The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1) Weight loss 2) Flat neck and hand veins 3) An increase in blood pressure 4) a decreased central venous pressure (CVP) - Answer: 3 Rational: 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 colume 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. Options 1, 2, and 4 identify signs noted in fluid volume deficit. A nurse is preparing to care for a client with potassium deficit. The nurse reviews the client's record and determines that the client was a risk for developing the potassium deficit because the client: 1) Sustained tissue damage 2) Requires nasogastric suctioning 3) Has a history of Addison's disease 4) Is taking a potassium-sparing diuretic - Answer: 2 Rational: The normal serum potassium level is 3.5 mEq/L to 5 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal section, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia. A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? 1) U waves 2) Absent P waves 3) Elevated T waves 4) Elevated ST segment - Answer: 1 Rational: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially lifethreatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noting in a client with atrial fibrillation (A-fib). A nursing students needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? 1) Obtaining a controlled intravenous (IV) infusion pump 2) Monitoring urine output during administration 3) Preparing the medication for bolus administration 4) Diluting the medication in appropriate amount or normal saline - Answer: 3 Rational: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump or controller. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this types of solution increases intracellular potassium shifting. The IV site is monitored closely because the potassium chloride is irritating to the veins and there is a risk of phlebitis. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. A nurse caring for a group of clients reviews the electrolytes laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is a highest risk for developing a potassium value at this level? 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 - Answer: 4 Rational: A serum potassium level higher than 5 mEq/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. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the serum level. Which food item does the nurse instruct the client to avoid. 1) Peas 2) Nuts 3) Cauliflower 4) Processed oat cereals - Answer: 4 Rational: The normal serum sodium level is 135 - 145. a serum sodium level of 150 indicates hypernatremia. Based on this finding, the nurse would instruct the client to