NRS 1235 Fluid and Electrolytes

Front

The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity than blood. Which type of fluid should the nurse document that the patient is going to receive?

Back

hypotonic

Answer explanation

The patient is to receive a hypotonic fluid, which has a lower osmolarity than blood. This type of fluid causes water to move into cells, helping to hydrate them.

Front

The nurse is concerned that a patient has a high volume of insensible water loss. What is the patient experiencing that is causing the nurse this concern?

Back

perspiration

Answer explanation

The nurse is concerned about insensible water loss, which primarily occurs through perspiration. Unlike diarrhea, vomiting, or urination, perspiration is a significant source of water loss that is not easily measured.

Front

An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results:
Hct 56% (normal 40% to 51%)
BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL). Which nursing problem should the nurse select for this patient? Options: Risk for injury, Excess fluid volume, Deficient fluid volume, Impaired skin integrity.

Back

Deficient fluid volume

Answer explanation

The patient's elevated Hct and BUN indicate dehydration, suggesting a deficient fluid volume. This is critical in gastroenteritis, where fluid loss occurs. Therefore, 'Deficient fluid volume' is the appropriate nursing problem.

Front

A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the patient chooses which menu? Pork chop, steamed brown rice, and fruit cocktail; Broiled salmon, mashed sweet potato, broccoli, and pumpkin pie; Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie; Grilled chicken, boiled potatoes, frozen green beans, and gelatin dessert.

Back

Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie

Answer explanation

The tomato soup is typically high in sodium, making this menu choice inappropriate for a low-sodium diet. The other options contain lower sodium items, aligning better with the dietary needs of a patient with hypertension.

Front

An older adult patient has an IV infusion of 0.45% normal saline infusing at 150 mL/hr. Which assessment finding should cause the nurse to be most concerned? Tenderness at the IV site, Capillary refill is <3 seconds, Urine specific gravity is 1.018, Newly noted crackles in the lungs

Back

Newly noted crackles in the lungs

Answer explanation

Newly noted crackles in the lungs indicate potential fluid overload or pulmonary edema, which is a serious concern in an older adult receiving IV fluids. This finding requires immediate assessment and intervention.

Front

A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the patient to avoid? Options: gelatin, potatoes, zucchini, white bread

Back

potatoes

Answer explanation

Potatoes are high in potassium, which can exacerbate hyperkalemia in patients with renal failure. The nurse should teach the patient to avoid potatoes to help manage their potassium levels.

Front

A patient is diagnosed with an abnormal potassium level. Which complication should the nurse assess for in this patient?

Back

Cardiac arrest

Answer explanation

Abnormal potassium levels, especially hyperkalemia, can lead to serious cardiac complications, including cardiac arrest. Therefore, the nurse should closely monitor for signs of cardiac distress in this patient.

Front

A 22-year-old patient with inflammatory bowel disease has been having 16 or more stools per day. Which symptom should the nurse expect to find during the assessment?

Back

Furrows of the tongue and sticky mucous membranes

Answer explanation

In inflammatory bowel disease, severe diarrhea can lead to dehydration and malnutrition, causing oral symptoms like furrows of the tongue and sticky mucous membranes due to dry mouth. This is the expected finding.

Front

A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a thyroidectomy. Which emergency medication should the nurse anticipate being prescribed for this patient? Options: Furosemide (Lasix), Calcium gluconate, Potassium chloride, Diazepam (Valium)

Back

Calcium gluconate

Answer explanation

The patient's symptoms suggest hypocalcemia, which can occur after thyroidectomy due to potential damage to the parathyroid glands. Calcium gluconate is the appropriate emergency medication to treat this condition.

Front

The nurse is testing a patient for the presence of Trousseau’s sign. Which patient response should the nurse recognize as a positive result?

Back

Spasticity of the arm and fingers

Answer explanation

A positive Trousseau's sign indicates latent tetany, characterized by spasticity of the arm and fingers when a blood pressure cuff is inflated. This response suggests hypocalcemia, making 'spasticity of the arm and fingers' the correct answer.