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Questions and Answers
Which finding requires immediate intervention by the nurse for a 70-year-old client admitted with severe dehydration?
Which finding requires immediate intervention by the nurse for a 70-year-old client admitted with severe dehydration?
What nursing actions are indicated for a client with diarrhea for 3 days and taking diuretics for CHF? (Select all that apply)
What nursing actions are indicated for a client with diarrhea for 3 days and taking diuretics for CHF? (Select all that apply)
Which interventions does the nurse use to safely administer KCl to a client with hypokalemia? (Select all that apply)
Which interventions does the nurse use to safely administer KCl to a client with hypokalemia? (Select all that apply)
Which of these actions will be included in the care plan for a client receiving a loop diuretic for heart failure? (Select all that apply)
Which of these actions will be included in the care plan for a client receiving a loop diuretic for heart failure? (Select all that apply)
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Which additional assessment will the nurse make for a client taking furosemide with a potassium level of 2.5 mEq/L?
Which additional assessment will the nurse make for a client taking furosemide with a potassium level of 2.5 mEq/L?
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Which assessment finding indicates that Furosemide has been effective for a client with heart failure?
Which assessment finding indicates that Furosemide has been effective for a client with heart failure?
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What statement indicates the nursing student understand the side effects of bumetanide?
What statement indicates the nursing student understand the side effects of bumetanide?
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Which foods should a client taking a potassium-sparing diuretic avoid? (Select all that apply)
Which foods should a client taking a potassium-sparing diuretic avoid? (Select all that apply)
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I should call my provider if I gain more than 1 pound (0.5 kg) a week.
I should call my provider if I gain more than 1 pound (0.5 kg) a week.
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Which activity takes priority for a client with a sodium level of 118 mEq/L?
Which activity takes priority for a client with a sodium level of 118 mEq/L?
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Weighing myself daily can determine if my caloric intake is adequate.
Weighing myself daily can determine if my caloric intake is adequate.
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Which complication should the nurse report for a client receiving 3% saline for SIADH?
Which complication should the nurse report for a client receiving 3% saline for SIADH?
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Weighing myself daily can reveal increased fluid retention.
Weighing myself daily can reveal increased fluid retention.
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Which assessment parameter is critical for a client receiving IV magnesium sulfate?
Which assessment parameter is critical for a client receiving IV magnesium sulfate?
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Which newly written prescription will the nurse administer first?
Which newly written prescription will the nurse administer first?
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What assessments should the nurse make for a client with a potassium level of 7.0 mEq/L? (Select all that apply)
What assessments should the nurse make for a client with a potassium level of 7.0 mEq/L? (Select all that apply)
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Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?
Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?
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Which client should the RN assess first after receiving change-of-shift report?
Which client should the RN assess first after receiving change-of-shift report?
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Which intervention is most appropriate for a client with hypermagnesemia?
Which intervention is most appropriate for a client with hypermagnesemia?
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What should the nurse implement first for a client with a serum potassium level of 6.9 mEq/L?
What should the nurse implement first for a client with a serum potassium level of 6.9 mEq/L?
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Which action can the nurse delegate to unlicensed assistive personnel for a client with a history of dehydration?
Which action can the nurse delegate to unlicensed assistive personnel for a client with a history of dehydration?
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Which electrolyte laboratory value is assigned to the LPN/LVN?
Which electrolyte laboratory value is assigned to the LPN/LVN?
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Which staff member is assigned to care for a client with uncontrolled diabetes, polyuria, and low blood pressure?
Which staff member is assigned to care for a client with uncontrolled diabetes, polyuria, and low blood pressure?
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Which statement should be included in teaching about fluid intake for older adults?
Which statement should be included in teaching about fluid intake for older adults?
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Which intervention does the nurse perform first for a client with hypernatremia?
Which intervention does the nurse perform first for a client with hypernatremia?
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Which client will the nurse see first with electrolyte abnormalities?
Which client will the nurse see first with electrolyte abnormalities?
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Which nursing action can be delegated to unlicensed assistive personnel (UAP) for a client who is severely dehydrated?
Which nursing action can be delegated to unlicensed assistive personnel (UAP) for a client who is severely dehydrated?
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Which client is most appropriate to assign to the LPN/LVN?
Which client is most appropriate to assign to the LPN/LVN?
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Which assessments will the nurse monitor during intravenous therapy of lactated Ringer's solution?
Which assessments will the nurse monitor during intravenous therapy of lactated Ringer's solution?
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For a client with a heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L, which medication will the nurse anticipate a prescription for?
For a client with a heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L, which medication will the nurse anticipate a prescription for?
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Which nursing intervention does the nurse perform first for a client developing fluid overload?
Which nursing intervention does the nurse perform first for a client developing fluid overload?
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Which assessment determines whether an older adult admitted with dehydration is safe for independent ambulation?
Which assessment determines whether an older adult admitted with dehydration is safe for independent ambulation?
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Which strategy does the nurse employ when assessing fluid balance in a client with heart failure?
Which strategy does the nurse employ when assessing fluid balance in a client with heart failure?
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Which best practice technique does the nurse include when administering IV potassium replacement?
Which best practice technique does the nurse include when administering IV potassium replacement?
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Which intervention can be delegated to the home health aide for a client with mild hypokalemia?
Which intervention can be delegated to the home health aide for a client with mild hypokalemia?
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Study Notes
Severe Dehydration in Older Clients
- A shift from anxious to lethargic behavior in elderly clients indicates poor cerebral blood flow and requires immediate nursing intervention.
- Symptoms such as deep tongue furrows, poor skin turgor, and low urine output, while concerning, are not immediately life-threatening.
Client with Diarrhea and Diuretics
- Primary nursing actions include placing the client on bed rest, evaluating electrolyte levels, monitoring for orthostatic hypotension, and initiating cardiac monitoring.
- Fluid volume deficit and electrolyte imbalances, particularly hypokalemia, are significant risks due to diarrhea and diuretic use.
Safe Administration of Potassium Chloride
- Use pharmacy-prepared potassium infusions to ensure safety.
- Monitor for burning or redness during infusion; infuse potassium at a maximum rate of 10 mEq per hour to prevent complications.
- Potassium should never be administered via IV push.
Care for Clients on Loop Diuretics
- Key nursing actions include daily weight assessments and encouraging intake of potassium-rich foods like citrus fruits.
- Monitoring serum potassium levels is crucial due to the potassium-depleting nature of loop diuretics.
Assessing Heart Rate in Hypokalemia
- In clients with low potassium levels, assessing heart rate for bradycardia is critical due to increased sensitivity to digoxin, raising the risk of toxicity.
Indicators of Furosemide Effectiveness
- Signs that furosemide is effectively managing heart failure include the absence of adventitious breath sounds, weight loss, and improved urine output.
Side Effects of Bumetanide
- Understanding that bumetanide can cause inverted T waves and a U wave on EKG indicates knowledge of its potential effects on cardiac rhythm and potassium levels.
- Hypoglycemia is not a common effect of bumetanide; prolonged PT/INR is associated with anticoagulants rather than diuretics.
Precautions for Potassium-Sparing Diuretics
- Clients should avoid high-potassium foods, ACE inhibitors, and salt substitutes while on potassium-sparing diuretics to prevent hyperkalemia.
Prioritizing Safety in Severe Hyponatremia
- In situations of severe hyponatremia (sodium level of 118 mEq/L), priority is to instruct clients not to ambulate without assistance due to risk of muscle weakness and potential confusion.
Complications of 3% Saline Infusion
- Clinicians should closely monitor crackles in lung fields during hyperosmotic saline infusion, indicating possible fluid overload and need for intervention.
Critical Monitoring for IV Magnesium Sulfate
- Continuous assessment of blood pressure is vital due to the risk of hypotension associated with magnesium sulfate administration.
Assessing Causes of Hyperkalemia
- In clients with elevated potassium levels, evaluate for use of salt substitutes, ACE inhibitors, or potassium-sparing diuretics, which can contribute to hyperkalemia.
Prioritizing Client Assessments
- Priority assessments after shift change should focus on clients experiencing hypotension and potential hypovolemia resulting from diuretics.
Management of Hyperkalemia
- The priority action for a client with a potassium level of 6.9 mEq/L is to place them on a cardiac monitor to observe for potentially life-threatening dysrhythmias.
Delegating Tasks to UAP in Long-Term Care
- Delegation of offering fluids to clients for hydration is appropriate for UAP, while assessments must remain the responsibility of licensed nurses.
Teaching Fluid Intake for Older Adults
- Emphasis on regular offering of preferred fluids can help prevent dehydration in older adults due to their decreased thirst mechanism.
Weight Monitoring in Congestive Heart Failure
- Daily weight checks are essential for clients with CHF to detect fluid retention, indicating potential worsening of their condition.
Administering Potassium to Treat Hypokalemia
- Oral potassium chloride should be prioritized for a client with a potassium level of 3 mEq/L, as timely intervention is critical in managing hypokalemia.### Card 19: Client Assignment to LPN/LVN
- Assign to LPN/LVN: Client with heart failure and dependent pedal edema (most stable).
- Unstable clients include those with dehydration, tachycardia, potassium overload, and GI symptoms.
Card 20: Hypermagnesemia Intervention
- Most appropriate intervention: Place client on a cardiac monitor.
- Hypermagnesemia can cause cardiac rhythm changes and potential arrest.
- Reflexes typically reduced; monitor for respiratory distress.
Card 21: Electrolyte Laboratory Values Assignment
- Assign to LPN/LVN: Client with normal calcium level (9.5 mg/dL).
- High magnesium (4.1 mEq/L) and potassium (6.0 mEq/L) levels pose risks for dysrhythmia.
- Sodium level (120 mEq/L) may cause serious cerebral dysfunction requiring RN intervention.
Card 22: Uncontrolled Diabetes Care Assignment
- Assign to RN floated from ICU for unstable client with uncontrolled diabetes (BP 86/46 mm Hg).
- Indicates hypovolemia and possible shock; requires experienced assessment and intervention.
Card 23: Hypernatremia Intervention
- First intervention: Encourage fluid intake.
- Older adults are at risk for dehydration; fluids help correct sodium concentration.
- Restricting sodium is not sufficient; monitoring osmolarity alone is not an immediate resolution.
Card 24: Prioritization of Clients with Electrolyte Abnormalities
- First client to see: Client with elevated potassium (6.2 mEq/L) at risk for dysrhythmias.
- Random glucose (123 mg/dL) and other normal electrolyte levels require no immediate intervention.
Card 25: Delegation for Severely Dehydrated Client
- Delegate to UAP: Providing oral care every 1 to 2 hours.
- Oral care is crucial for clients with fluid volume deficit.
- Infusion of normal saline and monitoring IV fluids are complex tasks for licensed personnel.
Card 26: Client Assignment to LPN/LVN
- Assign to LPN/LVN: 76-year-old with poor skin turgor but normal serum osmolarity (300 mOsm/kg).
- Other clients have more critical conditions needing RN assessments.
Card 27: Assessments During IV Fluid Therapy
- Monitor: Blood pressure, pulse rate, urinary output, and urine specific gravity.
- Weight changes offer insights into fluid balance; blood glucose varies independently of hydration status.
Card 28: Rapid Response Team for Hyperkalemia
- Anticipated medication: Insulin to drive potassium into cells.
- Atropine treats bradycardia but not hyperkalemia; Kayexalate is slow-acting for emergencies.
Card 29: Intervention for Fluid Overload in ICU
- First action: Elevate the head of the bed to promote lung expansion and oxygenation.
- Blood tests may follow but don't take priority; positioning affects edema management.
Card 30: Assessing Safe Ambulation in Dehydrated Older Adult
- Key assessment: Check for orthostatic blood pressure changes.
- Vital to prevent falls due to potential hypotension and faintness in older clients.
Card 31: Assessing Fluid Balance in Heart Failure
- Weigh clients daily at the same time for accurate fluid balance assessment.
- Weight changes directly correlate with fluid volume variations; avoid unnecessary invasive procedures.
Card 32: IV Potassium Administration Best Practices
- Concentration should not exceed 1 mEq/10 mL; use an IV pump for controlled infusion.
- Avoid small veins; assess IV placement before administration; never push potassium.
Card 33: Home Health Aide Delegation
- Delegate: Measurement of client’s weight to home health aide.
- Monitoring intakes and outputs is crucial; education and assessments are RN responsibilities.
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