Question 1

A nurse is caring for a 4-year old child admitted after being burned over more than 50% of the body. Which lab data should be reviewed by the nurse as a priority in the initial 24 hours? 1. Blood glucose. 2. BUN. 3. Hematocrit. 4. WBC.?

Accepted Answer

Answer reason: Major burns in the first 24 hours cause massive capillary leak and fluid shifts from the intravascular space into tissues, creating hypovolemia and hemoconcentration. Hematocrit rises early with plasma loss and is a rapid marker to assess the severity of fluid deficit and the response to resuscitation. This directly informs urgency and adequacy of IV fluid therapy to prevent shock and end-organ hypoperfusion. BUN can reflect renal perfusion but is less immediate and can lag behind; WBC is often stress-elevated and infection is not the primary concern in the initial hours. Blood glucose may fluctuate with stress but is not the key indicator guiding early burn resuscitation priorities.

Question 2

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

Accepted Answer

Answer reason: Ongoing NG suction therefore places the client at significant risk for a potassium deficit and requires electrolyte monitoring and replacement as ordered. By contrast, Addison’s disease causes hypoaldosteronism, which decreases potassium excretion and more typically leads to hyperkalemia. Metabolic acidosis generally shifts potassium out of cells, tending toward elevated serum potassium rather than a true deficit.

Question 3

The nurse provides IV fluid resuscitation for a client with infectious colitis and dehydration. The nurse understands what intravenous solution is best for this client?

Accepted Answer

Answer reason: 0.9% normal saline. Initial IV fluid resuscitation for dehydration from infectious diarrhea prioritizes rapid restoration of intravascular volume with an isotonic crystalloid. This fluid stays primarily in the extracellular space and expands circulating volume without causing acute fluid shifts into cells. Dextrose-containing fluids become effectively hypotonic after metabolism and are not preferred for bolus resuscitation. Although lactated Ringer’s is also isotonic, normal saline is a standard first-line choice when the stem broadly asks for best resuscitation fluid in dehydration.

Question 4

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor?

Accepted Answer

Answer reason: This produces dilutional lowering of serum sodium, making low sodium the hallmark electrolyte abnormality to monitor. The resulting hypo-osmolality can cause neurologic manifestations (e.g., headache, confusion, seizures), so trending sodium is critical for early detection of deterioration. Potassium disturbances are not the primary expected electrolyte effect of isolated SIADH compared with the predictable water retention–driven sodium dilution.

Question 5

A nurse on a medical unit is assigned patients with acid-base irregularities. While caring for a patient with gastric lavage or prolonged vomiting, the nurse should assess for?

Accepted Answer

Answer reason: Gastric lavage and prolonged vomiting therefore most commonly lead to metabolic alkalosis, often accompanied by hypochloremia and volume depletion. The nurse should monitor for manifestations of alkalemia such as neuromuscular irritability (paresthesias, muscle cramps) and compensatory hypoventilation. In contrast, acidosis is more consistent with retained acids (e.g., renal failure) or bicarbonate loss (e.g., diarrhea), not acid loss from the stomach.

Question 6

The client with hyperemesis gravidarum is at risk for developing?

Accepted Answer

Answer reason: With worsening dehydration, hypovolemia reduces effective circulating volume and can contribute to lactic acid production and starvation ketosis, shifting the patient toward a metabolic acidosis picture in advanced cases. Dehydration is a key associated risk because ongoing emesis limits oral intake and causes fluid losses. Respiratory acid–base disorders are not the primary expected consequence of hyperemesis, and options that exclude dehydration do not match the typical clinical risk profile.

Question 7

The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

Accepted Answer

Answer reason: An ileostomy can produce large amounts of liquid effluent, especially early after surgery, making dehydration and electrolyte depletion more likely without careful replacement. In contrast, heart failure and long-term corticosteroid therapy more commonly predispose to fluid retention due to neurohormonal activation and sodium/water retention. Frequent wound irrigation may cause localized fluid loss but typically does not produce the sustained systemic volume losses seen with high-output stomas.

Question 8

A child newly diagnosed with type 1 diabetes mellitus who is receiving insulin suddenly experiences signs of a hypoglycemic reaction. Which item should the nurse give to the child immediately?

Accepted Answer

Answer reason: This choice provides a meaningful amount of carbohydrate in a form that is easy to ingest and commonly used as an urgent treatment in an awake child. Diet cola contains no sugar and will not correct hypoglycemia, and 1/2 teaspoon of sugar or honey is typically too small a dose to reliably raise glucose to a safe level. After initial correction, reassessment and follow-up carbohydrates/protein are used to prevent recurrent hypoglycemia.

Question 9

What are the potential side effects of laxatives?

Accepted Answer

Answer reason: Ongoing GI fluid loss can quickly produce dehydration, and the accompanying losses of sodium, potassium, and bicarbonate can cause clinically important electrolyte disturbances (e.g., hypokalemia), especially in older adults or those with renal/cardiac disease. This risk is the most safety-relevant and potentially systemic adverse effect compared with localized discomfort. Diarrhea and cramping are common, but the high-stakes complication nurses monitor for is volume depletion with electrolyte derangement that can precipitate weakness, arrhythmias, and hypotension.

Question 10

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances?

Accepted Answer

Answer reason: With chronic kidney impairment, these buffering and excretory functions decline, making metabolic acidosis (and broader electrolyte-related disturbances) more likely during illness or stress. The other factors are less directly tied to sustained acid–base derangements: a remote MI alone does not typically cause chronic acid–base disruption, occasional antacid use is usually insufficient to produce significant alkalosis, and dyspnea only with extreme exertion does not imply ongoing ventilatory failure.

Question 11

The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client’s acid-base balance?

Accepted Answer

Answer reason: In metabolic acidosis, hydrogen moves into cells and potassium shifts out, so serum potassium provides important indirect information about the severity and physiologic impact of the acidosis and guides urgent management due to dysrhythmia risk. Late-stage salicylate toxicity can produce significant metabolic acidosis, making potassium monitoring essential during treatment (including bicarbonate therapy) because levels may change rapidly. Sodium, magnesium, and phosphorus are important electrolytes but are less directly reflective of acid–base-related transcellular shifts than potassium in this context.

Question 12

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for?

Accepted Answer

Answer reason: Profuse diarrhea causes significant gastrointestinal loss of potassium, making low serum potassium a common and clinically important complication in Crohn’s flares. Hypokalemia increases risk for weakness, ileus, and potentially life-threatening dysrhythmias, so monitoring electrolytes and cardiac status is priority. In inflammatory bowel disease with poor intake and weight loss, malnutrition and volume depletion further worsen potassium deficits. Hyperalbuminemia is unlikely because inflammation and protein-losing enteropathy tend to reduce albumin rather than raise it. Hypercalcemia is not a typical consequence of diarrheal illness and active Crohn’s compared with electrolyte losses like potassium.

Question 13

The nurse caring for a client who is in acute Addison's disease crisis should give priority to which nursing intervention?

Accepted Answer

Answer reason: Addisonian crisis causes acute cortisol/aldosterone deficiency leading to hypovolemia, dehydration, hyponatremia, and hypotension, so rapid changes in fluid balance and perfusion are the key immediate threat. Strict intake and output trends provide the most direct, ongoing bedside indicator of volume status and response to emergent IV fluids and corticosteroid therapy. This intervention supports early recognition of worsening shock or inadequate resuscitation and guides escalation of care. Daily weights are useful for longer-term fluid assessment but are not as immediate or sensitive as I&O in an acute crisis. Lighting and room temperature are not priority interventions for reversing the life-threatening physiologic instability.

Question 14

The client with diabetes with a blood glucose level of 53 mg/dL reports feeling shaky, weak, and lightheaded. The nurse performs which intervention for the client?

Accepted Answer

Answer reason: Symptomatic hypoglycemia (glucose 53 mg/dL with shakiness, weakness, lightheadedness) in a client who can safely swallow is treated first with rapid-acting oral carbohydrate per the 15-15 rule. Four ounces of juice provides quick glucose to raise serum levels and relieve neuroglycopenic/adrenergic symptoms, then glucose should be rechecked and followed with longer-acting carbohydrate if needed. IV dextrose is generally reserved for severe hypoglycemia, altered mental status, seizures, or inability to take PO safely. Holding the next insulin dose does not correct the immediate low glucose, and water does not raise blood sugar.

Question 15

Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?

Accepted Answer

Answer reason: Continuous gastric suction removes hydrochloric acid, causing loss of hydrogen ions and chloride, which produces a metabolic alkalosis. Metabolic alkalosis is reflected by an elevated pH with an increased bicarbonate level, while PaCO2 may be normal early or rise later with hypoventilatory compensation. This option matches an alkalemic pH with elevated HCO3 and a non-acidotic PaCO2. By contrast, options showing low pH or low HCO3 represent acidosis patterns not expected from gastric acid loss.

Question 16

The nurse is caring for a client who has metabolic alkalosis. It would indicate that the client is experiencing systemic compensation if the client has?

Accepted Answer

Answer reason: A drop in respiratory rate reflects this compensatory mechanism and is a classic systemic response when the primary disturbance is elevated bicarbonate. The other options describe nonspecific sympathetic symptoms or hemodynamic/renal changes that do not directly represent the expected physiologic compensation pattern for metabolic alkalosis. Although kidneys can excrete bicarbonate, the immediate systemic compensation that is most readily observed at the bedside is decreased ventilation.

Question 17

The nurse is reviewing the list of components of the peritoneal dialysis solution with a client when the client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response on knowledge that glucose performs which action?

Accepted Answer

Answer reason: This gradient pulls water from the client’s bloodstream into the peritoneal cavity, allowing fluid removal (ultrafiltration) along with solute clearance. Higher dextrose concentrations increase the amount of fluid removed, which is why the glucose percentage is adjusted based on volume status. Peritonitis risk is primarily affected by aseptic technique and catheter care, not by glucose itself. Disequilibrium syndrome is associated with hemodialysis rapid solute shifts rather than peritoneal dialysis.

Question 18

A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient?

Accepted Answer

Answer reason: The safest initial treatment is to limit free water intake to reduce further dilution and help raise serum sodium while monitoring neurologic status. Giving a fluid bolus would worsen water intoxication and hyponatremia. A sodium-restricted diet is inappropriate because the key problem is low serum sodium from dilution, not sodium excess; urinalysis may aid evaluation but is not the initial therapeutic order.

Question 19

In preparing for the admission of a client in sickle cell crisis, what should the nurse anticipate will be prescribed as the first intervention in the reversal of the current crisis?

Accepted Answer

Answer reason: Rapid IV isotonic hydration is the key first-step therapy to improve plasma volume, lower viscosity, and enhance microcirculatory flow to help reverse the crisis process. Oxygen is given if hypoxemic, but it is not universally indicated as the initial intervention for every crisis. Opioids treat severe pain but do not address the underlying pathophysiologic trigger, and RBC transfusion is reserved for specific complications (e.g., acute chest syndrome, stroke, or severe symptomatic anemia) rather than routine first-line reversal.

Question 20

The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?

Accepted Answer

Answer reason: " Frequent laxative use can cause excessive gastrointestinal fluid losses and increased stool output, which commonly leads to dehydration and electrolyte disturbances (notably hypokalemia and metabolic acidosis/alkalosis depending on the agent and losses). Older adults have reduced physiologic reserve and impaired thirst and renal concentrating ability, making them more vulnerable to rapid shifts in volume status. This history finding is a clear risk factor that can precipitate weakness, dysrhythmias, and orthostatic hypotension from electrolyte/volume depletion. Dry skin is nonspecific for hydration status, drinking iced tea alone does not inherently imply imbalance, and urinary dribbling is more suggestive of incontinence rather than a primary fluid/electrolyte risk.

Question 21

The nurse is caring for a patient diagnosed with acute symptomatic hypernatremia. Which maintenance IV fluid would the nurse expect to hang for this patient?

Accepted Answer

Answer reason: In hypernatremia, the core problem is a free-water deficit relative to sodium, so treatment focuses on replacing free water to lower serum sodium and osmolality safely. D5W provides electrolyte-free water once dextrose is metabolized, making it an appropriate maintenance fluid when the goal is gradual correction of sodium. Isotonic fluids like 0.9% saline and Lactated Ringer’s add sodium and are more appropriate for initial resuscitation in hypovolemia rather than correcting hypernatremia. Hypotonic saline (0.45%) can also lower sodium but is not “free water” and may be less direct than D5W for maintenance free-water replacement in many protocols, with careful monitoring to avoid overly rapid correction and cerebral edema.

Question 22

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

Accepted Answer

Answer reason: In severe hyponatremia, the priority is to raise serum sodium in a controlled manner to reduce cerebral edema and neurologic complications. Hypertonic saline (typically 3% NaCl) provides a higher sodium concentration than plasma, pulling water out of cells and increasing serum sodium. A hypotonic fluid would further dilute sodium and worsen symptoms, and isotonic fluid may be ineffective or worsen volume status depending on urine osmolality in SIADH. Careful monitoring is required to avoid overly rapid correction and osmotic demyelination.

Question 23

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk?

Accepted Answer

Answer reason: Flattened neck veins (even when supine) are a classic bedside indicator of low intravascular volume/hypovolemia. In contrast, full bounding pulses, dependent pitting edema, and crackles suggest fluid overload or increased hydrostatic pressure rather than intravascular volume depletion. Therefore, the finding that best supports risk from decreased plasma volume is low jugular venous filling.

Question 24

A nurse is planning care for a child with hemolytic-uremic syndrome. The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to?

Accepted Answer

Answer reason: Anuria indicates minimal to no renal excretion, so free water and sodium intake can rapidly cause fluid overload, hypertension, and pulmonary edema. Even with peritoneal dialysis, fluid removal may be intermittent and may not match intake unless carefully controlled. Therefore, adhering to prescribed fluid restriction is a key safety intervention to prevent life-threatening volume excess. An arteriovenous fistula is used for hemodialysis rather than peritoneal dialysis, and potassium should not be encouraged because reduced kidney function increases the risk of dangerous hyperkalemia.

Question 25

The patient is diagnosed with hyponatremia. What should the RN expect to assess in this patient?

Accepted Answer

Answer reason: Hyponatremia causes water to shift into cells, including neurons, leading to neurologic irritability and possible neuromuscular symptoms. This can present as muscle cramps, twitching, weakness, confusion, and in severe cases seizures. The other choices point more toward hypovolemia (orthostatic hypotension) or hypernatremia (sodium 148 and increased thirst), not low sodium. Therefore the expected assessment finding is neuromuscular hyperexcitability.

Question 26

The nurse cares for a client with prolonged and intractable vomiting. Which clinical finding does the nurse determine is a complication of this condition?

Accepted Answer

Answer reason: Blood pH 7.48 Prolonged vomiting causes loss of gastric hydrochloric acid (H+ and chloride), producing a metabolic alkalosis. An alkalemic pH above 7.45 is therefore an expected complication and indicates impaired acid-base balance requiring evaluation and correction of volume/chloride depletion. The calcium value shown is within normal limits and does not reflect the typical complication profile of vomiting. PaCO2 elevation can occur as compensatory hypoventilation in metabolic alkalosis, but the primary complication finding is the elevated blood pH itself.

Question 27

During assessment, the nurse finds a client somnolent and weak with a respiratory rate of 8 breaths/min. Which acid–base finding does the nurse anticipate when analyzing the client's arterial blood gas results?

Accepted Answer

Answer reason: Therefore the ABG pattern most directly anticipated is an elevated PaCO2 above the normal ~35–45 mm Hg range. Somnolence and weakness are consistent with hypercapnia and its CNS depressant effects. A normal pH (7.41) would suggest full compensation and does not best match an acute hypoventilatory presentation. A low bicarbonate (18) instead supports metabolic acidosis, which would typically drive tachypnea rather than bradypnea.

Question 28

The nurse cares for a client with metabolic alkalosis. Which condition does the nurse recognize as the possible cause of the client’s acid-base imbalance?

Accepted Answer

Answer reason: Elevated aldosterone enhances sodium reabsorption in exchange for potassium and hydrogen ion excretion in the distal nephron, producing hypokalemia and increased bicarbonate retention. This pattern directly explains an alkalemic metabolic disturbance without requiring a primary respiratory trigger. In contrast, COPD and hyperventilation primarily cause respiratory acid–base disorders (respiratory acidosis and respiratory alkalosis, respectively).

Question 29

The nurse cares for a client with diabetes mellitus. Bedside glucose monitoring shows the client's blood sugar is 48 mg/dL. The client is alert. Which treatment option is the best choice for this client?

Accepted Answer

Answer reason: An alert client with a blood glucose of 48 mg/dL has symptomatic hypoglycemia risk and needs rapid-acting carbohydrate by mouth. Juice provides quickly absorbed glucose that raises serum glucose promptly, aligning with the 15–20 g fast carbohydrate rule. Options higher in fat/protein (peanut butter sandwich, ice cream, chocolate) slow gastric emptying and delay glucose absorption, making them poorer immediate rescue choices. After the initial fast carb and recheck, a longer-acting snack may be added to prevent recurrent hypoglycemia.

Question 30

The nurse receives the order, “10 units intravenous bolus of regular insulin with 50 ml of D50W STAT”. This order is indicated to which client?

Accepted Answer

Answer reason:  IV regular insulin paired with dextrose is an emergency temporizing treatment for hyperkalemia because it shifts potassium intracellularly via increased Na+/K+-ATPase activity. A potassium of 6.0 mEq/L in a client with end-stage renal disease indicates impaired potassium excretion and risk for lethal dysrhythmias, making this intervention appropriate. The dextrose is administered to prevent iatrogenic hypoglycemia from the insulin bolus. In contrast, neuroglycopenic/adrenergic symptoms like confusion, tremors, and clammy skin suggest hypoglycemia, where giving insulin would worsen the condition. It is also not indicated for hypokalemia or vomiting-related metabolic alkalosis, where further lowering serum potassium could be dangerous.

Question 31

Which finding indicates severe dehydration in a child?

Accepted Answer

Answer reason: Mottling reflects compromised perfusion/shock physiology, and tenting indicates significant interstitial fluid loss. Capillary refill under 2 seconds is a normal finding and argues against severe dehydration. Dry mucous membranes and decreased tears are more consistent with mild to moderate dehydration unless accompanied by perfusion changes.

Question 32

The nurse is caring for a patient with sickle cell disease who is infected with Haemophilus influenzae. What is the most important action to prevent a vasoocclusive crisis?

Accepted Answer

Answer reason: Vaso-occlusive crises are promoted by sickling and increased blood viscosity, which worsen when the patient is dehydrated from fever, infection, or poor intake. Prompt hydration improves plasma volume, decreases viscosity, and supports microcirculatory flow to reduce capillary obstruction. Infection is a common trigger for sickling, so preventing dehydration is a high-impact, preventative nursing action. Cooling with ice packs can cause vasoconstriction and may worsen occlusion. Pain medication treats symptoms once a crisis is occurring but does not address the primary preventable trigger of hemoconcentration.

Question 33

A nurse is reviewing the records of the clients assigned to her during the shift. The nurse determines that which client is at greatest risk for fluid volume deficit?

Accepted Answer

Answer reason: This places the client at increased risk for dehydration, hypovolemia, and electrolyte disturbances (especially hyponatremia and hypokalemia), particularly early after surgery or with increased stoma output. In contrast, congestive heart failure and end-stage renal disease more commonly predispose to fluid volume excess due to impaired cardiac/renal handling of fluid. Wound irrigations generally do not produce systemic fluid loss significant enough to rival continuous enteric losses from an ileostomy.

Question 34

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Consensus formula, the minimum fluid requirements are which of the following during the first 24 hours after the burn?

Accepted Answer

Answer reason: The Consensus (adult) burn resuscitation estimate is 2 mL/kg/%TBSA for the first 24 hours, so 2 × 60 × 40 = 4800 mL. Lactated Ringer’s is preferred because it is isotonic and more physiologic for large-volume replacement than dextrose-containing or hypotonic fluids. A common distractor is 4 mL/kg/%TBSA (Parkland), which would calculate to 9600 mL but is not the consensus minimum asked here. D5W and 0.45% saline are inappropriate initially because they do not adequately expand the intravascular space and can worsen hyponatremia/edema in acute burn resuscitation.

Question 35

The nurse is assessing a patient who may be in the early stages of dehydration. Early signs and symptoms of dehydration include?

Accepted Answer

Answer reason: Thirst is one of the earliest and most sensitive subjective indicators of rising serum osmolality. Early volume depletion can also reduce cerebral perfusion and contribute to restlessness or mild confusion, especially in older adults. In contrast, hypotension, coma, and seizures are late/severe findings and suggest significant hypovolemia or marked electrolyte derangement rather than early dehydration. Skin turgor changes and sunken eyes can occur with dehydration but are less reliable early and vary by age and baseline tissue elasticity.

Question 36

The nurse obtains a fingerstick glucose level of 45 mg/dL from a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client’s skin is warm and dry. How should the nurse intervene?

Accepted Answer

Answer reason: A fingerstick glucose of 45 mg/dL is clinically significant hypoglycemia and requires immediate treatment rather than confirmation testing when the client is stable and able to swallow. Because the client is alert and oriented, oral carbohydrate is the safest fastest first-line intervention to raise glucose and prevent progression to neuroglycopenic symptoms or seizure. Adding a complex carbohydrate/protein snack helps sustain glucose after the initial rise and reduces recurrence. Repeating a fingerstick or obtaining a serum glucose delays treatment, and notifying the provider is secondary once the immediate hypoglycemia has been addressed.

Question 37

Management of a BUN of 71 and a creatinine of 2.7 in a client with diabetic ketoacidosis (DKA) is correctly accomplished with?

Accepted Answer

Answer reason: In DKA, severe osmotic diuresis causes profound dehydration and decreased renal perfusion, commonly producing pre-renal azotemia with elevated BUN and creatinine. Restoring intravascular volume with isotonic fluids improves kidney perfusion and typically lowers these values as the dehydration resolves. Fluid restriction would worsen hypovolemia and kidney injury, and dialysis is not first-line unless there is refractory severe acidosis, hyperkalemia, or uremic complications despite resuscitation. Bladder catheterization may help monitor urine output but does not correct the underlying cause of the elevated labs.

Question 38

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first?

Accepted Answer

Answer reason: Massive bloody emesis with severe lightheadedness indicates acute volume depletion and possible hypovolemic shock, so restoring intravascular volume is the immediate priority (circulation in ABCs). Rapid isotonic crystalloid infusion supports blood pressure, tissue perfusion, and oxygen delivery while further assessment and interventions occur. Antiemetics and analgesics may improve symptoms but do not address the life-threatening hemodynamic instability causing dizziness. Increasing oxygen can be appropriate if hypoxic, but without evidence of respiratory compromise, correcting shock physiology with fluids is the most urgent first step.

Question 39

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?

Accepted Answer

Answer reason: IV calcium gluconate rapidly stabilizes the myocardial cell membrane, reducing excitability and providing the fastest protection against arrhythmias without changing the serum potassium level. Insulin with dextrose shifts potassium into cells but does not provide the same immediate membrane-stabilizing effect when ECG changes are present. Sodium polystyrene and hemodialysis remove potassium but have slower onset relative to the urgent need to prevent imminent dysrhythmia.

Question 40

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which problem?

Accepted Answer

Answer reason: Children are at higher risk for rapid fluid and electrolyte shifts, so monitoring for alkalosis-related signs (e.g., neuromuscular irritability, dysrhythmias from potassium depletion) is clinically important. Metabolic acidosis is more classically associated with diarrhea (bicarbonate loss) rather than vomiting. Hyperactive bowel sounds are not the most critical expected complication of isolated persistent emesis compared with acid–base and electrolyte derangements.

Question 41

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?

Accepted Answer

Answer reason: Continuous nasogastric suction removes gastric contents and can produce significant ongoing electrolyte loss, making a potassium deficit likely. By contrast, Addison’s disease more typically causes hyperkalemia due to low aldosterone and reduced renal potassium excretion. Sustained tissue damage is more associated with potassium shifting out of cells (risking hyperkalemia) rather than causing a deficit.

Question 42

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?

Accepted Answer

Answer reason: IV calcium gluconate rapidly antagonizes the cardiac membrane effects of elevated potassium, lowering the chance of ventricular arrhythmias within minutes without changing serum potassium. Insulin with dextrose shifts potassium intracellularly but is not the most immediate membrane-stabilizing measure when ECG changes are present. Sodium polystyrene sulfonate and hemodialysis remove potassium from the body but act too slowly to provide the immediate cardiac protection needed first.

Question 43

A patient presents to the emergency department with a complaint of watery diarrhea for the past three days. Assessment findings include blood pressure - 100/60, pulse - 98, and dry mucous membranes. The healthcare provider would anticipate intravenous therapy administration with which of the following fluids?

Accepted Answer

Answer reason: Watery diarrhea for 3 days with borderline low BP and dry mucous membranes indicates extracellular fluid volume depletion. Isotonic crystalloids (e.g., 0.9% NS or LR) remain largely in the extracellular space and effectively restore circulating volume without causing rapid osmotic shifts. Hypotonic fluids would worsen intravascular depletion by moving water into cells, and hypertonic solutions/colloids are not first-line for routine dehydration without specific indications.

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Fluid and Electrolyte Imbalances NCLEX Practice Test

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A nurse is caring for a 4-year old child admitted after being burned over more than 50% of the body. Which lab data should be reviewed by the nurse as a priority in the initial 24 hours? 1. Blood glucose. 2. BUN. 3. Hematocrit. 4. WBC.?

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The nurse provides IV fluid resuscitation for a client with infectious colitis and dehydration. The nurse understands what intravenous solution is best for this client?

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor?

A nurse on a medical unit is assigned patients with acid-base irregularities. While caring for a patient with gastric lavage or prolonged vomiting, the nurse should assess for?

The client with hyperemesis gravidarum is at risk for developing?

The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A child newly diagnosed with type 1 diabetes mellitus who is receiving insulin suddenly experiences signs of a hypoglycemic reaction. Which item should the nurse give to the child immediately?

What are the potential side effects of laxatives?

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances?

The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client’s acid-base balance?

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for?

The nurse caring for a client who is in acute Addison's disease crisis should give priority to which nursing intervention?

The client with diabetes with a blood glucose level of 53 mg/dL reports feeling shaky, weak, and lightheaded. The nurse performs which intervention for the client?

Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?

The nurse is caring for a client who has metabolic alkalosis. It would indicate that the client is experiencing systemic compensation if the client has?

The nurse is reviewing the list of components of the peritoneal dialysis solution with a client when the client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response on knowledge that glucose performs which action?

A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient?

In preparing for the admission of a client in sickle cell crisis, what should the nurse anticipate will be prescribed as the first intervention in the reversal of the current crisis?

The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?

The nurse is caring for a patient diagnosed with acute symptomatic hypernatremia. Which maintenance IV fluid would the nurse expect to hang for this patient?

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk?

A nurse is planning care for a child with hemolytic-uremic syndrome. The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to?

The patient is diagnosed with hyponatremia. What should the RN expect to assess in this patient?

The nurse cares for a client with prolonged and intractable vomiting. Which clinical finding does the nurse determine is a complication of this condition?

During assessment, the nurse finds a client somnolent and weak with a respiratory rate of 8 breaths/min. Which acid–base finding does the nurse anticipate when analyzing the client's arterial blood gas results?

The nurse cares for a client with metabolic alkalosis. Which condition does the nurse recognize as the possible cause of the client’s acid-base imbalance?

The nurse cares for a client with diabetes mellitus. Bedside glucose monitoring shows the client's blood sugar is 48 mg/dL. The client is alert. Which treatment option is the best choice for this client?

The nurse receives the order, “10 units intravenous bolus of regular insulin with 50 ml of D50W STAT”. This order is indicated to which client?

Which finding indicates severe dehydration in a child?

The nurse is caring for a patient with sickle cell disease who is infected with Haemophilus influenzae. What is the most important action to prevent a vasoocclusive crisis?

A nurse is reviewing the records of the clients assigned to her during the shift. The nurse determines that which client is at greatest risk for fluid volume deficit?

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Consensus formula, the minimum fluid requirements are which of the following during the first 24 hours after the burn?

The nurse is assessing a patient who may be in the early stages of dehydration. Early signs and symptoms of dehydration include?

The nurse obtains a fingerstick glucose level of 45 mg/dL from a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client’s skin is warm and dry. How should the nurse intervene?

Management of a BUN of 71 and a creatinine of 2.7 in a client with diabetic ketoacidosis (DKA) is correctly accomplished with?

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first?

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which problem?

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?

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