Nokea
Your patient has a low potassium level, uncorrected by oral medications. The physician orders 30 mEq of KCl added to the IV of 1,000 mL of normal saline to infuse at 80 mL per hour. Which nursing intervention is of the most importance to perform today?
- A. Serve a diet with potassium-rich foods
- B. Restrict sodium in the diet
- C. Monitor blood levels of all electrolytes
- D. Make certain urine output is at least 30 mL per hour
- E. Monitor for fever and tachypnea
Correct Answer: D
Rationale: Adequate urine output ('?¥30 mL/hour) is critical when administering IV potassium to prevent hyperkalemia.
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You will expect to find which of the following during the skin assessment of a patient with dehydration?
- A. Redness
- B. Dryness
- C. Dependent edema
- D. Blisters
- E. Prolonged skin tenting
Correct Answer: B,E
Rationale: Dryness and prolonged skin tenting are classic signs of dehydration due to reduced skin moisture and elasticity.
When teaching a patient about ways to avoid fluid overload, the nurse explains it is best to eat a diet that is low in:
- A. potassium
- B. calcium
- C. magnesium
- D. sodium
- E. phosphorus
Correct Answer: D
Rationale: A low-sodium diet helps prevent fluid retention, reducing the risk of fluid overload.
The nurse is completing an I&O sheet for the patient. Which will the nurse include in the output?
- A. Sweat
- B. Peritoneal fluid
- C. Liquid stool
- D. Emesis
- E. Interstitial fluid
- F. Urine
Correct Answer: C,D,F
Rationale: Liquid stool, emesis, and urine are measurable outputs included in an I&O sheet.
Which is true of respiratory acidosis?
- A. The patient is hyperventilating
- B. The patient is hypoventilating
- C. This causes the pH to elevate above 7.45
- D. This causes the pH to drop below 7.35
- F. Hypokalemia
- G. Hyperchloremia
Correct Answer: B,D
Rationale: Respiratory acidosis results from hypoventilation, causing CO2 retention and a pH drop below 7.35.
The patient complains of shortness of breath and is expectorating pink frothy sputum. The nurse would assess for further signs and symptoms of:
- A. hyperkalemia
- B. hypomagnesemia
- C. fluid overload
- D. fluid deficit
- E. dehydration
Correct Answer: C
Rationale: Pink frothy sputum and shortness of breath are hallmark signs of fluid overload, often due to pulmonary edema.