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This document from saunders comprehensive review nclex provides essential information for nurses on assessing fluid volume imbalances and potassium levels in clients. It covers manifestations of fluid volume excess and deficit, risks for hypo- and hyperkalemia, and assessment findings for both conditions. The document also includes case scenarios to help nurses identify clients at risk.
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1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 4. Weakness and decreased central venous pressure (CVP) Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough , dyspnea , crackles , tachypnea , tachycardia , elevated blood pressure , bounding pulse , elevated CVP , weight gain, edema , neck and hand vein distention , altered level of consciousness , and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. 2. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison’s disease 4. Uric acid level of 9.4 mg/dL (559 μmol/L) Rationale: The n ormal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L) and for a male is 4.0 to 8. mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. 3. The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2. mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 3. An increase in blood pressure and increased respirations
1. U waves
Rationale: The normal serum calcium level is 9 to 10. mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
9. The nurse reviews the electrolyte results of an assigned client and notes that the potassium levelis 5. mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 4. Prolonged ST segment Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3. to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves , prolonged PR intervals , widened QRS complexes , and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia. 10. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 2. The client with hyperaldosteronism 3. The client with Cushing’s syndrome 4. The client who is taking corticosteroids Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia. 3. Tall peaked T waves 5. Widened QRS complexes 1. The client who is taking diuretics
11. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output , and decreased specific gravity of the urine would be noted. 12. The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1. mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide– based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia. 13. The nurse is reading a health care provider’s (HCP’s) progress notes in the client’s record and reads that the HCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination , wound drainage, and gastrointestinal tract losses.
heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
17. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing’s syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn Rationale: T he normal potassium level is 3.5 to 5.0 mEq/L (3. to 5.0 mmol/L). A serum potassium level higher than 5. mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
Rationale: An anaphylactic reaction requires immediate action, starting with quickly assessing the client’s respiratory status. Although the HCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. D ocumentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client’s blood pressure is normal.
4. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. “My skin will have tiny red vesicles.” 2. “The presence of the skin vesicles is caused by a virus.” 4. “The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin.” Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis. 5. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority 6. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client’s neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 3. “I have an autoimmune disease that causes blistering in the epidermis.”
14. The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects. 15. The nurse is performing an assessment on a client ho has been diagnosed with an allergy to latex. In determining the client’s risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross reaction between the food and the latex allergen. Options 1 , 2 , and 3 are unrelated to latex allergy. IMMUNOLOGICAL MEDICATIONS 1. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101 °F (38.3 °C). The nurse continues to assess the client, 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified.
of which adverse effects of the medication? Select all that apply.