ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 16 : Caring for Clients With Fluid, Electrolyte, and Acid? Base Imbalances Questions
Question 1 of 5
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?
Correct Answer: C
Rationale: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
Question 2 of 5
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
Correct Answer: A,D,E
Rationale: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.
Question 3 of 5
The nurse is reviewing lab work on a newly admitted client. Which diagnostic stud(ies) confirms the nursing problem statement of dehydration? Select all that apply.
Correct Answer: A,C
Rationale: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
Question 4 of 5
A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
Correct Answer: B
Rationale: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.
Question 5 of 5
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?
Correct Answer: C
Rationale: Hypocalcemia or low serum calcium levels can affect clotting.
Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.