Nokea
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
- A. Similar causes are present in both conditions.
- B. Hypovolemia contains only low blood volume.
- C. In dehydration, only extracellular is depleted.
- D. Both conditions result in abnormal laboratory studies.
Correct Answer: C
Rationale: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
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The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?
- A. Dehydration
- B. Hypokalemia
- C. Hypocalcemia
- D. Hypomagnesemia
Correct Answer: C
Rationale: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.
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.
The nurse is caring for an older adult client in the home setting who is experiencing decreased thirst. Which type of fluid imbalance should the nurse anticipate?
- A. Dehydration
- B. Hypovolemia
- C. Hypervolemia
- D. Third spacing
Correct Answer: A
Rationale: The nurse should anticipate the presence of dehydration, which is the most common fluid imbalance in older adult clients that results from decreased thirst. Hypovolemia is a condition in which only the blood volume is low. Hypervolemia is when the intravascular fluid volume is too high. Third spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. It is associated with the loss of colloids.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the health care provider for additional prescriptions?
- A. Potassium: $5.8 \mathrm{mEq} / \mathrm{L}$
- B. Sodium: $138 \mathrm{mEq} / \mathrm{L}$
- C. Magnesium: $2 \mathrm{mEq} / \mathrm{L}$
- D. Calcium: $10 \mathrm{mg} / \mathrm{dL}$
Correct Answer: A
Rationale: Normal potassium level is 3.5 to $5.5 \mathrm{mEq} / \mathrm{L}$. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
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.