NSG 170 FLUID AND ELECTROLYTE AND GLUCOSE
REGULATION || WITH CERTIFIED ANSWERS.
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The
nurse should plan which actions as a priority? Select all that apply.
1. Place the client on a cardiac monitor.
2. Notify the primary health care provider (PHCP).
3. Put the client on NPO (nothing by mouth) status except for ice chips.
4. Review the client's medications to determine whether any contain or retain potassium.
5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
correct answers Answer: 1,2,4,
The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium level of 7.0 is
elevated. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac
arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify
the PHCP and also review medications to determine whether any contain potassium or are
potassium retaining. The client does not need to be put on NPO status. Fluid intake is not
increased because it contributes to fluid overload and would not affect the serum potassium level
significantly.
The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing
the plan of care, which priority problem should the nurse assign to this client?
1. Deficient fluid volume related to acute blood loss
2. Risk for aspiration related to acute bleeding in the GI tract
3. Risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased
metabolism correct answers Answer:1
The priority problem for the client with acute gastrointestinal bleeding among these options is
deficient fluid volume related to acute blood less. This state can result in decreased cardiac
,output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a
priority. The client is at risk for aspiration and infection, but these are not actual problems at this
point in time.
Which laboratory test results may be associated with peaked or tall, tented T waves on a client's
electrocardiogram (ECG)?
1. Chloride level of 98 mEq/L (98 mmol/L)
2. Sodium level of 135 mEq/L (135 mmol/L)
3. Potassium level of 6.8 mEq/L (6.8 mmol/L)
4. Magnesium level of 1.6 mEq/L (0.8 mmol/L) correct answers Answer: 3
Hyperkalemia can cause tall, peaked, or tented T waves on the ECG. Potassium levels of 5.0
mEq/L (5.0 mmol/L) or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.
Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to
the client, the nurse identifies the need to avoid foods that are high in which electrolyte?
1. Calcium
2. Potassium
3. Magnesium
4. Phosphorus correct answers Answer: 2
Rationale: Spironolactone is a potassium-retaining diuretic, and the client should avoid foods
high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could
develop. The client does not need to avoid foods that contain calcium, magnesium, or
phosphorus while taking this medication
A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription
for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will
also be started on digoxin, which laboratory result should the nurse review as the priority?
, 1. Sodium level
2. Digoxin level
3. Creatinine level
4. Potassium level correct answers Annswer: 4
Diuretic therapy can cause hypokalemia. The serum potassium level is measured in the client
receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can
occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular
dysrhythmias.
The nurse is caring for a postoperative client who has lost a significant amount of blood because
of complications during a surgical procedure. Which assessment finding would be indicative of
further fluid volume deficit?
1. 4+ edema noted in lower extremities
2. Crackles auscultated from lung bases to apices
3. Blood pressure rises from 116/68 to 118/74 mm Hg
4. Pulse rate increases from 100 beats/min to 136 beats/min correct answers Answer: 4
The cardiac output is determined by the volume of the circulating blood, the pumping action of
the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for
decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure
is expected in a postoperative client who lost a significant amount of blood.
The nurse identifies that a client is having occasional premature ventricular contractions (PVCs)
on the cardiac monitor. The nurse reviews the client's laboratory results and determines that
which result would be consistent with the observation?
1. Serum chloride level of 98 mEq/L (98 mmol/L)
2. Serum sodium level of 145 mEq/L (145 mmol/L)
3. Serum calcium level of 10.5 mg/dL (2.75 mmol/L)
REGULATION || WITH CERTIFIED ANSWERS.
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The
nurse should plan which actions as a priority? Select all that apply.
1. Place the client on a cardiac monitor.
2. Notify the primary health care provider (PHCP).
3. Put the client on NPO (nothing by mouth) status except for ice chips.
4. Review the client's medications to determine whether any contain or retain potassium.
5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
correct answers Answer: 1,2,4,
The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium level of 7.0 is
elevated. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac
arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify
the PHCP and also review medications to determine whether any contain potassium or are
potassium retaining. The client does not need to be put on NPO status. Fluid intake is not
increased because it contributes to fluid overload and would not affect the serum potassium level
significantly.
The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing
the plan of care, which priority problem should the nurse assign to this client?
1. Deficient fluid volume related to acute blood loss
2. Risk for aspiration related to acute bleeding in the GI tract
3. Risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased
metabolism correct answers Answer:1
The priority problem for the client with acute gastrointestinal bleeding among these options is
deficient fluid volume related to acute blood less. This state can result in decreased cardiac
,output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a
priority. The client is at risk for aspiration and infection, but these are not actual problems at this
point in time.
Which laboratory test results may be associated with peaked or tall, tented T waves on a client's
electrocardiogram (ECG)?
1. Chloride level of 98 mEq/L (98 mmol/L)
2. Sodium level of 135 mEq/L (135 mmol/L)
3. Potassium level of 6.8 mEq/L (6.8 mmol/L)
4. Magnesium level of 1.6 mEq/L (0.8 mmol/L) correct answers Answer: 3
Hyperkalemia can cause tall, peaked, or tented T waves on the ECG. Potassium levels of 5.0
mEq/L (5.0 mmol/L) or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.
Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to
the client, the nurse identifies the need to avoid foods that are high in which electrolyte?
1. Calcium
2. Potassium
3. Magnesium
4. Phosphorus correct answers Answer: 2
Rationale: Spironolactone is a potassium-retaining diuretic, and the client should avoid foods
high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could
develop. The client does not need to avoid foods that contain calcium, magnesium, or
phosphorus while taking this medication
A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription
for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will
also be started on digoxin, which laboratory result should the nurse review as the priority?
, 1. Sodium level
2. Digoxin level
3. Creatinine level
4. Potassium level correct answers Annswer: 4
Diuretic therapy can cause hypokalemia. The serum potassium level is measured in the client
receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can
occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular
dysrhythmias.
The nurse is caring for a postoperative client who has lost a significant amount of blood because
of complications during a surgical procedure. Which assessment finding would be indicative of
further fluid volume deficit?
1. 4+ edema noted in lower extremities
2. Crackles auscultated from lung bases to apices
3. Blood pressure rises from 116/68 to 118/74 mm Hg
4. Pulse rate increases from 100 beats/min to 136 beats/min correct answers Answer: 4
The cardiac output is determined by the volume of the circulating blood, the pumping action of
the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for
decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure
is expected in a postoperative client who lost a significant amount of blood.
The nurse identifies that a client is having occasional premature ventricular contractions (PVCs)
on the cardiac monitor. The nurse reviews the client's laboratory results and determines that
which result would be consistent with the observation?
1. Serum chloride level of 98 mEq/L (98 mmol/L)
2. Serum sodium level of 145 mEq/L (145 mmol/L)
3. Serum calcium level of 10.5 mg/dL (2.75 mmol/L)
