ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 16 Questions
Question 1 of 5
The nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?
Correct Answer: C
Rationale: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
Question 2 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 3 of 5
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
Correct Answer: D
Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb $(0.9 \mathrm{kg})$ weight gain in 24 hours indicates that the client is retaining $1 \mathrm{~L}$ of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
Question 4 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 5 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.