Exam View - Chapter 13 - Ignatavicius: Medical-Surgical Nursing, 10th Edition Bank PDF

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Ignatavicius: Medical-Surgical Nursing, 10th Edition
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Chapter 13: Concepts of Fluid and Electrolyte Balance Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which

dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure. ANS: C

Older adults, because they have less total body water than younger adults, are at greater risk for develop Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her n high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term st administration do not increase the risk of dehydration. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position. ANS: B

Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. T is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakne response is to do a more thorough evaluation of the client’s risk for falls. Measuring intake and output m frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flo prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overlo high-Fowler position may or may not be comfortable but still does not address the most important issue DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding.

that the client correctly understood the teaching? a. “I must drink a quart (liter) of water or other liquid each day.” b. “I will weigh myself each morning before I eat or drink.” c. “I will use a salt substitute when making and eating my meals.” d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.” ANS: B

One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insuf not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day. DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Dehydration, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as bein

insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea.

c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain. ANS: B

Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water

5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nur

therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client’s posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing ANS: D

The focus of management for clients with dehydration is to increase fluid volumes to normal. When bloo orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of contin DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understand

for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots ANS: D

Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, sal usually high in sodium. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first a. A 34 year old who is NPO and receiving rapid intravenous D 5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin. ANS: A

Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamid digoxin will not put a client at risk for hyponatremia. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this a. “Have you spouse watch you for irritability and anxiety.” b. “Notify the clinic if you notice muscle twitching.” c. “Call your primary health care provider for diarrhea.” d. “Bake or grill your meat rather than frying it.” ANS: C

One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to c provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle hypernatremia. Cooking methods are not a cause of hyponatremia. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/

(0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assess complete first? a. Depth of respirations b B l d

10. A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardi

intervention will the nurse implement first ? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment. ANS: C

A client with a critically high serum potassium level and cardiac changes would be treated immediately t potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of s Insulin will decrease both serum potassium and glucose levels and therefore would be administered with hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. D but this treatment will take much longer to implement and is not the first intervention the nurse would im potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current p DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client’s lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale. ANS: B

All interventions are appropriate for the client who is overhydrated. However, client safety is the priority overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely m respiratory status. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 12. A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength has diminish

assessment 1 hour ago. What action does the nurse take first ? a. Assess the client’s respiratory rate, rhythm, and depth. b. Measure the client’s pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider. ANS: A

In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nu respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythm hypokalemia. The client’s pulse and blood pressure would be assessed after assessing respiratory status. the health care primary health care provider to obtain orders for potassium replacement. Documenting fi monitor the client would occur during and after potassium replacement therapy. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates

this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client’s IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse. ANS: C

IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action s knowledge. The other actions are acceptable for this high-alert drug.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control...