The nurse checks a client's skin turgor and documents that the client exhibits
normal fluid balance. Which statement correctly describes what the nurse has
documented?
1.The skin when pinched remained elevated when released.
2.The skin when pinched failed to return to normal when released.
3.The skin when pinched immediately fell back to normal when released.
4.The skin when pinched remained tented for several seconds when released.
3.
The skin when pinched immediately fell back to normal when released.
Rationale:Turgor (degree of elasticity) is checked by gently pinching up the
skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with
normal fluid balance, the skin when pinched will immediately fall back to
normal when released. If a fluid deficit is present, the skin may remain elevated
or tented for several seconds after the pinch.
The nurse reviews the client's serum calcium level and notes that the level is 8.0
mg/dL (2.0 mmol/L). The nurse understands which condition would cause this
serum calcium level?
1.Prolonged bed rest
2.Adrenal insufficiency
3.Hyperparathyroidism
4.Excessive ingestion of vitamin D
1. Prolonged bed rest
,Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25–2.75
mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is
experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal
insufficiency, and hyperparathyroidism are causative factors associated with
hypercalcemia. Although immobilization can initially cause hypercalcemia, the
long-term effect of prolonged bed rest is hypocalcemia.
The nurse is assisting in caring for a client who is receiving an intravenous
infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The
nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom
should be noted in the client if hyperkalemia is present?
1.Muscle pain
2.Mental confusion
3.Muscle weakness
4.Depressed deep tendon reflexes
3.
Muscle weakness
Rationale:Because potassium plays a major role in neuromuscular activity,
elevation in serum potassium initially causes muscle weakness not muscle pain.
Mental status changes and confusion are most likely noted in the client
experiencing hypocalcemia hyponatremia. Depressed deep tendon reflexes are
noted in the client with hypermagnesemia.
-
The nurse is caring for a client with kidney failure. The laboratory results reveal
a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse
expect to note in the client, based on this magnesium level?
1.Twitching
2.Irritability
, 3.Hyperactive reflexes
4.Loss of deep tendon reflexes
4.Loss of deep tendon reflexes
Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05
mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is
experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic
of this condition. Twitching, irritability, and hyperactive reflexes should be
noted in a client with hypomagnesemia.
The nurse is caring for a group of clients on a clinical nursing unit. The nurse
interprets that which assigned clients are at risk for excess fluid volume? Select
all that apply.
1.The client with renal failure
2.The client with an ileostomy
3.The client with chronic cirrhosis
4.The client with a draining abdominal wound
5.The client with a nasogastric tube to low suction
1.The client with renal failure
3.The client with chronic cirrhosis
Rationale:The client with renal failure is most at risk for excess fluid volume
because of the inability of the kidneys to excrete fluid. The client with chronic
cirrhosis is at risk for fluid volume excess due to fluid retention secondary to
portal hypertension and low levels of protein. Other causes of excess fluid
volume include heart failure, liver disorders, excessive use of hypotonic
intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body
fluids, and excessive ingestion of table salt. The client with an ileostomy, a
draining abdominal wound, or a nasogastric tube attached to suction is at risk
for deficient fluid volume.
A client needs to be placed on strict intake and output (I&O) measurement. The
nurse collects the data as a baseline and then checks the client's skin turgor by
normal fluid balance. Which statement correctly describes what the nurse has
documented?
1.The skin when pinched remained elevated when released.
2.The skin when pinched failed to return to normal when released.
3.The skin when pinched immediately fell back to normal when released.
4.The skin when pinched remained tented for several seconds when released.
3.
The skin when pinched immediately fell back to normal when released.
Rationale:Turgor (degree of elasticity) is checked by gently pinching up the
skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with
normal fluid balance, the skin when pinched will immediately fall back to
normal when released. If a fluid deficit is present, the skin may remain elevated
or tented for several seconds after the pinch.
The nurse reviews the client's serum calcium level and notes that the level is 8.0
mg/dL (2.0 mmol/L). The nurse understands which condition would cause this
serum calcium level?
1.Prolonged bed rest
2.Adrenal insufficiency
3.Hyperparathyroidism
4.Excessive ingestion of vitamin D
1. Prolonged bed rest
,Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25–2.75
mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is
experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal
insufficiency, and hyperparathyroidism are causative factors associated with
hypercalcemia. Although immobilization can initially cause hypercalcemia, the
long-term effect of prolonged bed rest is hypocalcemia.
The nurse is assisting in caring for a client who is receiving an intravenous
infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The
nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom
should be noted in the client if hyperkalemia is present?
1.Muscle pain
2.Mental confusion
3.Muscle weakness
4.Depressed deep tendon reflexes
3.
Muscle weakness
Rationale:Because potassium plays a major role in neuromuscular activity,
elevation in serum potassium initially causes muscle weakness not muscle pain.
Mental status changes and confusion are most likely noted in the client
experiencing hypocalcemia hyponatremia. Depressed deep tendon reflexes are
noted in the client with hypermagnesemia.
-
The nurse is caring for a client with kidney failure. The laboratory results reveal
a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse
expect to note in the client, based on this magnesium level?
1.Twitching
2.Irritability
, 3.Hyperactive reflexes
4.Loss of deep tendon reflexes
4.Loss of deep tendon reflexes
Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05
mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is
experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic
of this condition. Twitching, irritability, and hyperactive reflexes should be
noted in a client with hypomagnesemia.
The nurse is caring for a group of clients on a clinical nursing unit. The nurse
interprets that which assigned clients are at risk for excess fluid volume? Select
all that apply.
1.The client with renal failure
2.The client with an ileostomy
3.The client with chronic cirrhosis
4.The client with a draining abdominal wound
5.The client with a nasogastric tube to low suction
1.The client with renal failure
3.The client with chronic cirrhosis
Rationale:The client with renal failure is most at risk for excess fluid volume
because of the inability of the kidneys to excrete fluid. The client with chronic
cirrhosis is at risk for fluid volume excess due to fluid retention secondary to
portal hypertension and low levels of protein. Other causes of excess fluid
volume include heart failure, liver disorders, excessive use of hypotonic
intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body
fluids, and excessive ingestion of table salt. The client with an ileostomy, a
draining abdominal wound, or a nasogastric tube attached to suction is at risk
for deficient fluid volume.
A client needs to be placed on strict intake and output (I&O) measurement. The
nurse collects the data as a baseline and then checks the client's skin turgor by
