1. The nurse is providing teaching to clients regarding intake of dietary potassium.
The nurse recognizes that the client at risk of developing an electrolyte imbalance
of potassium is the client who
A. has fatty stools from taking an over-the-counter (OTC) weight loss product.
B. experiences anorexia.
C. has chronic heart failure (HF) that is being treated with diuretics.
D. takes very large doses of vitamin D as a chemotherapy supplement.
C. The client who has chronic heart failure (HF) that is being treated with diuretics.
Rationale: Clients with chronic heart failure (HF) who are being treated with diuretics, particularly
loop diuretics like furosemide, are at risk for hypokalemia (low potassium levels) because diuretics
increase the excretion of potassium through urine. Monitoring potassium levels and ensuring
adequate intake is critical for these clients.
The other clients are at lower risk for potassium imbalances:
Fatty stools from OTC weight loss products (A) may cause malabsorption of fats but are
less likely to affect potassium.
Anorexia (B) can lead to multiple nutritional deficiencies, but potassium imbalance may not
be as immediate unless there is significant malnutrition or vomiting.
Large doses of vitamin D (D) do not directly affect potassium levels; however, they may
affect calcium and phosphate balance.
2. The nurse is caring for a client who has had diarrhea for 48 hours and has
developed fatigue, muscle weakness, and an irregular pulse. Which of the
following laboratory results should the nurse correlate to these signs and
symptoms?
A. Serum phosphate of 4 mEq/L.
B. Serum magnesium of 2 mEq/L.
C. Serum calcium of 9.5 mEq/L.
D. Serum potassium of 2.8 mEq/L.
D. Serum potassium of 2.8 mEq/L.
Rationale: A serum potassium level of 2.8 mEq/L indicates hypokalemia, which can result from
prolonged diarrhea. Hypokalemia is associated with symptoms such as fatigue, muscle weakness, and
cardiac dysrhythmias (irregular pulse), which are all present in this client.
The other values are within normal ranges and are not typically associated with these symptoms:
Serum phosphate (A) normal range: 2.5-4.5 mEq/L.
Serum magnesium (B) normal range: 1.5-2.5 mEq/L.
Serum calcium (C) normal range: 8.5-10.5 mEq/L.
3. The nurse is caring for a client who has multiple draining wounds and has been
admitted for hypovolemia. Which of the following assessment findings is consistent
with hypovolemia?
A. Increased urine output.
B. Decreased skin turgor.
C. Hypertension.
D. Bounding peripheral pulses.
B. Decreased skin turgor.
Rationale: Decreased skin turgor is a common sign of dehydration, which often accompanies
hypovolemia. It indicates that the skin does not quickly return to its normal position after being
pinched, reflecting reduced fluid volume in the body.
The other options are not consistent with hypovolemia:
Increased urine output (A) would typically occur with hypervolemia or conditions with
excess fluid, not hypovolemia.
, Hypertension (C) is usually associated with fluid overload, whereas hypovolemia typically
leads to hypotension.
Bounding peripheral pulses (D) are more indicative of fluid overload rather than
hypovolemia, which usually causes weak or thready pulses.
4. The nurse is caring for assigned clients. The nurse should see the client with which
of the following symptoms first?
A. Serum potassium concentration is decreasing; abdominal distention, but denies any
difÏcult breathing.
B. Serum calcium concentration is increasing; reports constipation; is alert and denies any
discomfort.
C. Serum potassium concentration is increasing; has developed cardiac dysrhythmias, but
denies any difÏculty breathing.
D. Serum calcium concentration is decreasing; reports constipation; is alert and reports a
pain level of 3 on a scale of 0 (no pain) to 10 (severe pain).
C. Serum potassium concentration is increasing; has developed cardiac dysrhythmias, but
denies any difÏculty breathing.
Rationale: Elevated potassium levels (hyperkalemia) are the most critical concern among the listed
options because they can lead to life-threatening cardiac dysrhythmias, even if the client is not
experiencing difÏculty breathing. Immediate intervention is required to prevent serious complications,
such as cardiac arrest.
The other symptoms listed are not as immediately life-threatening as hyperkalemia with cardiac
dysrhythmias:
A: Decreasing potassium with abdominal distention should be monitored, but it is less critical.
B: Increasing calcium with constipation and no discomfort does not require immediate
intervention.
D: Decreasing calcium with mild pain also does not pose an immediate threat.
5. The nurse is caring for the following clients. The nurse identifies which client as
being at risk for developing metabolic acidosis?
A. The client who is extremely anxious.
B. The client who has had diarrhea for over a week.
C. The client who has a nasogastric (NG) tube.
D. The client who has newly diagnosed pneumonia.
B. The client who has had diarrhea for over a week.
Rationale: Prolonged diarrhea leads to the loss of bicarbonate, which is a critical buffer in the body.
When bicarbonate is lost in large amounts, the body becomes more acidic, leading to metabolic
acidosis.
The other conditions are associated with different imbalances:
A. Extremely anxious: This may lead to respiratory alkalosis due to hyperventilation.
C. Nasogastric (NG) tube: This may cause metabolic alkalosis due to the loss of stomach
acids.
D. Newly diagnosed pneumonia: This could lead to respiratory acidosis due to impaired
gas exchange, not metabolic acidosis.
6. The nurse is reviewing laboratory results for assigned clients. The nurse should
follow-up with a client who has a
A. serum chloride of 100 mEq/dL.
B. specific gravity of 1.025.
C. blood sugar of 125 mg/dL.
D. serum potassium of 6 mEq/L.
, D. Serum potassium of 6 mEq/L.
Rationale: A serum potassium level of 6 mEq/L is elevated, indicating hyperkalemia, which can
lead to dangerous cardiac dysrhythmias and requires immediate follow-up.
The other lab values are within or near normal limits:
Serum chloride: Normal range is approximately 96-106 mEq/L.
Specific gravity: Normal range is approximately 1.005 to 1.030.
Blood sugar: 125 mg/dL is slightly elevated, but not as urgent as the potassium level and
may indicate pre-diabetes or mild hyperglycemia.
7. The nurse is caring for a client who has fluid overload. Which of the following
should the nurse include in the client’s plan of care?
A. Measure the client’s intake and output (I/O) every 24 hours.
B. Provide the client with unlimited low-sodium liquids.
C. Assess lung sounds at least every 2 hours.
D. Maintain the client’s head of bed (HOB) at a 90-degree angle.
C. Assess lung sounds at least every 2 hours.
Rationale: Fluid overload can lead to pulmonary complications, including pulmonary edema.
Regular assessment of lung sounds is crucial to detect signs of fluid accumulation in the lungs, such
as crackles, which require immediate intervention.
The other options are not appropriate for managing fluid overload:
Measuring intake and output every 24 hours (A) is insufÏcient; it should be done more
frequently, such as every shift.
Providing unlimited low-sodium liquids (B) could worsen fluid overload. Fluid and sodium
intake should be restricted.
Maintaining the head of bed at a 90-degree angle (D) is unnecessary and can cause
discomfort. Elevating the HOB to a semi-Fowler’s or Fowler’s position (30-45 degrees) is
generally adequate to promote comfort and ease of breathing.
8. The nurse is assessing a client who is at risk for fluid volume overload. Which of
the following assessment findings indicates hypotonic fluid volume overload?
A. Decreased level of consciousness (LOC).
B. Dry mucous membranes.
C. A decrease in capillary refill.
D. Postural hypotension.
A. Decreased level of consciousness (LOC).
Rationale: Hypotonic fluid volume overload occurs when there is an excess of water in relation to
electrolytes, leading to water intoxication and cerebral edema. A decreased level of
consciousness (LOC) is a common sign of cerebral edema, which can occur when excess water
shifts into brain cells.
The other options are not indicative of hypotonic fluid volume overload:
Dry mucous membranes (B) are typically a sign of dehydration.
A decrease in capillary refill (C) is associated with poor circulation or dehydration, not fluid
overload.
Postural hypotension (D) is more common in fluid volume deficit rather than overload.
9. The nurse is caring for a client who has severe fatigue and confusion. Which of the
following laboratory values requires immediate action by the nurse?
A. SaO₂ is 95%.
B. Arterial blood pH is 7.32.
C. Serum calcium is 18 mg/dL.
D. Serum potassium is 5.1 mEq/L.
The nurse recognizes that the client at risk of developing an electrolyte imbalance
of potassium is the client who
A. has fatty stools from taking an over-the-counter (OTC) weight loss product.
B. experiences anorexia.
C. has chronic heart failure (HF) that is being treated with diuretics.
D. takes very large doses of vitamin D as a chemotherapy supplement.
C. The client who has chronic heart failure (HF) that is being treated with diuretics.
Rationale: Clients with chronic heart failure (HF) who are being treated with diuretics, particularly
loop diuretics like furosemide, are at risk for hypokalemia (low potassium levels) because diuretics
increase the excretion of potassium through urine. Monitoring potassium levels and ensuring
adequate intake is critical for these clients.
The other clients are at lower risk for potassium imbalances:
Fatty stools from OTC weight loss products (A) may cause malabsorption of fats but are
less likely to affect potassium.
Anorexia (B) can lead to multiple nutritional deficiencies, but potassium imbalance may not
be as immediate unless there is significant malnutrition or vomiting.
Large doses of vitamin D (D) do not directly affect potassium levels; however, they may
affect calcium and phosphate balance.
2. The nurse is caring for a client who has had diarrhea for 48 hours and has
developed fatigue, muscle weakness, and an irregular pulse. Which of the
following laboratory results should the nurse correlate to these signs and
symptoms?
A. Serum phosphate of 4 mEq/L.
B. Serum magnesium of 2 mEq/L.
C. Serum calcium of 9.5 mEq/L.
D. Serum potassium of 2.8 mEq/L.
D. Serum potassium of 2.8 mEq/L.
Rationale: A serum potassium level of 2.8 mEq/L indicates hypokalemia, which can result from
prolonged diarrhea. Hypokalemia is associated with symptoms such as fatigue, muscle weakness, and
cardiac dysrhythmias (irregular pulse), which are all present in this client.
The other values are within normal ranges and are not typically associated with these symptoms:
Serum phosphate (A) normal range: 2.5-4.5 mEq/L.
Serum magnesium (B) normal range: 1.5-2.5 mEq/L.
Serum calcium (C) normal range: 8.5-10.5 mEq/L.
3. The nurse is caring for a client who has multiple draining wounds and has been
admitted for hypovolemia. Which of the following assessment findings is consistent
with hypovolemia?
A. Increased urine output.
B. Decreased skin turgor.
C. Hypertension.
D. Bounding peripheral pulses.
B. Decreased skin turgor.
Rationale: Decreased skin turgor is a common sign of dehydration, which often accompanies
hypovolemia. It indicates that the skin does not quickly return to its normal position after being
pinched, reflecting reduced fluid volume in the body.
The other options are not consistent with hypovolemia:
Increased urine output (A) would typically occur with hypervolemia or conditions with
excess fluid, not hypovolemia.
, Hypertension (C) is usually associated with fluid overload, whereas hypovolemia typically
leads to hypotension.
Bounding peripheral pulses (D) are more indicative of fluid overload rather than
hypovolemia, which usually causes weak or thready pulses.
4. The nurse is caring for assigned clients. The nurse should see the client with which
of the following symptoms first?
A. Serum potassium concentration is decreasing; abdominal distention, but denies any
difÏcult breathing.
B. Serum calcium concentration is increasing; reports constipation; is alert and denies any
discomfort.
C. Serum potassium concentration is increasing; has developed cardiac dysrhythmias, but
denies any difÏculty breathing.
D. Serum calcium concentration is decreasing; reports constipation; is alert and reports a
pain level of 3 on a scale of 0 (no pain) to 10 (severe pain).
C. Serum potassium concentration is increasing; has developed cardiac dysrhythmias, but
denies any difÏculty breathing.
Rationale: Elevated potassium levels (hyperkalemia) are the most critical concern among the listed
options because they can lead to life-threatening cardiac dysrhythmias, even if the client is not
experiencing difÏculty breathing. Immediate intervention is required to prevent serious complications,
such as cardiac arrest.
The other symptoms listed are not as immediately life-threatening as hyperkalemia with cardiac
dysrhythmias:
A: Decreasing potassium with abdominal distention should be monitored, but it is less critical.
B: Increasing calcium with constipation and no discomfort does not require immediate
intervention.
D: Decreasing calcium with mild pain also does not pose an immediate threat.
5. The nurse is caring for the following clients. The nurse identifies which client as
being at risk for developing metabolic acidosis?
A. The client who is extremely anxious.
B. The client who has had diarrhea for over a week.
C. The client who has a nasogastric (NG) tube.
D. The client who has newly diagnosed pneumonia.
B. The client who has had diarrhea for over a week.
Rationale: Prolonged diarrhea leads to the loss of bicarbonate, which is a critical buffer in the body.
When bicarbonate is lost in large amounts, the body becomes more acidic, leading to metabolic
acidosis.
The other conditions are associated with different imbalances:
A. Extremely anxious: This may lead to respiratory alkalosis due to hyperventilation.
C. Nasogastric (NG) tube: This may cause metabolic alkalosis due to the loss of stomach
acids.
D. Newly diagnosed pneumonia: This could lead to respiratory acidosis due to impaired
gas exchange, not metabolic acidosis.
6. The nurse is reviewing laboratory results for assigned clients. The nurse should
follow-up with a client who has a
A. serum chloride of 100 mEq/dL.
B. specific gravity of 1.025.
C. blood sugar of 125 mg/dL.
D. serum potassium of 6 mEq/L.
, D. Serum potassium of 6 mEq/L.
Rationale: A serum potassium level of 6 mEq/L is elevated, indicating hyperkalemia, which can
lead to dangerous cardiac dysrhythmias and requires immediate follow-up.
The other lab values are within or near normal limits:
Serum chloride: Normal range is approximately 96-106 mEq/L.
Specific gravity: Normal range is approximately 1.005 to 1.030.
Blood sugar: 125 mg/dL is slightly elevated, but not as urgent as the potassium level and
may indicate pre-diabetes or mild hyperglycemia.
7. The nurse is caring for a client who has fluid overload. Which of the following
should the nurse include in the client’s plan of care?
A. Measure the client’s intake and output (I/O) every 24 hours.
B. Provide the client with unlimited low-sodium liquids.
C. Assess lung sounds at least every 2 hours.
D. Maintain the client’s head of bed (HOB) at a 90-degree angle.
C. Assess lung sounds at least every 2 hours.
Rationale: Fluid overload can lead to pulmonary complications, including pulmonary edema.
Regular assessment of lung sounds is crucial to detect signs of fluid accumulation in the lungs, such
as crackles, which require immediate intervention.
The other options are not appropriate for managing fluid overload:
Measuring intake and output every 24 hours (A) is insufÏcient; it should be done more
frequently, such as every shift.
Providing unlimited low-sodium liquids (B) could worsen fluid overload. Fluid and sodium
intake should be restricted.
Maintaining the head of bed at a 90-degree angle (D) is unnecessary and can cause
discomfort. Elevating the HOB to a semi-Fowler’s or Fowler’s position (30-45 degrees) is
generally adequate to promote comfort and ease of breathing.
8. The nurse is assessing a client who is at risk for fluid volume overload. Which of
the following assessment findings indicates hypotonic fluid volume overload?
A. Decreased level of consciousness (LOC).
B. Dry mucous membranes.
C. A decrease in capillary refill.
D. Postural hypotension.
A. Decreased level of consciousness (LOC).
Rationale: Hypotonic fluid volume overload occurs when there is an excess of water in relation to
electrolytes, leading to water intoxication and cerebral edema. A decreased level of
consciousness (LOC) is a common sign of cerebral edema, which can occur when excess water
shifts into brain cells.
The other options are not indicative of hypotonic fluid volume overload:
Dry mucous membranes (B) are typically a sign of dehydration.
A decrease in capillary refill (C) is associated with poor circulation or dehydration, not fluid
overload.
Postural hypotension (D) is more common in fluid volume deficit rather than overload.
9. The nurse is caring for a client who has severe fatigue and confusion. Which of the
following laboratory values requires immediate action by the nurse?
A. SaO₂ is 95%.
B. Arterial blood pH is 7.32.
C. Serum calcium is 18 mg/dL.
D. Serum potassium is 5.1 mEq/L.
