Untitled Quiz

Questions and Answers

Which finding requires immediate intervention by the nurse for a 70-year-old client admitted with severe dehydration?

Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched

Deep furrows on the surface of the tongue

Urine output of 950 mL for the past 24 hours

Client behavior that changes from anxious to lethargic (correct)

What nursing actions are indicated for a client with diarrhea for 3 days and taking diuretics for CHF? (Select all that apply)

Place the client on bed rest (correct)

Evaluate the electrolyte levels (correct)

Administer the ordered diuretic

Initiate cardiac monitoring (correct)

Assess for orthostatic hypotension (correct)

Which interventions does the nurse use to safely administer KCl to a client with hypokalemia? (Select all that apply)

Assess for burning or redness during infusion (correct)

Administer only through a central venous catheter

Administer by IV push only during cardiac arrest

Infuse at a rate of no more than 10 mEq per hour (correct)

Use a potassium infusion prepared by a registered pharmacist (correct)

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)

Assess daily weights Signup and view all the answers

Which additional assessment will the nurse make for a client taking furosemide with a potassium level of 2.5 mEq/L?

Heart rate Signup and view all the answers

Which assessment finding indicates that Furosemide has been effective for a client with heart failure?

The client is free from adventitious breath sounds Signup and view all the answers

What statement indicates the nursing student understand the side effects of bumetanide?

Inverted T waves and a U wave may appear on the ECG Signup and view all the answers

Which foods should a client taking a potassium-sparing diuretic avoid? (Select all that apply)

Bananas Signup and view all the answers

I should call my provider if I gain more than 1 pound (0.5 kg) a week.

True Signup and view all the answers

Which activity takes priority for a client with a sodium level of 118 mEq/L?

Instructing the client not to ambulate without assistance Signup and view all the answers

Weighing myself daily can determine if my caloric intake is adequate.

False Signup and view all the answers

Which complication should the nurse report for a client receiving 3% saline for SIADH?

Crackles ½ way up the lung fields Signup and view all the answers

Weighing myself daily can reveal increased fluid retention.

True Signup and view all the answers

Which assessment parameter is critical for a client receiving IV magnesium sulfate?

Assessing the blood pressure hourly Signup and view all the answers

Which newly written prescription will the nurse administer first?

Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) Signup and view all the answers

What assessments should the nurse make for a client with a potassium level of 7.0 mEq/L? (Select all that apply)

Use of an ACE inhibitor Signup and view all the answers

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?

A client admitted yesterday with heart failure with dependent pedal edema Signup and view all the answers

Which client should the RN assess first after receiving change-of-shift report?

A client receiving IV diuretics whose blood pressure is 88/52 mm Hg Signup and view all the answers

Which intervention is most appropriate for a client with hypermagnesemia?

Place the client on a cardiac monitor Signup and view all the answers

What should the nurse implement first for a client with a serum potassium level of 6.9 mEq/L?

Place the client on a cardiac monitor Signup and view all the answers

Which action can the nurse delegate to unlicensed assistive personnel for a client with a history of dehydration?

Offering fluids to drink every hour Signup and view all the answers

Which electrolyte laboratory value is assigned to the LPN/LVN?

Calcium level of 9.5 mg/dL (2.4 mmol/L) Signup and view all the answers

Which staff member is assigned to care for a client with uncontrolled diabetes, polyuria, and low blood pressure?

RN who has floated from the intensive care unit Signup and view all the answers

Which statement should be included in teaching about fluid intake for older adults?

Offer fluids that they prefer frequently and on a regular schedule Signup and view all the answers

Which intervention does the nurse perform first for a client with hypernatremia?

Encourage fluid intake Signup and view all the answers

Which client will the nurse see first with electrolyte abnormalities?

The client whose potassium is 6.2 mEq/L (6.2 mmol/L) Signup and view all the answers

Which nursing action can be delegated to unlicensed assistive personnel (UAP) for a client who is severely dehydrated?

Providing oral care every 1 to 2 hours Signup and view all the answers

Which client is most appropriate to assign to the LPN/LVN?

A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) Signup and view all the answers

Which assessments will the nurse monitor during intravenous therapy of lactated Ringer's solution?

Blood pressure Signup and view all the answers

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?

Insulin Signup and view all the answers

Which nursing intervention does the nurse perform first for a client developing fluid overload?

Elevates the head of the bed Signup and view all the answers

Which assessment determines whether an older adult admitted with dehydration is safe for independent ambulation?

Checks for orthostatic blood pressure changes Signup and view all the answers

Which strategy does the nurse employ when assessing fluid balance in a client with heart failure?

Weigh the client daily, at the same time Signup and view all the answers

Which best practice technique does the nurse include when administering IV potassium replacement?

Use an IV pump to deliver the medication Signup and view all the answers

Which intervention can be delegated to the home health aide for a client with mild hypokalemia?

Measurement of the client's weight Signup and view all the answers

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.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Untitled Quiz

Questions and Answers

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)

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 additional assessment will the nurse make for a client taking furosemide with a potassium level of 2.5 mEq/L?

Which assessment finding indicates that Furosemide has been effective for a client with heart failure?

What statement indicates the nursing student understand the side effects of bumetanide?

Which foods should a client taking a potassium-sparing diuretic avoid? (Select all that apply)

I should call my provider if I gain more than 1 pound (0.5 kg) a week.

Which activity takes priority for a client with a sodium level of 118 mEq/L?

Weighing myself daily can determine if my caloric intake is adequate.

Which complication should the nurse report for a client receiving 3% saline for SIADH?

Weighing myself daily can reveal increased fluid retention.

Which assessment parameter is critical for a client receiving IV magnesium sulfate?

Which newly written prescription will the nurse administer first?

What assessments should the nurse make for a client with a potassium level of 7.0 mEq/L? (Select all that apply)

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?

Which client should the RN assess first after receiving change-of-shift report?

Which intervention is most appropriate for a client with hypermagnesemia?

What should the nurse implement first for a client with a serum potassium level of 6.9 mEq/L?

Which action can the nurse delegate to unlicensed assistive personnel for a client with a history of dehydration?

Which electrolyte laboratory value is assigned to the LPN/LVN?

Which staff member is assigned to care for a client with uncontrolled diabetes, polyuria, and low blood pressure?

Which statement should be included in teaching about fluid intake for older adults?

Which intervention does the nurse perform first for a client with hypernatremia?

Which client will the nurse see first with electrolyte abnormalities?

Which nursing action can be delegated to unlicensed assistive personnel (UAP) for a client who is severely dehydrated?

Which client is most appropriate to assign to the LPN/LVN?

Which assessments will the nurse monitor during intravenous therapy of lactated Ringer's solution?

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?

Which nursing intervention does the nurse perform first for a client developing fluid overload?

Which assessment determines whether an older adult admitted with dehydration is safe for independent ambulation?

Which strategy does the nurse employ when assessing fluid balance in a client with heart failure?

Which best practice technique does the nurse include when administering IV potassium replacement?

Which intervention can be delegated to the home health aide for a client with mild hypokalemia?

Study Notes

Severe Dehydration in Older Clients

Client with Diarrhea and Diuretics

Safe Administration of Potassium Chloride

Care for Clients on Loop Diuretics

Assessing Heart Rate in Hypokalemia

Indicators of Furosemide Effectiveness

Side Effects of Bumetanide

Precautions for Potassium-Sparing Diuretics

Prioritizing Safety in Severe Hyponatremia

Complications of 3% Saline Infusion

Critical Monitoring for IV Magnesium Sulfate

Assessing Causes of Hyperkalemia

Prioritizing Client Assessments

Management of Hyperkalemia

Delegating Tasks to UAP in Long-Term Care

Teaching Fluid Intake for Older Adults

Weight Monitoring in Congestive Heart Failure

Administering Potassium to Treat Hypokalemia

Card 20: Hypermagnesemia Intervention

Card 21: Electrolyte Laboratory Values Assignment

Card 22: Uncontrolled Diabetes Care Assignment

Card 23: Hypernatremia Intervention

Card 24: Prioritization of Clients with Electrolyte Abnormalities

Card 25: Delegation for Severely Dehydrated Client

Card 26: Client Assignment to LPN/LVN

Card 27: Assessments During IV Fluid Therapy

Card 28: Rapid Response Team for Hyperkalemia

Card 29: Intervention for Fluid Overload in ICU

Card 30: Assessing Safe Ambulation in Dehydrated Older Adult

Card 31: Assessing Fluid Balance in Heart Failure

Card 32: IV Potassium Administration Best Practices

Card 33: Home Health Aide Delegation

Studying That Suits You

More Quizzes Like This

Untitled Quiz

Untitled Quiz

Untitled Quiz

Untitled Quiz