FLUID AND ELECTROLYTES NCLEXQUESTIONSANDANSWERS VERIFIED RATIONALE 100%COMPLETEGRADED A+

FLUID AND ELECTROLYTES NCLEXQUESTIONSANDANSWERS VERIFIED RATIONALE 100%COMPLETEGRADED A+A client develops fluid overload while in the intensive care unit. Which nursing intervention does thenurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position - ansB. Elevates the head of the bed The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenationto relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but wouldnot be performed first. Placing the extremities in a dependent position increases peripheral edema, andpositioning the client in a side- A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Whichof these best practice techniques does the nurse include when administering this medication? SELECT ALL THAT APPLY. A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution B. Use a vein in the hand for better flow C. Use an IV pump to deliver the medication D. Check IV access for blood return after the infusion E. Push the medication over 5 minutes - ansA, C RATIONALE: Best practice technique for administering IV potassium replacement is to ensure that the concentrationis no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the AGRADESTUVIA STORE 2025 ALL THE BEST AGRADESTUVIA STORE 2 DO NOT COPY medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. Themaximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed20mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement andanadequate blood return before administering potassium-containing solutions. A client is brought to the emergency department for increasing weakness and muscle twitching. Thelaboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does thenurse make? SELECT ALL THAT APPLY. A. History of liver disease B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics E. Prescription for insulin - ansB, C, D, RATIONALE: When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidneydisease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Takinginsulin would lower the potassium level. A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure(CHF). What nursing actions are indicated at this time? SELECT ALL THAT APPLY. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. Assess for orthostatic hypotension AGRADESTUVIA STORE 2025 ALL THE BEST AGRADESTUVIA STORE 3 DO NOT COPY E. Initiate cardiac monitoring. - ansA, B, D, E RATIONALE: Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyteimbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely withdiarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for invertedTwaveor presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order inthepresence of assessment data indicating fluid loss from the diuretics and diarrhea. A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventionsis most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor - ansD. Place the client on a cardiac monitor RATIONALE: Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distressat this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesiumexcess is determined. A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of theseinterventions does the nurse use to safely administer KCl? SELECT ALL THAT APPLY. AGRADESTUVIA STORE 2025 ALL THE BEST AGRADESTUVIA STORE 4 DO NOT COPY A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest. - ansA, B, C RATIONALE: Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy preparedpotassium infusion, checking the client for any burning or redness during infusion, and infusing theIVat not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registeredpharmacist and that vials of concentrated potassium not be available in client care areas. IV potassiumsolutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether heor shefeels burning or pain at the site. The presence of pain or burning at the insertion site may require anewintravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstancewhere potassium is given by IV push. A client with mild hypokalemia caused by diuretic use is discharged home. The home health nursedelegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's weight - ansD. Measurement of the client's weight RATIONALE: The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of carehas been effective.Assessment, education, and instruction are higher-level nursing actions withinthescope of practice of the professional nurse. After receiving change-of-shift report, which client does the RN assess first? AGRADESTUVIA STORE 2025 ALL THE BEST AGRADESTUVIA STORE 5 DO NOT COPY A. A client with nausea and vomiting who complains of abdominal cramps B. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg D. A client with normal saline infu