NCLEX® Review

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Chapter 52

NCLEX® Review

This activity contains 10 questions.

Which individual would least likely suffer from a disturbance in fluid volume, electrolyte, or acid-base balance?

	An infant suffering from gastroenteritis for three days
	An elderly client suffering from a type I decubitus
	Adults with impaired cardiac function
	Clients who are confused

An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of:

	Hypovolemia, and needs more fluids
	Hypervolemia, and needs the fluids adjusted
	An acid-base disturbance
	Needing no adjustment in fluid administration

A client taking lasix (furosemide) for congestive heart failure is seeing the physician for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except:

	Baked potato
	White bread
	Apricot
	Orange juice

Edema that forms in clients with kidney disease is due to:

	Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues
	Decreased capillary hydrostatic pressures pushing fluid into the interstitial tissues
	Capillaries becoming less permeable, allowing fluid to escape into interstitial tissues
	Obstructed lymph flow that assists the movement of fluid from the interstitial tissues back into the vascular compartment

A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are T 102.6, HR 128, R 24, and BP 130/86. A blood gas analysis sample was drawn on room air, and the results are as follows: pH 7.33, PaCO₂ 53, PaO₂ 72, HCO₃ 24. This client is at risk for:

	Respiratory acidosis
	Respiratory alkalosis
	Metabolic acidosis
	Metabolic alkalosis

Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include:

	Daily weights, vital signs, and fluid intake and output
	Daily weights, diuretics, and waist measurement
	Monitoring temperature, fluid intake and output, and calorie count
	Auscultating lung sounds, monitoring color of urine, and placing a Foley catheter into the client

The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents club meeting. Of the following actions, which is not representative of this topic?

	Recognizing possible risk factors for fluid and electrolyte balance, such as prolonged or repeated vomiting, frequent watery stools, or inability to consume fluids
	Increasing fluid intake before, during, and after strenuous exercise, particularly when the environmental temperature is high, and replacing lost electrolytes from excessive perspiration as needed with commercial electrolyte solutions
	Consuming six to eight glasses of water daily
	Encouraging excessive amounts of foods or fluids high in salt or caffeine

The nurse is admitting a new client, 80 years old, with congestive heart failure into your home health agency. The following assessment findings have been determined after meeting the client: overweight but no gain since the client left the hospital two days ago; VS: T 99.0, HR 100, R 22, BP 130/86. Foods eaten include canned soup at each meal, ham, and cheese. When completing the care plan for this client, the nurse should include which of the following nursing diagnosis:

	Improved Gas Exchange
	Risk for Fluid Volume Deficit
	Risk for Fluid Volume Imbalance
	Impaired Skin Integrity

	Within the question text below, there is one text entry field where you can enter your answer. The results of an arterial blood gas are as follows: pH: 7.5, PaCO₂: 50, PaO₂: 88, HCO₃: 28; Base excess: +5. Evaluate the acid-base imbalance.

Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood:

	Hanging for a longer four hours creates an increased risk of sepsis
	May clot in the bag
	May evaporate
	May not clot in the recipient after this time period

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NCLEX® Review

Which individual would least likely suffer from a disturbance in fluid volume, electrolyte, or acid-base balance?

Edema that forms in clients with kidney disease is due to:

Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include:

The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents club meeting. Of the following actions, which is not representative of this topic?

Within the question text below, there is one text entry field where you can enter your answer.

Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: