Nokea
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
- A. Client receiving 5% dextrose in water (D5W) intravenously and is NPO
- B. A 34-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: Clients receiving 5% dextrose in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia.
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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.
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, whole-wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct Answer: C
Rationale: Meat, dairy products, and dried fruit have high concentrations of potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of high-potassium items.
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
- A. Client with fever and rapid respirations
- B. Client with diabetes mellitus
- C. Client receiving intravenous isotonic fluids
- D. Client with stable heart failure
Correct Answer: A
Rationale: Insensible water loss occurs through the skin, lungs, and stool. Clients with fever and rapid respirations lose more water through increased respiratory rate and perspiration, putting them at greatest risk for insensible water loss.
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 cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
- A. Prepare to administer sodium polystyrene sulfonate (Kayexalate) 15 g by mouth
- B. Provide a client healthy, low potassium diet
- C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
- D. Prepare the client for hemodialysis treatment
Correct Answer: C
Rationale: A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the serum potassium level. Insulin with dextrose enhances potassium movement into cells, reducing serum levels quickly. This is the fastest and most immediate intervention.