1. A 10-month-old infant is admitted to the emergency department
with a 1.2°F1.2°F (38.9°C38.9°C) rectal temperature and a
history of vomiting and diarrhea for 48 hours. For which signs
should the nurse assess?
1. Bulging fontanels, tearless cry, and low urine output
2. Sunken eyes, lethargy, and dry, furrowed tongue
3. Weight loss, dilute urine, and peripheral edema
4. Dry skin, thready pulse, and neck vein distention
2. Which assessment of an adult client is a reliable indicator that
therapy for fluid overload is achieving the desired outcome?
Select all that apply.
1. Full, bounding peripheral pulses
2. Flat neck veins with the head of the bed elevated
3. Hand veins emptying longer than 20 seconds
4. S3S3 heart sound clearly audible on auscultation
5. Lung sounds are clear
3. The nurse concludes that which sign reliably indicates that
ascites fluid is being effectively mobilized in response to
therapy? Select all that apply.
1. Weight gain of 0.45 kg (1 lb) in 24 hours
2. Increase in urine output
3. Drop in blood pressure
4. Hand veins fill slowly
5. Abdominal girth has decreased by 2.5 cm (1 in.) in 24
hours
4. What instruction should the nurse include in an education
program to prevent dehydration for a high school hiking club that
is planning a 12-mile hike in early summer?
1. Take water and commercial sports drinks to sip often along
the way.
2. Drink large amounts of water, at least 0.47 L (16 oz) every
hour, while hiking.
3. Take salt tablets every 3 to 4 hours, and drink plenty of
water while in the heat.
4. Stop every 4 hours along the way, and drink a few ounces
of water while resting.
5. Which postoperative client would be at risk for developing a
sodium imbalance?
1. A client who has just had a tonsillectomy
2. A client who has a primary cesarean delivery for failure to
progress in labor
, 3. A client who has a transurethral resection of the prostate
(TURP)
4. A client who has a right knee arthroscopy
6. The nurse is caring for a client who has a sodium level of 128
mEq/L. As part of the care, the nurse should restrict which item
for this client?
1. Sports drinks containing electrolytes
2. Eggs and cheese products
3. Salt on the diet tray
4. Water
7. The nurse is caring for a client who has a sodium level of 149
mEq/L. The nurse anticipates that this client would benefit from
which therapy?
1. Cough suppressant
2. 3% saline solution
3. 5% dextrose in water solution
4. Lactulose
8. The community health nurse makes a home visit to a client
newly discharged from the hospital with resolving hypernatremia.
During the initial interview, what information should the nurse
follow up on to determine an effective plan of care?
1. The client lives on the second floor of an apartment
building that has an elevator.
2. The client needs to walk 100 feet each day to reach the
mailbox for the apartment building.
3. The client performs self-monitoring of blood glucose once a
day.
4. The client uses antacids on a frequent basis for
gastrointestinal complaints.
9. The nurse is caring for a client who has sustained partial- and
full-thickness burns over 30% of his body 18 hours ago. The
nurse assesses for which fluid and electrolyte imbalances at this
time? Select all that apply.
1. Hyperkalemia
2. Hypokalemia
3. Hypervolemia
4. Hypercalcemia
5. Hypovolemia
10. The nurse concludes that a history of which condition
places a client at risk for possible hypokalemia?
1. Chronic obstructive pulmonary disease (COPD)
2. Cirrhosis
3. Addison’s disease
4. Chronic renal failure (CRF)
, 11. Which healthcare provider prescription for potassium
chloride (KCl) should the nurse question for a client with severe
hypokalemia?
1. Infuse 1000 mL normal saline with 20 mEq KCl IV over 8
hours.
2. Give KCl 20 mEq PO daily after meals.
3. Infuse 1000 mL normal saline with 40 mEq KCl IV at 200
mL/hour.
4. Give 20 mEq KCl IV over 10 minutes.
12. Which treatment option does the nurse anticipate will be
most appropriate for a client with a potassium level of 3.5
mEq/L?
1. Give sodium polystyrene sulfate (Kayexalate) per rectum.
2. Use salt substitutes in the diet.
3. Administer oral potassium chloride (KCl).
4. Continue to monitor and offer foods high in potassium.
13. The nurse includes in the plan of care to periodically
monitor which item for a client who is at risk for developing
hypocalcemia? Select all that apply.
1. Blood urea nitrogen (BUN) and creatinine levels
2. Constipation
3. Serum albumin level
4. Fluid overload related to intravenous saline therapy
5. Serum magnesium level
14. A client with hypocalcemia is taking supplemental vitamin
D. When the client asks the purpose of this therapy, what
explanation should the nurse give?
1. It directly opposes calcitonin.
2. It prevents renal disease in clients with hypocalcemia.
3. Calcium is absorbed in the intestines only under the
influence of activated vitamin D.
4. The only way to obtain vitamin D is with oral
supplementation.
15. Which medication reported by a client during a nursing
history could be associated with the development of
hypocalcemia?
1. Phenytoin
2. Calcium carbonate
3. Calcitriol
4. Hydrochlorothiazide
16. The family of a client with hypercalcemia states that the
client is “not acting like himself.” The nurse focuses assessment
on which manifestation?
1. Personality change
2. Anxiety
3. Seizure activity