Nokea
The nurse is performing a continuing education program about fluid and electrolytes. It would be appropriate for the nurse to reinforce that which intravenous (IV) solution is hypertonic? Select all that apply.
- A. 3% saline
- B. Dextrose 10% in water (D10W)
- C. 5% Dextrose with 0.45% Sodium Chloride
- D. Lactated Ringers (LR)
- E. 0.45% Sodium Chloride (0.45% NaCl)
Correct Answer: A,B,C
Rationale: 3% saline, D10W, and 5% Dextrose with 0.45% NaCl are hypertonic, with osmolality higher than plasma.
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The nurse is caring for a client with a sodium level of 130 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following medications may cause this abnormality? Select all that apply.
- A. Spironolactone
- B. Hydrochlorothiazide
- C. Prednisone
- D. Sodium polystyrene
- E. Tolvaptan
Correct Answer: B,E
Rationale: Hydrochlorothiazide and tolvaptan can cause hyponatremia by increasing sodium loss or water retention.
The nurse is assessing a client with an acute kidney injury (AKI). Which of the following findings would support a diagnosis of AKI?
- A. hypernatremia
- B. metabolic alkalosis
- C. oliguria
- D. hypokalemia
Correct Answer: C
Rationale: Oliguria is a hallmark of AKI due to reduced kidney perfusion and filtration.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 78-year-old female client
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Nurses' Note
1355: Client was brought to the ED by the client's adult children, who reported that while she was visiting, she reported dizziness and seemed slightly confused. The adult child reports that the symptoms started one day ago. The client recently had a change in her blood pressure medication, with the physician increasing the dosage of her prescribed furosemide. Medical history of hypertension, hyperlipidemia, and osteoarthritis. Vital signs: T 100° F (37.8° C), P 104, RR 22, BP 110/66, pulse oximetry reading 95% on room air.
On assessment, the client is lethargic and oriented to person and place, but not time. The client's breathing appears unlabored with tachypnea. Clear lung sounds throughout all lung fields. Skin is warm, dry, and flaky. Peripheral pulses 1+ in all extremities. Aching pain reported in the hips and knees and rated 5 on a scale of 0 (no pain) to 10 (severe pain). Client was ambulated to the bathroom, where she urinated 300 mL of clear, yellow urine without any odor or particulates. 22-gauge peripheral venous access device (VAD) placed in right forearm.
Complete the sentence below by choosing from the list of options. Based on the client's..... and............. this client is at highest risk for........
- A. lung sounds
- B. vital signs
- C. pain level
- D. dosage increase of diuretic
- E. urinary infection.
- F. fluid volume deficit.
Correct Answer: B, D,F
Rationale: Increased furosemide dosage increases the risk of fluid volume deficit, as evidenced by dizziness and lethargy.
The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?
- A. Drain the client's bladder entirely and place a small amount in a urine specimen cup. This client needs a urine sample to check for rhabdomyolysis.
- B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.
- C. Stop draining the client's bladder because the client is at risk for developing bladder spasms.
- D. Stop draining the client's bladder to prevent the risk of urinary tract infection (UTI) and notify the primary healthcare provider (PHCP) for further instructions.
Correct Answer: A
Rationale: Prolonged immobility increases rhabdomyolysis risk, requiring a urine sample to check for myoglobin.
The following scenario applies to the next 1 items
The medical-surgical nurse is caring for a 67-year-old client
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Nurses’ Note
1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred when he quickly changed positions. The client was assessed, and vital signs were obtained.
Vital Signs
• Temperature 97° F (36° C)
• Pulse 94/minute; irregular
• Respirations 14/minute
• Blood Pressure 91/58 mm Hg
• Oxygen saturation 92% on room air
Assessment
Neurological:
Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.
Cardiovascular:
Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied which is dry with a scant amount of dry blood
Respiratory:
Diminished lung sounds, occasional cough
GI/GU:
Normoactive bowel sounds in all quadrants. Anuria.
Skin:
Warm and dry
Medical History
• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation
The nurse reviews the nursing note, vital signs, assessment, and medical history. Which clinical data is most concerning to the nurse? Select all that apply.
- A. A/V fistula assessment
- B. Oxygen saturation
- C. Pulse
- D. Blood pressure
- E. Neurological assessment
- F. Temperature
- G. Anuria
Correct Answer: C,D,E,G
Rationale: Irregular pulse, low blood pressure (91/58 mmHg), dizziness, and anuria indicate potential cardiovascular and renal complications post-hemodialysis.