Fluid Imbalances
Which set of vital signs is most likely to indicate fluid volume deficit?
a. BP: 120/80, HR 65
b. BP: 145/98, HR 123
c. BP: 89/52, HR 135
d. BP: 105/78, HR 88
c. BP 89/52, HR 135
A nurse is caring for a client with a Sodium level of 128 mg/dL. Should the nruse encourage fluid intake or restrict fluids?
a. Restrict fluids
Which acidic gas is retained when a client experiences hypoventilation?
A client presents to the hospital with hyperkalemia. What should be the nurse's initial intervention?
a. assess deep tendon reflexes (DTRs)
b. prepare to administer ordered diuretic
c. test for Chvostek and Trousseau signs
d. place on cardiac monitor
d. place on cardiac monitor
What populations are most at risk for fluid volume deficits?
The very old and the very young
A client with end stage renal disease is admitted to the hospital after missing dialysis last week. The nurse notes jugular venous distension, lung crackles, and pitting edema in the legs. What imbalance is this patient experiencing?
Fluid volume excess (hypervolemia)
The nurse is educating a client with hypercalcemia. Which statement by the client indicates understanding of the plan of care?
a. "I should increase my fluid intake to 3-4L daily."
b. "I should increase intake of dairy and dark, leafy greens."
c. "I should take my Tums with vitamin D supplements."
d. "I should expect twitching and muscle spasms."
a. increase fluid intake to 3-4L daily
Which substance do the kidneys excrete?
a. bicarbonate
b. carbon dioxide
c. hydrogen ions
c. hydrogen ions
The nurse is assisting a client with a Sodium level of 118 mEq/L. Which activity takes priority?
a. Monitoring intake and output
b. Encouraging sodium-rich foods
c. Instructing the client not to ambulate without assistance.
d. Auscultating apical pulse.
c. Instructing the client not to ambulate without assistance.
What two labs would most help the nurse in determining the fluid and electrolyte status of a client?
CBC and CMP (or BMP)
A client is experiencing hypervolemia. What is the most concerning finding?
a. lower extremity edema
b. shortness of breath and lung crackles
c. weight gain of 3kg over 2 days
d. output of 40ml/hr
b. shortness of breath and lung crackles
A client with tremors, increased reflexes, and muscle cramps may have which type of electrolyte imbalances? (Name FOUR)
Hyperkalemia (high potassium)
Hypocalcemia (low calcium)
Hyperphosphatemia (high phosphate)
Hypomagnesemia (low magnesium)
Which body system takes the longest to compensate for an acid-base imbalance?
a. respiratory
b. renal
c. cardiac
b. renal
The nurse is caring for a client with a large burn wound. Which assessment is most concerning?
a. new onset confusion and lethargy
b. blood pressure of 105/79
c. weight loss of 1kg over 2 days
d. urinary output of 30ml/hr
a. new onset confusion and lethargy
Name two electrolytes which have a close parallel relationship.
A client is admitted to the hospital after three days of nausea, vomting, and diarrhea. What is the PRIORITY assessment for the nurse?
a. Take the client's weight at baseline
b. Take the client's blood pressure
c. Measure the client's intake and output
d. Ask the client what they've recently eaten
b. blood pressure
The nurse is caring for a client with hypernatremia. Which intervention is highest PRIORITY?
a. initiate seizure precautions
b. initiate cardiac monitoring
c. administer 0.9% sodium chloride
d. administer potassium-sparing diuretic
a. initiate seizure precautions
A client with chronic kidney disease (CKD) is likely to have which of the following?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
b. Metabolic acidosis
A client with diarrhea for three days and inability to eat or drink is brought to the emergency department. Which nursing actions are indicated at this time? SELECT ALL THAT APPLY
a. place client on bedrest
b. collect cmp
c. administer ordered diuretic
d. assess for orthostatic hypotension
b. cmp
d. orthostatic hypotension
What is the most accurate way the nurse can determine whether a client is retaining or losing fluid over time?
Daily Weights
A client is admitted to the hospital with fluid voume deficit secondary to intense exercise. Which type of fludis should the nurse anticipate administering?
a. hypotonic
b. isotonic
c. hypertonic
b. isotonic
The nurse is caring for a post-operative client who underwent a complete thyroidectomy. Which electrolyte imbalances should the nurse monitor for?
Hypocalcemia and hyperphosphatemia
A client experiencing hyperventilation from high altitude is at risk for which acid-base imbalance?
Respiratory Alkalosis
A client presents with severe dehydration due to four days of excessive diarrhea. The nurse notes deep, gasping respirations. Which imbalance is likely the cause?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
Name two electrolytes which have an INVERSE relationship.
Sodium and Potassium
Calcium and Phosphate