Med-Surg: Fluid & Electrolyte

Med-Surg: Fluid & Electrolyte

• A nurse is caring for a client who had CKD. The nurse should monitor the client for which of

the following manifestations of fluid overload?

• Flat Neck Veins
• Weak Pulse
• Increased Hematocrit
• Increased Blood Pressure

Answer: D. The nurse should monitor the blood pressure of a client who has CKD. The client who is experiencing fluid overload due to CKD will manifest an increase in blood pressure.

• A nurse is caring for a client who has CKD. Which of the following actions should the nurse

take to manage fluid overload?

• Weight the client periodically throughout the day.
• Measures the client’s output every 8 hours
• Obtain the client’s blood pressure at least every 4 hours
• Limit client’s oral fluid intake to meal times

Answer: C. The nurse should obtain the client’s blood pressure at least every 4 hr. An increase in the blood pressure can indicate fluid overload and hypertension which can lead to further kidney damage. The nurse should monitor the blood pressure of a client who has CKD. The client who is experiencing fluid overload due to CKD will manifest an increase in blood pressure.

• A nurse is reinforcing discharge teaching with a client who has undergone a transurethral

resection of the prostate (TURP). Which of the following statements should the nurse include in the teaching?

• increase fluid intake if you’re in becomes blood tinged
• take naproxen for discomfort.
• sexual activity is permitted after two weeks.
• urinary dribble and will resolve within 5 days.

Answer : A.

Rational. The nurse should reinforce that strenuous activity, straining to the bowel movement and coughing may cause the urine to become blood tinged. If this should occur the client should stop the activity, rest, and increase fluid intake. If urine becomes increasingly blood tinged or does not clear , or if the client has difficulty voiding, then he or she should be instructed to notify the provider.

• A nurse is reviewing the medical records of a group of clients. The nurse should identify that

hemodialysis is appropriate for which of the following clients ?

• A client who has minimal urine output following a drug overdose.
• A client who has acute kidney disease and is responding to diuretics.
• A client who took excessive laxatives and has a potassium level of 2.8mEq/L.
• A client who has been vomiting and has metabolic alkalosis.
• A client with a potassium level of 5.8 mEq/L
• A client who has been diarrhea and has metabolic acidosis

Answer. A Rational: the nurse should recognize that hemodialysis therapy is appropriate for clients who have end stage kidney disease, drug overdose, hyperkalemia, fluid overdose or metabolic acidosis.

• A nurse is observing a client who has acute alcohol intoxication. The nurse should identify

that the client is at risk for which of the following acid-base imbalances?

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis

Answer: C. Common causes of metabolic acidosis include alcohol or ethanol intoxication, diabetic ketoacidosis, hypoxia, kidney failure, diarrhea, and pancreatitis.

• A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of

the following laboratory values should the nurse expect?

• pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg
• pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg
• pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg
• pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg

Answer: D. These laboratory values reflect metabolic alkalosis. The pH and the bicarbonate are greater than the expected reference range, and the PaCO2 is within the expected reference range.

• A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's

ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

• Respiratory acidosis
• Metabolic acidosis
• Respiratory alkalosis
• Metabolic alkalosis

Answer: C. Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.

Which one is not common causes of metabolic acidosis?Liver Failure

• A nurse is providing dietary teaching to a client who has kidney disease. Which of the

following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?

• Yogurt
• Corn Flakes
• Hard boiled egg
• Leafy Greens

Answer: C. Hard Boiled Egg

Rationale: Hard Boiled eggs contain as little as 5 mg of Magnesium, while yogurt contains 19 mg, leafy greens contain 24 mg and corn flakes contain 11 mg of Magnesium.

• A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is

confused and lethargic. Which of the following laboratory values should the nurse report to the provider?

• Magnesium 1.8 mg/dL
• Sodium 128 mEq/L
• Potassium 4.0 mEq/L
• Phosphate 3.0 mg/dL

Answer: B. Sodium 128 mEq/L

Rationale: Normal sodium levels should always be between 135 to 145.

• A nurse is caring for a client whose ABG results are pH 7.30, PaCO2 32 mm HG, and HCO3

19 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

a) Respiratory acidosis

b) Respiratory alkalosis

c) Metabolic acidosis

d) Metabolic alkalosis

Answer: c) Metabolic acidosis. With metabolic acidosis, the pH is low, the PaCO2 is low or within the expected reference range, and the bicarbonate is low.

• A nurse is caring for a client who has a NG tube with low intermittent suctioning. The nurse

should monitor the client for which of the following electrolyte imbalances? (SATA)

• Hypercalcemia
• Hyponatremia
• Hyperphosphatemia
• Hypomagnesemia
• Hyperkalemia

Answer: B, D: Hyponatremia, Hypomagnesemia Rationale: Nasogastric losses are isotonic and contain sodium. Thus, nasogastric suction can cause hyponatremia. Nasogastric losses due to suctioning, diarrhea, and fistula drainage can deplete magnesium levels.

Which one can you deplete magnesium level(SATA)?Nasogastric losses due to suctioning Fistula drainage Diarrhea

• A nurse is caring for a client who has a serum sodium level of 133 mEq/L and serum

potassium level of 3.4 mEq/L. Which of the following treatments is a risk factor for these laboratory findings?

• Three tap water enemas
• 0.9% NaCl IV
• Dextrose 5% in water with 20 mEq of K+ IV
• Spironolactone therapy

Answer: A. Three tap water enemas

Rationale: Three tap water enemas can deplete Na & K. Tap water is hypotonic and can move

from the bowel lumen into the ICF, causing water intoxication and electrolyte imbalance

• A nurse is caring for a client who has metabolic alkalosis. As the client compensates for this

acid-base imbalance, which of the following mechanisms should the nurse expect the client's body to use?

• Hypoventilation
• Hyperventilation
• Increased renal acid excretion
• Decreased renal acid excretion

Answer: A.

Rationale: Hypoventilation is the mechanism that helps clients compensate for metabolic alkalosis. As a result, the client's PaCO2 and HCO3- will increase.

• A nurse is caring for a client who has metabolic acidosis. As the client compensates for this acid-base imbalance,

which of the Following mechanisms should the nurse expect the clients body to use?Hyperventilation

• A nurse is caring for an older adult client in a long-term care facility who is dehydrated.

Which of the following actions should the nurse take?

• Initiate fluid restrictions to limit the client’s intake.
• Observe for indications of peripheral edema
• Encourage the client to promote oxygenation by ambulating
• Monitor for orthostatic hypotension

Answer: D.

Rationale: The nurse should monitor for orthostatic hypotension because the client has manifestations of dehydration due to decreased circulatory volume.

• A nurse is collecting data from a client who has hyperkalemia. Which of the following

disorders is a risk factor for this electrolyte imbalance?

• Diabetic ketoacidosis
• Heart Failure
• Aldosterone excess
• Excessive sweating

Answer: A. Ketoacidosis. Diabetic ketoacidosis, kidney disease, and crash injuries are all risk factors of hyperkalemia

• A nurse is collecting data from a client who has hypomagnesemia. Which of the following

techniques should the nurse use to check for Chvostek sign?

• Apply a blood pressure cuff to the client's arm.
• Place the stethoscope's bell over the client's carotid artery.
• Tap lightly on the client's cheek.
• Ask the client to lower her chin to her chest.