Level of Cognitive Ability – AnaysisA nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?
* a) A client with a colostomy
b) A client with congestive heart failure
c) A...
level of cognitive ability – anaysis 1 a nurse is assigned to care for a group of clients on review of the clients’ medical records
the nurse determines that which client is at risk for deficient f
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Level of Cognitive Ability – Anaysis
1. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse
determines that which client is at risk for deficient fluid volume?
* a) A client with a colostomy
b) A client with congestive heart failure
c) A client with decreased kidney function
d) A client receiving frequent wound irrigations
R: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or
increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy
or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent
wound irrigations, is at risk for excess fluid volume.
2. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is
experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this
condition?
a) Lung congestion
b) Decreased hematocrit
c) Increased blood pressure
* d) Decreased central venous pressure (CVP)
R: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate,
decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased
urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness.
The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment
findings in options 1, 2, and 3 are seen in a client with excess fluid volume.
3. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse
determines that which client is at risk for excess fluid volume?
a) The client taking diuretics
* b) The client with renal failure
c) The client with an ileostomy
d) The client who requires gastrointestinal suctioning
R: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the 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 deficient fluid volume.
4. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is
dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional
signs would the nurse expect to note in this client if excess fluid volume is present?
a) Weight loss
b) Flat neck and hand veins
,* c) An increase in blood pressure
d) A decreased central venous pressure (CVP)
R: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea,
tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and
hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify
signs noted in deficient fluid volume.
5. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and
determines that the client was at risk for developing the potassium deficit because the client:
a) Has renal failure.
* b) Requires nasogastric suction.
c) Has a history of Addison’s disease.
d) Is taking a potassium-sparing diuretic.
R: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for
hypokalemia. The client with renal failure or Addison’s disease and the client taking a potassium-sparing
diuretic are at risk for hyperkalemia.
6. A nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L.
Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
* a) U waves
b) Absent P waves
c) Elevated T waves
d) Elevated ST segment
R: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common
electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves,
ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.
7. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with
hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student
states that which of the following is part of the plan for preparation and administration of the potassium?
a) Obtaining a controlled IV infusion pump
b) Monitoring urine output during administration
c) Diluting in appropriate amount of normal saline
* d) Preparing the medication for bolus administration
R: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or
controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never
given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal
saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular
potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The
IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists.
,The nurse monitors urinary output during administration and contacts the physician if the urinary output is less
than 30 mL/hr.
8. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of
5.5 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the
development of a potassium value at this level?
a) The client with colitis
b) The client with Cushing’s syndrome
c) The client who has been overusing laxatives
* d) The client who has sustained a traumatic burn
R: A serum potassium level higher than 5.1 mEq/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.
9. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L.
Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory
value?
a) ST depression
b) Inverted T wave
c) Prominent U wave
* d) Tall peaked T waves
R: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes
include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.
10. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of
130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the
development of a sodium value at this level?
a) The client with renal failure
* b) The client who is taking diuretics
c) The client with hyperaldosteronism
d) The client who is taking corticosteroids
R: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the
client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism
are at risk for hypernatremia.
11. A nurse is caring for a client with acute congestive 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
this client if hyponatremia were present?
a) Dry skin
b) Decreased urinary output
, * c) Hyperactive bowel sounds
d) Increased specific gravity of the urine
R: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In
hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin
occurs in deficient fluid volume.
12. A nurse is reviewing a client’s laboratory report and notes that the serum calcium level is 4.0 mg/dL. The
nurse understands that which condition most likely caused this serum calcium level?
* a) Prolonged bed rest
b) Renal insufficiency
c) Hyperparathyroidism
d) Excessive ingestion of vitamin D
R: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is
experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative
factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of
hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause
hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.
13. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical
manifestations would the nurse expect to note in the client?
* a) Twitching
b) Negative Trousseau’s sign
c) Hypoactive bowel sounds
d) Hypoactive deep tendon reflexes
R: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a
positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular
excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms
include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
14. A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the
electrocardiogram?
a) Widened T wave
b) Prominent U wave
* c) Prolonged QT interval
d) Shortened ST segment
R: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT
interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur
with hypokalemia.
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