,1. Which of the following findings is the nurse's priority concern when providing care for a client
with a serum sodium level of 130 mEq/L?
A) Thirst and dry mucous membranes
B) Decreased level of consciousness and convulsions
C) Muscle weakness and cardiac dysrhythmias
D) Polyuria and polydipsia
Correct Answer: Decreased level of consciousness and convulsions
Rationale: Hyponatremia (sodium <135 mEq/L) causes water to shift into brain cells, leading to
cerebral edema . Early signs include headache and confusion, but a decreasing level of
consciousness and seizures are life-threatening complications indicating significant neurological
compromise. Thirst and dry membranes suggest hypernatremia, while polyuria and polydipsia
are characteristic of diabetes insipidus or hyperglycemia.
2. A client with a serum potassium level of 5.2 mEq/L requires close monitoring for which
clinical manifestation?
A) Hyperactive bowel sounds
B) Cardiac dysrhythmias and muscle weakness
C) Hypertension and tachycardia
D) Respiratory alkalosis
Correct Answer: Cardiac dysrhythmias and muscle weakness
Rationale: Hyperkalemia (potassium >5.0 mEq/L) increases myocardial irritability and impairs
neuromuscular transmission, leading to cardiac dysrhythmias and skeletal muscle weakness .
This can progress to life-threatening ventricular dysrhythmias, making ECG monitoring essential.
The other options are not characteristic findings of hyperkalemia; GI symptoms may occur but
are not the priority.
,3. A nurse is assessing a client with fluid volume deficit. Which finding would the nurse expect
to observe first?
A) Decreased blood pressure
B) Tachycardia
C) Poor skin turgor
D) Weight loss
Correct Answer: Tachycardia
Rationale: Tachycardia is the earliest compensatory response to fluid volume deficit as the heart
rate increases to maintain cardiac output . Blood pressure drops later as a sign of severe deficit,
while poor skin turgor and weight loss reflect more established fluid loss. Prompt recognition
allows for early intervention to prevent hypovolemic shock.
4. A client's serum calcium level is low. Which food should the nurse recommend to increase
dietary calcium intake?
A) Fresh apples
B) Broccoli
C) Sardines with bones
D) White rice
Correct Answer: Sardines with bones
Rationale: Sardines with bones are an excellent dietary source of calcium, along with milk and
cheese . Clients with hypocalcemia require calcium-rich foods to restore normal levels and
prevent complications such as tetany and positive Chvostek's sign.
, 5. The nurse is caring for a client in renal failure who demonstrates facial muscle spasms while
the face is being washed. Which electrolyte imbalance should the nurse suspect?
A) Hyperkalemia
B) Hyponatremia
C) Hypocalcemia
D) Hypermagnesemia
Correct Answer: Hypocalcemia
Rationale: Facial muscle spasms during touch or manipulation (Chvostek's sign) indicate
neuromuscular irritability caused by hypocalcemia . This finding is significant in renal failure,
where calcium metabolism is disrupted. Prompt assessment and treatment are needed to
prevent laryngospasm and seizures.
6. Which laboratory values are the most useful for assessing a client's overall fluid volume
status?
A) Serum albumin and total protein
B) Blood urea nitrogen (BUN), creatinine, and serum sodium
C) White blood cell count and platelets
D) Serum glucose and hemoglobin A1C
Correct Answer: Blood urea nitrogen (BUN), creatinine, and serum sodium
Rationale: BUN, creatinine, and serum sodium provide a comprehensive picture of fluid volume
status . Elevated BUN and creatinine may indicate prerenal azotemia from dehydration, while
sodium levels reflect water balance. These values are essential for differentiating between fluid
volume deficit and overload.
with a serum sodium level of 130 mEq/L?
A) Thirst and dry mucous membranes
B) Decreased level of consciousness and convulsions
C) Muscle weakness and cardiac dysrhythmias
D) Polyuria and polydipsia
Correct Answer: Decreased level of consciousness and convulsions
Rationale: Hyponatremia (sodium <135 mEq/L) causes water to shift into brain cells, leading to
cerebral edema . Early signs include headache and confusion, but a decreasing level of
consciousness and seizures are life-threatening complications indicating significant neurological
compromise. Thirst and dry membranes suggest hypernatremia, while polyuria and polydipsia
are characteristic of diabetes insipidus or hyperglycemia.
2. A client with a serum potassium level of 5.2 mEq/L requires close monitoring for which
clinical manifestation?
A) Hyperactive bowel sounds
B) Cardiac dysrhythmias and muscle weakness
C) Hypertension and tachycardia
D) Respiratory alkalosis
Correct Answer: Cardiac dysrhythmias and muscle weakness
Rationale: Hyperkalemia (potassium >5.0 mEq/L) increases myocardial irritability and impairs
neuromuscular transmission, leading to cardiac dysrhythmias and skeletal muscle weakness .
This can progress to life-threatening ventricular dysrhythmias, making ECG monitoring essential.
The other options are not characteristic findings of hyperkalemia; GI symptoms may occur but
are not the priority.
,3. A nurse is assessing a client with fluid volume deficit. Which finding would the nurse expect
to observe first?
A) Decreased blood pressure
B) Tachycardia
C) Poor skin turgor
D) Weight loss
Correct Answer: Tachycardia
Rationale: Tachycardia is the earliest compensatory response to fluid volume deficit as the heart
rate increases to maintain cardiac output . Blood pressure drops later as a sign of severe deficit,
while poor skin turgor and weight loss reflect more established fluid loss. Prompt recognition
allows for early intervention to prevent hypovolemic shock.
4. A client's serum calcium level is low. Which food should the nurse recommend to increase
dietary calcium intake?
A) Fresh apples
B) Broccoli
C) Sardines with bones
D) White rice
Correct Answer: Sardines with bones
Rationale: Sardines with bones are an excellent dietary source of calcium, along with milk and
cheese . Clients with hypocalcemia require calcium-rich foods to restore normal levels and
prevent complications such as tetany and positive Chvostek's sign.
, 5. The nurse is caring for a client in renal failure who demonstrates facial muscle spasms while
the face is being washed. Which electrolyte imbalance should the nurse suspect?
A) Hyperkalemia
B) Hyponatremia
C) Hypocalcemia
D) Hypermagnesemia
Correct Answer: Hypocalcemia
Rationale: Facial muscle spasms during touch or manipulation (Chvostek's sign) indicate
neuromuscular irritability caused by hypocalcemia . This finding is significant in renal failure,
where calcium metabolism is disrupted. Prompt assessment and treatment are needed to
prevent laryngospasm and seizures.
6. Which laboratory values are the most useful for assessing a client's overall fluid volume
status?
A) Serum albumin and total protein
B) Blood urea nitrogen (BUN), creatinine, and serum sodium
C) White blood cell count and platelets
D) Serum glucose and hemoglobin A1C
Correct Answer: Blood urea nitrogen (BUN), creatinine, and serum sodium
Rationale: BUN, creatinine, and serum sodium provide a comprehensive picture of fluid volume
status . Elevated BUN and creatinine may indicate prerenal azotemia from dehydration, while
sodium levels reflect water balance. These values are essential for differentiating between fluid
volume deficit and overload.
