Fluids and Electrolytes
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP)
1. Answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease.
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
1. Adding a dose of heparin sodium
2. Holding the next dose of warfarin
3. Increasing the next dose of warfarin
4. Administering the next dose of warfarin
Answer: 2
Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse would anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.
Test-Taking Strategy: Focus on the subject, a PT of 35 seconds. Recall the normal range for this value and remember that a PT greater than 25 seconds places the client at risk for bleeding; this will direct you to the correct option.
The nurse is teaching a client who has iron-deficiency anemia about foods the client needs to include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?
1. Nuts and milk
2. Coffee and tea
3. Cooked rolled oats and fish
4. Oranges and dark green leafy vegetables
Answer: 4
Rationale: Dark green leafy vegetables are a good source of iron, and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.
Test-Taking Strategy: Focus on the subject, diet choices for a client with anemia. Think about the pathophysiology of anemia. Determine that the client needs foods high in iron, and recall that vitamin C enhances iron absorption. Use knowledge of foods high in iron and vitamin C. Remember that green leafy vegetables are high in iron and that oranges are high in vitamin C.
The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action?
1. Initiate the IV line without the use of a pump.
2. Contact the electrical maintenance department for assistance.
3. Plug in the pump cord in the available plug above the room sink.
4. Use an extension cord from the nurses’ lounge for the pump plug.
Answer: 2
Rationale: Electrical equipment must be maintained in good working order and needs to be grounded; otherwise, it presents an electrical hazard. An IV line that contains potassium chloride would be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord would not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.
Test-Taking Strategy: Note the subject, electrical safety. Recalling safety issues will direct you to the correct option. Contacting the maintenance department is the only correct option, since the other options are not considered safe practice when implementing electrical actions. In addition, since potassium chloride is in the IV solution, a pump must be used.
The nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
1. “I change my pouch every week.”
2. “I change the appliance in the morning.”
3. “I empty the urinary collection bag when it is two-thirds full.”
4. “When I’m in the shower, I direct the flow of water away from my stoma.”
Answer: 3
Rationale: The urinary collection bag needs to be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma.
Test-Taking Strategy: Note the strategic words, need for more education. These words indicate a negative event query and the need to select the incorrect client statement. Therefore, eliminate the options that indicate client understanding. Noting the words two-thirds full will assist in directing you to the correct option.
The nurse reviews a client’s record and determines that the client is at risk for developing a potassium deficit if which situation is documented?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison’s disease
4. Uric acid level of 9.4 mg/dL (557 mcmol/L)
Answer: 2
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level ranges from 2.7 to 8.5 mg/dL (160 to 501 mcmol/L).
Test-Taking Strategy: Note the subject, causes of potassium deficit. First recall the normal uric acid levels and the causes of hyperkalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid.
A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?
1. “I will be sure to ask my client what their pain level is on a scale of 0 to 10.”
2. “I know that I should follow up after giving medication to make sure it is effective.”
3. “I will be sure to cue in to any indicators that the client may be exaggerating pain.”
4. “I know that pain in the older client might manifest as sleep disturbances or depression.”
Answer: 3
Rationale: Pain is a highly individual experience, and the new graduate nurse would not assume that the client is exaggerating pain. Rather, the nurse would frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse would assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain. The nurse would follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently from pain experienced by clients in other age-groups. Older clients with pain may experience sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse needs to be aware of this attribute in this population.
Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement as the answer. Recall that pain is a highly individual experience, and the nurse would not assume that the client is exaggerating pain.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and would include which food items on the list? Select all that apply.
1. Oranges
2. Broccoli
3. Margarine
4. Cream cheese
5. Luncheon meats
6. Broiled haddock
Answer: 3, 4, 5
Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.
Test-Taking Strategy: Focus on the subject of the question, the high-fat foods. Oranges and broccoli (fruit and vegetable) can be eliminated first. Next eliminate haddock because it is a broiled food. Remember that margarine, cheese, and luncheon meats are high in fat content.
The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?
1. Placing a safety knot in the safety device straps
2. Safely securing the safety device straps to the side rails
3. Applying safety device straps that do not tighten when force is applied against them
4. Securing so that two fingers can slide easily between the safety device and the client’s skin
Answer: 2
Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle would be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device would be secure, and one or two fingers need to slide easily between the safety device and the client’s skin.
The nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon?
1. Stoma is beefy red and shiny.
2. Stoma has a purple discoloration.
3. Skin excoriation is noted around the stoma.
4. Semiformed stool is noted in the ostomy pouch.
Answer: 2
Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding.
Test-Taking Strategy: Note the strategic word, immediate, and focus on the subject, the observation that requires surgeon notification. Note the words purple discoloration in option 2. Recall that purple indicates ischemia.
The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
Answer: 1, 3, 4
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
Test-Taking Strategy: Focus on the subject, the ECG patterns that may be noted in a client with a potassium level of 2.5 mEq/L (2.5 mmol/L). From the information in the question, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the electrocardiographic changes that are expected when severe hypokalemia exists.
A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
1. 3 mg/dL (1.08 mmol/L)
2. 15 mg/dL (5.4 mmol/L)
3. 29 mg/dL (10.44 mmol/L)
4. 35 mg/dL (12.6 mmol/L)
Answer: 2
Rationale: The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.08 mmol/L) reflects a lower-than-normal value, which may occur with fluid volume overload, among other conditions.
Test-Taking Strategy: Focus on the subject, adequate fluid replacement and the normal BUN level. The correct option is the only option that identifies a normal value.
The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?
1. Cream of wheat, blueberries, coffee
2. Sausage and eggs, banana, orange juice
3. Bacon, cantaloupe melon, tomato juice
4. Cured pork, grits, strawberries, orange juice
Answer: 1
Rationale: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium.
Test-Taking Strategy: Focus on the subject, dietary modification for a client with chronic kidney disease. Think about the pathophysiology of this disorder to recall that sodium needs to be limited. Noting the items sausage, bacon, and cured pork will assist in eliminating these options.
The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.
1. Bites from ticks or deer flies
2. Inhalation of bacterial spores
3. Through a cut or abrasion in the skin
4. Direct contact with an infected individual
5. Sexual contact with an infected individual
6. Ingestion of contaminated undercooked meat
Answer: 2, 3, 6
Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.
Test-Taking Strategy: Focus on the subject, routes of transmission of anthrax, and note the strategic word, effective. Knowledge regarding the methods of contracting anthrax is needed to answer this question. Remember that it is not spread by person-to-person contact or contracted via tick or deer fly bites.
A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?
1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client should not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel preparation.
Answer: 1
Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
Test-Taking Strategy: Focus on the subject, that the client is passing flatus from the stoma. Think about the normal functioning of the gastrointestinal tract and note the time frame in the question to assist in answering correctly.
Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions would the nurse take to plan for preparation and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled with the volume of potassium in the solution.
Answer: 1, 2, 4, 5, 6
Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride is always labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse needs to monitor for infiltration. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr.
Test-Taking Strategy: Focus on the subject, the preparation and administration of potassium chloride intravenously. Think about this procedure and the effects of potassium. Note the word bolus in option 3 to assist in eliminating this option.
The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?
1. Taking a rectal temperature for a client who has undergone nasal surgery
2. Taking an oral temperature for a client with a cough and nasal congestion
3. Taking an axillary temperature for a client who has just consumed hot coffee
4. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
Answer: 2
Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used, according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If electronic equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching and would focus on foods high in which vitamin that may be lacking in a vegan diet?
1. Vitamin A
2. Vitamin B12
3. Vitamin C
4. Vitamin E
Answer: 2
Rationale: Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.
Test-Taking Strategy: Focus on the subject, a vegan diet and the vitamin lacking in this diet. Recalling the food items eaten and restricted in this diet will direct you to the correct option. Remember that vegans do not consume any animal products and as a result may be deficient in vitamin B12.
The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity?
1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 6 hours
Answer: 1
Rationale: The nurse would instruct the AP to remove the safety device at least every 2 hours to permit muscle exercise and to promote circulation. Options 2, 3, and 4 are incorrect because they are too infrequent time checks. Agency guidelines regarding the use of safety devices would always be followed.
Test-Taking Strategy: Focus on the subject, removing safety device to permit muscle exercise and to promote circulation. In this situation, selecting the option that identifies the most frequent time frame is best.
A client with Crohn’s disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?
1. Folate deficiency
2. Malabsorption of fat
3. Intestinal obstruction
4. Fluid and electrolyte imbalance
Answer: 4
Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output so that measures can be implemented to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau’s sign
4. Hypoactive deep tendon reflexes
Answer: 1
Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
Test-Taking Strategy: Focus on the subject, a suspected diagnosis of hypocalcemia. Note that the incorrect options are comparable or alike in that they reflect a hypoactivity or are associated with myocardial infarction. The option that is different is the correct option.
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?
1. Discontinuing the heparin infusion
2. Increasing the rate of the heparin infusion
3. Decreasing the rate of the heparin infusion
4. Leaving the rate of the heparin infusion as is
Answer: 4
Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 times (45 to 60) and 2.5 times (75 to 100) normal. This means that the client’s value should not be less than 45 seconds or greater than 100 seconds. Thus, the client’s aPTT is within the therapeutic range and the dose should remain unchanged.
Test-Taking Strategy: Focus on the subject, the expected aPTT for a client receiving a heparin sodium infusion. Remember that the normal range is 30 to 40 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 30 and 40 will yield a range of 45 to 100 seconds. This client’s value is 65 seconds.
A postoperative client has been placed on a clear liquid diet. The nurse would provide the client with which items that are allowed to be consumed on this diet? Select all that apply.
1. Broth
2. Coffee
3. Gelatin
4. Pudding
5. Vegetable juice
6. Pureed vegetables
Answer: 1, 2, 3
Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?
1. Wearing gloves when emptying the client’s bedpan
2. Keeping all linens in the room until the implant is removed
3. Wearing a lead apron when providing direct care to the client
4. Placing the client in a semiprivate room at the end of the hallway
Answer: 4
Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.
Test-Taking Strategy: Note the strategic words, indicates the need for revision. These words indicate a negative event query and the need to select the incorrect nursing intervention. Remember that the client with an internal radiation implant needs to be placed in a private room.
The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching?
1. Cleans the catheter proximally to distally with soap and water
2. Maintains the urinary collection bag below the level of the bladder
3. Removes a loose catheter anchor and places a new anchor on the lower leg
4. Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position
Answer: 3
Rationale: Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised persons, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm, soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure that the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the lower leg. Therefore, option 3 is the action that requires a need for further teaching.