.
The bnurse bis bcaring bfor ba bclient bwho bis breceiving ba bloop bdiuretic bfor btreatment bof
bheart bfailure. bWhich bof bthese bactions bwill bbe bincluded bin bthe bplan bof bcare? b
SELECT bALL bTHAT bAPPLY. b
A. bAssess bdaily bweights.
B. bEncourage bconsumption bof bcitrus bfruits.
C. bWeigh bthe bclient bweekly.
D. bMonitor bserum bpotassium.
E. bDiscourage bintake bof bspinach.
F. bMonitor bfor bbradycardia. b- bCORRECT✅✅A, bB, bD
RATIONALE:
Actions bfor bthe bnurse bto binclude bwhen bcaring bfor ba bclient btaking ba bloop bdiuretic
bfor bheart bfailure binclude: bassessing bdaily bweights, bencouraging bconsumption bof
bcitrus bfruits, band bmonitoring bthe bclient's bserum bpotassium. bHigh-ceiling b(loop)
bdiuretics bremove bexcess bfluid band bare bpotassium-depleting bdrugs. bConsuming
bcitrus bfruit, bgreen bleafy bvegetables, bcantaloupe, btomato, band bother bfood bwith
bpotassium bis bindicated bwhile breceiving bthis btype bof bdiuretic bto bcompensate bfor
burinary bloss bof bpotassium. bThe bclient bmust bbe bweighed bat bthe bsame btime beach
bday, busing bthe bsame bscale band bwearing bapproximately bthe bsame bamount bof
bclothes. bGreen bleafy bvegetables bsuch bas bspinach bcontain bpotassium band bare
bencouraged. bThe bdiuretic bitself bhas bno beffect bon bthe bheart brate, bhowever
bpotassium bdepletion bcaused bby bthe bdiuretic bmay bcause bcardiac birritability bwith ba
bweak band bthready bpulse.
The bnurse bis bcaring bfor ba bclient bwho btakes bfurosemide b(Lasix) band bdigoxin
b(Lanoxin). bThe bclient's bpotassium b(K+) blevel bis b2.5 bmEq/L b(2.5 bmmol/L). bWhich
badditional bassessment bwill bthe bnurse bmake?
A. bHeart brate
B. bBlood bpressure b(BP)
C. bIncreases bin bedema b
D. bSodium blevel b- bCORRECT✅✅A. bHeart brate
,RATIONALE:
The bnurse bmust bassess bthe bheart brate bfor bbradycardia brelated bto bdigoxin band
birritability bor birregularity brelated bto bhypokalemia. bHypokalemia bincreases bthe
bsensitivity bof bcardiac bmuscle bto bdigoxin band bmay bresult bin bdigoxin btoxicity, beven
bwhen bthe bdigoxin blevel bis bwithin bthe btherapeutic brange. bThe bnurse balso bassesses
bfor bGI bsymptoms bsuch bas bdiarrhea, band bother bsymptoms bof btoxicity bto
bdigoxin.The bBP bmay bdecrease bwith blow bpotassium blevel bbut bmonitoring bthe bpulse
bis bessential. bThe bdiuretic bwould breduce bedema, btherefore bassessing bthe bheart
brate bis bthe bpriority. bHigh bserum bsodium blevels bwould bnot bbe bexpected bin bthis
bscenario bunless bfluid bvolume bdeficit bis bpresent.
Furosemide b(Lasix) bhas bbeen bordered bfor ba bclient bwith bheart bfailure, bshortness bof
bbreath, band b3+ bpitting bedema bof bthe blower bextremities. bWhich bassessment bfinding
bindicates bto bthe bnurse bthat bthe bmedication bhas bbeen beffective?
A. bThe bclient's bpotassium blevel bis b5.1 bmEq/L b(5.1 bmmol/L).
B. bThe bclient's bheart brate bis b101 bbeats bper bminute.
C. bThe bclient bis bfree bfrom badventitious bbreath bsounds.
D. bThe bclient bhas bexperienced ba bweight bgain bof b1 bpound b(0.5 bkg). b-
bCORRECT✅✅C. bThe bclient bis bfree bfrom badventitious bbreath bsounds.
RATIONALE:
The bnurse brecognizes bthat bFurosemide bis beffective bwhen bthe bclient bis bfree bfrom
badventitious bbreath bsounds bsuch bas bcrackles. bOther bpositive boutcomes bto bthe
bdiuretic binclude bnormal bheart brate, bweight bloss bwith bresolution bof bedema, band
bincreased burine boutput.A bpotassium bvalue bof b5.1 bmEq/L bor b(5.1 bmmol/L) bis
bnormal. bChanges bin bpotassium blevels bsuch bas bhypokalemia bare bside beffects bof
bfurosemide, bnot btherapeutic beffects. bAlthough ba bfall bin bthe bclient's bBP bmay boccur
bwith bthe bdecrease bin bbody bfluid, bthis bis bnot bthe bpriority. bTachycardia bmay boccur
bduring bepisodes bof bfluid bvolume bexcess bor bdeficit band bdoes bnot bdirectly bindicate
bthe bmedication bhas bbeen beffective. bWeight bloss, brather bthan bweight bgain, bis boften
bthe beffect bof bFurosemide, bcaused bby bthe bdiuresis.
The bnurse bis bdiscussing bsafety bwhen badministering bbumetanide bwith ba bnursing
bstudent. bThe bnurse brecognizes bthat bthe bstudent bunderstands bside beffects bof bthis
bmedication bwhen bthe bstudent bmakes bwhich bstatement?
A. b"The bclient's bPT band bINR bmay bbe bprolonged bwhile btaking bthis bmedication."
B. b"The bclient bmay bdevelop bhypoglycemia bduring btreatment."
C. b"Inverted bT bwaves band ba bU bwave bmay bappear bon bthe bECG."
D. b"I bneed bto btell bthe bclient bto bavoid bsalt bsubstitutes." b- bCORRECT✅✅C.
b"Inverted bT bwaves band ba bU bwave bmay bappear bon bthe bECG."
RATIONALE:
The bnursing bstudent bunderstands bthe bside beffects bof bBumex bwhen bcommenting
bthat binverted bT bwaves band ba bU bwave bmay bappear bon bthe bEKG. bHypokalemia
, bmay bcause bdepressed bST bsegments, bflat bor binverted bT bwaves bor bthe bpresence
bof ba bU bwave bon bthe bECG bas bwell bas bdysrhythmias. bHigh-ceiling b(loop) bdiuretics,
bsuch bas bfurosemide b(Lasix, bfurosemide), bpromote bloss bof bwater, bsodium, band
bpotassium.PT band bINR bare btypically bprolonged bwith btherapy bwith bwarfarin
b(Coumadin) bor bindividuals bwith bliver bdisease. bHypoglycemia bmay boccur bwith boral
bhypoglycemic bmedications bor binsulin. bSalt bsubstitutes bare btypically bavoided bwhen
bthe bclient bhas bhyperkalemia bor bis btaking ban bACE binhibitor bbecause bmany
bsubstitutes bcontain bpotassium bchloride.
The bnurse bis bteaching ba bclient bwho bis btaking ba bpotassium-sparing bdiuretic babout
bprecautions bwhile btaking bthis bmedication. bWhich bof bthese bdoes bthe bnurse bteach
bthe bclient bto bavoid bor buse bcautiously?
SELECT bALL bTHAT bAPPLY.
A. bApples
B. bBananas
C. bACE binhibitors
D. bGrapes
E. bSalt bsubstitute b- bCORRECT✅✅B, bC, bE b
RATIONALE: b
While btaking ba bpotassium-sparing bdiuretic, bthe bnurse bteaches bthe bclient bto bavoid
bbananas, bACE binhibitors, band bsalt bsubstitutes. bOther bfoods bhigh bin bpotassium
binclude bcantaloupe, bkiwi, boranges, bavocados, bbroccoli, bdried bbeans, blima bbeans,
bmushrooms, bpotatoes, bseaweed, bsoybeans, band bspinach. bSalt bsubstitutes bcontain
bpotassium band bmay bpredispose bthe bclient bto bhyperkalemia.Apples band bgrapes bare
bconsidered blower bpotassium-containing bfoods.
The bnurse bis bassessing ba bclient bwith ba bsodium blevel bof b118 bmEq/L b(118
bmmol/L). bWhich bactivity btakes bpriority?
A. bMonitoring burine boutput
B. bEncouraging bsodium brich bfluids band bfoods bthroughout bthe bday
C. bInstructing bthe bclient bnot bto bambulate bwithout bassistance
D. bAssessing bdeep btendon breflexes b- bCORRECT✅✅C. bInstructing bthe bclient bnot
bto bambulate bwithout bassistance
RATIONALE:
Safety bis bthe bpriority bin bthis binstance. bInstructing bthe bclient bnot bto bambulate
bwithout bassistance bis bthe bpriority bfor ba bclient bwith ba bsodium blevel bof b118 bmEq/L
b(118 bmmol/L). bThis bsodium blevel bdenotes bsevere bhyponatremia bwhich bmakes
bdepolarization bslower band bcell bmembranes bless bexcitable. bThis bis bmanifested bas
bgeneral bmuscle bweakness bwhich bis bworse bin bthe blegs band barms. bAdditionally,
bthis bclient bmay bhave bdeveloped bconfusion bfrom bcerebral bedema.Monitoring burine
boutput bneeds bto bbe bdone bbut bis bnot bthe bpriority baction bin bthis bsituation.
bGenerally, bfluid bis brestricted, brather bthan bsodium brich bfoods boffered, bto bminimize
