Question

A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?

Answer 1

Correct Answers:

hypomagnesemia

Rationale :

✅Chronic alcohol use, combined with vomiting and diarrhea, commonly results in hypomagnesemia due to poor dietary intake, renal losses, and GI fluid losses.

✅Magnesium is essential for neuromuscular and cardiac function, and its deficiency may lead to muscle cramps, seizures, dysrhythmias, and positive Chvostek or Trousseau signs.

✅Recognizing electrolyte disturbances is critical in alcohol withdrawal and acute illness.

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Answer 2

Correct Answers:

Increased urine specific gravity

Rationale :

✅An increased urine specific gravity indicates that the kidneys are conserving water in response to fluid volume deficit, resulting in concentrated urine.

✅This condition is commonly observed in dehydration, where intravascular volume is reduced and the body attempts to preserve fluid by reducing urine output and concentrating the urine.

✅Normal urine specific gravity ranges from 1.005 to 1.030. Values above 1.030 suggest dehydration or hypovolemia, prompting further assessment and fluid replacement.

✅This finding is consistent with other clinical signs of fluid volume deficit, such as dry mucous membranes, tachycardia, and low blood pressure.

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Answer 3

Correct Answers:

baked potato

Rationale :

🔹Furosemide, a loop diuretic, promotes the excretion of sodium, chloride, and potassium, putting clients at risk for hypokalemia, which can cause cardiac arrhythmias, muscle weakness, and fatigue.

🔹To counter this, clients should be encouraged to eat high-potassium foods.

🔹A baked potato is one of the richest natural sources of potassium, providing over 900 mg per medium-sized serving, making it an excellent dietary option for potassium replacement.

🔹Although carrots, cheese, and milk contain some potassium, they do not match the concentration found in potatoes.

🔹 Potassium-rich dietary intake is a key non-pharmacological strategy for preventing complications of loop diuretic therapy.

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Answer 4

Correct Answers:

The first 15 min

Rationale :

💥The first 15 minutes of a blood transfusion are the most critical for monitoring because life-threatening reactions, such as acute hemolytic, febrile non-hemolytic, or anaphylactic responses, are most likely to occur during this period.

💥These reactions can present with chills, fever, flank pain, hypotension, or shortness of breath.

💥Nursing best practice includes remaining at the client’s bedside for the initial 15 minutes, infusing the blood slowly, and closely observing for any adverse symptoms.

💥Early identification allows for immediate cessation of the transfusion and appropriate interventions, such as notifying the provider, initiating saline infusion, and returning the blood to the lab.

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Answer 5

Correct Answers:

Lethargy

Rationale :

🟣A serum sodium level of 116 mEq/L is considered critically low and places the client at risk for cerebral edema and neurologic compromise. 🟣Water shifts into brain cells due to the hypotonic extracellular environment, leading to increased intracranial pressure.

🟣Lethargy is a hallmark early symptom of hyponatremia, often followed by confusion, headache, nausea, and, if uncorrected, seizures or coma.

🟣 Unlike hypernatremia, which causes thirst, hyponatremia presents with central nervous system depression due to cerebral swelling.

🟣Recognizing lethargy as a red flag allows the nurse to initiate timely sodium correction and neurologic monitoring.

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Answer 6

Correct Answers:

Hypotonic solution

Rationale :

🔹Hypernatremia results in hypertonicity of the extracellular fluid, drawing water out of cells, leading to cellular dehydration, particularly in brain cells.

🔹The appropriate treatment is the gradual administration of a hypotonic solution, such as 0.45% normal saline (½ NS), to restore intracellular hydration without causing cerebral edema.

🔹The goal is to slowly reduce serum sodium levels and normalize fluid shifts. Isotonic or hypertonic solutions are contraindicated because they do not correct the osmotic imbalance or could worsen hypernatremia.

🔹TPN and sodium bicarbonate are inappropriate for addressing elevated sodium levels.

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Answer 7

Correct Answers:

They must also take a vitamin D supplement.

Rationale :

💥Calcium absorption in the small intestine is vitamin D-dependent.

💥Without adequate levels of vitamin D—obtained through sunlight, fortified foods, or supplements—calcium supplements are not fully effective.

💥This is particularly important in older adults, clients with malabsorption syndromes, or those on corticosteroids.

💥Teaching clients to take vitamin D along with calcium ensures optimal bioavailability and supports bone health, reducing the risk of osteoporosis or osteomalacia.

💥Fiber, sodium, and hydration do not enhance calcium absorption and are unrelated to this pharmacologic action.

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Answer 8

Correct Answers:

Edema

Rationale :

✅Edema is a primary sign of fluid volume excess, caused by increased hydrostatic pressure in the vasculature, pushing fluid into interstitial spaces. ✅Conditions such as renal failure, heart failure, or excessive fluid administration can lead to extracellular fluid accumulation and peripheral or generalized swelling.

✅Recognizing edema helps the nurse initiate interventions like fluid restriction, diuretic therapy, and monitoring weight and intake/output.

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Answer 9

Correct Answers:

The client's height

Rationale :

⚫To calculate Body Mass Index (BMI), the nurse needs two key pieces of information: weight (in kilograms) and height (in meters squared). BMI = weight (kg) / height (m²).

⚫This measure is used to classify clients into categories such as underweight, normal weight, overweight, and obese, helping identify nutritional risks or weight-related health issues.

⚫While waist circumference or skinfold thickness offers additional insight into body fat distribution, they are not required for BMI calculation.

⚫Caloric intake relates to dietary assessment, not BMI.

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Answer 10

Correct Answers:

Chvostek's sign

Rationale :

🔹A calcium level of 3 mg/dL is critically low (normal: 9–10.5 mg/dL) and indicates severe hypocalcemia, a common complication following subtotal thyroidectomy due to potential trauma or accidental removal of the parathyroid glands, which regulate calcium balance via parathyroid hormone (PTH).

🔹Chvostek’s sign is a classic clinical finding in hypocalcemia.

🔹It is elicited by tapping over the facial nerve just in front of the ear, which triggers facial muscle twitching (especially the cheek or lips) due to neuromuscular excitability from decreased calcium levels.

🔹This sign, along with Trousseau’s sign (carpal spasm with BP cuff inflation), signals tetany and requires urgent calcium replacement to prevent further complications such as seizures or laryngospasm.

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RN Fundamentals~Exam 4

No.

1 : A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?

2 : A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

3 : A nurse is providing dietary teaching for a client who takes furosemide (Lasix), a loop diuretic. The nurse should recommend which of the food is a great source of potassium?

4 : A nurse is caring for a client with an order for one unit of packed red blood cells (PRBCs). The nurse should anticipate to remain ate client's bedside during which time period of the infusion?

5 : A nurse is assessing a client with a sodium level of 116 mEq/L (135-145 mEq/L). Which finding should the nurse expect for this client to have?

6 : A nurse is caring for a client who has hypernatremia and requires IV fluid therapy. Which solution should the nurse prepare to infuse for this client?

7 : A nurse is providing teaching to a client who needs to start taking a calcium supplement. Which recommendation should the nurse make about taking calcium supplements?

8 : A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?

9 : A nurse is calculating a client's body mass index (BMI). Which of the following information does the nurse require?

10 : A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. This morning's labs show a calcium level of 3 mg/dL (9-10.5 mg/dL). Which assessment would the nurse anticipate to be positive?

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