Question

A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider?

Answer 1

Correct Answers:

BUN 25 mg/dL (10-20 mg/dL)

Rationale :

🔹 BUN is elevated in dehydration due to hemoconcentration, which causes urea nitrogen to rise.

🔹 Although the value is only slightly above normal, it indicates impaired renal perfusion or fluid deficit.

🔹 BUN is often used along with creatinine and urine specific gravity to evaluate fluid status.

🔹 This finding should be reported because it can signal pre-renal azotemia if untreated.

🔹 Prompt intervention may prevent acute kidney injury in a dehydrated client.

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Answer 2

Correct Answers:

Urine output 20 mL/hr

Rationale :

🔸 Urine output less than 30 mL/hr is a critical indicator of inadequate renal perfusion.

🔸 Dehydration leads to reduced intravascular volume, which decreases renal blood flow.

🔸 This oliguria may progress to renal failure if not promptly addressed.

🔸 Cool skin can occur with hypovolemia but is not a consistent early sign.

🔸 Monitoring urine output is essential in evaluating fluid balance.

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Answer 3

Correct Answers:

Sodium polystyrene (Kayexalate)

Rationale :

🟠 Sodium polystyrene sulfonate is used to treat hyperkalemia by promoting potassium excretion via the gastrointestinal tract.

🟠 A potassium level of 6.8 mEq/L is dangerously high and can result in cardiac dysrhythmias.

🟠 Immediate intervention is necessary to lower serum potassium and prevent life-threatening outcomes.

🟠 The nurse must monitor the client closely for EKG changes and bowel function due to this drug's action.

🟠 Treatment should be initiated without delay in symptomatic or critically high values.

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Answer 4

Correct Answers:

Sodium polystyrene

Rationale :

🟡 A potassium level of 5.3 mEq/L is slightly above the normal range and requires intervention to prevent worsening hyperkalemia.

🟡 Sodium polystyrene works by exchanging sodium for potassium in the intestines, promoting excretion.

🟡 This medication is commonly prescribed for non-emergent hyperkalemia and is effective when there's no immediate cardiac risk.

🟡 The nurse should educate the client about bowel movement frequency and monitor electrolytes.

🟡 Avoid potassium-rich foods while receiving this therapy.

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Answer 5

Correct Answers:

Tetany

Rationale :

🔷 A calcium level of 8 mg/dL is below the normal range, indicating hypocalcemia.

🔷 Tetany, or involuntary muscle contractions, is a classic manifestation due to increased neuromuscular excitability.

🔷 Other signs may include positive Chvostek's or Trousseau's signs, paresthesias, and muscle spasms.

🔷 The nurse should closely monitor for airway involvement or seizures in severe cases.

🔷 Hypocalcemia can result from parathyroid removal or vitamin D deficiency.

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Answer 6

Correct Answers:

Magnesium level 1.0 mEq/L (1.3-2.1 mEq/L)

Rationale :

♦️ A magnesium level of 1.0 mEq/L is critically low and may lead to life-threatening arrhythmias.

♦️ Magnesium plays a vital role in cardiac stability, neuromuscular function, and potassium retention.

♦️ Low magnesium often coexists with hypokalemia and requires prompt replacement.

♦️ Symptoms may include tremors, muscle cramps, seizures, or cardiac dysrhythmias.

♦️ Always monitor deep tendon reflexes and cardiac rhythm during correction.

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Answer 7

Correct Answers:

120

Rationale :

📚To calculate the IV flow rate in drops per minute (gtt/min),

Flow Rate (gtt/min)=Total Volume (mL)×Drop Factor (gtt/mL) Time (min)

Given:

✍️Infusion rate: 120 mL/hr

✍️Drop factor: 60 gtt/mL

✍️Time conversion: 1 hour = 60 minutes

Step-by-Step Calculation:

Calculate mL/min:

🖋️120 mL / 60 min=2 mL/min

Multiply by drop factor:

🖋️60min × 2mL/min

= 120 gtt/min

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Answer 8

Correct Answers:

Skin tenting

Rationale :

🔶 Skin tenting is a hallmark physical sign of dehydration, indicating reduced skin elasticity.

🔶 This occurs due to decreased interstitial fluid, a key consequence of volume loss.

🔶 It is commonly assessed over the sternum, clavicle, or abdomen in older adults.

🔶 Tenting must be evaluated in conjunction with other symptoms like low urine output or dry mucosa.

🔶 Document and report findings that suggest hypovolemia to prevent complications.

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Answer 9

Correct Answers:

100

Rationale :

✍️To determine the IV flow rate in drops per minute (gtt/min) for the dextrose 5% in water (D5W) infusion,

Formula:

🖍️Flow Rate (gtt/min)=Volume (mL)×Drop Factor (gtt/mL) / Time (min)

Given:

🖋️Infusion volume: 100 mL

🖋️Infusion time: 60 minutes

🖋️Drop factor: 60 gtt/mL

🖍️ (100 mL/hr×60 gtt/mL) / 60 min/hr

👉=100 gtt/min

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Answer 10

Correct Answers:

Check for kinking of the tubing or a closed clamp.

Rationale :

🟥 When an occlusion alarm sounds, the first step is to inspect for mechanical obstruction.

🟥 Kinks, closed clamps, or a positional issue are the most common causes.

🟥 Do not flush or push fluid before verifying that the tubing is patent.

🟥 Alarms indicate an interruption in flow, which can affect medication delivery and pressure.

🟥 After correcting the issue, observe for line patency and any backflow.

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QLexNursing

1 :
A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider?

2 :
A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

3 :
A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

4 :
A nurse is caring for a client whose serum potassium level is 5.3 mEq/L (3.5-5 mEq/L). The nurse should anticipate a prescription for which of the following medications?

5 :
A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

6 :
The nurse is reviewing laboratory results for a group of patients. Which value should be of most concern to the nurse?

7 :
A nurse is preparing to administer lactated Ringer's solution IV to infuse at 120 mL/hr for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

8 :
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

9 :
A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

10 :
The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

QLexNursing

1 : A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider?

2 : A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

3 : A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

4 : A nurse is caring for a client whose serum potassium level is 5.3 mEq/L (3.5-5 mEq/L). The nurse should anticipate a prescription for which of the following medications?

5 : A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

6 : The nurse is reviewing laboratory results for a group of patients. Which value should be of most concern to the nurse?

7 : A nurse is preparing to administer lactated Ringer's solution IV to infuse at 120 mL/hr for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

8 : A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

9 : A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

10 : The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

1 :
A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider?

2 :
A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

3 :
A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

4 :
A nurse is caring for a client whose serum potassium level is 5.3 mEq/L (3.5-5 mEq/L). The nurse should anticipate a prescription for which of the following medications?

5 :
A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

6 :
The nurse is reviewing laboratory results for a group of patients. Which value should be of most concern to the nurse?

7 :
A nurse is preparing to administer lactated Ringer's solution IV to infuse at 120 mL/hr for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

8 :
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

9 :
A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

10 :
The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?