Nokea
The nurse is working with a client who has been diagnosed with hypervolemia. Which of the following conditions can cause hypervolemia? Select all that apply.
- A. Heart failure
- B. Renal failure
- C. Type 1 Diabetes Mellitus
- D. Third degree burns
- E. Hormonal imbalances
Correct Answer: A,B,E
Rationale: Heart failure, renal failure, and hormonal imbalances (e.g., SIADH) impair fluid excretion, causing hypervolemia.
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Which nursing assessment finding are consistent with hypocalcemia? Select all that apply.
- A. Chvostek's sign
- B. Grey-Turner's sign
- C. Homan's sign
- D. Trousseau's sign
- E. Numbness and tingling of the fingers and toes
Correct Answer: A,D,E
Rationale: Hypocalcemia causes Chvostek's sign, Trousseau's sign, and numbness/tingling due to neuromuscular irritability.
The nurse is administering IV magnesium to a client with a magnesium level of 1.5 mEq/L (0.62 mmol/L) [1.5-2.5 mEq/L, 0.6-1.2 mmol/L]. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention?
- A. Slow down the infusion rate.
- B. Notify the primary healthcare provider (PHCP).
- C. Reassess the client when the infusion finishes.
- D. Stop the infusion.
Correct Answer: A
Rationale: Flushing is a common side effect of IV magnesium infusion and can often be managed by slowing the infusion rate to reduce symptoms. Stopping the infusion (D) or notifying the PHCP (B) is not necessary unless symptoms worsen. Reassessing later (C) delays intervention.
The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply.
- A. Spironolactone
- B. Sodium polystyrene
- C. Regular insulin
- D. Hemodialysis
- E. Magnesium sulfate
Correct Answer: B,C,D
Rationale: Sodium polystyrene (B) binds potassium in the gut, regular insulin (C) shifts potassium into cells, and hemodialysis (D) removes potassium from the blood, all effective for hyperkalemia. Spironolactone (A) is a potassium-sparing diuretic and would worsen hyperkalemia. Magnesium sulfate (E) is not used for hyperkalemia.
The nurse is placing a client with chronic kidney disease on a cardiac monitor. What is the reason for this action?
- A. Clients with chronic kidney disease are prone to hypertension
- B. Hyperkalemia may result in dysrhythmias
- C. Cardiac monitoring is necessary to evaluate the need for hemodialysis
- D. Clients with chronic kidney disease may experience false episodes of asystole
Correct Answer: B
Rationale: Hyperkalemia, common in CKD, can cause dysrhythmias, necessitating cardiac monitoring.
The client is diagnosed with acute kidney failure. Which of the following is an appropriate psychosocial problem for the nurse to include in the care plan?
- A. Imbalanced nutrition: less than body requirements related to altered metabolic state and dietary restrictions.
- B. Anxiety related to the disease process and uncertainty of prognosis.
- C. Excess fluid volume related to compromised regulatory mechanisms secondary to acute renal failure.
- D. Risk for infection related to invasive procedures and an altered immune response secondary to renal failure.
Correct Answer: B
Rationale: Anxiety is a psychosocial issue related to the uncertainty and stress of acute kidney failure, unlike the other physiological options.