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Restlessness, Concentrated urine, Dry mucous membranes - ANS ✔A nurse has been caring for
a client with a high fever and diarrhea for the past 5 days. Which clinical manifestations suggest
extracellular fluid volume deficit? Select all that apply.
An older adult who is homeless and has a history of chronic alcoholism - ANS ✔A charge nurse
is reviewing the electrolyte laboratory study results for the unit's assigned clients. Which client
would be at greatest risk for the potential development of hypomagnesemia?
A nurse is caring for a client admitted to the hospital with heart failure. The morning laboratory
results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should
be withheld until consulting with a health care provider? - ANS ✔A nurse is caring for a client
admitted to the hospital with heart failure. The morning laboratory results reveal a serum
potassium level of 2.9 mEq/L. Which classification of medications should be withheld until
consulting with a health care provider?
Oral intake balances output - ANS ✔A client has been successfully treated for dehydration.
What does the nurse expect?
Listen to the client's lung sounds and assess respiratory status - ANS ✔An older adult is
receiving intravenous (IV) fluids postoperatively. During the 0800 assessment of the client, the
nurse notes that the IV solution, which was prescribed to infuse at 125 mL/hr, has infused 950
mL since it was hung at 0400. What is the priority nursing intervention?
Dysrhythmias - ANS ✔A nurse notes that a client with a serum potassium of 2.8 mmol/L is at
highest risk for what?
, Excessive thirst - ANS ✔While caring for a client who had a pituitary tumour removed, which
finding should be reported immediately to a primary health care provider?
Respiratory acidosis - ANS ✔An older adult has been admitted to the hospital with exacerbation
of chronic obstructive pulmonary disease (COPD). The arterial blood gas (ABG) reveals the
following information: pH 7.34, PaCO2 46 mm Hg, PaO2 87 mm Hg, and O2 saturation 94%. How
does the nurse interpret these results?
Metabolic acidosis - ANS ✔A client living with diabetes mellitus who is fasting before surgery
reports feeling dizzy and has deep rapid breathing. A nurse observes that the client has
developed Kussmaul respirations. What condition is the client most likely experiencing?
Urine output 10 mL/hr, Tachycardia, Sunken eye - ANS ✔An older adult is admitted to the
hospital with nausea and vomiting. Which manifestations would a nurse assess to check for the
presence of dehydration? Select all that apply.
2000-3000ml - ANS ✔When planning care for adult clients, a nurse concludes which oral intake
is adequate to meet the daily fluid needs of a stable client?
Fluid movement from the interstitial space into the blood vessels - ANS ✔When planning care
for a client with dehydration related to nausea and vomiting, a nurse would anticipate which
fluid shift to occur because of the fluid volume deficit?
- ANS ✔A client has been admitted for dehydration. What is a priority nursing intervention?
Administer lactated Ringer's solution - ANS ✔A nurse finds that a client has severe diarrhea and
may be at risk of fluid volume deficit. After the appropriate prescription by a health care
provider, what is the most appropriate nursing intervention to treat fluid deficit?
Metabolic alkalosis - ANS ✔Administer lactated Ringer's solution