The nurse in ~ a family members picnic top top a warm day in July is mindful that which human is at greatest risk for dehydration while play softball?

a. 32yo male cousin who is a skilled hockey player.

b. 28yo female cousin who has kind 1 diabetes mellitus.

c. 72yo grandmother who is 15 pounds overweight.

d. 72yo grand who take away 81 mg of aspirin daily.

You are watching: A nurse is reviewing the laboratory report of a client who has fluid volume excess


c. 72yo grandmother that is 15 pounds overweight.

* An larger adult has less complete body water 보다 a younger adult.

* plenty of older adults have lessened thirst sensation.

* older adults may have an obstacle with wade or various other motor an abilities needed because that obtaining fluids.

* enlarge adults may take medicine such together diuretics, antihypertensives, and also laxatives the increase fluid excretion.

* ladies of any age have less total body water than guys of comparable sizes and ages due to the fact that women have actually less muscle fixed and much more body fat (muscle contains mostly water; fat contains virtually no water).

* an obese person has less total water 보다 a lean person of the exact same weight because fat cells contain practically no water.


A nurse is assessing a client who is making use of PCA following a thoracotomy. The customer is SOB, shows up restless, and also has a RR of 28/min. The client"s ABG outcomes are pH 7.52, PaO2 89 mmHg, PaCO2 28 mmHg, and also HCO3- 24 mEq/L. I m sorry of the following actions need to the nurse take?

a. Instruct the client to cough forcefully.

b. Assist the customer with ambulation.

c. Administer calming interventions.

d. Discontinue the PCA.


c. Carry out calming interventions.

* The client"s RR is over the intended range. Calming the client should diminish the RR, i beg your pardon will reason the client"s CO2 level to increase to the expected levels the 35-45 mmHg, and also lower the pH to meant levels of 7.35-7.45. The nurse need to instruct the client to breath slowly.

* Coughing commonly will not treat the basic cause.

* Ambulation can exacerbate the client"s respiratory tract distress and also is not appropriate at this time.

* Discontinuing the PCA pump will certainly not act the underlying cause and could exacerbate the client"s respiratory tract distress.


A nurse is caring because that a client who is receiving furosemide daily. Throughout the morning assessment, the customer tells the nurse the he is "feeling weak in the legs." i beg your pardon of the complying with actions must the nurse take first?

a. Monitor the client"s bowel sounds.

b. Testimonial the client"s daily laboratory results.

c. Auscultate the client"s lungs.

d. Palpate the client"s peripheral pulses.A nurse is caring for a customer who is receiving furosemide daily. During the morning assessment, the client tells the nurse t


c. Auscultate the client"s lungs.

* an adverse impact of numerous diuretics, consisting of furosemide, is hypokalemia. When using the airway, breathing, circulation technique to customer care, the nurse should very first auscultate the client"s lung to assess because that respiratory alters due to weakness the the respiratory muscles.

* The nurse should monitor the client"s bowel sounds for raised or diminished peristalsis due to hypokalemia, however this no the priority action.

* The nurse need to review the client"s everyday lab results, especially his potassium level, however this is not the priority action.

* The nurse need to palpate the client"s peripheral pulses come assess for cardiovascular changes, such as a thready and weak pulse, yet this is not the priority action.


While reviewing a client"s lab results, a nurse notes a serum calcium level the 8.0 mg/dL. I m sorry of the complying with actions should the nurse take?

a. Implement seizure precautions.

b. Administer phosphate.

c. Start diuretic therapy.

d. Prepare the client for hemodialysis.


a. Implement seizure precautions.

* The customer is at risk for seizures due to low excitation threshold together a an outcome of lessened calcium level (normal reference variety = 8.5-10.5 mg/dL). The nurse have to initiate seizure precautions to stop injury.

* Administering phosphate can more decrease the client"s calcium levels.

* Diuretic therapy can additional decrease the client"s calcium levels.

* Hemodialysis is administered come treat HYPERCALCEMIA, not hypocalcemia.


A nurse is assessing a customer who has actually a phosphorus level the 2.4 mg/dL. i m sorry of the complying with findings should the nurse expect?

a. Hepatic failure.

b. Ab pain.

c. Slow-moving peripheral pulses.

d. Increase in cardiac output.


c. Sluggish peripheral pulses.

* This phosphorus level is listed below the meant reference range (2.5-4.5 mg/dl). The nurse must expect the customer to have slow peripheral pulses and also might find that the client"s pulses are difficult to find and easy come block.

* Hypophosphatemia = manifestations that kidney failure, no hepatic failure.

* Hypophosphatemia does no cause ab pain. It reasons weakness of skeletal muscles and also rhabdomyolysis, which is acute muscle breakdown.

* The nurse have to expect a decrease in cardiac output.


A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the adhering to lab values should the nurse expect?

a. Hemoglobin 20 g/dL.

b. Hematocrit 34%.

c. BUN 25 mg/dL.

d. Urine details gravity 1.050.


b. Hematocrit 34%.

* The nurse should determine that a client who has liquid volume excess deserve to have a Hct level the is below the expected reference variety of 35 come 44.5% for females and also 38 come 50% for males. Liquid volume overabundance can cause hemodilution and also a reduced Hct level.

* Hgb reference variety = 13.5-17.5 because that males & 12-15.5 because that females, therefore, the listed value is over the referral range. Fluid volume overfill can cause hemodilution and also a lessened Hgb level.

* fluid volume excess can cause a to decrease in BUN (normal reference variety = 10-20 mg/dL). The BUN level detailed is increased, i m sorry is connected with dehydration.

* liquid volume overfill can cause a diminish in urine particular gravity (normal reference variety = 1.010-1.025). The urine details gravity noted is increased, which is connected with dehydration.


A nurse is reviewing the medical record that a client who has actually DM and also is receiving constant insulin by continuous IV infusion to treat DKA. Which of the adhering to findings need to the nurse report come the provider?

a. Urine output of 30 mL/hr.

b. Blood glucose of 180 mg/dL.

c. Serum K+ 3.0 mEq/L.

d. BUN 18 mg/dL


c. Serum K+ 3.0 mEq/L.

* The meant reference selection for serum K+ is 3.5-5.5 mEq/L. Therefore, this patient has actually hypokalemia, i beg your pardon is a major complication as soon as a pt through DKA is receiving insulin.

* Urine calculation of 30 mL/hr is within the expected recommendation range.

* A blood glucose of 200 mg/dL or much less is an indication that the client"s DKA is resolving and also is within the meant reference range for a casual glucose level.

* A BUN the 18 mg/dL is in ~ the expected referral range. A BUN that 30 mg/dL or higher can occur due to dehydration for a customer who has actually DKA.


A nurse is analyzing a client who is receiving IV fluids come treat isotonic dehydration. I m sorry of the complying with lab findings suggests that the liquid therapy has been effective?

a. BUN 26 mg/dL.

b. Serum Na+ 138 mEq/L.

c. Hct 56%

d. Urine specific gravity 1.035


b. Serum Na+ 138 mEq/L.

* Isotonic dehydration consists of loss of water and also electrolytes as result of a diminish in oral intake of water and also salt. A serum sodium level the 138 mEq/L is in ~ the expected recommendation range.

* BUN of 26 mg/dL is above. Elevated BUN indicates dehydration.

* Hct that 56% is elevated and also an indicator that dehydration.

* Urine specific gravity the 1.035 is elevated and an indicator that dehydration.


A nurse is caring for a customer who reports an obstacle breathing and tingling in both hands. His RR is 36/min and he appears an extremely restless. I m sorry of the complying with values must the nurse anticipate come be outside the supposed reference range is the client is suffering respiratory alkalosis?

a. PaO2

b. PaCO2

c. Salt

d. Bicarbonate


b. PaCO2

* reduced PaCO2 in respiratory tract alkalosis as result of hyperventilation.

* PaO2 will certainly be within the expected recommendation range.

* sodium levels will certainly be in ~ the expected referral range.

* Bicarbonate level within the intended reference variety (bicarbonate levels increase in METABOLIC alkalosis).


A nurse is assessing a client who has dehydration. Which of the adhering to assessments is the priority?

a. Skin turgor.

b. To pee output.

c. Weight.

d. Mental status.


d. Psychological status.

* The biggest risk come the client is injury from a fall due to a decrease in the client"s mental status.

* The nurse must assess skin turgor, urine output, and also weight, but mental condition is the priority assessment.


A nurse is assessing a client who has actually a serum calcium level of 8.1 mg/dL. I m sorry of the adhering to is the priority for the nurse to assess?

a. Deep-tendon reflexes.

b. Cardiac rhythm.

c. Peripheral sensation.

d. Bowel sounds.


b. Cardiac rhythm.

* as soon as using the ABC strategy to client care, the nurse should first assess the client"s cardiac rhythm due to the fact that this complete serum calcium level is listed below the supposed reference variety (8.5-10.5 mg/dL). Hypocalcemia can reason ECG changes, bradycardia, or tachycardia.

* The nurse should assess the client"s DTR since hypocalcemia can cause neuromuscular changes, yet not priority assessment.

* The nurse must assess peripheral sensation due to the fact that paresthesias can occur with hypocalcemia as result of neuromuscular changes, however not priority assessment.

* The nurse have to assess bowel sounds because that hypermotility r/t hypocalcemia, but not priority assessment.


A nurse is providing teaching to a customer who has actually heart failure and is receiving furosemide. I m sorry of the adhering to foods have to the nurse recommend as containing the best amount of potassium?

a. 1/2 cup chopped celery.

b. 1 cup level yogurt.

c. 1 slice whole-grain bread.

d. 1/2 cup cooked tofu.


b. 1 cup level yogurt. * includes 380g of potassium.

* Celery has 132g.

* 1 part of entirety grain bread contains 60g.

* cook tofu includes 164g.


A nurse is preparing to carry out oral potassium for a client who has a potassium level the 5.5 mEq/L. I beg your pardon of the adhering to actions should the nurse take it first?

a. Provide a hypertonic solution.

b. Repeat the potassium level.

c. Withhold the medication.

d. Monitor for paresthesia.


c. Withhold the medication.

* The best risk v hyperkalemia = bradycardia, hypotension, and life-threatening cardiac complications. Hyperkalemia = >5.0 mEq/L. Priority action = withhold and also notify provider.

* The nurse should administer a hypertonic equipment to correct hyperkalemia, yet after withholding medication and notifying provider.

* The nurse should repeat the potassium level to advice for effective treatment, but after withholding medication and notifying provider.

* The nurse have to monitor the customer for paresthesia since numbness and also tingling room indications, but after withholding medication and notifying provider.


A nurse is caring because that a customer who calls for NG suctioning. I beg your pardon of the following sets of laboratory results suggests that the client has metabolic alkalosis?

a. PH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L

b. PH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 26 mEq/L

c. PH 7.31, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 23 mEq/L

d. PH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L


a. PH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L

* an elevated pH (>7.45) with an elevated PaCO2 (or within meant reference variety sometimes) shows metabolic alkalosis.


A nurse is caring for a customer who has actually dehydration and also is receiving IV fluids. When assessing because that complications, the nurse have to recognize i beg your pardon of the complying with manifestations as a authorize of liquid overload?

a. Enhanced urine specific gravity.

b. Hypoactive bowel sounds.

c. Bounding peripheral pulses.

d. Lessened respiratory rate.


c. Bounding peripheral pulses.

* increased vascular volume outcomes in full, bounding peripheral pulses.

* raised urine details gravity shows a better concentration that urine, i beg your pardon occurs through dehydration, not liquid volume overload.

* enhanced GI motility is a manifestation of liquid volume overload, not hypoactive.

* enhanced RR is a manifestation of fluid volume overload, no decreased.


A nurse is caring because that a customer who is suffering respiratory distress together a an outcome of pulmonary edema. Which of the complying with actions need to the nurse take first?

a. Assist with intubation.

b. Initiate high-flow oxygen therapy.

c. Provide a rapid-acting diuretic.

d. Provide cardiac monitoring.


b. Begin high-flow oxygen therapy.

* once using the ABC technique to customer care, the nurse should an initial administer high-flow oxygen therapy by challenge mask at 5-6 L/min to save the client"s oxygen saturation over 90%.

* The nurse should administer a rapid-acting diuretic IV bolus to a customer to relieve pulmonary congestion, after initiating high-flow oxygen therapy.

* The nurse should administer cardiac monitoring due to the fact that premature ventricular contractions and also dysrhythmias room manifestations that pulmonary edema, yet after initiating high-flow oxygen therapy.

* The nurse need to prepare to help the provider v intubation and also mechanical ventilation if less invasive measures are ineffective only.


A nurse is admitting a client who take away 40 mg furosemide day-to-day for love failure and has competent 3 days of vomiting. The nurse doubt hypokalemia. I beg your pardon of the complying with medications must the nurse prepare come administer?

a. Sodium polystyrene sulfonate 30 g/day.

b. 0.9% salt chloride with 10 mEq/L the potassium chloride in ~ 100 mL/hr.

c. Bumetanide 8 mg/day.

d. 100 mL of dextrose 10% in water through 10 units of insulin.


b. 0.9% salt chloride v 10 mEq/L the potassium chloride at 100 mL/hr.

* This IV solution will administer adequate fluid and also potassium replacement to balance out the losses from vomiting. The usual amount the potassium chloride to carry out IV is 5-10 mEq/hr and also not come exceed 20 mEq/hr. The dilution must be 1 mEq to 10 mL of 0.9% NaCl.

* sodium polystyrene sulfonate is an electrolyte cation exchange medication the is given to act hyperkalemia, not hypokalemia.

* High-ceiling loop diuretics, like bumetanide, are provided to treat hyperkalemia, no hypokalemia.

* Dextrose 10% in water v 10 units of insulin is one IV solution offered to act hyperkalemia, not hypokalemia.


A nurse is admitting a client who has actually status asthmaticus. The client"s ABG results are pH 7.32, PaO2 74 mmHg, PaCO2 56 mmHg, and HCO3- 26 mEq/L. The nurse should translate these lab worths as i beg your pardon of the adhering to imbalances?

a. Respiratory tract acidosis.

b. Respiratory tract alkalosis.

c. Metabolic acidosis.

d. Metabolic alkalosis.


a. Respiratory tract acidosis.

* standing asthmaticus causes inadequate gas exchange, bring about low pH and also PaO2, an elevated PaCO2, and also an HCO3- in ~ the expected referral range.

* pH >7.45 in both respiratory and metabolic ALKALOSIS.

* Metabolic acidosis = pH

b. Chloride 102 mEq/L

c. Magnesium 1.8 mEq/L

d. Potassium 6.1 mEq/L



A nurse is giving dietary to teach to a customer who has kidney disease. Which of the following food selections should the nurse include in the teaching as containing the shortest amount that magnesium?

a. 1 large hard-boiled egg.

b. 1 cup bran cereal.

c. 1/2 cup almonds.

d. 1 cup cooking spinach.



A nurse is assessing a client who has hypomagnesemia. Which of the adhering to findings have to the nurse expect?

a. Hyperactive deep-tendon reflexes.

b. Enhanced bowel sounds.

c. Drowsiness.

d. Reduced blood pressure.



A nurse is reviewing the ABG outcomes for 4 clients. I m sorry of the following findings must the nurse determine as metabolic acidosis?

a. PH 7.51, PaO2 94 mmHg, PaCO2 38 mmHg, HCO3- 29 mEq/L

b. PH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 24 mEq/L

c. PH 7.36, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 26 mEq/L

d. PH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L



A nurse is offering teaching because that a customer who has venous insufficiency of the lower extremities. Which of the adhering to statements by the client indicates an expertise of the teaching?

a. "If my stockings feel tight, I"ll simply roll them down for awhile."

b. "I"ll put on my elastic stockings at the an initial sign that swelling."

c. "When ns sit down to watch television, I"ll be certain to put my feet up."

d. "It"s yes sir to overcome my legs as lengthy as it"s for less than an hour."



A nurse is caring because that a client who has a salt level that 155 mEq/L. I m sorry of the following IV fluids should the nurse suspect the provider to prescribe?

a. Dextrose 5% in 0.9% sodium chloride.

b. Dextrose 5% in lactated Ringer"s.

c. 3% NaCl.

d. 0.45% NaCl.



A nurse is to teach nutritional methods to a customer who has actually a short serum calcium level and an allergy to milk. Which of the following statements through the client indicates an understanding of the teaching?

a. "I will eat much more cheese since I can"t drink milk."

b. "I need to avoid foods with vitamin D because I am allergy to milk."

c. "I will stop taking mine calcium additionally if they wake up my stomach."

d. "I will add broccoli and kale to mine diet."



A nurse is assessing a client who has hyperkalemia. I m sorry of the adhering to findings must the nurse expect?

a. Diminished muscle strength.

b. Reduced gastric motility.

c. Boosted heart rate.

d. Enhanced blood pressure.



A nurse is assessing a client who has respiratory acidosis. I beg your pardon of the following findings have to the nurse expect?

a. Hypotension

b. Peripheral edema

c. Facial flushing

d. Hyperreflexia



A nurse is planning treatment for a client who has experienced too much fluid loss. I beg your pardon of the following interventions have to the nurse encompass in the plan of care?

(SATA)

a. Provide IV fluids come the customer evenly end 24 hr.

b. Administer the customer with a salt substitute.

c. Assess the customer for pitting edema.

d. Encourage the client to rise progressively when standing up.

e. Sweet the customer every 8 hr.

See more: 11 Problems Only Girls With No Ass, 12 Things About Being A Girl With No Butt



A nurse is planning care for a customer who has a serum potassium level the 3.0 mEq/L. The nurse should setup to monitor the client for i m sorry of the complying with findings?

a. Hyperactive deep-tendon reflexes.

b. Orthostatic hypotension.

c. Rapid, deep respirations.

d. Strong, bounding pulse.



A nurse is assessing a client who is receiving hydrochlorothiazide and notes the the customer is confused and also lethargic. I m sorry of the complying with lab values must the nurse report to the provider?

a. Sodium 128 mEq/L

b. Potassium 4.8 mEq/L

c. Calcium 9.1 mg/dL

d. Magnesium 2.0 mEq/L



A nurse is giving teaching because that a client who is at threat for arising respiratory acidosis adhering to surgery. I m sorry of the following statements through the client indicates an expertise of the teaching?

a. "I have to conserve power by limiting my physics activity."

b. "I will certainly wait till my pains is at the very least six out of ten before I usage the PCA."

c. "I will certainly limit my everyday fluid intake come 2-3 glasses."

d. "I will usage the impetus spirometer every hour."



Osmolality meant reference variety > = ? "HIGH and DRY" If osmolality is >295 = dehydrated!! FVD
If osmolality is

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