Question 1

A nurse is caring for a client with diabetes insipidus. Which laboratory value is most important for the nurse to monitor?

Accepted Answer

Answer reason: This places the client at high risk for dehydration and hypernatremia, so serum sodium is the most critical lab to trend for early recognition and prevention of neurologic complications. Glucose monitoring is central to diabetes mellitus, not diabetes insipidus, and does not reflect the primary instability here. Creatinine and hemoglobin may change with volume status, but they are less sensitive and less immediately tied to the key life-threatening derangement than sodium.

Question 2

A client has been admitted to the burn unit with extensive full-thickness burns. What is the nurse’s priority in implementing the treatment plan for the client?

Accepted Answer

Answer reason: Immediate priorities follow ABCs and circulation, so maintaining adequate intravascular volume with rapid fluid resuscitation and close monitoring of urine output and hemodynamics is time-critical. Pain control and infection prevention are important but are secondary to restoring perfusion because untreated hypovolemia quickly leads to organ failure. Body image is a longer-term psychosocial concern that is not the initial physiologic priority in acute burn management.

Question 3

Which of the following would be the priority focus of nursing care for a client with peritonitis?

Accepted Answer

Answer reason: Nursing priorities focus on supporting circulation by closely monitoring intake/output, vital signs, urine output, and laboratory electrolytes, and administering ordered IV fluids to maintain perfusion. Pain control is important, but it is secondary to stabilizing hemodynamics and preventing life-threatening fluid deficits. Gastric irrigation is not a routine priority intervention for peritonitis, and psychosocial concerns are addressed after acute physiologic stability is ensured.

Question 4

An infant has been diagnosed with pyloric stenosis. The nurse would assess the infant for which symptom?

Accepted Answer

Answer reason: Early nursing assessment focuses on dehydration findings such as dry mucous membranes, decreased skin turgor, and fewer wet diapers. This option directly reflects fluid deficit from ongoing emesis. The other options are not typical primary assessment cues for pyloric stenosis compared with signs of dehydration and associated electrolyte disturbances.

Question 5

Nursing assessments in an infant with gastroenteritis should be directed toward detecting which potential problem?

Accepted Answer

Answer reason: Ongoing fluid losses can quickly produce metabolic acidosis and potassium shifts, creating risk for dysrhythmias, lethargy, and worsening dehydration. Nursing assessment should therefore focus on signs of dehydration and electrolyte derangements (intake/output, urine output, weight changes, mucous membranes, capillary refill, and mental status), and prompt lab evaluation when indicated. Urinary retention is not a typical consequence; instead, oliguria from volume depletion is expected. Heart failure and hyperactive reflexes are not the primary predictable complications in uncomplicated pediatric gastroenteritis compared with fluid/electrolyte disturbances.

Question 6

An infant has been admitted to the hospital with gastroenteritis. What is the priority nursing diagnosis?

Accepted Answer

Answer reason: Using ABCs and safety priorities, maintaining circulating volume and preventing hypovolemic shock outweighs comfort or longer-term concerns. This diagnosis directly targets the most immediate threat—fluid and electrolyte loss—guiding urgent interventions like oral/IV rehydration and close intake/output and weight monitoring. Diarrhea is expected but is the cause of the volume loss rather than the most dangerous consequence to address first. Nutrition and pain are important but typically become priorities after stabilization of hydration status.

Question 7

The nurse studies an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this is caused by?

Accepted Answer

Answer reason: A prominent U wave on an ECG is a classic manifestation of low serum potassium due to delayed ventricular repolarization, often accompanied by ST depression and flattened T waves. Potassium abnormalities have direct effects on cardiac electrical conduction and are high-risk for dysrhythmias, making this finding clinically important. Hypocalcemia more typically prolongs the QT interval rather than producing U waves. Hypermagnesemia commonly causes PR prolongation, QRS widening, and bradycardia at higher levels, while hyponatremia does not produce a characteristic U-wave pattern on ECG.

Question 8

Which condition is characterized by weight loss, excessive thirst, and dry mucous membranes?

Accepted Answer

Answer reason: These findings reflect loss of intravascular/total body water, which reduces circulating volume and triggers thirst via osmoreceptor and baroreceptor responses. Weight loss is a key clue for fluid deficit because rapid changes in body weight closely track water balance. Dry mucous membranes indicate decreased tissue hydration from reduced fluid volume. In contrast, volume overload typically causes weight gain and edema, while isolated osmolality abnormalities do not best explain the full triad as directly as a fluid volume deficit does.

Question 9

When caring for a neonate diagnosed with diabetes insipidus, the nurse determines further intervention is necessary when the assessment identifies?

Accepted Answer

Answer reason: Diabetes insipidus causes inadequate antidiuretic hormone effect, leading to excessive free-water loss through large volumes of dilute urine. In a neonate, ongoing water loss quickly produces dehydration and a drop in weight, making this a key indicator that the current management is insufficient. This finding signals risk for hypernatremia, poor perfusion, and hemodynamic instability, requiring prompt reassessment of fluid balance and therapy. By contrast, edema and weight gain suggest fluid retention rather than the typical fluid-deficit pattern of diabetes insipidus.

Question 10

Which nursing diagnosis has the highest priority in a 1-month-old infant admitted with projectile vomiting after feeding?

Accepted Answer

Answer reason: Using ABCs/physiologic stability priority frameworks, restoring and maintaining circulating volume takes precedence over psychosocial, feeding-pattern, or potential infection concerns. This diagnosis directly addresses the most time-sensitive risk: hypovolemia with signs such as decreased urine output, sunken fontanel, and poor perfusion. The other options may be relevant after stabilization, but they do not pose as immediate a threat to life and physiologic function as volume depletion.

Question 11

The emaciated client is admitted with a total serum protein level of 4 g/dL. When assessing the client, the nurse should especially check for which alteration due to the low serum protein level?

Accepted Answer

Answer reason: This third-spacing leads to dependent or generalized swelling and can also contribute to ascites. With a total protein of 4 g/dL in an emaciated client, this mechanism is a direct, expected complication to assess for. Confusion and restlessness are more consistent with hypoxia, electrolyte derangements, or acid-base problems, while pallor is more suggestive of anemia rather than hypoproteinemia.

Question 12

The nurse is assessing the 10-year-old client with ARF. Which electrolyte imbalance should be the priority concern for the nurse?

Accepted Answer

Answer reason: This is the priority because elevated potassium can cause lethal cardiac dysrhythmias (peaked T waves, widened QRS, ventricular fibrillation/asystole) and requires rapid recognition and intervention. While phosphate may also increase in renal failure, it typically causes longer-term complications (e.g., hypocalcemia, bone/mineral disorders) rather than immediate arrest risk. Sodium abnormalities and hypercalcemia are less characteristic as the most urgent, life-threatening electrolyte issue in ARF compared with potassium.

Question 13

The client admitted to the ED has a serum potassium level of 3.0 mEq/L. The nurse should assess for which finding?

Accepted Answer

Answer reason: 0 mEq/L) decreases cardiac cell excitability and conduction stability, predisposing the patient to dysrhythmias and reduced contractility. These changes commonly manifest as weak pulses and an irregular rhythm, which are key assessment findings and safety concerns in the ED. In contrast, bounding pulses are more consistent with hyperdynamic states or fluid overload rather than low potassium. Hypokalemia more often slows GI activity (decreased motility/ileus), making increased GI motility an unlikely finding.

Question 14

The client is hospitalized with a history of chronic emesis from purging. Based on the client's history, the nurse should monitor for which complication?

Accepted Answer

Answer reason: Ongoing volume depletion also promotes renal bicarbonate reabsorption (contraction alkalosis), sustaining the alkalosis. This complication fits purging history more directly than acidosis, which is more consistent with diarrhea or renal failure. Electrolyte patterns with vomiting more often include hypokalemia and hypochloremia rather than the elevated potassium or chloride listed in other options.

Question 15

Chronic alcohol abuse, rapid administration of citrated blood products, or treatment with total parenteral nutrition puts the client at risk for which condition?

Accepted Answer

Answer reason: These scenarios are classic risk factors for magnesium depletion or shifts that lower serum magnesium. Chronic alcohol use commonly causes poor intake, GI losses, and renal wasting of magnesium. Citrated blood products can contribute to electrolyte disturbances during rapid transfusion, including lowering ionized calcium and promoting related electrolyte abnormalities; patients receiving high-acuity transfusions or TPN are therefore monitored closely for hypomagnesemia. Magnesium deficiency is clinically important because it predisposes to dysrhythmias and can make associated hypokalemia and hypocalcemia difficult to correct until magnesium is replaced.

Question 16

Client incidence of hypermagnesemia is rare in comparison with hypomagnesemia. Hypermagnesemia generally occurs secondary to?

Accepted Answer

Answer reason: Magnesium balance is primarily maintained by renal excretion, so impaired kidney function is the most common driver of clinically significant magnesium accumulation. When GFR declines, the kidneys cannot adequately clear magnesium, and serum levels rise, especially if magnesium-containing medications (e.g., antacids/laxatives) are used. Cardiac contractility changes are typically an effect of abnormal magnesium levels rather than an underlying cause. Hypokalemia more often coexists with low magnesium due to shared renal wasting mechanisms, not elevated magnesium.

Question 17

A postsurgical client requires a blood transfusion. Which disorder is common in critically ill and postsurgical clients requiring blood transfusions?

Accepted Answer

Answer reason: Massive or rapid transfusion can cause citrate toxicity because citrate in stored blood binds ionized calcium, lowering physiologically active calcium levels. Critically ill and postsurgical patients are at higher risk due to larger transfusion volumes and reduced citrate metabolism with hypoperfusion or liver dysfunction. The resulting low ionized calcium can lead to hypotension, prolonged QT, and neuromuscular irritability, so monitoring and replacement may be needed. Although potassium can rise with older stored blood, the most classically expected electrolyte complication of transfusion is decreased calcium from citrate binding.

Question 18

A client’s electrocardiogram (EKG) shows a shortened QT interval. Which electrolyte deficiency is most likely the cause of this EKG change?

Accepted Answer

Answer reason: QT interval primarily reflects the duration of ventricular depolarization and repolarization, which is strongly influenced by serum calcium. Elevated calcium levels shorten the ventricular action potential (shorter ST segment), producing a shortened QT on the EKG. In contrast, low calcium prolongs the QT, while potassium abnormalities more classically change T-wave morphology and can prolong repolarization (often widening QRS/peaked T with severe hyperkalemia). Therefore, the electrolyte disturbance most consistent with a shortened QT is increased serum calcium.

Question 19

Treatment of fluid and electrolyte disorders is based on?

Accepted Answer

Answer reason: Fluid and electrolyte problems are primarily disorders of body fluid compartments (intravascular, interstitial, intracellular) and tonicity, so therapy must target where water is gained/lost and how it shifts between compartments. Assessing total body water status and its distribution guides safe selection and rate of IV fluids (e.g., isotonic vs hypotonic vs hypertonic) and whether volume expansion or free-water replacement is needed. Serum values alone can be misleading because they reflect concentration and can change with dilution/concentration without matching total body content. Urine osmolality helps evaluate renal concentrating ability and ADH response, but it is adjunct data rather than the fundamental basis for treatment decisions.

Question 20

Which intervention should a nurse perform for a client with respiratory alkalosis?

Accepted Answer

Answer reason: Respiratory alkalosis results from alveolar hyperventilation causing excessive CO2 loss and an increased blood pH. Rebreathing into a paper bag can acutely increase inspired CO2, helping correct hypocapnia and reduce alkalemia when the cause is anxiety-related hyperventilation and the patient is otherwise stable. Administering bicarbonate would worsen alkalosis because it adds base rather than correcting the primary respiratory problem. Oxygen or high Fowler’s may be appropriate for hypoxemia/respiratory distress, but they do not directly treat the CO2 deficit driving respiratory alkalosis.

Question 21

A client admitted with hypoparathyroidism is being monitored for hypocalcemia. Which finding would the nurse observe with hypocalcemia?

Accepted Answer

Answer reason: Tapping the facial nerve triggers ipsilateral facial muscle twitching in this electrolyte disturbance, making this a classic bedside finding. Hypoparathyroidism reduces parathyroid hormone, which lowers serum calcium and predisposes the client to these signs. A common distractor is Brudzinski’s sign, which indicates meningeal irritation rather than an electrolyte imbalance.

Question 22

A nurse notes crackles in the lung bases and pedal edema during a client assessment. Which factor is a common cause of fluid volume excess?

Accepted Answer

Answer reason: Excessive I.V. infusion Fluid volume excess occurs when intake exceeds the body’s ability to excrete or redistribute fluid, leading to intravascular overload and leakage into interstitial spaces. Overinfusion of IV fluids is a common iatrogenic cause and directly explains findings like bibasilar crackles (pulmonary congestion) and pedal edema. In contrast, prolonged fever and vomiting more typically cause fluid volume deficit due to increased insensible losses or gastrointestinal losses. Hyperventilation primarily affects acid–base balance and does not usually produce fluid overload signs.

Question 23

Which nursing diagnosis would have the highest priority for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

Accepted Answer

Answer reason: Using ABCs and circulation-first priorities, restoring intravascular volume is the most urgent need to prevent shock, acute kidney injury, and worsening hyperosmolality. Mental status changes and confusion are common but are typically secondary to dehydration and hyperosmolality and often improve with aggressive fluid replacement. Infection risk and skin integrity are important but do not outweigh the immediate life-threatening consequences of volume depletion.

Question 24

The nurse is caring for an infant hospitalized with congenital adrenal hypoplasia. Which problem is the nurse’s priority?

Accepted Answer

Answer reason: The immediate nursing priority is to identify and manage the most physiologically urgent problem affecting circulation and perfusion. Compared with longer-term concerns like growth patterns, bonding, or caregiver education, acute volume and electrolyte disturbances pose the greatest short-term threat to survival and require prompt assessment and intervention. In priority frameworks (ABCs/physiologic stability first), this outranks psychosocial and teaching needs during hospitalization.

Question 25

A client with Crohn’s disease experiences 20 watery stools per day. When assessing the client, the nurse would anticipate which finding?

Accepted Answer

Answer reason: Dehydration commonly presents with poor skin elasticity, producing tenting skin turgor on assessment. With hypovolemia the expected compensatory response is tachycardia and hypotension rather than bradycardia or hypertension. Ongoing fluid loss also tends to reduce urine output and concentrate urine, making dilute urine an unlikely finding.

Question 26

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

Accepted Answer

Answer reason: Successful fluid resuscitation is reflected by improvement in clinical signs of hydration and intravascular volume. Skin turgor improves as interstitial fluid volume is restored, making it a direct bedside indicator that dehydration from diarrhea is being corrected. Decreased stool frequency/liquidity or formed stools indicate improvement of the diarrhea itself, which may lag behind or occur independently of hydration status. Relief of perianal burning reflects skin irritation management rather than adequacy of fluid replacement.

Question 27

The nurse is most concerned when a neonate with esophageal atresia and tracheoesophageal fistula presents with?

Accepted Answer

Answer reason: A neonate with esophageal atresia/tracheoesophageal fistula is at high risk for inadequate intake, aspiration-related stress, and rapid fluid losses, so early recognition of dehydration is critical. A sunken anterior fontanelle is a classic, concerning sign of significant volume depletion in infants and requires prompt assessment and intervention to prevent hypovolemia and electrolyte derangements. By contrast, skin that returns briskly indicates normal hydration rather than a problem needing urgent action. The other findings are less directly tied to immediate fluid-volume compromise in this condition.

Question 28

What is the most appropriate nursing intervention for an infant with pyloric stenosis who is vomiting?

Accepted Answer

Answer reason: Persistent vomiting in pyloric stenosis rapidly causes fluid volume deficit and electrolyte/acid–base disturbances, making early recognition of dehydration the priority. Focused assessment (e.g., decreased wet diapers, dry mucous membranes, sunken fontanel, poor skin turgor, lethargy, delayed capillary refill) directly identifies the most immediate risk to perfusion and stability. Vital signs every 8 hours and weights can help trend status but are less immediate and may miss evolving hypovolemia in an infant. Supine sleep positioning does not address the acute complication risk from ongoing emesis.

Question 29

A nurse admits an infant diagnosed with pyloric stenosis. Which nursing intervention would be a priority?

Accepted Answer

Answer reason: Place an I.V. catheter. Infants with pyloric stenosis typically have persistent projectile vomiting, placing them at high risk for dehydration, hypovolemia, and hypochloremic metabolic alkalosis. The immediate priority on admission is to establish IV access so fluids and electrolytes can be corrected and the infant can be stabilized before surgery. Assessment actions like daily weight, diaper weights, or urine specific gravity help trend hydration status but do not correct the acute deficit. Securing IV access also supports NPO management and potential preoperative labs/medications, making it the most time-sensitive intervention.

Question 30

Which electrolyte imbalance will the nurse find with hyperparathyroidism, Paget’s disease, adrenal insufficiency, and prolonged immobilization?

Accepted Answer

Answer reason: These conditions commonly increase serum calcium by promoting bone resorption or reducing calcium deposition in bone. Hyperparathyroidism raises PTH, which increases osteoclastic activity and renal calcium reabsorption, elevating calcium levels. Prolonged immobilization accelerates bone demineralization, shifting calcium from bone into the bloodstream, and Paget’s disease involves disordered bone remodeling that can also contribute to elevated calcium, especially with high turnover. The magnesium options are not the hallmark electrolyte disturbance for this cluster, and hypocalcemia is more typical of hypoparathyroidism or vitamin D deficiency rather than increased bone breakdown.

Question 31

The serum calcium level of a client with hyperparathyroidism is 14.6 mg/dl. Which treatment should the nurse anticipate?

Accepted Answer

Answer reason: Administering I.V. fluids at 200 ml/hour Severe hypercalcemia (14.6 mg/dL) is a medical risk for dehydration, dysrhythmias, and kidney injury, and initial management focuses on promoting renal calcium excretion. Isotonic IV fluid infusion expands intravascular volume and increases glomerular filtration, enabling calciuresis. Withholding fluids would worsen hypercalcemia by concentrating serum calcium and reducing urinary clearance. Calcium or vitamin D supplementation would further increase calcium levels and is inappropriate in acute symptomatic-range hypercalcemia.

Question 32

A client with diabetes mellitus asks the nurse what condition could possibly cause hypoglycemia. What is the best response by the nurse?

Accepted Answer

Answer reason: Exercise increases skeletal muscle glucose uptake and insulin sensitivity, which can rapidly lower blood glucose if no snack is taken. In contrast, too little insulin and illness with fever typically raise blood glucose through reduced cellular uptake and stress-hormone–mediated gluconeogenesis. High-sugar foods like cake and ice cream are more likely to cause hyperglycemia rather than a low glucose episode.

Question 33

The nurse is assessing an infant with diabetes insipidus. What initial observation would the nurse would expect?

Accepted Answer

Answer reason: Infants cannot verbalize thirst, so early manifestations are often irritability and inconsolable crying that improves when free water is offered. Milk does not relieve the thirst as effectively because it adds solute load and does not correct the free-water deficit as directly. Dehydration can occur but this option is less specific as an “initial observation” than thirst-driven irritability that is selectively relieved by water. Severe CNS depression (e.g., inability to be aroused) would suggest advanced dehydration/hypernatremia rather than an early finding.

Question 34

The client has arterial blood results of pH 7.50, Paco2 35 mm Hg, and HCO3 30 mmol/L. Which interpretation of the client’s acid-base imbalance is correct?

Accepted Answer

Answer reason: Indicates an overall alkalosis, so the next step is to determine whether the primary change is respiratory (PaCO2) or metabolic (HCO3−). The PaCO2 of 35 mm Hg is within the normal range (35–45), while the HCO3− of 30 mmol/L is elevated (normal ~22–26), identifying a primary metabolic process. In metabolic alkalosis, bicarbonate rises from acid loss or alkali gain (e.g., vomiting, nasogastric suction, diuretics), and respiratory compensation—if present—would trend toward an increased PaCO2 rather than a normal/low value. Therefore the pattern best fits an uncompensated (or minimally compensated) metabolic alkalosis rather than a respiratory disorder.

Question 35

The nurse is caring for the client with hypotension. Which electrolytes should be closely monitored by the nurse?

Accepted Answer

Answer reason: Sodium is the dominant extracellular cation and drives water movement; low sodium states and overall sodium depletion can contribute to reduced effective circulating volume. Chloride usually tracks with sodium in extracellular fluid losses (e.g., GI/renal losses) and helps assess isotonic depletion patterns. Potassium should be monitored closely because volume depletion, renal hypoperfusion, diuretics, and replacement therapies can rapidly shift levels and precipitate dysrhythmias during hypotension management.

Question 36

The nurse is caring for the client who has an NG tube that is attached to intermittent suction. The nurse should monitor for which most important electrolyte imbalances?

Accepted Answer

Answer reason: Potassium is lost directly in gastric/intestinal secretions and can also drop due to alkalosis-driven intracellular shift, making arrhythmias and ileus key risks to monitor for. Sodium can fall from combined GI losses and free-water replacement or hypotonic IV fluids given to maintain hydration, leading to neurologic symptoms if severe. Chloride depletion is also common with NG suction, but among the given choices, the pair that best captures the highest-priority and most expected clinically significant abnormalities is low potassium with low sodium.

Question 37

A client’s arterial blood gases (ABG) reveal pH 7.0, HCO3 24 mEq/L, PaCO2 56 mm Hg. Which illness does this indicate?

Accepted Answer

Answer reason: A low pH indicates acidemia, and the next step is to determine whether the primary change is respiratory (PaCO2) or metabolic (HCO3−). PaCO2 is elevated at 56 mm Hg, meaning CO2 retention is driving the pH down, which is the defining pattern of respiratory acidosis. HCO3− is normal at 24 mEq/L, supporting an acute/uncompensated respiratory process rather than a primary metabolic disorder. In metabolic acidosis, HCO3− would be decreased, not normal, and in respiratory alkalosis the PaCO2 would be low, not high.

Question 38

A client’s arterial blood gases (ABG) reveal pH 7.8, HCO3 26 mEq/L, and PaCO2 38 mm Hg. Which illness does this indicate?

Accepted Answer

Answer reason: A markedly elevated pH indicates alkalemia. With bicarbonate in the normal range (26 mEq/L), the primary disturbance is not metabolic; the remaining driver is a reduction in CO2 from alveolar hyperventilation, which produces a respiratory alkalosis pattern on ABG interpretation. While the listed PaCO2 (38 mm Hg) is within the normal range, it is not elevated (which would be needed for respiratory acidosis) and does not support a metabolic alkalosis picture where HCO3- would be increased. Therefore, the best matching option among those provided is a respiratory alkalosis process.

Question 39

When caring for a client with a diagnosis of diabetes insipidus, which nursing intervention should be the priority?

Accepted Answer

Answer reason: The priority nursing action is to ensure sufficient oral/IV fluid replacement to maintain circulating volume and prevent shock. Serial weights and urine monitoring are useful trend assessments but do not address the urgent physiologic threat if fluids are not replaced. A urine specific gravity in DI is typically low (dilute), so targeting a value greater than 1.030 is inconsistent with expected findings and not a priority intervention.

Question 40

The nurse is caring for the 8-month-old recovering from acute diarrhea. The child has not had a loose stool for two hours. Which initial drink should the nurse give to the child hourly?

Accepted Answer

Answer reason: Giving small, frequent amounts hourly helps prevent vomiting and supports gradual rehydration in an 8-month-old. Juice and soda are hyperosmolar with high sugar and minimal sodium, which can worsen osmotic diarrhea and fail to correct electrolyte losses. Milk-based drinks may be harder to tolerate during or after gastroenteritis and do not provide the balanced electrolyte replacement needed.

Question 41

Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

Accepted Answer

Answer reason: Decompression with a Miller-Abbott tube removes additional gastric/intestinal fluids, increasing risk for hypovolemia and electrolyte loss. Circulatory volume deficits can quickly lead to hypotension, tachycardia, decreased urine output, and shock, making this the most urgent, life-threatening problem. Pain and nutrition are important but are addressed after stabilizing volume status; excess volume is not the typical priority risk in acute obstruction with suction.

Question 42

A child has experienced symptoms of hypoglycemia and has eaten sugar cubes. The priority intervention by the nurse would be to have the client ingest which of the following?

Accepted Answer

Answer reason: Complex carbohydrates provide sustained blood glucose as they are digested more slowly than simple sugars. Adding protein further blunts rapid glucose swings and helps maintain euglycemia until the next planned meal/snack. Fruit juice is appropriate as the initial fast-acting carbohydrate, but the child has already taken simple sugar, so the next step is stabilization rather than another rapid spike. Water does not correct or prevent hypoglycemia, and protein alone is too slow and lacks sufficient immediate carbohydrate for maintenance.

Question 43

The nurse is caring for the child with hydronephrosis. Which assessment should the nurse perform to obtain the most accurate determination of fluid balance?

Accepted Answer

Answer reason: Using the same scale (and ideally the same time of day and similar clothing) minimizes measurement variability and improves trend accuracy. Intake/output can be incomplete or inaccurate (missed emesis, unmeasured urine, insensible losses), particularly with renal/urinary conditions like hydronephrosis. Edema is a late and sometimes subtle sign, and serum electrolytes reflect solute balance and renal handling rather than directly quantifying overall fluid volume change.

Question 44

The nurse is caring for the 90-year-old client with hypernatremia. Which assessment findings should prompt the nurse to conclude that interventions have been ineffective?

Accepted Answer

Answer reason: Persistent or worsening agitation indicates ongoing hyperosmolarity/cerebral dehydration and therefore ineffective interventions. In contrast, muscle cramps/spasms are more characteristic of hypocalcemia or sometimes hypo-/hyperkalemia rather than isolated hypernatremia. Hypothermia and shivering are not typical indicators of sodium imbalance response and more often suggest environmental exposure or sepsis/other thermoregulation problems in older adults.

Question 45

A 1-day-old infant exhibits jitteriness, apnea, cyanotic episodes, abdominal distention, and a high-pitched cry. The mother is diabetic. Which electrolyte imbalance pertaining to the infant should the nurse further explore?

Accepted Answer

Answer reason: Neuromuscular irritability from low calcium commonly presents as jitteriness and a high-pitched cry, and can progress to apnea and cyanotic episodes from laryngospasm or seizures. The time course (1 day old) fits the early-onset pattern rather than late-onset hypocalcemia, which more often occurs after several days and is commonly linked to high phosphate intake. While abnormal glucose is also a concern in these newborns, the question specifically asks for an electrolyte imbalance that aligns with the symptom cluster of irritability and episodic apnea/cyanosis.

Question 46

A client undergoes an electrocardiogram (EKG) to assess the impact of hypokalemia. The earliest EKG changes that are most often seen in hypokalemia are?

Accepted Answer

Answer reason: Hypokalemia increases myocardial irritability and delays ventricular repolarization, predisposing the heart to ectopy early in the course of potassium depletion. The most common early rhythm manifestation is ventricular premature beats, which can appear before more advanced conduction disturbances develop. As hypokalemia worsens, EKG findings can progress to more significant dysrhythmias and conduction blocks, but these are generally later findings rather than the earliest. Recognizing early ventricular ectopy is clinically important because it may be the first warning sign before potentially life-threatening ventricular arrhythmias occur.

Question 47

A client has just arrived at the emergency department after sustaining a major burn injury. During the first 8 hours after the injury, the nurse will assess the client for which of the following?

Accepted Answer

Answer reason: At the same time, cellular injury and hemolysis release intracellular potassium into the bloodstream, creating early hyperkalemia. These changes heighten risk for dysrhythmias and shock, so they are priority assessment targets on arrival. Later, with ongoing diuresis and fluid resuscitation, potassium may trend low, which is why early hypokalemia is less expected.

Question 48

The nurse is reviewing the plan of care for the child hospitalized with congenital adrenal hyperplasia. Which intervention is the nurse’s priority?

Accepted Answer

Answer reason: In congenital adrenal hyperplasia, aldosterone deficiency can cause salt-wasting with life-threatening hyponatremia, hyperkalemia, dehydration, and shock risk. The immediate nursing priority in a hospitalized child is to stabilize electrolytes and intravascular volume to prevent dysrhythmias and cardiovascular collapse. Parent teaching and chromosomal analysis are important but can be safely addressed after physiologic stabilization. Fluid restriction is inappropriate because these patients typically require volume and sodium replacement, not restriction.

Question 49

The nurse is taking a history of the 9-month-old. Which finding is most important for the nurse to report to the HCP for further follow-up?

Accepted Answer

Answer reason: A 9-month-old should be producing regular wet diapers; this finding signals potential compromise in fluid balance and renal perfusion. Dark amber urine can suggest concentrated urine from mild dehydration but does not carry the same immediate risk as complete absence of output. Odorless urine and a stated usual daily output without other red flags are not as urgent as anuria.

Question 50

A child arrives in the emergency department after sustaining a major burn injury. During the first 8 hours of admission, it is most important for the nurse to assess the child for which conditions?

Accepted Answer

Answer reason: Cellular injury and acidosis also drive potassium out of damaged cells into the bloodstream, creating early hyperkalemia that can precipitate dysrhythmias. Because these electrolyte derangements can be rapidly life-threatening, close monitoring of sodium and potassium is a priority alongside hemodynamic assessment and resuscitation. Hypokalemia is more typical later as diuresis begins and ongoing losses/replacement therapy occur.

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