A nurse is planning care for a client who has experienced excessive fluid loss. Which of the
following interventions should the nurse include in the plan of care? A. Administer IV fluids
evenly over 24 hr.
B. Provide the client with a salt substitute.
C. Assess for pitting edema.
D. Encourage the client to rise slowly when standing up.
E. Weigh the client every 8 hr. - ANSWER A, D, E
A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the fol-
lowing IV fluid prescriptions should the nurse anticipate administering?
a. Dextrose 5% in 0.9% sodium chloride
b. dextrose 5% in lactated ringer's
c. 3% sodium chloride
d. 0.45% sodium chloride - ANSWER D. this pt is hypernatremic, so want to give a hypo-
tonic solution The 0.45% sodium chloride is a hypotonic solution used to provide free water
and treat cellular dehydration, which promotes waste elimination by the kidneys.
A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the fol-
lowing lab values should the nurse expect?
a. Hemoglobin 20 g/dL.
b. Hematocrit 34%.
c. BUN 25 mg/dL.
d. Urine specific gravity 1.050. - ANSWER b. hematocrit 34%
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, fluid volume excess will cause what in hemoglobin levels? - ANSWER Hgb reference range
= 13.5-17.5 for males & 12-15.5 for females, therefore, the listed value is above the refer-
ence range. Fluid volume excess can cause hemodilution and a decreased Hgb level.
fluid volume excess will do what to the BUN level? why? - ANSWER Fluid volume excess
can cause a decrease in BUN (normal reference range = 10-20 mg/dL). The BUN level listed is
increased, which is associated with dehydration.
Fluid volume excess will do what to specific gravity of urine? why? - ANSWER Fluid vol-
ume excess can cause a decrease in urine specific gravity (normal reference range = 1.010-
1.025). The urine specific gravity listed is increased, which is associated with dehydration.
A nurse is caring for a client who is receiving furosemide daily. During the morning assess-
ment, the client tells the nurse that he is "feeling weak in the legs." Which of the following
actions should the nurse take first?
a. Monitor the client's bowel sounds.
b. Review the client's daily laboratory results.
c. Auscultate the client's lungs.
d. Palpate the client's peripheral pulses. - ANSWER C. an adverse affect of many diuretics
is hypokalemia; so check lungs for any respi changes due to weakness of the respi muscles
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His
respirations are 36/min and he appears very restless. Which of the following values should
the nurse anticipate to be outside the expected reference range if the client is experiencing
respiratory alkalosis?
A. PaO2
B. PaCO2
C. Sodium
D. Bicarbonate - ANSWER B. paCO2
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following interventions should the nurse include in the plan of care? A. Administer IV fluids
evenly over 24 hr.
B. Provide the client with a salt substitute.
C. Assess for pitting edema.
D. Encourage the client to rise slowly when standing up.
E. Weigh the client every 8 hr. - ANSWER A, D, E
A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the fol-
lowing IV fluid prescriptions should the nurse anticipate administering?
a. Dextrose 5% in 0.9% sodium chloride
b. dextrose 5% in lactated ringer's
c. 3% sodium chloride
d. 0.45% sodium chloride - ANSWER D. this pt is hypernatremic, so want to give a hypo-
tonic solution The 0.45% sodium chloride is a hypotonic solution used to provide free water
and treat cellular dehydration, which promotes waste elimination by the kidneys.
A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the fol-
lowing lab values should the nurse expect?
a. Hemoglobin 20 g/dL.
b. Hematocrit 34%.
c. BUN 25 mg/dL.
d. Urine specific gravity 1.050. - ANSWER b. hematocrit 34%
1
, fluid volume excess will cause what in hemoglobin levels? - ANSWER Hgb reference range
= 13.5-17.5 for males & 12-15.5 for females, therefore, the listed value is above the refer-
ence range. Fluid volume excess can cause hemodilution and a decreased Hgb level.
fluid volume excess will do what to the BUN level? why? - ANSWER Fluid volume excess
can cause a decrease in BUN (normal reference range = 10-20 mg/dL). The BUN level listed is
increased, which is associated with dehydration.
Fluid volume excess will do what to specific gravity of urine? why? - ANSWER Fluid vol-
ume excess can cause a decrease in urine specific gravity (normal reference range = 1.010-
1.025). The urine specific gravity listed is increased, which is associated with dehydration.
A nurse is caring for a client who is receiving furosemide daily. During the morning assess-
ment, the client tells the nurse that he is "feeling weak in the legs." Which of the following
actions should the nurse take first?
a. Monitor the client's bowel sounds.
b. Review the client's daily laboratory results.
c. Auscultate the client's lungs.
d. Palpate the client's peripheral pulses. - ANSWER C. an adverse affect of many diuretics
is hypokalemia; so check lungs for any respi changes due to weakness of the respi muscles
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His
respirations are 36/min and he appears very restless. Which of the following values should
the nurse anticipate to be outside the expected reference range if the client is experiencing
respiratory alkalosis?
A. PaO2
B. PaCO2
C. Sodium
D. Bicarbonate - ANSWER B. paCO2
2
