cellular regulation saunders.pdf

Cellular Regulation Saunders Practice Questions 1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid v...

Cellular Regulation Saunders Practice Questions 1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, 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 reviews a client’s record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 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 (557 mcmol/L) 3. The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex 4. Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions would the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled with the volume of potassium in the solution. 5. The nurse is assessing a client with a lactose intolerance disorder for 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 6. The nurse is caring for a client with Crohn’s disease who has a calcium level of 8 mg/dL (2 mmol/L).Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1. Peaked T wave 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment 7. The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes 8. 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 9. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine 10. The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome 11. The nurse is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800 mL daily.” The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract 12. The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations 13. The nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure 14. On review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease that developed as a complication of diabetes mellitus 15. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing’s syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn Answers 1. 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, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Cardiovascular: Heart Failure Priority Concepts: Fluid and Electrolytes; Perfusion Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 740-741. 2. 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 ranges from 2.7 to 8.5 mg/dL (160 to 501 mcmol/L). Test-Taking Strategy: Note the subject, causes of potassium deficit. First recall the normal uric acid levels and the causes of hyperkalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems/Electrolyte Imbalances Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. pp. 254-255. 3. Answer: 1, 3, 4 Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia. Test-Taking Strategy: Focus on the subject, the ECG patterns that may be noted in a client with a potassium level of 2.5 mEq/L (2.5 mmol/L). From the information in the question, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the electrocardiographic changes that are expected when severe hypokalemia exists. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems/Electrolyte Imbalances Priority Concepts: Clinical Judgment; Fluid and Electrolytes References: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. pp. 253-254. 4. Answer: 1, 2, 4, 5, 6 Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride is always labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse needs to monitor for infiltration. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. Test-Taking Strategy: Focus on the subject, the preparation and administration of potassium chloride intravenously. Think about this procedure and the effects of potassium. Note the word bolus in option 3 to assist in eliminating this option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Pharmacology: Fluid and Electrolyte Balance: Electrolytes Health Problem: Adult Health: Cardiovascular: Heart Failure Priority Concepts: Clinical Judgment; Safety References: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 279-280. 5. Answer: 1 Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. 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. Test-Taking Strategy: Focus on the subject, a suspected diagnosis of hypocalcemia. Note that the incorrect options are comparable or alike in that they reflect a hypoactivity or are associated with myocardial infarction. The option that is different is the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems/Electrolyte Imbalances Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. pp. 256-257. 6. Answer: 4, 5 Rationale: A client with Crohn’s disease is at risk for hypocalcemia. 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. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. Peaked T waves occur with myocardial infarction. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia. Test-Taking Strategy: Focus on the subject, the electrocardiographic patterns that occur in a client with Crohn’s disease who has a calcium level of 8 mg/dL (2 mmol/L). It is necessary to know that this client is at risk for hypocalcemia and that a level of 8 mg/dL (2 mmol/L) is low. Then it is necessary to recall the electrocardiographic changes that occur in hypocalcemia. Remember that hypocalcemia causes a prolonged ST segment and prolonged QT interval. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Gastrointestinal: Inflammatory Bowel Disease Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 279-280. 7. Answer: 3, 5 Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occur in hypokalemia. A prolonged ST segment occurs in hypocalcemia. Test-Taking Strategy: Focus on the subject, a client with chronic kidney disease and the electrocardiographic changes that occur in a potassium imbalance. From the information in the question you need to determine that this condition is a hyperkalemic one. From this point, you must know the elec trocardiographic changes that are expected when hyperkalemia exists. Remember that tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR interval are associated with hyperkalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Renal and Urinary: Acute Kidney Injury/Chronic Kidney Disease Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 279-280. 8. 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 can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia. Test-Taking Strategy: Focus on the subject, the causes of a sodium level of 130 mEq/L (130 mmol/L). First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to the correct option. Also, recall that when a client takes a diuretic, the client loses fluid and electrolytes. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Prioritize Hypotheses Content Area: Foundations of Care: Fluids & Electrolytes Health Problem: N/A Priority Concepts: Clinical Judgment; Fluids and Electrolytes Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. pp. 251-252. 9. Answer: 3 Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted. Test-Taking Strategy: Focus on the data in the question and the subject of the question, signs of hyponatremia. It is necessary to know the signs of hyponatremia to answer correctly. Also, think about the action and effects of sodium on the body to answer correctly. Remember that increased bowel motility and hyperactive bowel sounds indicate hyponatremia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Cardiovascular: Heart Failure Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. p. 252. 10. Answer: 1 Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide–based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L). First, you must determine that the client is experiencing hypophosphatemia. From this point, think about the effects of phosphorus on the body and recall the causes of hypophosphatemia in order to answer correctly. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Analyze Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: N/A Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 283-284. 11. Answer: 3 Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses. Test-Taking Strategy: Note that the subject of the question is insensible fluid loss. Note that urination, wound drainage, and gastrointestinal tract losses are comparable or alike in that they can be measured for accurate output. Fluid loss through the skin cannot be measured accurately; it can only be approximated. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: N/A Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 272. 12. Answer: 1 Rationale: A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess. Test-Taking Strategy: Note the strategic words, most likely. Read the question carefully, noting the subject, the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients with heart failure, on long-term corticosteroid therapy, and receiving frequent wound irrigations retain fluid. The only condition that can cause a deficit is the condition noted in the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Prioritize Hypotheses Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Gastrointestinal: Dehydration Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 274. 13. Answer: 1 Rationale: A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess. Test-Taking Strategy: Focus on the subject, assessment findings in fluid volume deficit. Think about the pathophysiology for fluid volume deficit and fluid volume excess to answer correctly. Note that options 2, 3, and 4 are comparable or alike and are manifestations associated with fluid volume excess. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: Adult Health: Cardiovascular: Heart Failure Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 274. 14. Answer: 4 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. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Kidney disease is a complication of diabetes mellitus and as a result of the kidney disease, the elimination of fluid is affected and the client retains fluid. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit. Test-Taking Strategy: Focus on the subject, fluid volume excess. Think about the pathophysiology associated with fluid volume excess. Read each option, and think about the fluid imbalance that can occur in each. Clients taking diuretics or having ileostomies or gastrointestinal suctioning all lose fluid. The only condition that can cause an excess is the condition noted in the correct option. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Prioritize Hypotheses Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: N/A Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medicalsurgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. p. 250. 15. Answer: 4 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. Test-Taking Strategy: Eliminate the client with colitis and the client overusing laxatives first, because they are comparable or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Also, remember that Cushing’s syndrome presents a risk for hypokalemia and that Addison’s disease presents a risk for hyperkalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Prioritize Hypotheses Content Area: Foundations of Care: Fluid & Electrolytes Health Problem: N/A Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. pp. 279-280.