Fund 6 Welcome to your Fund 6 Match each condition with the correct fluid volume imbalance (hypovolemia or hypervolemia). Clinical Scenario: A 72-year-old patient is admitted to the hospital with complaints of fatigue, dizziness, and shortness of breath. The patient's medical history includes congestive heart failure (CHF), chronic kidney disease (CKD), and hypertension. The nurse reviews the patient’s recent fluid intake and output, medication regimen, and laboratory values. Laboratory Results: Serum sodium (Na⁺): 150 mEq/L (↑) Serum potassium (K⁺): 3.2 mEq/L (↓) BUN: 34 mg/dL (↑) Creatinine: 2.1 mg/dL (↑) BNP: 650 pg/mL (↑) Hematocrit: 55% (↑) Current Medications: Furosemide (Lasix) 40 mg IV BID Lisinopril 10 mg PO daily Low-sodium diet Clinical Signs Hypovolemia Hypervolemia Tachycardia O Ο Distended neck Veins Ο Ο Confusion Ο Ο Dry Mucous membrane Ο Ο Pitting edema Ο Ο Tachycardia - Hypervolemia Tachycardia - Hypovolemia Distended neck veins - Hypervolemia Distended neck veins - Hypovolemia Confusion - Hypovolemia Confusion - Hypervolemia Dry mucous membranes - Hypovolemia Dry mucous membranes - Hypervolemia Pitting edema - Hypovolemia Pitting edema - Hypervolemia Match each electrolyte with its correct primary function (Fluid Balance, Cardiac Function, Neuromuscular Function, or Enzyme Activation). A 62-year-old patient is admitted with muscle weakness, palpitations, and confusion. The patient has a history of hypertension, chronic kidney disease (CKD), and osteoporosis. The nurse reviews the patient’s vital signs, laboratory values, and physical assessment findings to determine appropriate interventions. Vital Signs: Heart rate (HR): 110 bpm (↑) Blood pressure (BP): 88/52 mmHg (↓) Respiratory rate (RR): 24 breaths/min (↑) Oxygen saturation (SpO₂): 97% on room air Temperature: 98.4°F (36.9°C) Lab Test Patient Value Normal Range Interpretation Sodium (Na⁺) 128 mEq/L 135 - 145 mEq/L ↓ Hyponatremia Potassium (K⁺) 6.1 mEq/L 3.5 - 5.0 mEq/L ↑ Hyperkalemia Calcium (Ca²⁺) 7.6 mg/dL 8.5 - 10.5 mg/dL ↓ Hypocalcemia Magnesium (Mg²⁺) 1.1 mg/dL 1.5 - 2.5 mg/dL ↓ Hypomagnesemia Physical Assessment Findings: Neurological: Confusion, difficulty concentrating Cardiovascular: Irregular heartbeat, palpitations Neuromuscular: Muscle cramps, + Chvostek’s sign Gastrointestinal: Nausea, decreased bowel sounds Electrolyte Fluid Balance Cardiac Function Neuromuscular Function Enzyme Activation Sodium (Na⁺) Potassium (K⁺) Calcium (Ca²⁺) Magnesium (Mg²⁺) Sodium (Na⁺) - Fluid Balance Sodium (Na⁺) - Cardiac Function Sodium (Na⁺) - Balanced Neuromuscular function Sodium (Na⁺) - Enzyme Activation Potassium (K⁺) - Fluid Balance Potassium (K⁺) - Cardiac Function Potassium (K⁺) - Balanced Neuromuscular function Potassium (K⁺)- Enzyme Activation Calcium (Ca²⁺) -Fluid Balance Calcium (Ca²⁺) - Cardiac Function Calcium (Ca²⁺) - Balanced Neuromuscular function Calcium (Ca²⁺) -- Enzyme Activation Magnesium (Mg²⁺) -Fluid Balance Magnesium (Mg²⁺) - Cardiac Function Magnesium (Mg²⁺) - Balanced Neuromuscular function Magnesium (Mg²⁺) - Enzyme Activation A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? Fat Protein Glycogen Carbohydrates None A 68-year-old female with a history of metastatic bone cancer is admitted to the hospital with complaints of fatigue, muscle weakness, and frequent urination. Her vital signs are BP 145/85 mmHg, HR 60 bpm, RR 16/min, and SpO₂ 98%. Laboratory results show a serum calcium level of 12.8 mg/dL. Based on this information, which of the following physical assessment findings should the nurse expect? Select all that apply. Decreased deep tendon reflexes (DTRs) Constipation Positive Chvostek’s sign Polyuria Bone pain A 34-year-old female with a history of hypoparathyroidism presents with muscle cramps and tingling in her hands. Her vital signs are BP 105/70 mmHg, HR 95 bpm, RR 20/min, and SpO₂ 99%. Laboratory results show a serum calcium level of 7.5 mg/dL. Based on these findings, which of the following additional assessment findings should the nurse expect? Select all that apply Positive Trousseau’s sign Diarrhea Seizures Decreased deep tendon reflexes (DTRs) Prolonged QT interval on ECG Match each condition with the correct fluid volume imbalance (hypovolemia or hypervolemia). Clinical Scenario: A 72-year-old patient is admitted to the hospital with complaints of fatigue, dizziness, and shortness of breath. The patient's medical history includes congestive heart failure (CHF), chronic kidney disease (CKD), and hypertension. The nurse reviews the patient’s recent fluid intake and output, medication regimen, and laboratory values. Laboratory Results: Serum sodium (Na⁺): 150 mEq/L (↑) Serum potassium (K⁺): 3.2 mEq/L (↓) BUN: 34 mg/dL (↑) Creatinine: 2.1 mg/dL (↑) BNP: 650 pg/mL (↑) Hematocrit: 55% (↑) Current Medications: Furosemide (Lasix) 40 mg IV BID Lisinopril 10 mg PO daily Low-sodium diet Condition Hypovolemia Hypervolemia Diuretic Therapy O O Congestive Heart Failure (CHF) O O Vomiting and Diarrhea O O Chronic Kidney Diseases (CKD) O O Excessive Sodium Intake O O Diuretic therapy - Hypovolemia Diuretic therapy - Hypervolemia Congestive heart failure- Hypovolemia Congestive heart failure - Hypervolemia Vomiting and diarrhea - Hypovolemia Vomiting and diarrhea - Hypervolemia Chronic kidney disease - Hypovolemia Chronic kidney disease - Hypervolemia Excessive sodium intake - Hypovolemia Excessive sodium intake - Hypervolemia A 70-year-old female with a history of heart failure presents to the hospital with confusion, headache, and generalized weakness. Her vital signs are BP 110/70 mmHg, HR 88 bpm, RR 18/min, and SpO₂ 98%. Laboratory results show a serum sodium level of 120 mEq/L. Shortly after admission, she has a tonic-clonic seizure. Which of the following is the nurse’s priority action? Administer an anti-seizure medication as prescribed Place the client in a supine position with her legs elevated Administer hypertonic saline (3% NaCl) as prescribed Ensure the client's airway is open and clear None A 60-year-old male with uncontrolled type 2 diabetes mellitus presents with extreme fatigue, polyuria, and blurred vision. His vital signs are BP 90/60 mmHg, HR 120 bpm, RR 26/min, and SpO₂ 96%. Laboratory results reveal a blood glucose level of 650 mg/dL, serum sodium of 130 mEq/L, and serum potassium of 3.2 mEq/L. The client suddenly begins to have a seizure. Which of the following interventions should the nurse perform first? Administer IV insulin as prescribed Protect the client from injury during the seizure Administer IV potassium chloride as prescribed Recheck the client’s blood glucose level immediately None Match each condition with the correct type of fluid imbalance (Intracellular Fluid (ICF) or Extracellular Fluid (ECF) Imbalance). Clinical Scenario: A 62-year-old patient presents to the emergency department with nausea, vomiting, and confusion after experiencing severe blood loss from a gastrointestinal bleed. The patient has a history of hypertension, heart failure, and chronic kidney disease. The nurse assesses the patient’s fluid balance and reviews vital signs, lab values, and physical findings. Vital Signs: Heart rate (HR): 115 bpm (↑) Blood pressure (BP): 82/50 mmHg (↓) Respiratory rate (RR): 20 breaths/min Temperature: 98.4°F (36.9°C) Oxygen saturation (SpO₂): 97% on room air Laboratory Results: Serum sodium (Na⁺): 155 mEq/L (↑) Serum potassium (K⁺): 3.1 mEq/L (↓) Hematocrit: 60% (↑) Blood urea nitrogen (BUN): 35 mg/dL (↑) Serum osmolality: 310 mOsm/kg (↑) Physical Assessment Findings: Skin turgor: Poor Mucous membranes: Dry Capillary refill: Delayed Lower extremities: 3+ pitting edema Condition ICF Imbalance ECF Imbalance Dehydration due to vomiting O O Cellular dehydration O O Hypovolemia due to hemorrhage O O Hypovolemia due to hemorrhage O O Dehydration due to vomiting - ICF Imbalance Dehydration due to vomiting - ECF Imbalance Cellular dehydration - ICF Imbalance Cellular dehydration - ECF Imbalance Hypovolemia due to hemorrhage - ICF Imbalance Hypovolemia due to hemorrhage - ECF Imbalance Edema in legs - ICF Imbalance Edema in legs - ECF Imbalance A 45-year-old male who sustained extensive burns 24 hours ago is now experiencing decreased urine output, restlessness, and muscle twitching. His vital signs are BP 90/60 mmHg, HR 110 bpm, RR 24/min, and SpO₂ 95%. Laboratory results reveal a serum sodium of 125 mEq/L, potassium of 5.8 mEq/L, and serum calcium of 7.5 mg/dL. The client suddenly begins to have a seizure. What is the nurse’s priority intervention? Administer IV calcium gluconate as prescribed Administer hypertonic saline as prescribed Protect the client from injury during the seizure Administer a diuretic to reduce potassium levels None A 10-year-old female with type 1 diabetes mellitus is brought to the emergency department after being found unresponsive. Her vital signs are BP 100/60 mmHg, HR 120 bpm, RR 20/min, and SpO₂ 99%. The blood glucose level is 38 mg/dL. During the nurse’s assessment, the client begins to have a seizure. What is the nurse’s priority action? Administer an IV bolus of 50% dextrose as prescribed Place the client in the Trendelenburg position Administer IM glucagon as prescribed Ensure the client’s airway is patent and side-lying position is maintained None A 72-year-old male with hyperparathyroidism presents to the emergency department with confusion, nausea, and abdominal pain. His vital signs are BP 150/90 mmHg, HR 65 bpm, RR 18/min, and SpO₂ 97%. His serum calcium level is 13.2 mg/dL. Which of the following interventions should the nurse implement? Select all that apply. Administer IV normal saline Encourage increased fluid intake Administer a calcium supplement Administer loop diuretics onitor for signs of tetany A 58-year-old female who underwent a thyroidectomy 24 hours ago reports tingling around her mouth and in her fingers. Her vital signs are BP 110/70 mmHg, HR 88 bpm, RR 18/min, and SpO₂ 98%. The nurse suspects hypocalcemia. Which of the following findings would confirm this diagnosis? Select all that apply. Positive Chvostek’s sign Muscle twitching and cramps Hyperactive deep tendon reflexes Shortened QT interval on ECG Laryngospasm A 70-year-old male presents to the emergency department with complaints of extreme thirst, dry mouth, and confusion. His vital signs are BP 150/90 mmHg, HR 100 bpm, RR 22/min, and SpO₂ 95%. Laboratory results reveal a serum sodium level of 155 mEq/L. Based on this information, which of the following physical assessment findings should the nurse expect? Select all that apply. Dry mucous membrane Muscle twitching Hypertension Decreased deep tendon reflexes Edema A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration than younger adults. The recommended intake of daily fiber decreases in older adults. Many older adults need calcium supplementation. Older adults need more calories than they did when they were younger. Older adults should consume a diet low in carbohydrates. Match each physiological function with the correct classification (Transportation or Metabolism). Clinical Scenario: A 45-year-old patient is admitted to the hospital with complaints of fatigue, nausea, and dizziness. The patient has a history of type 2 diabetes, chronic kidney disease (CKD), and hypertension. The nurse reviews the patient’s hydration status, metabolic function, and laboratory values. Vital Signs: Heart rate (HR): 102 bpm (↑) Blood pressure (BP): 88/56 mmHg (↓) Respiratory rate (RR): 22 breaths/min Temperature: 97.9°F (36.6°C) Oxygen saturation (SpO₂): 96% on room air Laboratory Results: Serum sodium (Na⁺): 132 mEq/L (↓) Serum potassium (K⁺): 5.3 mEq/L (↑) Blood urea nitrogen (BUN): 48 mg/dL (↑) Creatinine: 3.2 mg/dL (↑) Blood glucose: 280 mg/dL (↑) Serum osmolality: 295 mOsm/kg (normal) Hemoglobin (Hgb): 11.0 g/dL (↓) Physical Assessment Findings: Skin turgor: Slightly decreased Extremities: Cool to touch Oral mucosa: Moist Urine output: 25 mL/hr (low) Function Transportation Metabolism Transporting nutrients to Cells Acting as a solvent for electrolytes and nonelectrolytes Facilitating digestion Transporting hormones and enzymes Facilitating cellular metabolism Transporting nutrients to cells - Transportation Transporting nutrients to cells - Metabolism Acting as a solvent for electrolytes and nonelectrolytes - Transportation Acting as a solvent for electrolytes and nonelectrolytes - Metabolism Facilitating digestion - Transportation Facilitating digestion - Metabolism Transporting hormones and enzymes - Transportation Transporting hormones and enzymes - Metabolism Facilitating cellular metabolism - Transportation Facilitating cellular metabolism - Metabolism A 55-year-old female who has been taking a diuretic for heart failure presents with confusion, nausea, and muscle cramps. Her vital signs are BP 110/70 mmHg, HR 88 bpm, RR 18/min, and SpO₂ 96%. Her serum sodium level is 125 mEq/L. Based on these findings, which of the following additional physical assessment findings should the nurse expect? Select all that apply. Headache Seizures Hyperactive bowel sounds Tachycardia Positive Trousseau’s sign A 65-year-old male with a history of diabetes insipidus presents to the emergency department with lethargy and weakness. His vital signs are BP 135/85 mmHg, HR 98 bpm, RR 20/min, and SpO₂ 97%. His serum sodium level is 158 mEq/L. Which of the following interventions should the nurse implement? Select all that apply. Administer hypotonic IV fluids Restrict sodium intake Monitor for signs of fluid overload Administer a loop diuretic Encourage increased oral fluid intake A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client’s BMI indicates a healthy weight, underweight, overweight, or obese. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? Giving the client thin liquids Instructing the client to tuck their chin when swallowing Having the client use a straw Encouraging the client to lie down and rest after meals None A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client’s meal tray? Cooked barley Pureed broccoli Vanilla custard Lentil soup None The nurse is preparing to insert an NG tube on a client for stomach decompression. When determining the length of the tube to be inserted, what anatomical locations should the nurse use for measurement? (Select all that apply.) Tip of nose Abdomen Clavicle Earlobe Xiphoid process A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? “Water helps clear the tube so it doesn’t get clogged.” “Flushing helps make sure the tube stays in place.” “This will help you get enough fluids.” “Adding water makes the formula less concentrated.” None Match each organ with its correct function (Conserves Sodium or Regulates Calcium). Clinical Scenario: A 56-year-old patient is admitted for generalized weakness, confusion, and muscle cramps. The patient has a history of chronic kidney disease (CKD), osteoporosis, and hypertension. The nurse reviews the patient's laboratory values and physical assessment findings to determine the cause of the electrolyte imbalance. Vital Signs: Heart rate (HR): 98 bpm (normal) Blood pressure (BP): 146/88 mmHg (↑) Respiratory rate (RR): 20 breaths/min Temperature: 98.7°F (37.0°C) Oxygen saturation (SpO₂): 97% on room air Laboratory Results: Serum sodium (Na⁺): 130 mEq/L (↓) Serum calcium (Ca²⁺): 7.8 mg/dL (↓) Parathyroid hormone (PTH): Low Serum creatinine: 2.5 mg/dL (↑) Blood urea nitrogen (BUN): 40 mg/dL (↑) Serum osmolality: 270 mOsm/kg (↓) Serum aldosterone: High Physical Assessment Findings: Neuromuscular: Muscle cramps, tingling around the mouth, positive Chvostek’s sign Urine output: 35 mL/hr (low-normal) Extremities: No edema Organ Conserve Sodium Regulates Calcium Adrenal Glands Parathyroid Glands Pituitary Gland Kidneys Adrenal Glands - Conserves Sodium Adrenal Glands - Regulates Calcium Parathyroid Glands - Conserves Sodium Parathyroid Glands - Regulates Calcium Pituitary Gland - Conserves Sodium Pituitary Gland - Regulates Calcium Kidneys - Conserves Sodium Kidneys - Regulates Calcium Match each age group with the correct nutritional need (High-Protein Needs, Increased Calcium Needs, or Decreased Caloric Needs). Clinical Scenario: The nurse is reviewing the nutritional needs of different age groups to provide education to patients and their families. The nurse is assessing three different patients in a clinical setting: 1️⃣ A 2-week-old newborn brought in for a well-baby checkup. The mother is concerned about the baby’s feeding habits.2️⃣ A 15-year-old adolescent being evaluated for sports participation who has recently become a vegetarian.3️⃣ A 78-year-old older adult with osteoporosis and unintentional weight loss over the last 6 months. The nurse assesses each patient's dietary intake, growth patterns, and laboratory values to provide appropriate nutritional recommendations. Laboratory Results: Lab Test Newborn Adolescent Older Adult Serum Albumin 3.8 g/dL (Normal) 4.1 g/dL (Normal) 3.2 g/dL (↓) Serum Calcium 9.8 mg/dL (Normal) 9.1 mg/dL (Normal) 8.2 mg/dL (↓) Total Protein 6.0 g/dL (Normal) 6.8 g/dL (Normal) 5.5 g/dL (↓) Vitamin D 35 ng/mL (Normal) 30 ng/mL (Normal) 18 ng/mL (↓) Physical Assessment Findings: Newborn: Normal weight gain, breastfeeding well, no abnormalities. Adolescent: Increased physical activity, mild fatigue, and new vegetarian diet. Older Adult: Osteopenia, mild muscle wasting, and reports of poor appetite. Lab Test New born Adolescent Older adult Serum Albumin 3.8 g/dL (Normal) 4.1 g/dL (Normal) 3.2 g/dL (↓) Serum Calcium 9.8 mg/dL (Normal) 9.1 mg/dL (Normal) 8.2 mg/dL (↓) Total Protein 6.0 g/dL (Normal) 6.8 g/dL (Normal) 5.5 g/dL (↓) Vitamin D 35 ng/mL (Normal) 30 ng/mL (Normal) 18 ng/mL (↓) Age group High Protein Needs Increase Calcium Needs Decreased Caloric Needs Newborn and Infants Adolescents Older Adults Newborns and Infants - High-Protein Needs Newborns and Infants - Increased Calcium Needs Newborns and Infants - Decreased Caloric Needs Adolescents - High-Protein Needs Adolescents - Increased Calcium Needs Adolescents - Decreased Caloric Needs Older Adults - High-Protein Needs Older Adults - Increased Calcium Needs Older Adults - Decreased Caloric Needs A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse’s highest assessment priority before performing this procedure? Check how long the feeding container has been open. Verify the placement of the NG tube. Confirm that the client does not have diarrhea. Make sure the client is alert and oriented. None A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) Auscultate bowel sounds. Assist the client to an upright position. Test the pH of gastric aspirate. Warm the formula to body temperature. Discard any residual gastric contents. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) Review a signal the client can use if feeling any distress. Lay a towel across the client’s chest. Administer oral pain medication. Obtain a Dobhoff tube for insertion. Have a petroleum-based lubricant available. The nurse is performing an assessment on the client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) Hypothermia Bradycardia Orthostatic hypotension Distended neck veins Decreased skin turgor The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia? (Select all that apply.) Increased Hct Increased blood pressure Decreased urine specific gravity Decreased urine output Increased sodium level The nurse is planning care for the client who is admitted to an acute care facility with dehydration. What actions should the nurse include in the plan? (Select all that apply.) Measure daily weight Monitor I&O Administer diuretics Restrict fluid intake Assess level of consciousness A nurse is caring for a client who has hypervolemia. Which of the following findings should the nurse expect? (Select all that apply.) Distended neck veins Bradycardia Edema Tachycardia Hypotension A nurse is teaching a class about fluid imbalances. Which of the following manifestations should the nurse identify as associated with hypervolemia? (Select all that apply.) Tachycardia Confusion Hypertension Weight loss Crackles in the lungs A nurse is assessing a client who is suspected of having hypovolemia. Which of the following findings should the nurse expect? (Select all that apply.) Hypothermia Tachycardia Distended neck veins Oliguria Pitting edema A nurse is assessing a client with hypokalemia. Which of the following findings should the nurse expect? (Select all that apply.) Muscle weakness Hyperactive reflexes Constipation Irregular pulse Tetany A nurse is assessing a client who is at risk for fluid volume deficit. Which of the following clients are at highest risk for developing fluid volume deficits? (Select all that apply.) An infant with diarrhea A middle-aged woman undergoing chemotherapy A young male athlete who drinks 3 liters of water daily An older adult with dementia who forgets to drink water A pregnant woman who drinks an adequate amount of fluids daily A nurse is educating a client about the function of the lungs in maintaining homeostasis. Which of the following functions of the lungs should the nurse include? (Select all that apply.) Assist in acid-base balance by regulating carbon dioxide levels Conserve potassium and excrete sodium Filter plasma and excrete urine Regulate oxygen levels in the blood Conserve chloride and water Match each nutrient with the correct primary function (Energy or Tissue Repair & Maintenance). A 33-year-old patient is admitted with malnutrition and unintentional weight loss over the past three months. The patient has a history of Crohn’s disease and chronic pancreatitis, leading to malabsorption issues. The nurse assesses the patient’s dietary intake, nutritional status, and laboratory values to determine appropriate interventions. Lab Test Value Range Range Interpretation Serum Albumin 2.8 g/dL 3.5 - 5.0 g/dL ↓ (Malnutrition) Total Protein 5.4 g/dL 6.4 - 8.3 g/dL ↓ (Protein Deficiency) Serum Glucose 65 mg/dL 70 - 110 mg/dL ↓ (Low Energy Reserves) Serum Lipase 98 U/L 10 - 140 U/L Normal Vitamin B12 200 pg/mL 200 - 900 pg/mL ↓ (Deficiency, Likely Malabsorption) Iron 40 mcg/dL 50 - 150 mcg/dL ↓ (Possible Anemia) Physical Assessment Findings: Body Mass Index (BMI): 17.2 kg/m² (Underweight) Muscle Wasting: Present in upper extremities Skin Integrity: Delayed wound healing, dry skin Energy Level: Fatigue and weakness Gastrointestinal Symptoms: Mild diarrhea and bloating Nutrition Energy Tissue Repair & Maintenance Carbohydrates Fats Proteins Vitamins Carbohydrates - Energy Carbohydrates - Tissue Repair and Maintenance Fats - Energy Fats - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Vitamins - Energy Vitamins - Tissue Repair and Maintenance A nurse in a senior center is counseling a group of older adults about their nutritional needs. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration than younger adults. The recommended intake of daily fiber decreases in older adults. Many older adults need calcium supplementation. Older adults need more calories than they did when they were younger. Older adults should consume a diet low in carbohydrates. A nurse is assessing a client who is at high risk for aspiration. Which of the following actions should the nurse take? (Select 2.) Giving the client thin liquids Instructing the client to tuck their chin when swallowing Having the client use a straw Encouraging the client to lie down and rest after meals Carbohydrates provide ____ of energy per gram. Fats provide ____ of energy per gram. Proteins contribute ____ of energy per gram. Proteins help in the growth, maintenance, and repair of body tissues. Sources include ____. A nurse in a senior center is counseling a group of older adults about their nutritional needs. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration than younger adults. The recommended intake of daily fiber decreases in older adults. Many older adults need calcium supplementation. Older adults need more calories than they did when they were younger. Older adults should consume a diet low in carbohydrates. A nurse is assessing a client who is at high risk for aspiration. Which of the following actions should the nurse take? (Select 2.) Giving the client thin liquids Instructing the client to tuck their chin when swallowing Having the client use a straw Encouraging the client to lie down and rest after meals A nurse is caring for a 75-year-old client who has been diagnosed with metabolic acidosis. The nurse performs a physical assessment. Which of the following findings would the nurse expect?Select all that apply. Kussmaul respirations Bradycardia Hyperkalemia Hypotension Warm, flushed skin A 28-year-old female presents to the emergency department with severe anxiety and hyperventilation. The nurse suspects respiratory alkalosis. Which of the following findings should the nurse expect during the physical assessment? Select all that apply. Tachypnea Hypotension Lightheadedness Tetany Warm, flushed skin A 60-year-old male who has been vomiting for the past 3 days is diagnosed with metabolic alkalosis. Which of the following compensatory mechanisms should the nurse expect during the physical assessment? Select all that apply. Bradypnea Tachycardia Hypoventilation Hypertension Confusion An 82-year-old client with chronic obstructive pulmonary disease (COPD) is admitted with respiratory acidosis. Which of the following physical assessment findings should the nurse expect? Select all that apply. Confusion Tachypnea Bradypnea Hypoxia Pale or cyanotic skin A 65-year-old male with chronic kidney disease (CKD) presents to the emergency department complaining of weakness and palpitations. His vital signs include BP 140/85 mmHg, HR 55 bpm, RR 20/min, and SpO₂ 95%. His laboratory results reveal a serum potassium level of 6.2 mEq/L. Based on this information, which of the following physical assessment findings should the nurse expect? Bradycardia Hyperactive reflexes Muscle weakness Abdominal cramping Tall, peaked T waves on ECG A 45-year-old female who has been taking diuretics for hypertension presents with fatigue, muscle cramps, and irregular heartbeat. Her vital signs include BP 120/80 mmHg, HR 110 bpm, RR 18/min, and SpO₂ 98%. Her potassium level is 2.8 mEq/L. Based on these findings, which of the following additional assessment findings should the nurse expect?Select all that apply. Flat or inverted T waves on ECG Hyperactive bowel sounds Weak, irregular pulse Decreased deep tendon reflexes (DTRs) Increased blood pressure A 70-year-old male with a history of heart failure and diabetes presents with lethargy and muscle weakness. His vital signs are BP 132/76 mmHg, HR 48 bpm, RR 20/min, and SpO₂ 96%. His potassium level is 6.8 mEq/L. Which of the following interventions should the nurse implement immediately? Select all that apply. Administer IV calcium gluconate Administer IV insulin and dextrose Monitor the client’s ECG for changes Administer oral potassium supplements Encourage potassium-rich foods such as bananas and oranges A 50-year-old woman who has been receiving total parenteral nutrition (TPN) for several weeks due to bowel surgery is at risk for hypokalemia. Her current vital signs are BP 110/70 mmHg, HR 102 bpm, RR 16/min, and SpO₂ 97%. Her laboratory findings show a serum potassium level of 3.0 mEq/L. What additional findings should the nurse assess for? Select all that apply. Shallow respirations Constipation Hyperglycemia Polyuria Hyperactive deep tendon reflexes A 60-year-old female recovering from surgery is receiving an IV infusion of D5W. She is now reporting confusion, fatigue, and muscle weakness. Her vital signs are BP 110/65 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 97%. Her serum sodium level is 122 mEq/L. Based on these findings, which of the following nursing interventions is appropriate? Select all that apply. Discontinue the D5W infusion Administer hypertonic saline solution Implement seizure precautions Encourage oral intake of fluids Monitor neurologic status closely A 60-year-old female recovering from surgery is receiving an IV infusion of D5W. She is now reporting confusion, fatigue, and muscle weakness. Her vital signs are BP 110/65 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 97%. Her serum sodium level is 122 mEq/L. Based on these findings, which of the following nursing interventions is appropriate? Select all that apply. Discontinue the D5W infusion Administer hypertonic saline solution Implement seizure precautions Encourage oral intake of fluids Monitor neurologic status closely A 70-year-old male with a history of chronic kidney disease is admitted to the hospital with muscle weakness and drowsiness. His vital signs are BP 95/60 mmHg, HR 50 bpm, RR 10/min, and SpO₂ 94%. Laboratory results show a serum magnesium level of 3.5 mEq/L. Based on these findings, which of the following physical assessment findings should the nurse expect? Select all that apply. Decreased deep tendon reflexes (DTRs) Hypotension Respiratory depression Hyperactive bowel sounds Bradycardia A 52-year-old female with a history of alcoholism presents with muscle tremors and confusion. Her vital signs are BP 120/75 mmHg, HR 105 bpm, RR 18/min, and SpO₂ 97%. Laboratory results show a serum magnesium level of 1.0 mEq/L. Based on these findings, which of the following additional physical assessment findings should the nurse expect? Select all that apply. Positive Chvostek’s sign Muscle cramps Tetany Prolonged PR interval on ECG Hyperactive deep tendon reflexes A 68-year-old male with chronic kidney disease is admitted with symptoms of lethargy and decreased urine output. His vital signs are BP 90/55 mmHg, HR 55 bpm, RR 12/min, and SpO₂ 95%. His serum magnesium level is 3.8 mEq/L. Which of the following nursing interventions should be implemented? Select all that apply. Administer calcium gluconate Discontinue magnesium-containing medications Administer magnesium supplements Prepare the client for dialysis Encourage foods high in magnesium A 60-year-old female who had a bowel resection two days ago presents with tremors, nausea, and irritability. Her vital signs are BP 118/72 mmHg, HR 110 bpm, RR 18/min, and SpO₂ 96%. Her serum magnesium level is 1.1 mEq/L. Based on these findings, which of the following nursing interventions are appropriate? Select all that apply. Administer oral magnesium supplements Administer IV magnesium sulfate Implement seizure precautions Monitor for signs of hypermagnesemia Encourage fluid intake to flush out excess magnesium A 60-year-old female who had a bowel resection two days ago presents with tremors, nausea, and irritability. Her vital signs are BP 118/72 mmHg, HR 110 bpm, RR 18/min, and SpO₂ 96%. Her serum magnesium level is 1.1 mEq/L. Based on these findings, which of the following nursing interventions are appropriate? Select all that apply. Administer oral magnesium supplements Administer IV magnesium sulfate Implement seizure precautions Monitor for signs of hypermagnesemia Encourage fluid intake to flush out excess magnesium A 72-year-old male with a history of gastrointestinal bleeding presents with lightheadedness, dry mouth, and decreased urine output. His vital signs are BP 90/60 mmHg, HR 120 bpm, RR 22/min, and SpO₂ 96%. Laboratory results reveal a hematocrit of 56% and blood urea nitrogen (BUN) of 30 mg/dL. Based on this information, which of the following additional physical assessment findings should the nurse expect? Select all that apply. Decreased skin turgor Weak, thready pulse Dry mucous membranes Jugular vein distention Flat neck veins A 65-year-old female with a history of heart failure presents with swelling in her legs and difficulty breathing. Her vital signs are BP 150/95 mmHg, HR 90 bpm, RR 24/min, and SpO₂ 91%. Laboratory results show a serum sodium level of 130 mEq/L and a decreased hematocrit. Based on these findings, which of the following additional physical assessment findings should the nurse expect? Select all that apply. Crackles in lung fields Distended neck veins Tachycardia Weight loss Pitting edema A 58-year-old female with vomiting and diarrhea for three days presents with weakness and dizziness. Her vital signs are BP 85/55 mmHg, HR 112 bpm, RR 20/min, and SpO₂ 97%. Laboratory findings include elevated BUN and serum creatinine. Which of the following interventions should the nurse implement? Select all that apply. Administer isotonic IV fluids (e.g., 0.9% sodium chloride) Encourage oral fluid intake if tolerated Monitor intake and output (I&O) Administer diuretics Place the client in a high Fowler’s position A 70-year-old male with chronic kidney disease presents with shortness of breath, swelling in his legs, and fatigue. His vital signs are BP 160/100 mmHg, HR 95 bpm, RR 24/min, and SpO₂ 89%. His serum creatinine is elevated, and his potassium level is 5.2 mEq/L. Which of the following nursing interventions is appropriate? Select all that apply. Restrict oral fluid intake Administer IV furosemide (Lasix) Monitor serum potassium levels Encourage high-sodium foods Place the client in semi-Fowler’s position A 78-year-old female with heart failure presents with swelling in her legs and shortness of breath. Her vital signs are BP 145/95 mmHg, HR 95 bpm, RR 24/min, and SpO₂ 89%. Laboratory results include BUN of 10 mg/dL, serum sodium of 125 mEq/L, and hematocrit of 35%. Which of the following physical assessment findings should the nurse expect? Select all that apply. Edema Dry skin Hyponatremia Dehydration Crackles in lung fields A 58-year-old male with chronic kidney disease presents with muscle weakness and lethargy. His vital signs are BP 138/85 mmHg, HR 55 bpm, RR 16/min, and SpO₂ 96%. Laboratory results include serum potassium of 6.5 mEq/L and arterial blood gas (ABG) results of pH 7.32, PaCO₂ 40 mmHg, and HCO₃ 18 mEq/L. Based on these findings, which of the following should the nurse expect? Select all that apply. Hyperkalemia Metabolic acidosis Respiratory alkalosis Peaked T waves on ECG Hyperactive deep tendon reflexes A 40-year-old female post-thyroidectomy patient presents with numbness and tingling around her mouth and hands. Her vital signs are BP 110/70 mmHg, HR 88 bpm, RR 18/min, and SpO₂ 97%. Laboratory results include a serum calcium level of 7.0 mg/dL and serum phosphorus of 5.0 mg/dL. Based on these findings, which of the following additional assessment findings should the nurse expect? Select all that apply Positive Chvostek’s sign Muscle cramps Decreased deep tendon reflexes Trousseau’s sign Constipation A 75-year-old female presents to the hospital with confusion and lethargy after excessive water intake over the past few days. Her vital signs are BP 110/70 mmHg, HR 85 bpm, RR 18/min, and SpO₂ 98%. Laboratory results show a serum sodium of 120 mEq/L and serum osmolarity of 260 mOsm/kg. Which of the following additional physical assessment findings should the nurse expect? Select all that apply. Seizures Edema Hyperactive bowel sounds Increased deep tendon reflexes Muscle cramps history of prolonged diuretic use for hypertension. His vital signs are BP 95/60 mmHg, HR 120 bpm, RR 20/min, and SpO₂ 97%. Laboratory results include a serum potassium of 2.8 mEq/L, BUN of 28 mg/dL, and serum sodium of 137 mEq/L. Based on these findings, which of the following additional assessment findings should the nurse expect? Select all that apply. Flattened T waves on ECG Constipation Hypotension Hyperactive bowel sounds Increase reflexes A 65-year-old male with chronic renal failure is admitted with lethargy and decreased respiratory effort. His vital signs are BP 90/55 mmHg, HR 50 bpm, RR 10/min, and SpO₂ 92%. Laboratory results reveal a serum magnesium level of 4.0 mEq/L and ABG showing pH 7.28, PaCO₂ 50 mmHg, and HCO₃ 26 mEq/L. Which of the following nursing interventions should the nurse expect to implement? Select all that apply. Administer calcium gluconate Discontinue magnesium-containing medications Prepare the client for dialysis Administer sodium bicarbonate IV Administer magnesium supplements A 55-year-old female post-thyroidectomy presents with tingling around her mouth and hands, muscle twitching, and irritability. Her vital signs are BP 105/65 mmHg, HR 95 bpm, RR 20/min, and SpO₂ 96%. Laboratory results show a serum calcium level of 7.0 mg/dL and serum phosphorus of 5.5 mg/dL. Which of the following assessment findings should the nurse expect? Select all that apply. Positive Trousseau’s sign Seizures Prolonged QT interval on ECG Constipation Hyperactive deep tendon reflexes A 75-year-old male presents to the emergency department with a history of nausea, vomiting, and diarrhea for the past three days. His vital signs are BP 90/60 mmHg, HR 120 bpm, RR 22/min, and SpO₂ 95%. Physical assessment reveals dry mucous membranes, poor skin turgor, and decreased urine output. Laboratory results show elevated blood urea nitrogen (BUN) of 35 mg/dL and a serum sodium level of 148 mEq/L. The provider prescribes IV fluids.Which of the following fluids would the nurse anticipate administering? 0.45% sodium chloride (half-normal saline) 3% sodium chloride (hypertonic saline) Dextrose 5% in water (D5W) 0.9% sodium chloride (normal saline) None A 60-year-old female receiving IV antibiotics through a peripheral IV catheter complains of pain and swelling at the IV site. Her vital signs are BP 120/80 mmHg, HR 85 bpm, RR 18/min, and SpO₂ 98%. Upon assessment, the nurse notes that the IV site is cool, pale, swollen, and tender to touch. Which of the following actions should the nurse take? Select all that apply. Stop the infusion Apply a cold compress to the IV site Elevate the affected limb Flush the IV line with normal saline Remove the IV catheter A 40-year-old male with hypokalemia (serum potassium 2.8 mEq/L) is receiving IV potassium chloride (KCl) as part of his treatment. His vital signs are BP 120/75 mmHg, HR 88 bpm, RR 18/min, and SpO₂ 99%. The nurse is preparing to administer potassium chloride through an IV infusion. Which of the following precautions should the nurse take when administering IV potassium? Select all that apply. Dilute the potassium chloride in IV fluids before administration Administer the potassium IV push over 5 minutes Monitor the client’s cardiac rhythm during the infusion Ensure the infusion rate does not exceed 10 mEq/hr Assess the client for burning at the IV site A 78-year-old female with a history of heart failure is receiving IV normal saline at 150 mL/hr for dehydration. Her current vital signs are BP 160/90 mmHg, HR 110 bpm, RR 24/min, and SpO₂ 92%. Upon physical assessment, the nurse notes crackles in the lung bases, jugular vein distention, and peripheral edema. Which of the following should the nurse anticipate? Administer a diuretic as prescribed Decrease the infusion rate to 100 mL/hr Elevate the head of the bed Discontinue the IV fluids immediately Monitor intake and output carefully A 65-year-old male receiving TPN for severe malnutrition has been on the therapy for 5 days. His vital signs are BP 130/85 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 98%. Laboratory results show a blood glucose level of 250 mg/dL, serum sodium of 140 mEq/L, and potassium of 4.0 mEq/L. During assessment, the nurse notes that the client has increased thirst, dry mucous membranes, and frequent urination. What complication is the client most likely experiencing? Hyperglycemia Fluid overload Hypokalemia Hyperkalemia None A 58-year-old female who recently had bowel surgery is receiving TPN through a central venous catheter. Her vital signs are BP 120/75 mmHg, HR 85 bpm, RR 18/min, and SpO₂ 97%. The nurse performs a central line dressing change and prepares to hang a new bag of TPN. Which of the following actions should the nurse take to prevent infection? Select all that apply. Use sterile technique during the dressing change Change the TPN tubing every 24 hours Wear clean gloves when handling the TPN bag Ensure the TPN solution is at room temperature before administration Monitor the client for signs of infection, such as fever or redness at the insertion site A 45-year-old male with Crohn’s disease is receiving lipid emulsion therapy in addition to TPN. His vital signs are BP 125/80 mmHg, HR 88 bpm, RR 20/min, and SpO₂ 99%. The nurse notes that the infusion is running at the correct rate, but the client complains of a slight headache and discomfort at the IV site. Which of the following should the nurse do next? Slow the infusion rate Stop the infusion and notify the provider Assess for allergic reaction signs, such as rash or dyspnea Check the IV site for signs of infiltration or phlebitis None A 45-year-old male with Crohn’s disease is receiving lipid emulsion therapy in addition to TPN. His vital signs are BP 125/80 mmHg, HR 88 bpm, RR 20/min, and SpO₂ 99%. The nurse notes that the infusion is running at the correct rate, but the client complains of a slight headache and discomfort at the IV site. Which of the following should the nurse do next? Slow the infusion rate Stop the infusion and notify the provider Assess for allergic reaction signs, such as rash or dyspnea Check the IV site for signs of infiltration or phlebitis None A 70-year-old female receiving TPN for nutritional support following bowel obstruction surgery has been on TPN for 7 days. Her vital signs are BP 118/76 mmHg, HR 82 bpm, RR 18/min, and SpO₂ 96%. Laboratory results reveal a serum magnesium of 1.0 mEq/L, potassium of 3.0 mEq/L, and serum calcium of 8.5 mg/dL. Which of the following interventions should the nurse anticipate based on these lab results? Select all that apply. Administer a potassium su Administer a magnesium supplement Reduce the rate of TPN infusion Monitor the client for signs of muscle weakness or cramps Encourage oral calcium supplements Time's up Post navigation Previous Previous post: Fund 5Next Next post: Fund 7
