ATI FLUID & ELECTROLYTE IMBALANCES

A nurse is assessing a client who has hypokalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A. Diabetic ketoacidosis Rationale: DKA is associated with HYPERKALEMIA (an increase in blood potassium) HF is associated with HYPONATREMIA (a decrease in blood sodium), Cushing's syndrome is associated with HYPERNATREMIA (increase in blood sodium), Thyroidectomy is associated with HYPOCALCEMIA (a decrease in blood calcium)

A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia

A. ECG changes Rationale: Assess of ECG changes. Potassium levels can affect the heart and result in arrhythmias Constipation, polyuria & paresthesia are manifestations of hypokalemia

A nurse is caring for a client who has emphysema & chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hyperkalemia Rationale: The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid Causes of hyponatremia include diuretics, kidney disease, vomiting & burn injuries. Causes of hypercalcemia include kidney failure & hyperparathyroidism. Causes of hypomagnesemia include malnutrition, alcohol use disorder & diarrhea.

A nurse is caring for a client who has a major burn injury & is experiencing 3rd spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C. Elevated Hct Rationale: The nurse should expect a client who is experiencing 3rd spacing resulting from a major burn to have elevated Hct level as blood volume is reduced by vascular dehydration

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting & diarrhea. The nurse should the which of the following findings? (Select all that apply) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

C. Tachycardia D. Syncope E. Decreased skin turgor Rationale: Tachycardia, syncope, decreased skin turgor are an expected finding of hypovolemia Distended neck veins & hyperthermia is an expected finding of hypervolemia

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D. Tachycardia Rationale: Tachycardia is an attempt to maintain BP, a manifestation of fluid volume deficit. Moist skin, distended neck veins & increased urine output are manifestations of fluid volume excess

A nurse on a med-surg unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has NG suctioning B. A client who has chronic constipation C. A client who has SIADH D. A client who took a toxic dose of sodium bicarbonate antacids

A. A client who has NG suctioning Rationale: A client who has NG suctioning & diarrhea rather than constipation is at risk for hypovolemia due to excessive GI losses SIADH places at risk for hypervolemia due to overhydration, a toxic dose of sodium bicarb antacids places the client at risk for hypervolemia due to excessive sodium intake

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Chron's disease B. Post-op following appendectomy C. History of bone cancer D. Hyperthyroidism

A. Chron's disease Rationale: Chron's disease is a risk factor for hypocalcemia due to inadequate calcium absorption. A history of bone cancer & hyperthyroidism places the client at risk for hypercalcemia due to the shift of calcium from bone to ECF

A nurse is admitting a client who reports nausea, vomiting & weakness. The client has dry oral mucous membranes & BP 102/64 mmHg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A. Decreased skin turgor Rationale: Decreased skin turgor is due to the lack of fluid within the body B. Concentrated urine Rationale: Concentrated urine is due to lack of fluid in the vascular system, causing a decreased profusion of kidneys and resulting in an increased urine specific gravity D. Low-grade fever Rationale: Low grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body E. Tachypnea Rationale: Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body

A nurse is admitting an older adult client who reports a weight gain of 2.3kg (5lb) in 48hr. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A. Dyspnea Rationale: Dyspnea is due to an excess of fluids within the body & lungs, & the client is struggling to breathe to obtain oxygen B. Edema Rationale: Weight gain can be a result of edema D. Hypertension Rationale: BP rises as the heart must work harder due to the excess fluid E. Weakness Rationale: Weakness is due to the excess fluid that is retained, which depletes energy & increases the workload for the body

A nurse is reviewing the lab test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL

A. Hct 55% Rationale: This is greater than the expected reference range of 42-52% for males & 37-47% for females & is an indication of dehydration due to hemoconcentration C. Blood sodium 150 mEq/L Rationale: This blood sodium level is greater than the expected reference range of 135-145 mEq/L & is an indication of dehydration D. Urine specific gravity 1.035 Rationale: This urine specific gravity is greater than the expected reference range of 1.005-1.030 & is an indication of dehydration

A nurse is assessing a client who has HF & is taking daily furosemide. The client's apical pulse is weak & irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia Rationale: Furosemide can cause the loss of potassium, sodium, calcium & magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, & ectopic heartbeats. Manifestations of hypophosphatemia can include muscle weakness & bradycardia. Manifestations of hypercalcemia can include tachycardia, hypertension & muscle weakness. Manifestations of hypermagnesemia can include bradycardia, hypotension & decreased deep tendon reflexes.

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate

A. Infuse hypotonic IV fluids Rationale: Hypotonic IV fluids are indicated for the treatment of hypernatremia related to fluid loss to expand the ECF volume & rehydrate the cells Increased fluid intake & decreased sodium intake is indicated for the treatment of hypernatremia. Administer sodium polystyrene sulfonate is indicated for the treatment of the treatment of HYPERKALEMIA

A nurse is caring for a client who has hyponatremia. Which of the following findings or interventions should the nurse expect? (Select all that apply) A. Sodium level of 127 mEq/L B. A prescription for the client to drink as much water as possible C. Client reporting headache & fatigue D. Sodium level of 147 mEq/L E. A prescription for a urine sodium test

A. Sodium level of 127 mEq/L Rationale: Hyponatremia is defined as a sodium level less than 136 mEq/L C. Client reporting headache & fatigue E. A prescription for a urine sodium test Rationale: Hyponatremia can cause head & fatigue & may require a urine sodium test.

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50mL/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A. Three tap water enemas Rationale: Three tap enemas can result in a decrease in blood sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution Options B & C are an isotonic solution & antibiotic therapy would not produce this results.

A nurse is reviewing the medical history of a client who is experiencing hyperkalemia. Which of the following findings put the client at a higher risk for hyperkalemia? (Select all that apply) A. Use of potassium supplements B. Taking a loop diuretic C. Allergy to bananas D. Kidney failure E. Hemodialysis

A. Use of potassium supplements Rationale: Potassium supplement use increases the potassium level in the body D. Kidney failure Rationale: Kidney failure is the leading cause of hyperkalemia, as it is associated with an inability to excrete sufficient amounts of potassium level in the body

A nurse on a med-surg unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has HF C. A client who is receiving treatment for DKA D. A client who has abdominal ascites

B. A client who has HF Rationale: Anticipate a client who has HF to require fluid & sodium restriction to reduce the workload on the heart A client with adrenal insufficiency is at risk for isotonic FVD (hypovolemia) because of a decrease in aldosterone secretion & an increase in sodium & water excretion. A client who has DKA is at risk for dehydration because hyperglycemia can cause osmotic diuresis which leads to dehydration & electrolyte loss.

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 30mL/hr D. Encourage independent ambulation 4 times a day

B. Check the client's weight each morning Rationale: To ensure accuracy, the client's weight should be obtained at the same time each day using the same scale. By determining the client's weight gain/loss each day, the nurse can evaluate the client's response to treatment. Hypotension is a manifestation of dehydration, urine output greater than 30mL/hr is an expected finding & an indicator of adequate fluid balance, a client who is dehydrated is at risk for falls due to orthostatic hypotension.

A nurse is collecting data from a client who has hypercalcemia as a result of long term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea & vomiting

B. Confusion Rationale: Expect the client who has hypercalcemia to have confusion & a possible decreased LOC D. Bone pain Rationale: Expect the client who has hypercalcemia to have bone pain E. Nausea & vomiting Rationale: Expect the client who has hypercalcemia to have nausea & vomiting along with anorexia

A nurse is caring for a client who has a NG tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypokalemia

B. Hyponatremia Rationale: Monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium An increase in calcium (HYPERCALCEMIA), a decrease in potassium (HYPOKALEMIA) & HYPERPHOSPHATEMIA are not indicated with NG losses due to suctioning

A nurse is caring for a client who has osteoporosis & has been taking a vitamin D supplement. The nurse notes that the client reports also taking a multivitamin daily. Which of the following findings should indicate to the nurse that the client might be experiencing vitamin D toxicity? A. Hyperkalemia B. Hypermagnesemia C. Hypercalcemia D. Hypernatremia

C. Hypercalcemia Rationale: The nurse should identify that vitamin D increases plasma calcium levels by increasing reabsorption from bone. Increased potassium levels can occur when clients take a prescribed potassium sparing diuretic along with a daily multivitamin might be taking too much calcium. Clients who take an excessive amount of magnesium hydroxide are at risk for magnesium toxicity. Mineralocorticoids promote the reabsorption of sodium & water in the kidneys.

A nurse receives a lab report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

C. Initiating continuous cardiac monitoring Rationale: A potassium level of 5.2 mEq/L indicates hyperkalemia. Anticipate the initiation of continuous cardiac monitoring due to the client's risk for dysrhythmias

A nurse is caring for an infant who has gastroenteritis & is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

C. Longer intestinal tract Rationale: Compared to adults, infants have a longer intestinal tract which results to greater fluid loss. Infants have a larger amount of extracellular fluid, larger body surfaces & increased rate of metabolism.

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm B. Place the stethoscope bell over the client's carotid artery C. Tap lightly on the client's cheek D. Ask the client to lower their chin to their chest

C. Tap lightly on the client's cheek Rationale: Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face. Applying a blood pressure cuff to the client's arm is performed to assess for Trousseau's sign, placing the stethoscope bell over the client's carotid artery is performed to auscultate a carotid bruit, asking the client to lower the chin to their chest is performed to assess ROM of the neck

A nurse is providing education for a client who has severe hypomagnesemia & is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication."

D. "Report diarrhea while taking this medication." Rationale: Instruct the client to report diarrhea while taking oral magnesium replacement. This is a potential adverse effect of taking oral magnesium, which could worsen the client's hypomagnesemia.

A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take? A. Place the client in a low Fowler's position B. Assist the client to use the incentive spirometer every 4hr C. Weigh the client every other day D. Enforce fluid restrictions

D. Enforce fluid restrictions Rationale: The nurse should enforce fluid restrictions to help reduce fluid retention in the lungs & lower extremities. The nurse should place the client in a high Fowler's position to, use incentive spirometer every 2 hrs to improve impaired oxygenation & weigh the client everyday

A nurse is caring for a client in a LTC facility who has become weak, confused & experienced dizziness when standing. The client's temperature is 38.3C (100.9F), pulse 92/min, respirations 20/min, & BP 108/60 mmHg. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake B. Check for peripheral edema C. Encourage the client to ambulate to promote oxygenation D. Monitor orthostatic hypotension

D. Monitor orthostatic hypotension Rationale: Monitor orthostatic hypotension because they have manifestations of dehydration due to decreased circulatory volume. Offer fluids, monitor for poor skin turgor when the client has manifestations of fluid volume deficit, keep client in bed & assist them to the bathroom as needed because are at risk for falling