Electrolytes
Side Effects
Plan of Care
FVD/FVE
Lab Values
100

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

A. skin turgor

B. daily weight

C. presence of edema 

D. hourly urine output

B. daily weight

100

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse’s priority?

a. Document the observation in the chart.

b. Measure urine specific gravity and volume.

c. Assess the pulse and blood pressure.

d. Assess the client’s deep tendon reflexes.

c. Assess the pulse and blood pressure.

100

Which client is at highest risk for developing hyponatremia?

Select one:

a. 60-year-old female with CHF

b. 55-year-old male with COPD

c. 25-year-old male with fever, severe vomiting and diarrhea

d. 28-year-old female with systemic lupus erythematosus


 

c. 25-year-old male with fever, severe vomiting and diarrhea

100

Which client does the nurse identify as being the most at risk for fluid volume deficit?

Select one:

a. A 90-year-old with frequent headaches

b. A 42-year-old with severe diarrhea

c. A 12-year-old who is moderately active in 80° F weather

d. A 6-month-old learning to drink from a cup

b. A 42-year-old with severe diarrhea

100

The nurse is caring for a client with a low serum calcium level. Which symptom of hypocalcemia is unexpected by the nurse?

Select one:

a. Tingling around the mouth

b. Muscle twitching

c. Confusion and disorientation

d. Heart rate of 52 beats/min.

d. Heart rate of 52 beats/min.

200

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

A. assess for facial muscle spasms 

B. ask the patient about loose stools 

C. suggest that the patient avoid orange juice with meals 

D. ask the health care provider to order a basic metabolic panel 

D. ask the health care provider to order a basic metabolic panel

200

Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances?

a.“My skin is always so dry, especially here in the Southwest.”

b.“I often use a glycerin suppository for constipation.”

c.“I don’t drink liquids after 5 PM so I don’t have to get up at night.”

d.“In addition to coffee, I drink at least one glass of water with each meal.”

c.“I don’t drink liquids after 5 PM so I don’t have to get up at night.”

200

Which of the following food choices indicates that the client has a good understanding of foods that are high in calcium?

Select one:

a. Bread

b. Peanut Butter

c. Yogurt

d. Potatoes

c. Yogurt

200

While caring for a newly admitted client with fluid and electrolyte imbalances, a nurse would be most concerned by which of the following?

Select one:

a. Blood pressure of 128/60 mm Hg

b. Nausea

c. Urinary output of 300 mL in 8 hours

d. Lung fields with crackles noted bilaterally

d. Lung fields with crackles noted bilaterally

200

The nurse receives the client’s most recent blood work results. Which laboratory value is of greatest concern?

Select one:

a. Sodium of 145 mEq/L

b. Calcium of 17.5 mg/dL

c. Potassium of 3.5 mEq/L

d. Chloride of 100 mEq/L

b. Calcium of 17.5 mg/dL

300

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

a. Oral temperature of 100.1° F

b. Serum sodium level of 138 mEq/L (138 mmol/L)

c. Gradually decreasing level of consciousness (LOC)

d. Weight gain of 2 pounds (1 kg) above the admission weight

c. Gradually decreasing level of consciousness (LOC)

300

Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

a.“I am often cold and need to wear a sweater.”

b.“I seem to urinate more when I drink coffee.”

c.“In the summer, I feel thirsty more often.”

d.“My rings seem to be tighter this week.”

d.“My rings seem to be tighter this week.”

300

The nurse is counseling a young female client who is a long-distance runner. Which factor does the nurse recognize as the greatest risk for this client to develop dehydration?

Select one:

a.Females will lose extra fluid volume due to menses.

b.Long distance runners lack the availability of fluids.

c. Sweating and hard breathing will cause fluid loss.

d. Excessive physical activity can cause vomiting and diarrhea

c. Sweating and hard breathing will cause fluid loss.

300

A nurse is caring for a client who is experiencing excess fluid volume evidenced by significant dependent edema. A 1,000 mL fluid restriction is prescribed. Which nursing intervention is most important?

Select one:

a. Keep the legs lower than the heart

b. Assess extent of edema daily

c. Offer ice chips frequently

d. Provide frequent mouth care

b. Assess extent of edema daily

300

In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority?*

 A. Set-up bedside suction

B. Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate

 C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions

 D. None of the above are correct

C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions

400

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

a. K+ 3.4 mEq/L (3.4 mmol/L)

b. Ca+2 7.8 mg/dL (1.95 mmol/L)

c. Na+ 154 mEq/L (154 mmol/L)

d. PO4-3 4.8 mg/dL (1.55 mmol/L)

c. Na+ 154 mEq/L (154 mmol/L)

400

Which patient is at most risk for fluid volume deficient?

A. A patient who has been vomiting and having diarrhea for 2 days.

B. A patient with continuous nasogastric suction.

C. A patient with an abdominal wound vac at intermittent suction.

D. All of the above are correct.

D. All of the above are correct.

400

A client receiving furosemide (Lasix) daily is admitted with a diagnosis of dehydration and hypokalemia. The client’s IV fluid is 1,000 mL 0.9% normal saline with 20 mEq of potassium chloride infusing at 125 ml/hr. What is most important for the nurse to assess?

Select one:

a. Intravenous site

b. Respiratory rate

c. Food intake

d. Serum potassium

d. Serum potassium

400

The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.

Select one or more:

a. Limit frequent oral hygiene for the client.

b. Offer the client fluids in small containers.

c. Provide hard candies for the client to suck on.

d. Provide a moisturizer for the lips and mouth.

e. Remove the water pitcher from the client's bedside.

b. Offer the client fluids in small containers.

d. Provide a moisturizer for the lips and mouth.

e. Remove the water pitcher from the client's bedside.

400

 Magnesium is absorbed by what system of the body?
A. Gastrointestinal
B. Hepatic
C. Lymphatic
D. Renal

A. Gastrointestinal

500

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

a. The patient is experiencing laryngeal stridor.

b. The patient complains of generalized fatigue.

c. The patient’s bowels have not moved for 4 days.

d. The patient has numbness and tingling of the lips.

a. The patient is experiencing laryngeal stridor.

500

Which patient is at more risk for an electrolyte imbalance?

A. An 8 month old with a fever of 102.3 ‘F and diarrhea

B. A 55 year old diabetic with nausea and vomiting

C. A 5 year old with RSV

D. A healthy 87 year old with intermittent episodes of gout

A. An 8 month old with a fever of 102.3 ‘F and diarrhea

500

The client’s serum sodium level is 120 mEq/L.  What body system is a priority for the nurse to assess?

Select one:

a. Neurological

b. Pulmonary

c. Hepatic

d. Gastrointestinal

a. Neurological

500

A nurse is providing care for a client admitted with fluid volume overload. Which of the following would the nurse include in the client’s plan of care? Select all that apply.              

Select one or more:

a. Provide low-sodium diet.

b. Assess daily weights.

c. Document intake/output every shift.

d. Provide diuretic therapy as ordered.

e. Administer antidiarrheal medications

b. Assess daily weights.

c. Document intake/output every shift.

d. Provide diuretic therapy as ordered.

500

3. A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?

A. Restrict fluid intake and monitor daily weights
B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output
C. Administer hypotonic IV fluid and administer sodium tablets.
D. No interventions are expected

B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output