Prioritization medsurg test 1 study guide

CHAPTER 4 Fluid, electrolyte, and acid-base balance problems        1.The client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? o 1.Administering IV fluids as prescribed by the physician o 2.Providing straws and offering fluids between meals o 3.Developing a plan for added fluid intake over 24 hours o 4.Teaching family members to assist the client with fluid intake 2.The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? o 1.Flattened neck veins when the client is in the supine position o 2.Full and bounding pedal and post-tibial pulses o 3.Pitting edema located in the feet, ankles, and calves o 4.Shallow respirations with crackles on auscultation 3.The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) o 1.Reminding the client to avoid commercial mouthwashes o 2.Encouraging mouth rinsing with warm saline o 3.Observing the lips, tongue, and mucous membranes o 4.Providing mouth care every 2 hours while the client is awake o 5.Seeking a dietary consult to increase fluids on meal trays 4.The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client’s morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? o 1.Weigh the client every morning. o 2.Maintain accurate intake and output records. o 3.Restrict fluids to 1500 mL/day. o 4.Administer furosemide (Lasix) 40 mg IV push. 5.You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? o 1.Sodium o 2.Potassium o 3.Magnesium o 4.Calcium 6.A client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? o 1.Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. o 2.Administer spironolactone (Aldactone) 25 mg orally. o 3.Assess the electrocardiogram (ECG) strip for tall T waves. o 4.Administer potassium 10 mEq orally. 7.A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? o 1.Hypokalemia o 2.Hyperkalemia o 3.Hyponatremia o 4.Hypernatremia