1. The nurse monitors for which clinical manifestations in the patient diagnosed with hyponatremia?
A. Irregular heart rate, leg cramps, confusion
B. Weakness, tachycardia, tingling of the skin
C. Headache, nausea, change in level of
consciousness
D. Bradycardia, hypotension, muscle weakness - correct answersAnswer: C
Rationale: Headache, nausea, and changes in level
of consciousness occur secondary to the shift
of fluid into the cells of the brain, increasing
intracranial pressure.
2. The nurse is screening patients for their risk of developing hyperkalemia. The nurse should consider
the patient with which disorder at greatest risk?
A. End-stage renal disease
B. Diabetic mellitus
C. Partial thickness burns
D. Receiving a loop diuretic - correct answersAnswer: A
Rationale: End-stage renal patients are not able
to excrete potassium through the renal system,
increasing the risk for developing hyperkalemia.
3. The nurse has just received a report on assigned
patients. Which patient should be assessed first?
A. A patient with abdominal pain who has drained
, 400 mL from her nasogastric tube over 6 hours
B. A patient postoperative total hip replacement
2 hours ago with 600-mL urine output
C. A patient receiving an IV infusion of 0.9%
NS at 125 mL/hr who is now complaining
of a cough
D. A patient complaining of leg cramps after
receiving furosemide (Lasix) for peripheral
edema - correct answersAnswer: C
Rationale: Development of a cough in a patient
receiving intravenous fluid can indicate the
development of fluid volume excess.
4. A patient has been admitted to the critical unit with
a serum magnesium level of 0.9 mEq/L. The nurse
closely monitors the patient for which potential
complication of this magnesium level?
A. Agitation and restlessness
B. Hypotension and bradycardia
C. Deep, rapid respirations
D. Seizure and ventricular fibrillation - correct answersAnswer: D
Rationale: Patients with low magnesium levels are
at risk for seizure and ventricular fibrillation. Agitation and restlessness are seen with hypernatremia.
Hypotension and bradycardia are associated with
high magnesium levels, and deep, rapid respirations
are observed with patients with hypochloremia.
5. The nurse has received a report on assigned patients
and receives the following laboratory results. Place