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A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
- A. A 34-year-old on NPO status who is receiving intravenous D5W
- B. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
- C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
- D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
Correct Answer: A
Rationale: The correct answer is A because intravenous D5W is a hypotonic solution that can lead to dilutional hyponatremia. D5W does not contain sodium, so it can cause a decrease in serum sodium levels. Clients on NPO status receiving D5W are at higher risk due to lack of sodium intake. Choices B, C, and D are incorrect because they do not directly contribute to hyponatremia. Sulfonamide antibiotics, ibuprofen, and digoxin are not typically associated with causing hyponatremia. Therefore, assessing the client on NPO status receiving D5W for potential hyponatremia is the priority.
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The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What
should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct Answer: B
Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement.
A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion.
C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient.
D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.
A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)
- A. A 36-year-old who is malnourished
- B. A 42-year-old with uncontrolled diabetes
- C. A 76-year-old who is prescribed antacids
- D. 50-year-old with hyperparathyroidism
Correct Answer: C
Rationale: The correct answer is C because antacids contain aluminum or magnesium, which can bind with phosphorus and decrease its absorption, leading to hypophosphatemia. Malnourishment (choice A) can cause hypophosphatemia due to inadequate intake, uncontrolled diabetes (choice B) is associated with hyperphosphatemia, and hyperparathyroidism (choice D) can lead to hyperphosphatemia due to increased calcium levels.
After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)
- A. Strong productive cough
- B. Active bowel sounds
- C. U waves present on the electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is C: U waves present on the electrocardiogram (ECG). U waves are indicative of hypokalemia, and their presence indicates that the potassium chloride treatment is improving the condition.
Explanation:
1. A: Strong productive cough - This manifestation is not related to potassium levels and does not indicate improvement in hypokalemia.
2. B: Active bowel sounds - While hypokalemia can cause gastrointestinal issues, active bowel sounds alone do not specifically indicate improvement in potassium levels.
3. C: U waves present on ECG - U waves are a classic ECG finding in hypokalemia. The presence of U waves indicates a positive response to potassium chloride treatment.
4. D: No response provided - Not applicable.
In summary, the presence of U waves on the ECG is a key indicator of improvement in hypokalemia, while the other manifestations do not directly relate to potassium levels.
A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a
more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water
intravenously?
- A. Never, because it rapidly enters red blood cells, causing them to rupture.
- B. When the patient is severely dehydrated resulting in neurologic signs and symptoms
- C. When the patient is in excess of calcium and/or magnesium ions
- D. When a patients fluid volume deficit is due to acute or chronic renal failure
Correct Answer: A
Rationale: The correct answer is A because electrolyte-free water, such as sterile water, can rapidly enter red blood cells due to osmotic differences, causing them to swell and potentially rupture, leading to hemolysis. This can result in severe harm to the patient.
Choice B is incorrect because electrolyte-free water is not indicated for severely dehydrated patients with neurologic signs and symptoms. They require electrolytes to correct their imbalances.
Choice C is incorrect as administering electrolyte-free water would not address excess calcium and/or magnesium ions in the body. Specific treatments for hypercalcemia or hypermagnesemia are needed.
Choice D is incorrect because patients with fluid deficits due to renal failure require electrolyte-balanced solutions to manage their condition effectively. Electrolyte-free water would not address the electrolyte imbalances associated with renal failure.
When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water
and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
- A. Active transport of hydrogen ions across the capillary walls
- B. Pressure of the blood in the renal capillaries
- C. Action of the dissolved particles contained in a unit of blood
- D. Hydrostatic pressure resulting from the pumping action of the heart
Correct Answer: D
Rationale: Rationale: The correct answer is D. Hydrostatic pressure resulting from the pumping action of the heart causes water and electrolytes to move from the arterial capillary bed to the interstitial fluid. This occurs due to the force exerted by the heart's pumping action, pushing fluid out of the capillaries into the interstitial space. This process is known as filtration and is essential for maintaining fluid balance in the body.
Summary of other choices:
A: Active transport of hydrogen ions does not directly cause the movement of water and electrolytes between capillaries and interstitial fluid.
B: The pressure in renal capillaries specifically relates to the kidneys, not the general movement of water and electrolytes in the body.
C: The dissolved particles in blood do not directly contribute to the movement of water and electrolytes between capillaries and interstitial fluid.