SNLE Question Discussion -Training4Nurse Academy

1.  Question

   The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
   
   
   

   • 1. Weight loss
   • 2. Flat neck and hand veins
   • 3. An increase in blood pressure
   • 4. Decreased central venous pressure (CVP)
   
   
   Option 3 (An increase in blood pressure )is correct answer.
   
   Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.
   
   

2. Question

   The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because of which situation?
   
   

   • 1. Sustained tissue damage
   • 2. Requires nasogastric suction
   • 3. Has a history of Addison’s disease
   • 4. Is taking a potassium-retaining diuretic
    

   Option 2 ( Requires nasogastric suction )  is correct.
   Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassiumrich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.
   
   

3.  Question

   The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value?
   
   
   

   • 1. U waves
   • 2. Absent P waves
   • 3. Elevated T waves
   • 4. Elevated ST segment
    

   Option 1 ( U waves )  is correct.
   Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms.
   
   Test-Taking Strategy: Focus on the subject, the ECG pattern noted with a client with a potassium level of 2.5 mEq/L. From the information in the question, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the electrocardiographic changes that are expected when severe hypokalemia exists. Remember that a prominent U wave is indicative of hypokalemia.
   
   

4. Question

   The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan for preparation and administration of the potassium?
   
   

   • 1. Obtaining an intravenous (IV) infusion pump
   • 2. Monitoring urine output during administration
   • 3. Preparing the medication for bolus administration
   • 4. Ensuring that the medication is diluted in the appropriate amount of normal saline
    

   Option 3 ( Preparing the medication for bolus administration )is correct answer.
   Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.
   
   Test-Taking Strategy: Focus on the subject, the administration of potassium chloride intravenously. Note the word unprepared. This word indicates the need to select the incorrect action. Noting the word bolus in the correct option will direct you to selecting this option.
   
   

5. Question

   The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
   

   • 1. Twitching
   • 2. Hypoactive bowel sounds
   • 3. Negative Trousseau’s sign
   • 4. Hypoactive deep tendon reflexes
    

   Option 1 ( Twitching ) is correct answer
   
   Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
   Test-Taking Strategy: Note that the three incorrect options are comparable or alike in that they reflect a hypoactivity. The option that is different is the correct option.
   

6. Question

   The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?
   

   • 1. Widened T wave
   • 2. Prominent U wave
   • 3. Prolonged QT interval
   • 4. Shortened ST segment
   
   Option 3 (Prolonged QT interval ) is correct answer.
   
   Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.
   Test-Taking Strategy: Focus on the subject, the electrocardiographic changes that occur in a calcium imbalance. Remember that hypocalcemia causes a prolonged ST or QT interval.
   

7. Question

   The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

   • 1. ST depression
   • 2. Inverted T wave
   • 3. Prominent U wave
   • 4. Tall peaked T waves
   
   Option 4 ( Tall peaked T waves )is correct answer.
   
   Rationale: A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.
   Test-Taking Strategy: Focus on the subject, the electrocardiographic changes that occur in a potassium imbalance. From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. Remember that tall peaked T waves are associated with hyperkalemia.
   

8.   Question

   The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
   

   • 1. The client who is taking diuretics
   • 2. The client with hyperaldosteronism
   • 3. The client with Cushing’s syndrome
   • 4. The client who is taking corticosteroids
   
   Option 1 ( The client who is taking diuretics ) is correct answer,
   
   Rationale: Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia.
   
   Test-Taking Strategy: Focus on the subject, the causes of a sodium level of 130 mEq/L. First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to the correct option. Also recall that when a client takes a diuretic, the client loses fluid and electrolytes.
   

9. Question

   The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
   

   • 1. Muscle twitches
   • 2. Decreased urinary output
   • 3. Hyperactive bowel sounds
   • 4. Increased specific gravity of the urine
    
   Option 3 ( Hyperactive bowel sounds ) is correct answer.
   Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.
   
   Test-Taking Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to the correct option. Remember that increased bowel motility and hyperactive bowel sounds indicate hyponatremia.
   
   

10. Question

    The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
    

    • 1. Lung congestion
    • 2. Decreased hematocrit
    • 3. Increased blood pressure
    • 4. Decreased central venous pressure (CVP)
    
    

    
    Option 4 is correct answer.
    Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.
    Test-Taking Strategy: Focus on the subject, fluid volume deficit. Eliminate lung congestion and increased blood pressure first because they are noted in fluid volume excess. From the remaining options, recall that CVP reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore pressure (volume) would be decreased in a deficient fluid volume.
    
    

11. Question

    The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess?
    

    • 1. The client taking diuretics
    • 2. The client with kidney disease
    • 3. The client with an ileostomy
    • 4. The client who requires gastrointestinal suctioning
    
    Option 2 is correct answer.
    Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
    Test-Taking Strategy: Focus on the subject, fluid volume excess. Read each option and think about the fluid imbalance that can occur in each. Clients taking diuretics or having ileostomies or gastrointestinal suctioning all lose fluid. The only condition that can cause an excess is the condition noted in the correct option.