Nokea
The nurse is teaching a group of students about fluids and electrolytes. It would be correct for the nurse to state that the role of calcium is to Select all that apply.
- A. promote blood clotting.
- B. increase bone density.
- C. promote healthy dentition.
- D. regulate fluid balance.
- E. maintain neuromuscular health.
Correct Answer: A,B,C,E
Rationale: Calcium promotes blood clotting, bone density, dentition, and neuromuscular function, but does not directly regulate fluid balance.
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The nurse is caring for a client in the medical-surgical unit. The nurse is reviewing the client's laboratory data and should take which action.
- A. Review the client's current medications
- B. Plan to initiate daily fluid restrictions
- C. Clarify the prescribed chest radiograph (x-ray)
- D. Insert an indwelling urinary catheter to monitor urinary output
Correct Answer: A
Rationale: Reviewing medications identifies potential causes of lab abnormalities, guiding appropriate interventions.
The nurse is caring for a client with a phosphorus level of 5.3 mg/dL (1.71 mmol/L) [normal range: 3.0-4.5 mg/dL (0.97-1.45 mmol/L)]. The nurse identifies which of the following as possible causes of this condition? Select all that apply.
- A. tumor lysis syndrome
- B. hypoparathyroidism
- C. hypercalcemia
- D. renal failure
- E. anorexia
Correct Answer: A,B,D
Rationale: Tumor lysis syndrome, hypoparathyroidism, and renal failure cause hyperphosphatemia by increasing phosphate release or reducing excretion.
The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching?
- A. My blood pressure may increase while I take this medication.
- B. This medication will help lower my calcium level.
- C. I should take this medication with my meal.
- D. I may experience bad diarrhea with this medication.
Correct Answer: C
Rationale: Sevelamer is taken with meals to bind dietary phosphate, reducing serum phosphorus. It does not affect blood pressure (D), lower calcium (A), or typically cause diarrhea (B).
The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.
- A. Cushing's disease.
- B. nasogastric tube suctioning.
- C. salt substitutes.
- D. hyperinsulinism.
- E. adrenal insufficiency.
Correct Answer: C,E
Rationale: Salt substitutes (potassium-based) and adrenal insufficiency (reduced aldosterone) cause hyperkalemia.
The following scenario applies to the next 1 items
The student nurse is assisting the nurse in caring for a 31-year-old female in the outpatient clinic.
Item 1 of 1
Nurses' Note
1415: The client requested her annual physical be moved up because of urinary symptoms that started nine months ago. She states that she has managed so far with them, but she is starting a new traveling job and would like to get any necessary treatment. She states that every time she laughs or sneezes, she leaks a small amount of urine. She reports that this also occurs while performing intense physical exercise. The symptoms occur daily. She denies increased frequency, urgency, and burning upon urination. She denies having any vaginal discharge. She was treated for a urinary tract infection two months ago with antibiotics.
Diagnostic Results
1500:
Bladder scan - post-void residual
20 mL
Medical History
• Chronic low back pain following a motor vehicle crash
• Obstetric history - G = 2, T = 2 (vaginal deliveries), P = 0, A = 0, L = 2
The nurse reviews the concept of urinary incontinence, its causes, and symptoms with the student nurse. Click to specify if the causes or symptoms are consistent with the disease process of stress incontinence, overflow incontinence, or urge incontinence.
- A. Urine loss with physical exertion, cough, sneeze, or exercise
- B. Palpable bladder during assessment
- C. Caused by neurologic disorders, such as multiple sclerosis or spinal cord damage
- D. Caused by vaginal prolapse from vaginal birth or aging
- E. Caused by bladder irritants, such as artificial sweeteners, caffeine, alcohol
- F. Caused by constipation
- G. Loss of large amounts of urine with each occurrence
Correct Answer: A: Stress incontinence, B: Overflow incontinence, C: Urge incontinence, D: Stress incontinence, E: Urge incontinence, F: Overflow incontinence, G: Overflow incontinence
Rationale: Stress incontinence involves urine loss with exertion. Overflow incontinence is associated with palpable bladder, constipation, and large urine loss. Urge incontinence is linked to neurologic disorders and bladder irritants.