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Sas 16

The document provides a 10 question quiz on electrolyte imbalances for nurses. It tests nurses' knowledge on identifying risks for and signs of various electrolyte imbalances, appropriate nursing interventions, and the functions of electrolytes. Nurses must select the correct answer and provide a rationale for each multiple choice question. Getting both the answer and rationale correct is required to receive full points for each question.

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Sistine Rose Labajo
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967 views4 pages

Sas 16

The document provides a 10 question quiz on electrolyte imbalances for nurses. It tests nurses' knowledge on identifying risks for and signs of various electrolyte imbalances, appropriate nursing interventions, and the functions of electrolytes. Nurses must select the correct answer and provide a rationale for each multiple choice question. Getting both the answer and rationale correct is required to receive full points for each question.

Uploaded by

Sistine Rose Labajo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SAS #16

CHECK FOR UNDERSTANDING (60 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 60 minutes for this activity:

Multiple Choice

1. A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating
that the kidneys also are retaining greater amounts of which substances?

A. Calcium and Chloride


B. Chloride and bicarbonate
C. Potassium and Phosphates
D. Aluminum and magnesium

Answer: B
Rationale: Sodium is a cation. With increased retention of sodium, the kidneys also increase
reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect because
calcium and potassium are cations. The same is true for option 4.

2. 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?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic

Answer: B
Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as
hypokalemia. Potassium-rich 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. A nurse is planning care for a client with hypokalemia. Which interventions should be included in
the plan of care? Select all that apply.
A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea.
D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate.

Answer: A,B, D, and E


Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should
maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness,
resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to
decreased peristalsis.

4. 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?
A. Muscle twitches
B. Decreased Urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine

Answer: C
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.

5. A patient prescribed spironolactone is demonstrating ECG changes & complaining of muscle


weakness. The nurse realizes this patient is exhibiting signs of which of the following.
A. hyperkalemia
B. hypokalemia
C. hypercalcemia
D. hypocalcemia

Answer: A
Rationale: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium
excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of
hyperkalemia are muscle weakness & ECG changes.

6. The nurse is planning care for a patient with fluid volume overload & hyponatremia. Which of the
following should be included in this patient's plan of care?
A. Restrict fluids.
B. Administer intravenous fluids.
C. Provide Kayexalate.
D. Administer intravenous normal saline with furosemide
Answer: A
Rationale: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids
to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from
dropping further due to dilution.

7. A patient is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the patient
is receiving this replacement is
A. to sustain respiratory function.
B. to help regulate acid-base balance.
C. to keep a vein open.
D. to encourage urine output.

Answer: B
Rationale: Electrolytes have many functions. They assist in regulating water balance, help regulate &
maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.

8. A patient with fluid retention related to renal problems is admitted to the hospital. The nurse
realizes that this patient could possibly have which of the following electrolyte imbalances?
A. hypokalemia
B. hypernatremia
C. carbon dioxide
D. magnesium

Answer: B
Rationale: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with
hypernatremia.

9. An elderly patient comes into the clinic with the complaint of watery diarrhea for several days with
abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the
following?
A. hypernatremia
B. hyponatremia
C. fluid volume excess
D. hyperkalemia

Answer: B
Rationale: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal &
muscle cramps are manifestations of a low serum sodium level.

10. A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic
Ocean for five days without a fresh water source. Which of the following is this patient at risk for
developing?
A. pulmonary edema
B. atrial dysrhythmias
C. cerebral bleeding
D. stress fractures

Answer: C
Rationale: The brain experiences the most serious effects of cellular dehydration. As brain cells contract,
the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, &
lead to cerebral vascular bleeding.

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