The client receiving nasogastric suction
The nurse should plan care
knowing that which client is Rationale:
at risk for a potassium Potassium-rich gastrointestinal (GI) fluids are lost
deficit? through GI suction, which places the client at risk for
hypokalemia
Traumatic burn
The nurse reviews a client's
Rationale:
electrolyte results and
A serum potassium level that exceeds 5.0 mEq/L is
notes a potassium level of
indicative of hyperkalemia. Clients who experience the
5.5 mEq/L. The nurse
cellular shifting of potassium, as in the early stages of
understands that a
massive cell destruction (i.e., with trauma, burns, sepsis,
potassium value at this level
or metabolic or respiratory acidosis), are at risk for
should be noted with which
hyperkalemia. The client with Cushing's syndrome or
condition?
diarrhea and the client who has been overusing laxatives
are at risk for hypokalemia.
The nurse reviews a client's Narrow, peaked T waves
electrolyte results and
notes that the potassium Rationale:
level is 5.4 mEq/L. Which A serum potassium level of 5.4 mEq/L is indicative of
should the nurse observe hyperkalemia. Cardiac changes include a wide, flat P
for on the cardiac monitor wave; a prolonged PR interval; a widened QRS complex;
as a result of this laboratory and narrow, peaked T waves.
value?
, Client with a fast respiratory rate
"insensible fluid loss of Rationale:
approximately 800 mL Sensible losses are those that the person is aware of,
daily." Which client is at risk such as those that occur through wound drainage, GI
for this loss? tract losses, and urination. Insensible losses may occur
without the person's awareness. Insensible losses occur
daily through the skin and the lungs.
The client with diabetes mellitus
The nurse is reviewing the Rationale:
health records of assigned Fluid that shifts into the interstitial spaces and remains
clients. The nurse should there is referred to as third-space fluid. Common sites
plan care knowing that for third-spacing include the abdomen, pleural cavity,
which client is at the least peritoneal cavity, and pericardial sac. Third-space fluid is
likely risk for the physiologically useless because it does not circulate to
development of third- provide nutrients for the cells. Risk factors include liver
spacing? or kidney disease, major trauma, burns, sepsis, wound
healing, major surgery, malignancy, malabsorption
syndrome, malnutrition, alcoholism, and older age.
The client with a colostomy
rationale:
The nurse should plan care
Causes of a fluid volume deficit include vomiting,
knowing that which client is
diarrhea, conditions that cause increased respirations or
at risk for fluid volume
increased urinary output, insufficient intravenous fluid
deficit?
replacement, draining fistulas, ileostomy, and colostomy.
A client with cirrhosis, HF, or decreased kidney function
is at risk for fluid volume excess.
, The nurse is caring for a Increased specific gravity of the urine
client who has been taking
diuretics on a long-term
basis. Which finding should
the nurse expect to note as
a result of this long-term
use?
The client with the syndrome of inappropriate secretion
The nurse reviews of antidiuretic hormone (SIADH)
electrolyte values and
notes a sodium level of 130 rationale:
mEq/L. The nurse expects Hyponatremia is a serum sodium level less than 135
that this sodium level would mEq/L. Hyponatremia can occur secondary to SIADH.
be noted in a client with The client with an inadequate daily water intake, watery
which condition? diarrhea, or diabetes insipidus is at risk for
hypernatremia.
The nurse is caring for a Postural blood pressure changes
client with leukemia and
notes that the client has Rationale:
poor skin turgor and flat Postural blood pressure changes occur in the client with
neck and hand veins. The hyponatremia. Intense thirst and dry mucous membranes
nurse suspects are seen in clients with hypernatremia. A slow, bounding
hyponatremia. Which pulse is not indicative of hyponatremia. In a client with
additional signs/symptoms hyponatremia, a rapid, thready pulse is noted.
should the nurse expect to
note in this client if
hyponatremia is present?
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