Fluids and Electrolytes
A client with a serum sodium level of 118 mEq/L is confused and has a seizure. Which intervention is the priority?
A. Encourage free-water intake
B. Initiate seizure precautions and notify the provider
C. Administer hypotonic IV fluids
D. Restrict sodium intake
B. Initiate seizure precautions and notify the provider
Explanation: Severe hyponatremia can cause cerebral edema, confusion, seizures, and increased intracranial pressure. Safety and seizure precautions are priorities. Hypotonic fluids and free water would further decrease serum sodium
A client with pneumonia has an oxygen saturation of 84% while receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?
A. Obtain a sputum culture
B. Assess airway, breathing, and respiratory effort
C. Administer an antitussive medication
D. Encourage ambulation
B. Assess airway, breathing, and respiratory effort
Explanation: Airway and breathing take priority when oxygen saturation is critically low. The nurse should assess respiratory effort, lung sounds, airway patency, and mental status while increasing oxygen according to orders or protocol. Diagnostic testing and ambulation can occur after stabilization.
A client with MS reports worsening weakness after exercising in a hot environment. Which response by the nurse is most appropriate?
A. "This indicates permanent progression of your disease."
B. "Heat can temporarily worsen MS symptoms."
C. "You should increase your exercise intensity."
D. "You should restrict your fluid intake."
B "Heat can temporarily worsen MS symptoms."
Rationale: Heat and fatigue can temporarily worsen neurologic symptoms in clients with MS (Uhthoff phenomenon). Cooling and rest can improve symptoms.
A conscious client with diabetes has a blood glucose level of 48 mg/dL and is diaphoretic and shaky. Which action should the nurse take?
A. Administer long-acting insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon immediately
D. Encourage the client to exercise
B. Give 15 g of rapid-acting carbohydrate
Explanation: A conscious client who can safely swallow should receive approximately 15 g of fast-acting carbohydrate, such as glucose tablets or 4 oz of juice. Blood glucose should be rechecked in about 15 minutes. Glucagon is generally used when the client cannot safely take oral carbohydrates.
A client with AKI has a potassium level of 6.6 mEq/L and peaked T waves on the ECG. Which action is the priority?
A. Encourage potassium-rich foods
B. Place the client on continuous cardiac monitoring and prepare for emergency treatment
C. Administer prescribed oral potassium
D. Restrict calcium intake
B. Place the client on continuous cardiac monitoring and prepare for emergency treatment
Explanation: Severe hyperkalemia with ECG changes can rapidly progress to ventricular dysrhythmias or cardiac arrest. The client requires immediate cardiac monitoring and treatment to stabilize the myocardium and lower serum potassium.
A client with a serum potassium level of 6.2 mEq/L reports muscle weakness. Which action should the nurse take first?
A. Encourage oral fluids
B. Place the client on continuous cardiac monitoring
C. Administer prescribed potassium replacement
D. Restrict dietary potassium
B. Place the client on continuous cardiac monitoring
Explanation: Hyperkalemia can cause life-threatening cardiac dysrhythmias. Continuous cardiac monitoring allows the nurse to identify ECG changes while emergency treatment is initiated. Potassium replacement would worsen the hyperkalemia.
A client’s arterial blood gases are pH 7.28, PaCO₂ 60 mmHg, and HCO₃⁻ 25 mEq/L. Which interpretation is correct?
A. Uncompensated respiratory acidosis
B. Partially compensated respiratory alkalosis
C. Uncompensated metabolic acidosis
D. Fully compensated metabolic alkalosis
A. Uncompensated respiratory acidosis
Explanation: The pH is acidic, and the PaCO₂ is elevated, indicating respiratory acidosis. The bicarbonate is normal, meaning the kidneys have not yet compensated.
The nurse is caring for four neurologic clients. Which client should be assessed first?
A. Client with MS reporting increased fatigue after physical therapy
B. Client with GBS whose vital capacity has decreased significantly since the previous assessment
C. Client with MS reporting numbness in both hands
D. Client with GBS reporting mild tingling in the feet
B
Rationale: A decreasing vital capacity in GBS indicates worsening respiratory muscle weakness and possible impending respiratory failure. This is the priority.
A client with diabetic ketoacidosis has a potassium level of 3.0 mEq/L. Which action should the nurse anticipate?
A. Start insulin immediately
B. Administer prescribed potassium replacement before initiating insulin
C. Restrict potassium intake
D. Administer sodium bicarbonate routinely
B. Administer prescribed potassium replacement before initiating insulin
Explanation: Insulin shifts potassium into the cells. If the serum potassium is already low, insulin can cause life-threatening hypokalemia and dysrhythmias. Potassium must be corrected before insulin is started according to DKA management protocols.
A client receiving peritoneal dialysis reports abdominal pain and fever. The dialysate is cloudy. Which action should the nurse take?
A. Document the finding as expected
B. Increase the dwell time
C. Notify the provider immediately because peritonitis is suspected
D. Encourage ambulation and reassess later
A client receiving peritoneal dialysis reports abdominal pain and fever. The dialysate is cloudy. Which action should the nurse take?
A. Document the finding as expected
B. Increase the dwell time
C. Notify the provider immediately because peritonitis is suspected
D. Encourage ambulation and reassess later
A client has been vomiting for 3 days. Arterial blood gases show pH 7.50, PaCO₂ 46 mmHg, and HCO₃⁻ 35 mEq/L. How should the nurse interpret these results?
A. Respiratory alkalosis, uncompensated
B. Respiratory acidosis, partially compensated
C. Metabolic alkalosis, partially compensated
D. Metabolic acidosis, fully compensated
Metabolic alkalosis with partial respiratory compensation.
The elevated pH indicates alkalosis. The elevated bicarbonate identifies a metabolic cause. The slightly elevated PaCO₂ indicates the lungs are retaining carbon dioxide to compensate. The pH remains abnormal, so compensation is partial.
A client with COPD receiving oxygen at 6 L/min becomes increasingly drowsy. Which assessment finding is most concerning?
A. Oxygen saturation of 90%
B. Respiratory rate of 20/min
C. Increasing somnolence and shallow respirations
D. Productive cough with clear sputum
C. Increasing somnolence and shallow respirations
Explanation: Increasing drowsiness and shallow breathing may indicate carbon dioxide retention and worsening respiratory failure. The nurse should immediately assess respiratory status and notify the provider. Oxygen saturation alone does not provide complete information about ventilation.
Which finding is more characteristic of GBS than MS?
A. Diplopia
B. Spasticity
C. Ascending symmetric weakness
D. Optic neuritis
C
Rationale: Ascending symmetric weakness is characteristic of GBS. MS more commonly produces CNS manifestations such as optic neuritis, diplopia, sensory disturbances, spasticity, and ataxia.
A patient with type 1 diabetes is admitted with DKA. Which assessment finding requires the nurse's immediate intervention?
A. Blood glucose 420 mg/dL
B. Urine ketones 4+
C. Potassium 6.2 mEq/L with peaked T waves
D. Respiratory rate 28/min
C. Potassium 6.2 mEq/L with peaked T waves
Explanation: Severe hyperkalemia with ECG changes can rapidly cause life-threatening dysrhythmias and cardiac arrest. Although DKA itself is an emergency, the ECG changes make hyperkalemia the most immediate threat.
A client with AKI has a BUN of 88 mg/dL, creatinine of 4.6 mg/dL, urine output of 100 mL/day, crackles, and a 4-kg weight gain. Which complication is the priority concern?
A. Dehydration
B. Fluid overload with pulmonary edema
C. Hypoglycemia
D. Respiratory alkalosis
B. Fluid overload with pulmonary edema
Explanation: Severe oliguria prevents the kidneys from excreting excess fluid. Crackles, rapid weight gain, and dyspnea indicate fluid accumulation and possible pulmonary edema, which can compromise oxygenation.
A client receiving IV fluids develops crackles, jugular venous distention, dyspnea, and an oxygen saturation of 88%. Which action should the nurse take first?
A. Increase the IV infusion rate
B. Place the client supine
C. Stop or slow the infusion according to protocol and assess the client
D. Encourage oral fluids
C. Stop or slow the infusion according to protocol and assess the client
Explanation: These findings suggest fluid overload and possible pulmonary edema. The nurse should stop or slow the IV infusion as appropriate, position the client upright, assess respiratory status, and notify the provider. Increasing fluids or placing the client supine would worsen pulmonary congestion.
A mechanically ventilated client suddenly becomes hypotensive and severely dyspneic. The nurse notes absent breath sounds on the right side and tracheal deviation. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Atelectasis
C. Tension pneumothorax
D. Fluid overload
C. Tension pneumothorax
Explanation: Sudden respiratory distress, unilateral absent breath sounds, hypotension, and tracheal deviation are classic signs of tension pneumothorax. Positive-pressure ventilation can increase the risk. This is an emergency requiring immediate intervention.
Which findings should the nurse associate with Guillain-Barré syndrome? Select all that apply.
A. Ascending muscle weakness
B. Decreased or absent deep tendon reflexes
C. Paresthesias
D. Respiratory muscle weakness
E. Symmetric weakness
F. Hyperactive deep tendon reflexes as the hallmark finding
G. Autonomic dysfunction
A, B, C, D, E, G
Rationale: GBS typically causes acute, symmetric, ascending weakness with decreased/absent reflexes. Respiratory failure and autonomic instability can occur.
A client with diabetes has a hemoglobin A1C of 10.2%. How should the nurse interpret this result?
A. The client has experienced frequent hypoglycemia during the last 24 hours.
B. The client's average glucose control has been above the usual target over approximately the past 2–3 months.
C. The client has normal long-term glucose control.
D. The result indicates acute DKA.
B. The client's average glucose control has been above the usual target over approximately the past 2–3 months.
Explanation: Hemoglobin A1C reflects average blood glucose over roughly the previous 2–3 months. A markedly elevated A1C indicates inadequate long-term glycemic control. It does not diagnose an acute episode of DKA.
Which findings in a client receiving peritoneal dialysis require immediate follow-up? Select all that apply.
A. Cloudy dialysate
B. Abdominal pain
C. Fever
D. Clear, pale-yellow effluent
E. Nausea and vomiting
F. Abdominal rigidity
A, B, C, E, F
Rationale: These findings can indicate peritonitis, a serious complication of peritoneal dialysis. Normal effluent should generally be clear.
A client with diabetic ketoacidosis has glucose 520 mg/dL, pH 7.21, HCO₃⁻ 12 mEq/L, and potassium 5.8 mEq/L. Which explanation best describes the potassium level?
A. The client has excessive total-body potassium stores.
B. Acidosis and insulin deficiency have shifted potassium from cells into the bloodstream.
C. Potassium is elevated because the kidneys are excreting excess potassium.
D. The client should receive potassium replacement immediately
B. Acidosis and insulin deficiency have shifted potassium from cells into the bloodstream.
Explanation: In DKA, insulin deficiency and metabolic acidosis cause potassium to shift out of cells, resulting in an elevated serum potassium level. However, osmotic diuresis causes significant total-body potassium loss. Potassium may fall rapidly once insulin and fluids are administered.
A client with COPD is admitted with worsening dyspnea. Which findings should the nurse recognize as possible manifestations of CO₂ retention? Select all that apply.
A. Headache
B. Confusion
C. Drowsiness
D. Decreased level of consciousness
E. Respiratory acidosis
F. Respiratory alkalosis
A, B, C, D, E
Rationale: CO₂ retention can produce hypercapnia, resulting in headache, confusion, drowsiness, decreased LOC, and respiratory acidosis.
The nurse is teaching a client with MS about managing fatigue. Which interventions should the nurse recommend? Select all that apply.
A. Schedule rest periods throughout the day.
B. Prioritize activities.
C. Avoid excessive heat exposure.
D. Complete all activities in the morning without rest.
E. Use energy-conservation techniques.
F. Balance activity with adequate rest.
A, B, C, E, F
Rationale: Fatigue is common with MS. Energy conservation, planned rest, activity prioritization, and avoiding heatcan help reduce fatigue.
Which findings are consistent with hypoglycemia? Select all that apply.
A. Tremors
B. Diaphoresis
C. Tachycardia
D. Hunger
E. Confusion
F. Seizures
G. Fruity breath
A, B, C, D, E, F
Rationale: Hypoglycemia produces adrenergic symptoms such as tremors, sweating, tachycardia, and hunger, followed by neuroglycopenic symptoms such as confusion, seizures, and potentially loss of consciousness. Fruity breath is associated with ketosis/DKA.
A client with AKI is receiving nephrotoxic medications. Which medications or substances should the nurse identify as potential concerns? Select all that apply.
A. NSAIDs
B. Aminoglycosides
C. IV contrast media
D. Certain antibiotics
E. Acetaminophen at therapeutic doses
F. Some chemotherapy agents
A, B, C, D, F
Rationale: NSAIDs, aminoglycosides, IV contrast, some antibiotics, and certain chemotherapy agents can contribute to kidney injury. Medication dosing should be carefully evaluated in clients with impaired renal function.