Nokea
Which of the following signs and symptoms may lead the nurse to suspect hypovolemia? Select all that apply.
- A. Decreased skin turgor
- B. Increased urine output
- C. Dry mucous membranes
- D. Weight gain
- E. Low blood pressure
Correct Answer: A,C,E
Rationale: Hypovolemia causes decreased skin turgor, dry mucous membranes, and low blood pressure due to reduced fluid volume.
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The nurse is assessing a client with suspected renal calculi. Which of the following findings would support a diagnosis of renal calculi? Select all that apply.
- A. hematuria
- B. nausea and vomiting
- C. hypotension
- D. dysuria
- E. increased urinary frequency
Correct Answer: A,B,D,E
Rationale: Renal calculi cause hematuria, nausea, vomiting, dysuria, and increased urinary frequency due to irritation and obstruction.
The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?
- A. Obtain the blood pressure on the client's calf
- B. Request an order for a magnesium level
- C. Assess the client's orthostatic blood pressure
- D. Obtain capillary blood glucose (CBG)
Correct Answer: B
Rationale: Palmar flexion (Trousseau's sign) suggests hypocalcemia or hypomagnesemia, warranting a magnesium level check.
The nurse cares for a client with a potassium of 3.2 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?
- A. spironolactone
- B. triamterene
- C. prednisone
- D. lisinopril
Correct Answer: B
Rationale: Triamterene is a potassium-sparing diuretic that can cause hypokalemia by reducing potassium excretion. Spironolactone (A) also spares potassium but is less likely to cause hypokalemia. Prednisone (C) primarily affects glucose and sodium, not potassium. Lisinopril (D) may cause hyperkalemia, not hypokalemia.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client.
Item 1 of 1
Progress Notes
Day 1
1700: Admitted from the emergency department with a small bowel obstruction. Nasogastric tube (NGT) was inserted with intermittent suction. Awaiting surgical consult.
Day 2
0900: Morning labs reviewed and orders were given. Still awaiting surgical consult.
Orders
Day 1:
• Insert nasogastric tube to low intermittent suction
• Insert a peripheral vascular access device
• nothing by mouth (n.p.o.) status
• consult surgery for evaluation
• continuous infusion of 0.9% sodium chloride (normal saline) 100 mL/hr
Day 2:
• potassium chloride 40 mEq via intravenous piggy-back x 1 dose
The nurse reviews the clinical data. The nurse prepares to implement the orders from day 2. Complete the following sentences by choosing from the list of options. Prior to the nurse administering the prescribed IV potassium, the nurse should....... The nurse should also.......... The nurse should infuse the IV potassium over. During the infusion, if the client should report pain at the vascular access device, the nurse should......
- A. ensure the client has adequate urine output.
- B. implement seizure precautions.
- C. initiate continuous cardiac monitoring
- D. 2 hours.
- E. 4 hours.
- F. stop the infusion.
- G. apply a warm compress to the vascular access device.
Correct Answer: A,C,E,F
Rationale: Adequate urine output and cardiac monitoring are essential before and during IV potassium infusion to prevent hyperkalemia. Infuse over 4 hours and stop if pain occurs to avoid complications.
The nurse is caring for a client who has just returned from an intravenous urography procedure. Which intervention should the nurse take to prevent post-procedure acute kidney injury?
- A. Assess the venipuncture site for redness
- B. Have the client obtain their daily weight for three days after the procedure
- C. Instruct the client to remain motionless
- D. Encourage the client to increase their fluid intake
Correct Answer: D
Rationale: Increased fluid intake helps flush contrast media, reducing the risk of AKI post-urography.