NURS 325 Module 2 Fluid & Electrolytes
Correct answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and
occurs when fluid intake or fluid retention exceeds the fluid needs of the body.
Assessment findings associated with fluid volume excess include cough, dyspnea,
crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated
CVP, weight gain, edema, neck and hand vein distention, altered level of
consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins,
decreased urinary output {is noted in fluid volume excess}, and decreased CVP are
noted in fluid volume deficit. Weakness can be present in either fluid volume excess or
deficit.
NOTE: In fluid volume excess, the intake usually exceeds the output and thus urine
output decreases. What makes option 2 incorrect is the flat neck veins. In fluid volume
excess, neck veins will be distended. - 1. The nurse is caring for a client with heart
failure. On assessment, the nurse notes that the client is dyspneic (difficulty in
breathing), and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) 2. 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?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 mmol/L) - Correct answer: 2
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are
lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client
with tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43
mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a
cause of hyperkalemia. 4. The nurse provides instructions to a client with a low
potassium level about the foods that are high in potassium and tells the client to
consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
, 5. Cauliflower
6. Strawberries - Correct answer: 2, 3, 4, 6
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common
food sources of potassium include avocado, bananas, cantaloupe, carrots, fish,
mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and
tomatoes. Peas and cauliflower are high in magnesium. 5. The nurse is reviewing
laboratory results and notes that a client's serum sodium level is 150 mEq/L (150
mmol/L). The nurse reports the serum sodium level to the health care provider (HCP)
and the HCP prescribes dietary instructions based on the sodium level. Which
acceptable food items does the nurse instruct the client to consume? Select all that
apply.
1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals - Correct answer: 1, 2, 4
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A
serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis
of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas,
nuts, and cauliflower are good food sources of phosphorus and are not high in sodium
(unless they are canned or salted). Peas are also a good source of magnesium.
Processed foods such as cheese and processed oat cereals are high in sodium content.
6. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which
clinical manifestation would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes - Correct answer: 1
Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A
serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of
hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon
reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of
hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching,
tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. 9.* Which
client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroids - Correct answer: 1
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A
serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia
Correct answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and
occurs when fluid intake or fluid retention exceeds the fluid needs of the body.
Assessment findings associated with fluid volume excess include cough, dyspnea,
crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated
CVP, weight gain, edema, neck and hand vein distention, altered level of
consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins,
decreased urinary output {is noted in fluid volume excess}, and decreased CVP are
noted in fluid volume deficit. Weakness can be present in either fluid volume excess or
deficit.
NOTE: In fluid volume excess, the intake usually exceeds the output and thus urine
output decreases. What makes option 2 incorrect is the flat neck veins. In fluid volume
excess, neck veins will be distended. - 1. The nurse is caring for a client with heart
failure. On assessment, the nurse notes that the client is dyspneic (difficulty in
breathing), and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) 2. 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?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 mmol/L) - Correct answer: 2
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are
lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client
with tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43
mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a
cause of hyperkalemia. 4. The nurse provides instructions to a client with a low
potassium level about the foods that are high in potassium and tells the client to
consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
, 5. Cauliflower
6. Strawberries - Correct answer: 2, 3, 4, 6
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common
food sources of potassium include avocado, bananas, cantaloupe, carrots, fish,
mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and
tomatoes. Peas and cauliflower are high in magnesium. 5. The nurse is reviewing
laboratory results and notes that a client's serum sodium level is 150 mEq/L (150
mmol/L). The nurse reports the serum sodium level to the health care provider (HCP)
and the HCP prescribes dietary instructions based on the sodium level. Which
acceptable food items does the nurse instruct the client to consume? Select all that
apply.
1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals - Correct answer: 1, 2, 4
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A
serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis
of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas,
nuts, and cauliflower are good food sources of phosphorus and are not high in sodium
(unless they are canned or salted). Peas are also a good source of magnesium.
Processed foods such as cheese and processed oat cereals are high in sodium content.
6. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which
clinical manifestation would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes - Correct answer: 1
Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A
serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of
hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon
reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of
hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching,
tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. 9.* Which
client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroids - Correct answer: 1
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A
serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia
