Fluid and Electrolytes

Which patient does the nurse advocate to be transferred to the intensive care unit?

Four patients have been ordered to receive a 12-lead electrocardiogram (ECG) but the floor only has one EKG machine. Which patient must receive the test first?

The nurse receives a set of orders for a patient. After reviewing the patient’s chart, the nurse clarifies which orders? Review the patient’s chart then select all that apply.

After reviewing the patient’s chart, which order(s) require clarification? Review the patient’s chart, then select all that apply.

The patient who underwent a partial thyroidectomy 1 day ago complains of tingling in the lips and tongue. Upon assessment, the nurse notes increased deep tendon reflexes. Which order does the nurse question for this patient?

The nurse monitors the patient with erysipelas for which symptoms that may indicate complications related to the condition? Select all that apply.

Following an apartment fire, the patient is brought to the emergency department by ambulance. The patient has third degree burns on the anterior bilateral lower legs and thighs, abdomen, and anterior bilateral arms. Soot is noted on the face; the patient appears to be speaking normally. Place the actions in the order the nurse performs them.

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The patient with third degree burns to bilateral lower legs is undergoing hydrotherapy to debride eschar tissue from the wounds. Prior to the procedure, the patient received a bolus of intravenous morphine in addition to the continuous infusion for pain control. During the procedure, the patient’s level of consciousness decreases to only rousable by painful stimuli. The patient’s temperature is 36.4°C, respiratory rate is 14 breaths per minute, heart rate is 82 bpm, and oxygen saturation is 93% on room air. The nurse ends the hydrotherapy session and contacts the provider to request which intervention?

The 32-year-old female patient (60 kg) is brought via ambulance to the emergency department following a water drinking competition. The patient has a Glasgow Coma score of 6, oxygen saturation of 94% on room air, heart rate of 62 bpm, and respiratory rate of 16 breaths per minute. The nurse anticipates administering which medication?

The 19-year-old female patient is found unconscious at a party. Bystanders report the individual imbibed a significant amount of grain alcohol and ingested several different pills, including 3,4-methylenedioxymethamphetamine. They observed the patient dancing wildly for several hours; after that, the patient disappeared and was found unconscious an hour later. Vital signs are within defined limits. Which lab result is consistent with the patient’s condition?

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse reviews the patient’s 24-hour intake and output for the patient with continuous bladder irrigation (CBI). The CBI intake is 2000 mL and the output is 2600 mL. Which action by the nurse is most appropriate?  

The nurse is supervising a nursing student in the emergency department. Which actions by the nursing student indicate effective learning? Select all that apply.  

The nurse places a call to the provider that the 74-year-old patient’s potassium level is 7.1 mEq/dL. The nurse is prepared to answer which questions from the provider? Select all that apply.  

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The 21-year-old patient with a body mass index of 10.1 undergoes placement of a peripherally inserted central catheter (PICC) at 1000 and total parenteral nutrition (TPN) is initiated at 1200. At 1600, 160 mL have infused and the patient is noted to be breathing shallowly, there is blood oozing from the PICC insertion site, and the patient is exhibiting confusion. Which action does the nurse perform first? 

The patient with chronic alcoholism begins parenteral nutrition (PN) at a rate of 50 mL/h for treatment of severe malnutrition. Four hours after the infusion begins, the patient’s urine output increases from 40 mL/h to 200 mL/h. The nurse contacts the provider to request which order?  

The patient is receiving parenteral nutrition while NPO for a bowel obstruction. Review the patient’s lab results and decide which change to the parenteral nutrition the nurse clarifies with the provider.   Blood urea nitrogen = 34 mg/dL   Serum Creatinine = 2.1 mg/dL  Potassium = 6.1 mEq/dL  Sodium = 131 mEq/dL  Chloride = 100 mEq/dL  Bicarbonate = 18 mEq/dL

At the beginning of the shift, the nurse assesses the patient receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter and notes a crack in the tubing with TPN leaking. The nurse notifies the provider and anticipates receiving which order first? 

The patient receiving total parenteral nutrition (TPN) is found to have received 24 hours’ worth of TPN in 4 hours. Which intervention does the nurse perform first? 

Following a bone marrow transplant, the patient exhibits a 10-pound weight gain in 3 days, increased abdominal circumference, and yellow tinge to the sclera and skin. The nurse notifies the provider and prepares to perform which intervention?  

The nurse is most concerned with encouraging the patient with multiple myeloma to ambulate frequently to prevent which complication? 

The home health nurse is assessing the patient with a colostomy. Which finding indicates the patient is performing the tap water irrigations too frequently?  

The nurse assesses the patient being treated for bipolar disorder for which signs of toxicity?  

The patient being treated for bipolar disorder is found to be lethargic, confused, and obtunded. It is determined that the morning dose of lithium was not taken. Which order does the nurse anticipate first?  

The 24-year-old otherwise healthy patient with bipolar disorder is found unconscious and brought to the emergency department. The patient is mildly febrile, significantly tachycardic, tachypneic, and hypotensive, with poor skin turgor and 5 second capillary refill. The patient’s EKG is notable for inverted T waves and sinus tachycardia. Which orders does the nurse anticipate for this patient? Select all that apply.  

The nurse creates the plan of care for the patient with crescent-shaped hemoglobin who presented with severe joint pain and stiffness with priority given to which type intervention? 

The 13-year-old patient presents to the emergency room following a sports practice in the late summer heat with severe joint pain, malaise, splenomegaly, tachypnea, and tachycardia. Upon assessment, the patient’s oxygen saturation is 92%. Which order does the nurse carry out first?

The nurse is providing health promotion teaching to the parents of a child recently diagnosed with sickle cell anemia. Which statement does the nurse include in teaching? 

The nurse questions which orders for the 12-year-old patient in sickle cell crisis? Select all that apply.

The 3-year-old patient is brought to the clinic after three days of nausea, vomiting, and diarrhea. Which assessment most prompts the nurse to advocate for hospital admission?  

The 11-month-old, previously healthy infant is brought to the emergency department after becoming increasingly lethargic over the past 24 hours. The infant’s vital signs are notable for a temperature of 40.8°C, heart rate 138 bpm, respiratory rate 31, and blood pressure 84/50 mmHg. Upon assessment, the nurse notes sensitivity to light and sound, bulging anterior fontanelle, and significant resistance to turning the head. Place the interventions in the correct order.  

The 36-hour-old neonate who was born at 37 weeks gestation to a G3P2 mother has yet to pass meconium. The baby was born by cesarean section due to refractory preeclampsia with severe features. The mother reports the baby has been breastfeeding well after a slow first 12 hours. Upon assessment, the baby appears well with good tone and responsiveness. The baby’s anus is patent and the abdomen is soft and rounded; bowel sounds present. The mother denies emesis in the baby. An abdominal x-ray is obtained, which is normal. The nurse informs the mother that which test will be performed next? 

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54 mmHg. The nurse contacts the provider to report these findings and advocate for which initial order?  

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54mmHg. The patient received maintenance fluids during the procedure and no blood transfusions. How many liters of isotonic fluid does the nurse anticipate administering to the patient during the postoperative period? Enter your response using a whole number. 

The 38-year-old patient who strictly adheres to a vegan diet complains of weakness and tingling in her lower extremities. She retains the strength in her lower extremities but proprioception is decreased.  Her complete blood count revealed a hemoglobin of 10.2 mg/dL, white blood cell count of 9 x 10³ cells/µL, and a mean corpuscular volume of 110. Which information does the nurse provide to the patient?  

The semi-professional athlete requests intravenous hydration after a particularly grueling practice. Which response by the nurse is most appropriate? 

The mother of the 7-week-old infant reports the baby has had fewer and fewer wet diapers and hasn’t stooled in 3 days despite having a ravenous appetite. The mother reports that the child has been vomiting with increasing force and volume over the past two weeks. The emesis just appears to be partially digested breastmilk and fluid. The infant appears well, but mucous membranes are dry, the child has a low-grade fever, and is tachycardic. Upon palpation of the abdomen, a small, olive-shaped mass is appreciated. A serum electrolyte panel reveals a sodium of 132, potassium of 2.7, chloride of 89, and a glucose of 92. The nurse performs which nursing action first? 

The patient experiencing an oversecretion of vasopressin presents with a decrease in which laboratory value?