.A.Q. Ch 11-2
What statement by the student nurse indicates a need for further teaching about the care to be taken in healthy adults to prevent mild dehydration?
"Consume more beverages that contain caffeine."
A patient is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond?
"Weigh her now. We need her weight daily, at the same time."
Which is the most critical fluid to prevent death?
Blood volume
Which condition is least likely to cause fluid overload?
Diabetes insipidus
Which will the nurse include when documenting a patient's fluid intake for the shift?
Enemas Oral fluids Irrigation fluids
The nurse instructs an older adult patient to increase intake of dietary potassium when the patient is prescribed which classification of drugs?
High-ceiling (loop) diuretics
What is a risk factor associated with tachypnea?
Increased insensible water loss
Which parameters should be monitored to assess a patient's response to fluid replacement therapy?
Monitoring pulse quality Monitoring urine output Monitoring weight changes every 8 hours
A patient with cerebral edema was prescribed a hyperosmotic IV solution. What is the purpose of this intervention?
Pull excessive water from the interstitial volume through osmosis to reduce edema
What is a consequence of fluid overload?
Pulmonary edema
Which condition would stimulate the renin-angiotensin II to maintain fluid balance within the body?
Shock
Which intervention does the nurse include in caring for a patient with generalized edema who is receiving a loop diuretic?
Turning the patient every 2 hours.
What parameter does the nurse assess for in a postoperative patient to determine perfusion adequacy?
Urine output
On the second day of caring for a patient with generalized edema, which change best reflects that the administered diuretic is effective?
Weight loss of 6 pounds
The patient with fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which changes indicate to the nurse that the diuretic resulted in overdiuresis?
Weight loss of 9 pounds Reports of lightheadedness when first standing from a lying position Heart rate increase from 70 to 96 beats/min Reports of fatigue
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin, chlorothiazide, and potassium supplements. He tells a nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the patient's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication?
Added to an IV, not to exceed 20 mEq/hr
Which hormones are responsible for maintaining fluid balance within the body?
Aldosterone Natriuretic peptide (NP) Antidiuretic hormone (ADH)
Which hormones play a role in the regulation of sodium balance by the kidneys?
Aldosterone Natriuretic peptide (NP) Antidiuretic hormone (ADH)
A patient receiving insulin and glucose infusion therapy for hyperkalemia now has a serum potassium level of 3.6 mEq/L. What is the nurse's first action?
Assess the patient's heart rate, rhythm, and respiratory status.
Laboratory results for a patient with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action?
Assess the patient's respiratory status.
A patient's morning laboratory results show a serum ionized calcium of 2.85 mmol/L. For what sign must the nurse assess?
Blood clotting
A patient presents with dehydration. Which parameter should be considered when deciding isotonic fluid replacement therapy for the patient?
Body temperature of 40°C for more than 8 hrs
A patient has edema in both lower extremities. The patient's edema is due to which occurrence?
Changes in normal hydrostatic pressure
What is the most appropriate nursing intervention in a patient with fluid overload and edema to prevent skin breakdown on pressure areas?
Changing position every 2 hours
A patient with diabetes mellitus who is prescribed diuretic medication reports giddiness and a dry mouth when in dry climates. After assessing the vital signs, the patient is diagnosed as having mild dehydration. Which is the best nursing intervention?
Consume small amounts of sugar-free fluids hourly.
Which signs does the nurse expect to find when assessing a patient with fluid overload?
Crackles in the lungs Pitting edema in the ankles and feet Weight gain
As adults age, which common physiologic change is likely to alter their hydration status?
Decreased muscle mass
An elderly patient who is prescribed diuretics and laxatives and has a history of diabetes mellitus is brought to the emergency room in an unconscious state. Which is the most likely reason for the patient's condition?
Dehydration
The nurse is providing care to a patient who is experiencing severe nausea, vomiting, and diarrhea. Which is the patient at risk of developing?
Dehydration Hyperkalemia Hypernatremia
Which situation can cause a patient to experience "insensible water loss?"
Diarrhea Dry, hot weather Fever Increased respiratory rate Mechanical ventilation
What is the neurological impact of age-related changes on fluid balance?
Diminished thirst reflex
Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance?
Diuretics
Which will the nurse consider when assessing a patient's insensible water loss?
Feces Respiration Perspiration
What is fluid overload or overhydration?
Fluid intake is greater than body's fluid needs
The nurse admits a patient with dehydration. Which electrolyte imbalances does the nurse anticipate based on this diagnosis?
Hyperkalemia Hypernatremia
The nurse is providing care to a patient who is receiving diuretic therapy. Which electrolyte imbalance will the nurse monitor this patient for while providing care?
Hypokalemia
What is the defense mechanism to combat the effects of isotonic dehydration and maintain blood flow to the vital organs?
Increased blood vessel constriction
Which order does the nurse clarify with the provider based on the following available patient data?
No activity restrictions; ambulate ad lib.
A patient has had a total urine output of 200 mL in the past 24 hours. Which priority action does the nurse take?
Notify the primary health care provider.
The RN is assessing a 70-year-old patient admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
Patient behavior that changes from anxious and restless to lethargic and confused
Which assessment findings will indicate the need for continuation of prescribed fluid replacement therapy in a patient diagnosed with dehydration?
Pulse pressure of 28 mm Hg Urine output of 400 mL per day
Which nursing action is recommended when providing care to a patient with hypokalemia?
Question the continued administration of bumetanide.
A patient with a history of hypertension asks the nurse what dietary changes are necessary to make in order to control the blood pressure. What does the nurse include in the instruction?
Reduce the intake of sodium
Which assessment finding would cause the kidneys to secrete renin in order to increase blood pressure and maintain perfusion and fluid balance?
Sodium 130 mEq/L
The nurse is assessing a patient's serum electrolyte values upon admission to the medical-surgical unit. Which value would cause the nurse to monitor the patient for dehydration?
Sodium 150 mEq/L
Which assessment data is the best indication of perfusion after a surgical procedure?
Urine output
Which medication can be administered to mimic the effect of antidiuretic hormone (ADH) on the body?
Vasopressin
An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this patient related to the reason for admission?
What is your typical daily fluid intake and what types of fluids do you drink?
A 5-year-old child is brought into the emergency department with persistent vomiting and diarrhea. The child's parents state that the child has lost 4 pounds since the symptoms began. Based on this information, approximately how much fluid has the child lost?
2 liters
Which patient is at increased risk for fluid and electrolyte imbalance?
24-year-old male athlete 45-year-old man on diuretics
Which value falls within the range for the minimal amount of urine that needs to be produced in 24 hours?
450 mL/day
After receiving change-of-shift report, which patient does the RN assess first?
46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin, chlorothiazide, and oral potassium supplements. He tells the nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer?
5% dextrose in water (D 5W)
Which total urine output for the previous day would place a patient at risk for accumulating waste products?
500 mL
Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration?
72-year-old woman appearing to be at least 20 pounds overweight
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which patient is assigned to the LPN/LVN?
76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L
A patient is brought in an unconscious state to the emergency department. The primary health care provider suspects dehydration and advises laboratory investigation to ascertain the cause. Which parameter in the laboratory investigations would indicate internal hemorrhage as a reason for dehydration?
Absence of hemoconcentration
When administering 20 mEq potassium chloride intravenously (IV), which is the priority intervention?
Administer at a rate of 10 mEq/hr.
A patient with severe vomiting and diarrhea was brought to the emergency department in a semiconscious condition. What interventions does the nurse implement to stabilize the patient?
Administer replacement fluids intravenously Administer drugs to correct the cause of dehydration ????????????
What priority intervention does the nurse anticipate for a patient based on the following available assessment data
Administering diuretic agents as prescribed.
What priority intervention does the nurse anticipate for a patient based on the following available assessment data?
Administering diuretic agents as prescribed.
A patient who is receiving intravenous fluid replacement therapy has a bounding pulse, difficulty in breathing, and distended neck veins when sitting in the upright position. What is the most appropriate nursing intervention for the patient?
Administering diuretic drug therapy
An older adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. What are the immediate nursing interventions to stabilize the patient?
Administering diuretics Administering 0.9% saline Administering 5% dextrose in 0.45% sodium chloride
A patient with a history of renal failure has a heart rate of 58 beats per minute, serum potassium levels of 5.5 mEq/L, and T wave spikes on the electrocardiogram (ECG). What nursing intervention may stabilize the patient?
Administering sodium polystyrene sulfonate
Which age-related change to the endocrine gland affects fluid balance in the body?
Adrenal atrophy
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the patient?
Blood pressure Pulse rate and quality Urinary output Urine specific gravity levels
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The patient with which electrolyte laboratory value is assigned to the LPN/LVN?
Calcium level of 9.5 mg/dL
A patient presents to the emergency room with confusion, altered level of consciousness, dry mouth, scaly skin, and very loose fitting shoes. Which finding in the patient's history is significant?
Decreased ingestion of solid foods such as gelatin
Which consequence of fluid overload may result in seizures, coma, and death?
Decreased serum sodium and potassium levels
Which age-related change to fluid balance does the nurse anticipate when conducting a neurological assessment for an older adult patient?
Decreased thirst reflex
The nurse is assessing an older adult patient during a scheduled health maintenance visit. Which assessment finding, related to fluid balance, does the nurse anticipate?
Decreased turgor
The nurse is admitting a 78-year-old patient with severe diarrhea in the emergency department. Which assessment findings indicate that the patient may be dehydrated?
Dizziness when standing Newly reported confusion Temperature of 99.4° F
To safely administer potassium to a patient with hypokalemia, which actions does the nurse perform?
Establish and evaluate the patency of a large vein. Obtain an IV controller device (pump). Plan to assess the respiratory rate and oxygen saturation every hour. Evaluate the heart rate and regularity.
Which will the nurse include in the documentation for a patient's measurable output at the end of the shift?
Feces Urine Emesis Chest tube drainage
What is the reason for relative dehydration?
Fluid shift from plasma to interstitial space
How is isotonic dehydration defined?
Fluids and electrolytes are lost from the body in equal amounts.
Laboratory results report a patient's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient?
Heart rate
The primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient?
Hyperkalemia
A patient's electrocardiogram demonstrates a heart rate of 52 beats/min, prolonged PR interval with widened QRS complex, and the patient is also hypotensive. The nurse reviews the morning labs for which conditions?
Hyperkalemia, hypercalcemia, hypermagnesemia
The nurse is providing care to a patient who is diagnosed with dehydration. Which laboratory finding supports the current diagnosis?
Hypernatremia
A patient reports painful muscle spasms in the lower legs at rest, a tingling sensation in the hands and lips, and abdominal cramping and diarrhea. The nurse reviews the patient's laboratory results for the presence of which disorder?
Hypocalcemia
A patient who recently experienced an anterior neck injury reports frequent and painful muscle spasms in the calf during sleep. Which condition does the nurse suspect in the patient?
Hypocalcemia
When assessing the laboratory results of a patient who has hypomagnesemia, for which additional electrolyte imbalance should the nurse monitor?
Hypocalcemia
Which two electrolyte imbalances does the nurse suspect based on the following assessment data of a patient?
Hypomagnesemia and hypocalcemia
The nurse is reviewing the basic metabolic panel for a patient who was admitted to the medical-surgical unit the previous day. Which finding indicates that the patient is suffering from fluid volume overload?
Hyponatremia
Which condition commonly occurs in patients who are on long-term furosemide therapy?
Hyponatremia
Which condition triggers aldosterone secretion to maintain fluid balance within the body?
Hyponatremia
The nurse is providing care to a patient who is experiencing tachypnea. Which intervention is most appropriate to maintain the patient's fluid balance?
Increase intravenous fluids.
A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide, digoxin, and an angiotensin-converting enzyme (ACE) inhibitor. She states that she stopped taking her furosemide because she did not think that it was helping her heart failure. Her health care provider orders furosemide 5 mg IV push. Which patient assessment determines that the medication is working?
Increased urine output
The nurse is providing care for a patient who has hyperkalemia. Which disease process documented in the patient's medical record is the cause for this electrolyte imbalance?
Renal failure
A patient who is suffering from chronic fluid overload asks the nurse to suggest necessary dietary changes. What dietary changes suggested by the nurse apart from restricting fluid intake would be effective to minimize fluid overload?
Intake of 2-4g/day of sodium
What is the function of aldosterone in the body?
It promotes resorption of water and sodium.
Which is an age-related change that impacts fluid balance?
Loss of skin elasticity
Which assessment findings would indicate decreased tissue perfusion stimulating the secretion of renin from the kidney tubular system?
Low blood oxygen Low blood volume
Which output source would the nurse exclude from the total output from the previous shift?
Lung vaporization
Which laboratory value requires a priority response by the nurse to notify the primary health care provider?
Magnesium 4.2 mEq/L
Which assessment finding is consistent with fluid overload?
Moist crackles in the lungs upon auscultation
A patient is being discharged from the hospital before completely resolving the problem of fluid overload. What instructions should the nurse give to the caretaker in order to avoid the recurrence of fluid overload?
Monitor the weight gain of the patient Monitor the sodium intake Monitor the fluid intake
A patient reports swelling of the right foot and ankle. Upon assessing the patient, the health care provider confirms it as pitting edema and prescribes diuretic therapy. Which nursing interventions are necessary for this patient?
Monitoring the urine output of the patient Assessing the sodium and potassium values Monitoring the electrocardiogram patterns (ECG)
A patient admitted with fluid overload from heart failure is treated with diuretic therapy. What laboratory test demonstrates effectiveness of the diuretic therapy?
Natriuretic peptide
The nurse is providing care to an edematous patient whose blood pressure is 190/110 mm Hg. Which hormone will be secreted in response to the patient's blood pressure in order to increase urine output?
Natriuretic peptides (NPs)
The RN is caring for a patient admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
Obtaining baseline vital signs before blood administration
Which is a true statement regarding fluid balance in older adult patients?
Older adult patients have less total body water.
Which newly written prescription does the nurse administer first?
Oral potassium chloride (KCl) to a patient whose serum potassium is 3 mEq/L
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling?
Orthostatic blood pressure changes
A patient's laboratory results show decreased hemoglobin levels, increased hematocrit, and serum protein levels leading to a diagnosis of fluid overload. What other changes support the diagnosis?
Pitting edema on the left foot and ankle.
Which written order does the nurse clarify with the provider when caring for a patient with a serum sodium level of 149 mEq/L?
Place the patient on nothing by mouth (NPO) status.
An ECG is ordered for a patient who was placed on IV fluids containing potassium. Which ECG finding is consistent with hyperkalemia?
Prolonged PR intervals
The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a patient who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy?
Pulse rate and quality Urinary output
A patient with swollen arms and legs was brought to the emergency department. Which laboratory parameter would help in the diagnosis of peripheral edema?
Specific gravity of urine
A 90-year-old patient with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the patient for admission to which inpatient unit?
Telemetry/cardiac stepdown
The nurse finds that a patient has dry skin, a heart rate of 115 beats per minute, a respiratory rate of 28 breaths per minute, and weight loss of 1 pound in 1 day. What does the nurse infer about the patient's condition?
The patient is suffering from dehydration.
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?
Transferring the patient from the bed to a stretcher using a lift sheet
What is the primary assessment in evaluating the effectiveness of diuretic therapy?
Urinary output