Fluid & Electrolyte

A patient with tented skin turgor, dry mucous membranes and decreased urinary output is under your care. Which nursing intervention should be included in his plan of care?

• Administer IV and oral fluids

• Monitoring WBC

• Accessing color, odor and amount of sputum

• Clustering activities throughout the day

Tags

NGSS.HS-LS1-3

A patient is admitted to the hospital due to having lower than normal K+ levels. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which of the following foods should the nurse encourage her to increase?

• Whole grains and nuts

• Milk products and green, leafy vegetables

• Pork products and canned vegetables

• Orange juice and bananas

Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

• Administering IV fluids

• Encouraging slow, deep breaths

• Preparing to administer sodium bicarbonate

• Administering oxygen via nasal cannula

Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

• Tetany

• Paraesthesia

• Positive Chvostek's sign

• Positive Trousseau's sign

Tags

NGSS.HS-LS1-3

Lab tests revealed that your patient’s sodium level is 170 mEq/L. Which clinical manifestation would you expect to assess?

• Tented skin turgor and thirst

• Muscle twitching and tetany

• Fruity breath and Kussmaul respirations

• Muscle weakness and paraesthesia

Tags

NGSS.HS-LS1-3

A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

• Accessing I&O

• Monitoring ABG's

• Obtaining the clients weight weekly

• Maintaining IV therapy at the keep-vein-open rate

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

• A 20 year old taking diuretics

• A 16 year old with an ileostomy

• A 16 year old with metabolic acidosis

• An 18 year old who has renal failure

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

• Instituting seizure precaution to prevent injury

• Instructing client on the importance of preventing infection

• Avoiding the use of tight tourniquet when drawing blood

• Teaching the client the importance of early ambulation

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

• Potassium

• Chloride

• Sodium

• Magnesium

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

• Increased respiratory rate and depth

• Hot flushed skin and diaphoresis

• Muscle pain and acute rhabdomyolysis

• Soft tissue calcification and hyperreflexia