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
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
Correct Answer: B
Rationale: Postural hypotension occurs when the client rises from a supine or semi- Fowler's position to a standing position and the systolic blood pressure drops by $15 \mathrm{~mm} \mathrm{Hg}$. The client has symptoms of dizziness or a near syncopal episode.
Question 2 of 5
An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?
Correct Answer: D
Rationale: The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.
Question 3 of 5
A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the correct answer from the nurse?
Correct Answer: D
Rationale: Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.
Question 4 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 5 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.