Nokea
The nurse reviews the lab values of a client and notes a serum sodium level of 125 mEq/L (mmol/L) [Reference range: 135-145 mEq/L (mmol/L)]. Which conditions does the nurse recognize as potential causes of this laboratory abnormality? Select all that apply.
- A. syndrome of inappropriate antidiuretic hormone (SIADH)
- B. diabetes Insipidus
- C. addison's disease (adrenal insufficiency)
- D. psychogenic polydipsia
- E. salt water drowning
Correct Answer: A,C,D
Rationale: SIADH causes water retention, diluting sodium. Addison's disease reduces aldosterone, leading to sodium loss. Psychogenic polydipsia causes excessive water intake, diluting sodium.
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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.
The nurse has obtained a physician's order to obtain a clean catch urine specimen from a client. The nurse should instruct the client to obtain the urine sample
- A. from the first stream of urine from the bladder.
- B. midstream from the bladder.
- C. from the final stream of urine from the bladder.
- D. by emptying the entire volume of urine in the specimen cup.
Correct Answer: B
Rationale: Midstream urine collection minimizes contamination for accurate testing.
A client with chronic kidney disease (CKD) is receiving hemodialysis treatment. Which of the following nursing interventions should be implemented for this client? Select all that apply.
- A. Monitor the client's blood pressure before, during, and after hemodialysis.
- B. Administer erythropoietin (EPO) as prescribed to stimulate red blood cell production.
- C. Restrict protein intake to minimize uremic symptoms.
- D. Assess the client's access site for signs of infection or thrombosis.
- E. Administer phosphate binders as prescribed to control serum phosphate levels.
- F. Encourage the client to consume a high-potassium diet to prevent electrolyte imbalances.
Correct Answer: A,B,D,E
Rationale: Monitoring BP, administering EPO, assessing the access site, and giving phosphate binders are standard CKD hemodialysis interventions. High-potassium diets are avoided.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 6 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
0850: Verbal order was received from physician to insert indwelling urethral catheter.
0910: Urinary catheter inserted with sterile technique. 40 mL of dark yellow urine returned.
Orders
• admit to intensive care unit
• nephrology consultation
• oncology consultation
• fluid restriction - 1 liter daily
• daily weight
• strict intake and output
• 250 mL of 3% saline at 75 mL/hr
• tolvaptan 15 mg PO daily - first dose now
• neurological assessments every two hours
The nurse transfers the client to the intensive care unit for further management. Eight hours later, the nurse in the ICU reassesses the client and determines which findings indicate that the treatment is effective. Select all that apply.
- A. pulse 105
- B. serum sodium 132 mEq/L
- C. Glasgow Coma Scale (GCS) score of 15
- D. orientation to person, situation, place, and time
- E. decreased lower extremity weakness
Correct Answer: B,C,D,E
Rationale: Improved sodium (132 mEq/L), GCS of 15, orientation, and reduced weakness indicate effective SIADH treatment.
The nurse is caring for a client who prescribed a 40 mEq potassium chloride capsule for hypokalemia. The client reports difficulty swallowing capsules. Which action should the nurse take when administering this medication?
- A. Sprinkle the contents of the capsule onto a spoonful of soft food.
- B. Have the client chew the capsule prior to swallowing.
- C. Sprinkle the contents of the capsule into a cup of warm water.
- D. Put the capsule under the client's tongue and have it dissolve.
Correct Answer: A
Rationale: Potassium chloride capsules can be opened and the contents sprinkled onto a small amount of soft food, such as applesauce, to aid swallowing. Chewing the capsule (B) could cause irritation or release the medication too quickly. Dissolving in warm water (C) is not recommended as it may affect the medication's stability. Sublingual administration (D) is not appropriate for potassium chloride.