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Chapter 8-12
Chapter 8
The nurse is caring for a client with heart failure, on assessment, the nurse notes
that the client is dyspneic, and crackles are audible on auscultation. What
additional manifestations would the nurse expect to note in this client if excess
fluid volume is present?
Ans: An increase in blood pressure and increased respirations
The nurse reviews a client’s record and determines that the client is at risk for
developing a potassium deficit if which situation is documented?
Ans: Requires nasogastric suction
The nurse reviews a client’s electrolyte laboratory report and notes that the
potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch
for on the electrocardiogram (ECG) as a result of the laboratory value? SELECT
ALL THAT APPLY
Ans:
U waves,
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Inverted T waves,
Depressed ST
segment
Potassium chloride intravenously is prescribed for a client with heart failure
experiencing hypokalemia. Which actions should the nurse take to plan for
preparation and administration of the potassium? SELECT ALL THAT APPLY
Ans:
Obtain an intravenous (IV) infusion
pump, Monitor urine output during
administration,
Monitor the IV site for signs of infiltration and phlebitis,
Ensure that the medication is diluted in the appropriate volume of fluid,
Ensure that the bag is labeled so that it reads the volume of potassium in the
solution.
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The nurse is assessing a client with lactose intolerance disorder for a
suspected diagnosis of hypocalcemia. Which clinical manifestation would the
nurse expect to note in the client?
Ans: Twitching
The nurse is caring for a client with Crohn’s disease who has a calcium level of
8mg/dL (2mmol/L). Which pattern would the nurse watch for on the
electrocardiogram? SELECT ALL THAT APPLY
Ans:
Prolonged QT
interval, Prolonged
ST segment
The nurse reviews the electrolyte results of a client with chronic kidney disease
and notes that the potassium level is 5.7 mEq/L (5.7mmol/L). Which patterns
would the nurse watch for on the cardiac monitor as a result of the laboratory
value? SELECT ALL THAT APPLY
Ans: Tall peaked T waves, Widened QRS complexes
Which Client is at risk for the development of a sodium level at 130 mEq/L
(130mmol/L)? Ans: The client who is taking diuretics
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The nurse is caring for a client with heart failure who is receiving high doses of
diuretic. On assessment, the nurse notes that the client has flat neck veins,
generalized muscle weakness, and diminished deep tendon reflexes. The nurse
suspects hyponatremia. What additional signs would the nurse expect to note in a
client with hyponatremia?
Ans: Hyperactive bowel sounds.
The nurse reviews a client’s laboratory report and notes that the client’s serum
phosphorus (phosphate) level is 1.8 mEq/dL (0.58 mmol/L). Which condition
most likely cause this serum phosphate level?
Ans: Malnutrition
The nurse is reading a PHCP progress notes in the client’s record and reads that
the PHCP has documented “insensible fluid loss of approximately 800 mL daily.”
The nurse makes a notation that the insensible fluid loss occurs through which
type of excretion?
Ans: Integumentary output
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