Nokea
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?
- A. Hypervolemia
- B. Hypercalcemia
- C. Hypomagnesemia
- D. Hypermagnesemia
Correct Answer: C
Rationale: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
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A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
- A. Drink at least eight glasses of fluid each day.
- B. Drink caffeinated beverages to retain fluid.
- C. Drink alcoholic beverages to help balance fluid volume.
- D. Drink water as an inexpensive way to meet fluid needs.
- E. Respond to thirst
Correct Answer: A,D,E
Rationale: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.
Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?
- A. Initiate an IV of an isotonic solution.
- B. Initiate an IV of albumin.
- C. Manage an infusion of plasma.
- D. Manage an infusion of total parenteral nutrition.
Correct Answer: B
Rationale: The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin. Administration of albumin pulls the trapped fluid back into the intravascular space. An isotonic solution will not pull water from the intercellular space. Blood products are used for third-spacing management; however, albumin is the product of choice. The management of total parenteral nutrition is not associated with third- spacing.
The nurse receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
- A. Call the health care provider with the report.
- B. Encourage the client to practice deep breathing.
- C. Finish the head-to-toe assessment.
- D. Obtain an ECG.
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
- A. Abnormal potassium level
- B. Elevated hematocrit level
- C. Low white blood count
- D. Low urine specific gravity
Correct Answer: B
Rationale: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
- A. vital signs
- B. edema
- C. intake and output
- D. weight
Correct Answer: D
Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb $(0.9 \mathrm{kg})$ weight gain in 24 hours indicates that the client is retaining $1 \mathrm{~L}$ of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.