Nokea
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)
- A. Increased pulse rate
- B. Distended neck veins
- C. Decreased blood pressure
- D. Pale and cool skin
- E. Skeletal muscle weakness
Correct Answer: A,B,E
Rationale: Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.
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A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
- A. Urine output of 250 mL in 8 hours
- B. Serum potassium level of 5.8 mEq/L
- C. Blood pressure of 88/54 mm Hg
- D. Decreased urine specific gravity
- E. Increased urine specific gravity
Correct Answer: B,E
Rationale: Aldosterone inhibition increases potassium retention and water excretion, leading to hyperkalemia (elevated serum potassium) and increased urine specific gravity due to concentrated urine.
A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
- A. A 24-year-old who is malnourished
- B. A 56-year-old with uncontrolled diabetes mellitus
- C. A 45-year-old with hyperparathyroidism
- D. A 62-year-old with chronic renal failure
- E. A 30-year-old using aluminum hydroxide-based antacids
Correct Answer: A,B,E
Rationale: Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide-based or magnesium-based antacids.
A nurse evaluates a client who is being treated for hypokalemia. Which findings indicate that treatment is effective? (Select all that apply.)
- A. Respiratory rate of 8 breaths/min
- B. Strong, productive cough
- C. Absent deep tendon reflexes
- D. Active bowel sounds
- E. U waves present on the ECG
Correct Answer: B,D
Rationale: A strong, productive cough indicates improved muscle strength, and active bowel sounds suggest resolution of hypokalemia-related gastrointestinal issues.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
- A. Electrocardiogram changes
- B. Sodium imbalance
- C. Orthostatic hypotension
- D. Paralytic ileus
- E. Skeletal muscle weakness
Correct Answer: A,D,E
Rationale: Renal failure can lead to hyperkalemia, which causes electrocardiogram changes, paralytic ileus due to impaired gastrointestinal motility, and skeletal muscle weakness.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm
- B. Assess the client's mental status daily
- C. Encourage the client to drink at least 1 liter of fluids each shift
- D. Dangle the client on the bedside before ambulating
Correct Answer: D
Rationale: An older adult with moderate dehydration may experience orthostatic hypotension. Dangling on the bedside before ambulating helps prevent falls and injuries due to sudden blood pressure drops.