Fluid and electrolyte imbalances & Nursing Process

1. 
A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?

2. 
The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

3. 
A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?

4. 
A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor

5. 
The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?

6. 
The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?

7. 
A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?

8. 
An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating

9. 
The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?

10. 
A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

11. 
A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?

12. 
A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

13. 
A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

14. 
The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of

15. 
The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?

16. 
The nurse evaluates which of the following clients to have hypermagnesemia?

17. 
Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)?

18. 
A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

19. 
The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?

20. 
Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?

21. 
The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider?

22. 
The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?

23. 
Which of the following is not a cause of hypocalcemia?

24. 
A patient has a calcium level of 12.5. Which medication will most likely be ordered for this patient?

25. 
An EKG shows a shortened QT interval. Which lab value below would be indicative of this change?

26. 
Lithium is known to affect the parathyroid by increasing ______ levels and decreasing _____ levels?

27. 
A patient's calcium level is 11.2. Which option below could be the cause?

28. 
A patient’s lab work shows that they have a high parathyroid hormone level. Which condition is the patient at risk for?

29. 
A patient has a calcium level of 7.2. What sign below is indicative of this lab value?

30. 
A patient's calcium level is 6.9. Which of the following is a nursing priority?

31. 
Stimulation of the facial nerve via the masseter muscle causes twitching of the nose/lips in hypocalcemia is known as?

32. 
A patient with Celiac disease is at risk for which of the following?

33. 
A patient is being discharged home after hospitalization with hypocalcemia. Which statement by the patient indicates she understood the dietary instructions?

34. 
A patient is recovering from parathyroid surgery. Morning labs values are back. Which of the following lab values would correlate as a complication from this type of surgery?

35. 
Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:

36. 
Planning is a category of nursing behaviors in which:

37. 
A client centered goal is a specific and measurable behavior or response that reflects a client’s:

38. 
The nurse writes an expected outcome statement in measurable terms. An example is:

39. 
When establishing realistic goals, the nurse:

40. 
Collaborative interventions are therapies that require:

41. 
Well formulated, client-centered goals should:

42. 
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an):

43. 
The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of:

44. 
The planning step of the nursing process includes which of the following activities?

45. 
The nursing care plan is:

46. 
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:

47. 
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:

48. 
A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:

49. 
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first.

50. 
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?

51. 
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first?

52. 
Which of the following statements about the nursing process is most accurate?

53. 
In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes?

54. 
After completing a thorough database and carrying out nursing interventions based on priority diagnoses, the nurse proceeds to which step of the nursing process?

55. 
A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate?

56. 
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient's headache. What is the nurse's next priority action for this patient?

57. 
A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient's plan of care, what does the nurse need to do?

58. 
The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility?

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