CH. 10: Fluid and Electrolytes

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The plan of care includes assessment of specific gravity every four hours. The results of this test will allow the nurse to assess which aspect of the client's health?

• Nutritional status

• Potassium balance

• Calcium balance

• Fluid volume status

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem?

• Diminished deep tendon reflexes

• Tachycardia

• Cool, clammy skin

• Acute flank pain

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance?

• Metabolic alkalosis

• Hypermagnesemia

• Hypercalcemia

• Hypovolemia

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

• Respiratory acidosis

• Respiratory alkalosis

• Increased PaCO2

• Metabolic acidosis

The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?

• Respiratory acidosis with no compensation

• Metabolic alkalosis with compensatory alkalosis

• Metabolic acidosis with no compensation

• Metabolic acidosis with compensatory respiratory alkalosis

While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation?

• Air embolism

• Phlebitis

• Infiltration

• Fluid overload

The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor?

• Overhydration is common among healthy older adults.

• Dehydration causes the skin to appear spongy.

• Inelastic skin turgor is a normal part of aging.

• Skin turgor cannot be assessed in clients over the age of 70.

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply.

• Administer potassium by IV push.

• Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration.

• Monitor complete blood count during potassium infusion.

• Follow the facility policy for infusion of potassium.

• Report a reduced urinary output to the health care provider.

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which of the following terms?

• Hydrostatic pressure

• Osmosis and osmolality

• Diffusion

• Active transport

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect?

• Hypophosphatemia

• Hypocalcemia

• Hypermagnesemia

• Hyperkalemia