Nokea
A client has been experiencing severe vomiting. The nurse notifies the primary health care provider based on the suspicion that the client may be developing hyponatremia. Which of the following would support the nurse's suspicion? Select all that apply.
- A. Increased skin turgor
- B. Hypotension
- C. bradycardia
- D. Anxiety
- E. Cold, clammy skin
Correct Answer: B,D,E
Rationale: Signs and symptoms of hyponatremia include clammy skin, decreased skin turgor, apprehension, confusion, irritability, anxiety, hypotension, postural hypotension, tachycardia, headache, tremors, convulsions, abdominal cramps, nausea, vomiting, and diarrhea.
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After teaching a group of nursing students about electrolyte imbalances, the instructor determines that the teaching was successful when the group identifies which of the following as indicative of hypercalcemia? Select all that apply.
- A. Constipation
- B. Oliguria
- C. Polydipsia
- D. Bone pain
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Signs and symptoms of hypercalcemia include anorexia, nausea, vomiting, lethargy, bone tenderness or pain, polyuria, polydipsia, constipation, dehydration, muscle weakness and atrophy, stupor, coma, and cardiac arrest.
A client is prescribed total parenteral nutrition due to weight loss secondary to cancer treatment. The nurse would most likely identify which nursing diagnosis as the priority?
- A. Risk for Injury
- B. Imbalanced Nutrition: Less Than Body Requirements
- C. Deficient Fluid Volume
- D. Risk for Decreased Cardiac Output
Correct Answer: B
Rationale: The need for total parenteral nutrition would support the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements to help promote weight gain and nutritional stability.
The use of an infusion pump or controller still requires nursing supervision and frequent monitoring of the IV infusion to monitor for signs of infiltration. Assessment of which of the following at the infusion site would lead the nurse to suspect that infiltration is occurring? Select all that apply.
- A. Edema
- B. Necrosis
- C. Burning
- D. Itching
- E. Redness
Correct Answer: A,E
Rationale: It is important for the nurse to monitor frequently for signs of infiltration while an infusion pump is in use. The signs of infiltration include edema and redness at the infusion site.
A client who is prescribed digoxin (Lanoxin) is receiving electrolyte replacement therapy. The nurse would monitor the client for signs of digoxin toxicity if which of the following electrolytes is administered?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Phosphorous
Correct Answer: B
Rationale: The nurse should monitor a client taking digoxin (Lanoxin) for signs of digoxin toxicity if potassium is being given.
A nurse is assessing a client receiving a continuous IV infusion. The nurse suspects that the client is developing fluid overload based on assessment of which of the following? Select all that apply.
- A. Weight loss
- B. Decreased blood pressure
- C. Distended neck veins
- D. Rapid breathing
- E. Hypernatremia
Correct Answer: C,D
Rationale: Signs of fluid overload include headache, weakness, blurred vision, behavioral changes, weight gain, isolated muscle twitching, hyponatremia, rapid breathing, wheezing, coughing, rise in blood pressure, distended neck veins, elevated central venous pressure, and convulsions.