A nurse is admitting a client who reports persistent nausea, vomiting, and weakness for three days. The client has dry oral mucous membranes, weak peripheral pulses, and decreased skin turgor. What additional assessment findings should the nurse identify as manifestations related to the fluid imbalance? (Select All That Apply)

Muscle cramps

Bradycardia

Concentrated urine

Tachycardia

Increased thirst

Answer and Explanation

Correct Answer : A,C,D,E

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

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Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

A. Potassium 2.9 mEq/L B. Sodium 125 mEq/L C. Potassium 4.6 mEq/L D. Sodium 139 mEq/L E. Magnesium 2.1 mEq/L

Correct Answer is ["A","B"]

Explanation

A. Potassium 2.9 mEq/L: This indicates hypokalemia, which is a common electrolyte imbalance associated with diuretic therapy, particularly with loop diuretics.
B. Sodium 125 mEq/L: This indicates hyponatremia, another possible electrolyte imbalance resulting from diuretic use.
C. Potassium 4.6 mEq/L: This is within the normal range and does not indicate an imbalance.
D. Sodium 139 mEq/L: This is within the normal range and does not indicate an imbalance.
E. Magnesium 2.1 mEq/L: This is within the normal range and does not indicate an imbalance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

Correct Answer is D

Explanation

The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

The nurse is rounding on a client who is 12 hours postoperative. Upon assessment, the client becomes tachycardic, hypotensive, and restless and complains of sudden chest pain. Which postoperative complication should the nurse conclude that the client most likely experienced?

The nurse is providing teaching to the client about the use of vitamins and supplements. The nurse would state that vitamin D has a major role in which process?

To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

A nurse cares for a client with a serum potassium of 5.4 mEq/L. The nurse should anticipate a prescription order for what medication?

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

The nurse is reviewing serum laboratory values for a client who is scheduled for surgery tomorrow. Which value requires the nurse to promptly notify the surgeon?