Question 1
A 74-year-old female patient with a history of congestive heart failure and chronic kidney disease is admitted to the hospital with complaints of headache, nausea, and confusion. Her laboratory results reveal a serum sodium level of 128 mEq/L. The nurse recognizes that the patient is experiencing hyponatremia. Which of the following actions should the nurse take first?
A. Administer a hypertonic saline solution intravenously.
B. Increase oral fluid intake.
C. Administer loop diuretics.
D. Restrict fluid intake.
E. Encourage consumption of sodium-rich foods.
Rationale: In patients with hyponatremia, especially in the context of congestive heart failure and kidney disease, fluid restriction is often the initial management step to prevent further dilution of serum sodium. Administering hypertonic saline is reserved for severe or symptomatic cases under close monitoring due to risks of rapid sodium correction. Increasing oral fluid intake would exacerbate the hyponatremia, while administering loop diuretics without managing fluid balance could worsen renal function. Encouraging the consumption of sodium-rich foods can be helpful but is a longer-term management strategy and not the first action.
Question 2
A 60-year-old male patient with end-stage renal disease on hemodialysis presents with weakness, paresthesia, and an irregular heartbeat. His EKG shows peaked T waves. His potassium level is reported to be 6.5 mEq/L. Which of the following should the nurse anticipate administering?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Insulin and dextrose
D. Oral potassium supplements
E. Sodium bicarbonate
Rationale: In the case of hyperkalemia with cardiac symptoms and changes on EKG, rapid reduction of serum potassium is critical. Insulin, along with dextrose to prevent hypoglycemia, helps shift potassium from the extracellular fluid back into the cells, quickly reducing serum potassium levels and mitigating cardiac risks. Calcium gluconate is used to stabilize the heart muscle but does not lower potassium levels. Sodium polystyrene sulfonate is a longer-term treatment, and sodium bicarbonate is used when acidosis is also present. Oral potassium supplements would be contraindicated in hyperkalemia.
Question 3
A 45-year-old woman with a history of chronic vomiting due to gastroesophageal reflux disease presents with muscle weakness and cramps. Her laboratory results show a potassium level of 3.2 mEq/L. The nurse knows that which of the following is the most appropriate intervention?
A. Administer a potassium-sparing diuretic.
B. Provide oral potassium chloride supplements.
C. Initiate insulin and dextrose infusion.
D. Administer calcium gluconate intravenously.
E. Increase dietary intake of sodium.
Rationale: For mild to moderate hypokalemia without severe symptoms, oral potassium chloride supplements are preferred due to their safety and efficacy. This method allows for gradual correction of potassium levels and can be easily monitored. Potassium-sparing diuretics are not indicated as they do not directly increase potassium levels and are used more for their retention effect. Insulin and dextrose would lower potassium levels further, and calcium gluconate is used to manage symptoms of hyperkalemia, not hypokalemia. Increasing sodium intake does not directly affect potassium levels and could worsen the patient’s condition by promoting potassium excretion.
Question 4
A patient with acute kidney injury is showing signs of fluid overload, evidenced by peripheral edema and an increased jugular venous pressure. Which of the following actions is most appropriate for the nurse to take?
A. Encourage increased fluid intake to flush the kidneys.
B. Administer a loop diuretic as prescribed.
C. Provide a high-sodium diet.
D. Initiate hypertonic saline infusion.
E. Restrict activity to decrease metabolic demand.
Rationale: In cases of fluid overload, especially in the context of acute kidney injury, administering a loop diuretic helps to remove excess fluid by increasing urine output. This action can relieve symptoms of fluid overload such as peripheral edema and elevated jugular venous pressure. Encouraging increased fluid intake or providing a high-sodium diet would worsen fluid overload. Hypertonic saline infusion is not appropriate in this scenario as it could exacerbate fluid retention.
Question 5
A nurse is assessing a patient who has been experiencing severe diarrhea for the past three days. Which of the following findings would be most indicative of a fluid volume deficit?
A) Pitting edema
B) Bounding pulse
C) Systolic hypertension
D) Sunken eyes
E) Frothy sputum
Rationale: Sunken eyes are a classic sign of fluid volume deficit, particularly in severe cases, reflecting the loss of subcutaneous fat due to dehydration. Pitting edema, a bounding pulse, and systolic hypertension are typically associated with fluid overload. Frothy sputum is more indicative of pulmonary edema, not dehydration.
Question 6
An elderly patient is admitted to the hospital with a diagnosis of gastroenteritis and suspected fluid volume deficit. The nurse is reviewing the patient’s laboratory test results. Which of the following lab findings would support the diagnosis of fluid volume deficit?
A) Decreased serum sodium
B) Increased hemoglobin and hematocrit
C) Decreased serum potassium
D) Increased serum creatinine
E) Decreased blood urea nitrogen (BUN)
Rationale: Increased hemoglobin and hematocrit levels can indicate a fluid volume deficit because they suggest hemoconcentration, which occurs when the plasma volume decreases relative to the number of red blood cells. This condition is common in dehydration, where fluid loss leads to a relative increase in the concentration of blood cells and other blood components. Decreased serum sodium and potassium might be seen in various conditions but do not directly indicate fluid volume deficit without considering clinical context. Increased serum creatinine and BUN can indicate renal impairment, which may be a consequence of severe dehydration, but increased hemoglobin and hematocrit more directly reflect the hemoconcentration associated with fluid volume deficit.
Question 7
A pediatric nurse is caring for a 4-year-old child with vomiting and diarrhea. The child’s parent expresses concern about the child’s decreased urine output. Which of the following actions should the nurse take first to assess for fluid volume deficit?
A) Check the child’s weight
B) Measure the child’s temperature
C) Assess the child’s mucous membranes
D) Listen to the child’s lung sounds
E) Palpate the child’s abdomen
Rationale: Checking the child’s weight is the most accurate and immediate method to assess for fluid volume deficit, especially in pediatric patients, as weight changes can quickly indicate fluid loss or gain. Daily weights provide essential information about the fluid status, with rapid weight loss suggesting significant fluid volume deficit. While assessing mucous membranes, measuring temperature, listening to lung sounds, and palpating the abdomen are important in the overall assessment, they do not offer the direct quantitative measure of fluid loss that weight does.
Question 8
A home health nurse is visiting an elderly patient with a recent history of mild dehydration. To prevent recurrence, which of the following dietary recommendations is most appropriate for the nurse to provide to the patient?
A) Increase sodium-rich foods
B) Drink at least eight glasses of water daily
C) Restrict fluid intake in the evening
D) Consume more diuretic beverages, like coffee and tea
E) Increase intake of high-protein foods
Rationale: Drinking at least eight glasses of water daily is a foundational recommendation for preventing dehydration, particularly in elderly patients who may have a diminished sense of thirst. This practice helps maintain hydration and supports overall health. Increasing sodium-rich foods is not advised without specific medical indications, as it can contribute to hypertension and fluid retention. Restricting fluid intake in the evening might be recommended for patients with nocturia or heart failure but does not prevent dehydration. Diuretic beverages can actually contribute to dehydration by increasing urine output. High-protein foods are important for nutrition but do not specifically prevent dehydration.
Question 9
A nurse is planning care for a patient with a fluid volume deficit related to excessive sweating due to high environmental temperatures. Which of the following nursing interventions is most appropriate to include in the plan of care?
A) Apply a cooling blanket
B) Limit oral fluid intake
C) Encourage the consumption of sports drinks
D) Administer diuretics as prescribed
E) Increase dietary sodium intake without increasing fluids
Rationale: Encouraging the consumption of sports drinks is appropriate for a patient with fluid volume deficit related to excessive sweating, as these beverages can help replenish electrolytes lost through sweat in addition to providing fluids. Sports drinks contain electrolytes such as sodium and potassium, which are important for maintaining fluid balance and preventing hyponatremia. Applying a cooling blanket addresses the external temperature but does not replenish lost fluids or electrolytes. Limiting oral fluid intake and administering diuretics would exacerbate the fluid deficit. Increasing dietary sodium without increasing fluid intake could lead to hypernatremia and worsen dehydration.
Question 10
A nurse is assessing a group of patients for risk factors associated with fluid volume deficit. Which of the patient’s condition poses the highest risk for developing this condition?
A) A patient with a fractured leg immobilized in a cast
B) A patient with congestive heart failure on diuretic therapy
C) A patient recovering from a viral upper respiratory infection
D) A patient with hypothyroidism
E) A patient undergoing chemotherapy treatment
Rationale: Patients undergoing chemotherapy treatment are at a high risk for fluid volume deficit due to the side effects of the treatment, such as vomiting, diarrhea, and decreased appetite, which can lead to inadequate fluid intake and increased fluid loss. While congestive heart failure patients on diuretic therapy are also at risk, their fluid status is usually closely monitored to balance the effects of the diuretics.