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The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dys- pneic, and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) - ANSWER ANSWER: 3.
Rationale: Afluid volume excess is also known as overhydration or fluid overload and occurs
when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit.
Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted
in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there
is more than one part to an option, all parts need to be correct in order for the option to be
correct. Think about the pathophysiology associated with a fluid volume excess to assist in
directing you to the correct option. Also, note that the incorrect options are comparable or
alike in that each includes manifestations that reflect a decrease.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the
client's record and determines that the client is at risk for developing the potassium deficit
because of which situation?
1
, 1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 μmol/L) - ANSWER ANSWER: 2.
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost
through gastrointestinal suction, placing the client at risk for hypokalemia. The client with
tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43
mmol/L) and for a male is 4.0 to 8.5 mg/dL(0.24 to 0.51 mmol/L). Hyperuricemia is a cause
of hyperkalemia.
Test-Taking Strategy: Note that the subject of the question is potassium deficit. First recall
the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4.
For the remaining options, note that the correct option is the only one that identifies a loss
of body fluid.
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level
is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the
electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment 5. Widened QRS complex - ANSWER ANSWER: 1, 3, 4
Rationale: The normal serum potassiumlevel is 3.5to5.0mEq/L (3.5to5.0 mmol/L).
Aserumpotassiumlevellowerthan3.5 mEq/ L (3.5 mmol/L) indicates hypokalemia. Potassium
deficit is an electrolyte imbalance that can be potentially life-threatening.
Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment
depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia
but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular
rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
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The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dys- pneic, and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) - ANSWER ANSWER: 3.
Rationale: Afluid volume excess is also known as overhydration or fluid overload and occurs
when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit.
Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted
in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there
is more than one part to an option, all parts need to be correct in order for the option to be
correct. Think about the pathophysiology associated with a fluid volume excess to assist in
directing you to the correct option. Also, note that the incorrect options are comparable or
alike in that each includes manifestations that reflect a decrease.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the
client's record and determines that the client is at risk for developing the potassium deficit
because of which situation?
1
, 1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 μmol/L) - ANSWER ANSWER: 2.
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost
through gastrointestinal suction, placing the client at risk for hypokalemia. The client with
tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43
mmol/L) and for a male is 4.0 to 8.5 mg/dL(0.24 to 0.51 mmol/L). Hyperuricemia is a cause
of hyperkalemia.
Test-Taking Strategy: Note that the subject of the question is potassium deficit. First recall
the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4.
For the remaining options, note that the correct option is the only one that identifies a loss
of body fluid.
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level
is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the
electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment 5. Widened QRS complex - ANSWER ANSWER: 1, 3, 4
Rationale: The normal serum potassiumlevel is 3.5to5.0mEq/L (3.5to5.0 mmol/L).
Aserumpotassiumlevellowerthan3.5 mEq/ L (3.5 mmol/L) indicates hypokalemia. Potassium
deficit is an electrolyte imbalance that can be potentially life-threatening.
Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment
depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia
but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular
rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
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