chapter 39
Which is an age-related change that impacts fluid balance? A.Loss of skin elasticity B.Adrenal hypertrophy C.Increased thirst reflex D.Increased muscle mass
A
A client with dehydration will have an increase in
Aldosterone
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? A.Reduce the intake of iron B.Reduce the intake of calcium C.Reduce the intake of sodium D.Reduced the intake of phosphorous
C High sodium intake raises the serum sodium level, which causes more water to be retained. This in turn increases the blood volume and raises the blood pressure. Hence, patients who have hypertension are often asked to limit their intake of sodium. Intake of iron, phosphorus, or calcium does not cause water retention in the blood, and therefore, does not affect the blood pressure.
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?
weight gain of 0.75 kg in a day Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.
You are the nurse caring for Jason Kent, a 16-year-old who got lost while on a desert hike. He was found after spending two days without food or water and was admitted to your unit through the Emergency Department. He is severely dehydrated and sunburned. You remember that which of the following are reasons why the human body requires fluid? Choose all that apply.
- Facilitates cellular metabolism - Helps maintain normal body temperature - Acts as a solvent for electrolytes
Positive Trousseau's and Chvostek's signs are consistent with which electrolyte imbalance? Hypocalcemia Hypokalemia Hypercalcemia Hyperkalemia
A Trousseau's sign (palmar flexion) and Chvostek's sign (facial twitching) are consistent with acute hypocalcemia. These manifestations are caused by overstimulation of the nerves and muscles. Trousseau's and Chvostek's signs are not used to assess for potassium imbalances.
Which drug therapies might be used to manage symptoms of hypocalcemia? A. Magnesium sulfate B. Calcium chloride C .Potassium chloride D. Vitamin D E. Zinc sulfate F. Vitamin E
A, B, D Magnesium sulfate may be used to manage neuromuscular symptoms of hypocalcemia. Calcium supplements are given to restore serum calcium levels. Vitamin D enhances the absorption of oral calcium. Potassium, zinc, and vitamin E are not indicated for the management of hypocalcemia.
Which drug therapies might be used to manage symptoms of hypocalcemia? Magnesium sulfate Calcium chloride Potassium chloride Vitamin D Zinc sulfate Vitamin E
A, B, D Magnesium sulfate may be used to manage neuromuscular symptoms of hypocalcemia. Calcium supplements are given to restore serum calcium levels. Vitamin D enhances the absorption of oral calcium. Potassium, zinc, and vitamin E are not indicated for the management of hypocalcemia.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" Which of the following would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
The nurse is performing discharge dietary teaching for a patient with hyperkalemia. Which statement does the nurse include in the teaching? "You may eat avocados, broccoli, and cantaloupe." "You may use salt substitutes." "You may eat apples, strawberries, and peaches." "You don't need to restrict dairy products."
C The patient with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches. The patient should avoid foods high in potassium, which include avocados, broccoli, cantaloupe, and dairy products. Salt substitutes contain potassium.
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?
Cardiac volume intolerance The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.
A patient who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?
Decreased blood volume and intracellular dehydration
Which of the following statements is an appropriate nursing diagnosis for an 80-year-old client with the diagnosis of congestive heart failure with symptoms of edema, orthopnea, and confusion?
Extracellular volume excess related to heart failure as evidenced by edema and orthopnea
A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply.
Hypokalemia Hypocalcemia Hyperphosphatemia Older adults are at increased risk for electrolyte imbalances during and after bowel preparation for procedures such as a colonoscopy or barium enema. Research has shown that bowel preparation solutions in clients over age 65 years are associated with vascular volume deficit, hyperphosphatemia, hypokalemia, and hypocalcemia.
An older adult client with dehydration repeatedly tells the nurse, "I am just not thirsty. I don't want anything to drink." Which nursing actions are appropriate? (Select all that apply.)
Identify fluid preferences. Offer fluids at times other than meals. Offer small amounts of preferred liquids frequently.
The nursing student's assessment has revealed that a patient has dependent edema in his lower legs. The student recognizes that this is caused by alterations in ECF, which is normally present in what location?
Interstitial spaces ECF is found between the cells in the interstitial space. ICF is located within cells, such as muscle fibers, red blood cells, and adipose tissue.
Miss Roberts is admitted to the unit with a diagnosis of three days of continuous vomiting. You would suspect which of the following acid/base imbalances related to the loss of stomach acid?
Metabolic alkalosis Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the ECF. This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate.
An older adult has been admitted to the hospital with an infection of Norovirus that has resulted in severe vomiting and diarrhea. The nurse should recognize that this patient is at risk for which of the following imbalances? Select all that apply.
Metabolic alkalosis Hypovolemia Hypokalemia Vomiting can cause dehydration/hypovolemia, hypokalemia, and metabolic alkalosis through loss of fluid, gastric acid, and potassium. Hypoparathyroidism is an endocrine disorder and is unrelated to fluid losses. Vomiting does not cause increased calcium levels.
A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D. Hyperphosphatemia
A. Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).
The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform? a. Perform regular neurologic checks and institute seizure precautions. b. Encourage the patient to eat foods that are high in sodium. c. Administer hypotonic IV solutions as ordered by the physician. d. Assess for signs and symptoms of digoxin (Lanoxin) toxicity.
ANS: A A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia. DIF: Understanding REF: p. 999
The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse? a. The patient's lung sounds will remain clear. b. The patient will have urine output of at least 30 mL/hr. c. The patient will verbalize understanding of fluid restrictions. d. The patient's pitting pedal edema will resolve within 72 hours.
ANS: A Oxygenation is the highest priority for the patient with congestive heart failure and fluid volume excess. Keeping the patient's lungs clear is the most important goal for the nurse to consider when caring for this patient. DIF: Applying REF: p. 1009
The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH? a. The patient's respirations are very deep and rapid. b. The patient's urine is dark and concentrated. c. The patient's skin is pale, cool, and diaphoretic. d. The patient is sleepy and difficult to arouse.
ANS: A The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide through deep, rapid respirations. Since carbon dioxide is converted to carbonic acid, removal of carbon dioxide will help shift the body's pH to a less acidotic state. DIF: Applying REF: p. 1004
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and
Aldosterone Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium
Which hormones play a role in the regulation of sodium balance by the kidneys? A. Cortisol B. Aldosterone C.Angiotensin D.Natriuretic peptide (NP) E.Antidiuretic hormone (ADH)
B, D, E Serum sodium levels are regulated by the kidneys under the influence of aldosterone, natriuretic peptide (NP), and antidiuretic hormone (ADH). Low serum sodium levels inhibit the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP) and trigger the secretion of aldosterone. This increases the serum sodium levels by increasing the reabsorption of sodium and enhancing water loss by the kidney. High serum sodium levels inhibit aldosterone secretion and stimulate the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP). These hormones increase the excretion of sodium and reabsorption of water by the kidney. Cortisol and angiotensin do not regulate the serum sodium levels.
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? A.Hyperkalemia B.Hypercalcemia C.Hyponatremia D.Hyperchloremia
C Most problems caused by fluid overload are related to excessive fluid in the vascular space or to dilution of specific electrolytes lowering their serum levels. Hyponatremia, or a low level of sodium is often manifested. Hyperkalemia, hypocalcemia, and hypercholoremia is not seen in a patient with fluid volume overload
The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A.24-hour urine output B.Asking the patient about feeling depressed C.Hourly deep tendon reflexes (DTRs) D.Monitoring of serum calcium levels
C The patient who is receiving IV magnesium sulfate should be assessed for signs of toxicity every hour by assessment of DTRs. Most patients who have fluid and electrolyte problems will be monitored for intake and output (I&O); this will not immediately generate data about problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not be a method by which to safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity
On the second day of caring for a patient with generalized edema, which change best reflects that the administered diuretic is effective? A. output decrease from 600 mL/8 hr to 200 mL/8 hr B.Respiratory rate decrease from 24 to 20 C. Weight loss of 6 pounds D.Blood pressure decrease from 138/88 to 126/78 mm Hg
C Weight loss and increased urinary output are primary indicators of the effectiveness of a diuretic. In patients with edema, each pound of weight gained after the first pound equates to 500 mL of retained water, so if water loss occurs with diuretic therapy, weight loss will result. The changes in vital signs may reflect volume loss, but are not the best indicators of the effectiveness of a diuretic.
An ECG is ordered for a patient who was placed on IV fluids containing potassium. Which ECG finding is consistent with hyperkalemia? A.Absent T waves B.Elevated P waves C.Prolonged PR intervals D.Shortened QRS complexes
C When hyperkalemia is present, an individual may show absent P waves, tall T waves, prolonged PR intervals, and widened QRS complexes.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse caring for the client knows that the client needs restoration of which of the following?
Electrolytes
Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance? A.Diuretics B.Anticoagulants C.Mood stabilizers D.Opioid analgesics
A Drug therapy for hypertension management may include diuretic drugs that increase the excretion of sodium so that less is present in the blood, resulting in a lower blood volume and increased urine output. Anticoagulants, mood stabilizers, and opioid analgesics do not play a role in maintaining fluid balance within the body
Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance? Diuretics Anticoagulants Mood stabilizers Opioid analgesics
A Drug therapy for hypertension management may include diuretic drugs that increase the excretion of sodium so that less is present in the blood, resulting in a lower blood volume and increased urine output. Anticoagulants, mood stabilizers, and opioid analgesics do not play a role in maintaining fluid balance within the body
The RN is assessing a 70-year-old patient admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A.Patient behavior that changes from anxious and restless to lethargic and confused B.Deep furrows on the surface of the tongue C.Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours
A The patient's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.
A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D.Hyperphosphatemia
A These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).
A patient who has had a prolonged period of nasogastric (NG) suctioning following colon surgery is experiencing electrolyte imbalances. The magnesium level is low (1.2 mg/dL). Knowing that magnesium deficiency occurs in conjunction with low calcium levels, the nurse should assess the patient for which of the following clinical manifestations of hypocalcaemia? Select all that apply. a. Personality changes b. Hyperactive reflexes c. Increase in ventricular arrhythmias d. Increase in bouts of atrial fibrillation e. Symptomatic hypotension
A, B, C
The nurse is providing care to a patient who is admitted with fluid volume overload. Which electrolyte imbalances does the nurse anticipate for this patient based on the admitting diagnosis? A.Hyponatremia B.Hypokalemia C.Hypercalcemia D.Hypochloremia E.Hypermagnesemia
A, B, D A patient admitted with fluid volume overload will often experience hyponatremia, hypokalemia, and hypocholoremia. Hypercalcemia and hypermagnesemia are not anticipated electrolyte imbalances associated with fluid volume overload.
A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. The provider has ordered fall precautions. Which interventions does the nurse implement as part of fall precautions? A.Assess for orthostatic hypotension. B.Orient the patient frequently. C.Loosely apply upper-extremity wrist restraints. D.Maintain a calm, dim room to reduce confusion. E.Place the bed in the lowest position with brakes locked. F.Activate the bed alarm.
A, B, E, F Multiple interventions are implemented to prevent falls, especially in older patients with dehydration. Assessing for orthostatic hypotension, orienting the patient frequently, placing the bed in the lowest position with the brakes locked, and activating the bed alarm should all be implemented to reduce the patient's risk of falling. In addition, frequent toileting and assistance to the bathroom may be indicated for this older patient. Restraints are never appropriate. A dimly lit room may increase the risk of falls.
Which of the following individuals would be considered to be at risk for the development of edema? Select all that apply. a. An 81-year-old man with right-sided heart failure and hypothyroidism b. A 60-year-old obese female with a diagnosis of poorly controlled diabetes mellitus c. A 34-year-old industrial worker who has suffered extensive burns in a job-related accident d. A 77-year-old woman who has an active gastrointestinal bleed and consequent anemia e. A 22-year-old female with hypoalbuminemia secondary to malnutrition and anorexia nervosa
A, C, E
The nurse admits a patient with dehydration. Which electrolyte imbalances does the nurse anticipate based on this diagnosis? Hyperkalemia Hypocalcemia Hypochloremia Hypernatremia Hypermagnesemia
A, D A patient who is admitted with dehydration will have hyperkalemia and hypernatremia. Hypocalcemia, hypochloremia, and hypermagnesemia are not expected electrolyte imbalances for a patient admitted with dehydration.
The nurse admits a patient with dehydration. Which electrolyte imbalances does the nurse anticipate based on this diagnosis? A. Hyperkalemia B. Hypocalcemia C. Hypochloremia D. Hypernatremia E. Hypermagnesemia
A, D A patient who is admitted with dehydration will have hyperkalemia and hypernatremia. Hypocalcemia, hypochloremia, and hypermagnesemia are not expected electrolyte imbalances for a patient admitted with dehydration.
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? A. Dizziness when standing B. Distended neck veins C. Bounding radial pulses D. Newly reported confusion E. Temperature of 99.4° F
A, D, E Postural hypotension causing dizziness may occur with dehydration. Neck veins are flat, not distended; peripheral pulses are weak, not bounding. Because of decreased perfusion to the brain, confusion is common in older adults. Low-grade fever is a common result of dehydration.
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 Distended neck veins Bounding radial pulses Newly reported confusion Temperature of 99.4° F
A, D, E Postural hypotension causing dizziness may occur with dehydration. Neck veins are flat, not distended; peripheral pulses are weak, not bounding. Because of decreased perfusion to the brain, confusion is common in older adults. Low-grade fever is a common result of dehydration.
MULTIPLE CHOICE 1. The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient? a. The patient has generalized 3+ pitting edema. b. The patient is confused and disoriented. c. The patient's urine is dark and very concentrated. d. The patient lung sounds are very diminished.
ANS: A The patient's low albumin level will lead to generalized pitting edema because there isn't enough protein in the blood to keep water within the bloodstream. Lack of oncotic pressure from low serum albumin leads to edema. DIF: Understanding REF: p. 996 | p. 1007
1. Which of the following findings would indicate effectiveness of fluid replacement for a patient admitted with dehydration? (Select all that apply.) a. Blood urea nitrogen - 18 mg/dL b. Pulse - 82 c. Blood pressure - 140/90 d. Urine specific gravity - 1.033 e. 24-hour fluid balance - +200
ANS: A, B, E Blood urea nitrogen will be elevated with dehydration and return to normal levels with hydration. Normal pulse rate and positive fluid balance also indicate adequate fluid levels. An increased urine specific gravity is an indication of dehydration while an increased blood pressure can indicate fluid volume excess.
The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance? a. "Check to make sure that your urine is a bright yellow color." b. "Weigh yourself every morning before breakfast." c. "Count your heart rate every evening before you go to bed." d. "Drink plain water rather than soda, coffee, or fruit juice."
ANS: B Checking the weight every morning before breakfast is a sensitive indicator of the patient's fluid volume status. Weight gain of 2 to 3 lb over 1 to 2 days generally indicates fluid retention and should be reported to the physician. DIF: Understanding REF: p. 997
The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse's best response? a. "You should ask your doctor to decrease the dose." b. "Take the diuretic early in the morning before breakfast." c. "Eat foods high in potassium and limit your salt intake." d. "Restrict your fluid intake after dinner and in the evening."
ANS: B The patient should be instructed to take the diuretic early in the morning so that the effects will wear off before the patient goes to bed at night. Decreasing the dose could lead to fluid overload and pulmonary edema. DIF: Applying REF: p. 1021
A nurse is caring for an 80-year-old patient who is receiving bumetanide (a loop diuretic) for hypertension. The nurse notes that the patient admits to taking bisacodyl (Dulcolax) daily to stimulate her bowels. The nurse should assess the patient for possible symptoms of a. hypoglycemia. b. hypoparathyroidism. c. hypokalemia. d. hypocalcemia.
ANS: C Loop diuretics act on the loop of Henle to block reabsorption of sodium and potassium and are considered potassium-wasting diuretics. Daily use of laxatives such as bisacodyl can lead to increased potassium loss through stool.
A nurse is caring for an adult patient who has gastric suction following abdominal surgery. The patient tells the nurse that he has tingling in his fingers and toes and is feeling dizzy. Which acid-base imbalance is the patient most likely experiencing? a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis
ANS: D In metabolic alkalosis, there is an excess of bicarbonate ions, which raises the pH above 7.45 and produces bicarbonate levels greater than 26 mEq/L. This occurs as a result of loss of gastric acids through vomiting or nasogastric suctioning, among other causes. Clinical manifestations include numbness and tingling in the fingers and toes.
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient's fluid imbalance? a. 0.33% normal saline b. 0.45% normal saline c. 0.9% normal saline d. 3% normal saline
ANS: D A hypertonic 3% saline solution will be used to correct the patient's hyponatremia and fluid overload that have developed as a result of SIADH. A 0.9% normal saline solution can be used once the serum sodium level has been raised nearer to normal range. A 0.45% or 0.33% normal saline solution is hypotonic and will only worsen the patient's fluid overload and hyponatremia. DIF: Understanding REF: p. 997 | p. 999 | pp. 1012-1013
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Administer oral K supplements as ordered.
A nurse in the emergency department is caring for an adult patient with numerous draining wounds from gunshots. The patient's pulse rate has increased from 100 to 130 beats/min over the past hour. For which imbalance should the nurse assess symptoms? a. Respiratory acidosis b. Extracellular fluid volume deficit c. Metabolic alkalosis d. Intracellular fluid volume excess
Answer: b The draining wounds indicate hypovolemia, or extracellular fluid volume deficit. As circulating blood volume decreases, the heart rate increases to maintain normal cardiac output. Respiratory acidosis and metabolic alkalosis do not have as a symptom a rapidly increasing pulse rate. Intracellular fluid volume excess causes pulmonary congestion and cerebral edema
The nurse is caring for a patient who needs to increase calcium in her diet but does not like milk. Which food should the nurse encourage the patient to consume? a. Cod b. Eggs c. Spinach d. Tomatoes
Answer: c Dark leafy vegetables such as spinach, kale, turnip greens, broccoli, Brussels sprouts, and cabbage are sources high in calcium.
A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which factor should the nurse question? a. Protein intake b. Potassium intake c. Calorie intake d. Sodium intake
Answer: d A weight gain of 2 kg in 3 days suggests fluid retention. Increased sodium intake leads to increased fluid retention. Although it is important to ask the patient about intake of all nutrients, the other options cannot cause this much weight gain in 3 days
Which condition triggers aldosterone secretion to maintain fluid balance within the body? A. Hypocalcemia B. Hyponatremia C.Diabetes mellitus D.Cardiovascular disease
B Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased in order to maintain fluid balance within the body. Hypocalcemia, diabetes mellitus, and cardiovascular disease do not cause the secretion of aldosterone.
Which condition triggers aldosterone secretion to maintain fluid balance within the body? A.Hypocalcemia B.Hyponatremia C.Diabetes mellitus D.Cardiovascular disease
B Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased in order to maintain fluid balance within the body. Hypocalcemia, diabetes mellitus, and cardiovascular disease do not cause the secretion of aldosterone.
Which condition triggers aldosterone secretion to maintain fluid balance within the body? Hypocalcemia Hyponatremia Diabetes mellitus Cardiovascular disease
B Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased in order to maintain fluid balance within the body. Hypocalcemia, diabetes mellitus, and cardiovascular disease do not cause the secretion of aldosterone.
What is the function of aldosterone in the body? A.It causes constriction of renal arterioles. B.It promotes resorption of water and sodium. C.It stimulates secretion of renin for the kidneys. D.It causes constriction of peripheral blood vessels.
B Aldosterone promotes reabsorption of sodium and water into the body, which helps in maintaining blood pressure. Angiotensin II causes constriction of renal arterioles, resulting in low urine output. Factors such as low blood pressure, low blood volume, low oxygen, and low sodium trigger secretion of renin. Angiotensin II causes constriction of peripheral blood vessels and helps in maintaining perfusion to vital organs.
What is the function of aldosterone in the body? It causes constriction of renal arterioles. It promotes resorption of water and sodium. It stimulates secretion of renin for the kidneys. It causes constriction of peripheral blood vessels.
B Aldosterone promotes reabsorption of sodium and water into the body, which helps in maintaining blood pressure. Angiotensin II causes constriction of renal arterioles, resulting in low urine output. Factors such as low blood pressure, low blood volume, low oxygen, and low sodium trigger secretion of renin. Angiotensin II causes constriction of peripheral blood vessels and helps in maintaining perfusion to vital organs.
Laboratory results report a patient's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient? A.Level of consciousness B.Heart rate C.Bowel sounds D.Feet for paresthesias
B Cardiovascular changes, specifically bradycardia; tall, peaked T waves; rhythm changes to complete heart block; asystole; and ventricular fibrillation are life-threatening consequences of elevated potassium. The provider or Rapid Response Team may need to be notified if changes in heart rate and rhythm are assessed. Paresthesias in the arms and feet and increased intestinal motility are lower-priority signs of elevated potassium. Level of consciousness would not be affected.
Laboratory results report a patient's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient? Level of consciousness Heart rate Bowel sounds Feet for paresthesias
B Cardiovascular changes, specifically bradycardia; tall, peaked T waves; rhythm changes to complete heart block; asystole; and ventricular fibrillation are life-threatening consequences of elevated potassium. The provider or Rapid Response Team may need to be notified if changes in heart rate and rhythm are assessed. Paresthesias in the arms and feet and increased intestinal motility are lower-priority signs of elevated potassium. Level of consciousness would not be affected.
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? A. Intake of 5-6g/day of sodium B. Intake of 2-4g/day of sodium C.Intake of 3-5g/day of sodium D.Intake of 4-6g/day of sodium
B Excessive sodium and fluid intake are the main causes of hypervolemia or fluid overload. Nutrition therapy for the patient with fluid overload may involve restriction of sodium and fluid intake. A patient suffering from chronic fluid overload may be restricted to 2-4g/day of sodium. Intake of 5-6g, 3-5g, or 4-6g of sodium per day may lead to further fluid overload and retention.
The nurse is providing education to a patient diagnosed with hypertension. Which statement by the nurse is most appropriate to help the patient maintain a normal fluid balance? A. "Increase your intake of water each day to increase urine output." B. "Limit your intake of sodium to decrease the water you are retaining." C."Foods rich in potassium, such as bananas, will increase urine output." D. "Foods rich in calcium, such as milk, will help to decrease urine output."
B The best way for a patient with hypertension to maintain a normal fluid balance is to limit the intake of dietary salt. The reason for this is that a high sodium intake raises the blood level of sodium, causing more water to be retained in the blood volume and raising blood pressure. The patient may be asked to decrease their fluid intake due to edema. Foods rich in potassium and calcium will not help the patient with hypertension maintain a normal fluid balance.
What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Decreased deep tendon reflexes without paresthesia Awakening at night with muscle spasms in the calf Recent blunt trauma to the throat during a football game Absent bowel sounds Tingling around the mouth
B, C, E A history of anterior neck injury may be associated with hypocalcemia. Symptoms of hypocalcemia include "charley horses" in the calf during rest or sleep, and tingling in the lips. Hypocalcemia does not affect bowel sounds. Decreased deep tendon reflexes without paresthesia is a neuromuscular change in hypercalcemia.
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? A.Monitoring the respiratory rate B.Monitoring the urine output of the patient C.Assessing the sodium and potassium values D.Checking the urine for correct specific gravity E.Monitoring the electrocardiogram patterns (ECG)
B, C, E Patients with fluid overload often have pitting edema, and diuretic therapy focuses on removing the excess fluid. The nursing interventions would be monitoring the patient's response to drug therapy, especially increased urine output and weight loss. Diuretic therapy is associated with electrolyte imbalance; therefore, sodium and potassium levels need to be monitored. Severe electrolyte disturbances may result in arrhythmias. Therefore, changes in the electrocardiogram (ECG) should be monitored. Diuretic therapy does not cause respiratory depression or changes in respiratory rate, so the respiratory rate does not need to be monitored. Checking the urine specific gravity is beneficial in patients to detect the fluid overload. However, it is not useful in patients on diuretic therapy.
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). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the patient's medication teaching? A.Daily weights are a poor indicator of fluid loss or gain. B. Diuretics can lead to fluid and electrolyte imbalances. C.Diuretics increase fluid retention. D.Laxatives can lead to fluid imbalance. E.It is important to weigh daily at the same time.
B, D, E Diuretics decrease fluid retention and increase loss of fluids, thus can lead to fluid and electrolyte imbalances. Laxatives can also lead to fluid imbalance. Daily weight recording is a good indicator of fluid retention. Patients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.
Which hormones play a role in the regulation of sodium balance by the kidneys? Cortisol Aldosterone Angiotensin Natriuretic peptide (NP) Antidiuretic hormone (ADH)
B, D, E Serum sodium levels are regulated by the kidneys under the influence of aldosterone, natriuretic peptide (NP), and antidiuretic hormone (ADH). Low serum sodium levels inhibit the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP) and trigger the secretion of aldosterone. This increases the serum sodium levels by increasing the reabsorption of sodium and enhancing water loss by the kidney. High serum sodium levels inhibit aldosterone secretion and stimulate the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP). These hormones increase the excretion of sodium and reabsorption of water by the kidney. Cortisol and angiotensin do not regulate the serum sodium levels.
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling? A. Dry oral mucous membranes B. Orthostatic blood pressure changes C. Pulse rate of 72 beats/min and bounding D. Serum potassium level of 4.0 mEq/L
B. Orthostatic blood pressure changes Blood pressure decreases when changing positions. The patient may not have sufficient blood flow to the brain, causing sensations of lightheadedness and dizziness. This problem increases the risk for falling, especially in older adults. Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does not assess for fall risk.
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 iron Reduce the intake of calcium Reduce the intake of sodium Reduced the intake of phosphorous
C High sodium intake raises the serum sodium level, which causes more water to be retained. This in turn increases the blood volume and raises the blood pressure. Hence, patients who have hypertension are often asked to limit their intake of sodium. Intake of iron, phosphorus, or calcium does not cause water retention in the blood, and therefore, does not affect the blood pressure.
When planning care for a patient with hypercalcemia, which intervention does the nurse consider? A.Assess oxygen saturation levels every 4 hours. B.Avoid invasive procedures due to increased bleeding tendency. C.Monitor cardiac rhythm for changes. D.Limit activities to protect against injury.
C Hypercalcemia increases the risk for cardiac dysrhythmias. It does not impair gas exchange, so oxygen saturation does not need to be routinely monitored. There is a greater tendency to clot, especially with slow venous perfusion, so invasive procedures do not need to be avoided and increased activity (not restriction) is recommended.
When planning care for a patient with hypercalcemia, which intervention does the nurse consider? Assess oxygen saturation levels every 4 hours. Avoid invasive procedures due to increased bleeding tendency. Monitor cardiac rhythm for changes. Limit activities to protect against injury
C Hypercalcemia increases the risk for cardiac dysrhythmias. It does not impair gas exchange, so oxygen saturation does not need to be routinely monitored. There is a greater tendency to clot, especially with slow venous perfusion, so invasive procedures do not need to be avoided and increased activity (not restriction) is recommended.
Which condition could be evident in laboratory reports of a hypervolemic patient? A. Hemostasis B. Homeostasis C.Hemodilution D.Hemoconcentration
C Hypervolemia or fluid overload is characterized by decreased hemoglobin, hematocrit, and serum protein levels due to excessive water in the vascular space. This condition is called hemodilution. Hemostasis and homeostasis are not associated with hypervolemia or fluid overload. Hemoconcentration is the condition associated with hypovolemia or dehydration.
Which condition could be evident in laboratory reports of a hypervolemic patient? Hemostasis Homeostasis Hemodilution Hemoconcentration
C Hypervolemia or fluid overload is characterized by decreased hemoglobin, hematocrit, and serum protein levels due to excessive water in the vascular space. This condition is called hemodilution. Hemostasis and homeostasis are not associated with hypervolemia or fluid overload. Hemoconcentration is the condition associated with hypovolemia or dehydration.
Which electrolyte imbalance should be anticipated and monitored in a patient with hyperphosphatemia? A. Hypernatremia B. Hypokalemia C. Hypocalcemia D. Hypermagnesemia
C Phosphorus and calcium have an inverse or reciprocal relationship. When one is increased, the other is usually decreased. Therefore, a patient with hyperphosphatemia should be monitored for hypocalcemia. Hyperphosphatemia does not cause hypernatremia, hypokalemia, or hypermagnesemia.
A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? A.Blood pressure B.Pulse C.Respirations D.Temperature
C Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any patient who might have hypokalemia. Blood pressure and pulse will be altered in this patient, but they are not the priority assessment. Temperature is not a priority assessment for the patient with hypokalemia.
Which is the most critical fluid to prevent death? Urine Perspiration Blood volume Intracellular fluid
C The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid). Of these two, the most critical fluid balance to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate perfusion and gas exchange of all organs and tissues. Urine and perspiration both play a role in fluid balance but are not critical fluids to prevent death.
Which is the most critical fluid to prevent death? A.Urine B.Perspiration C.Blood volume D.Intracellular fluid
C The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid). Of these two, the most critical fluid balance to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate perfusion and gas exchange of all organs and tissues. Urine and perspiration both play a role in fluid balance but are not critical fluids to prevent death.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.
A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?
Cardiac irregularities
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? A.Dialysis/home care B. Geriatric/rehabilitation C.Medical-surgical D. Telemetry/cardiac stepdown
D Because hypermagnesemia causes changes in the electrocardiogram that may result in cardiac arrest, the patient should be admitted to the telemetry/cardiac stepdown unit. Dialysis/home care units, geriatric/rehabilitation units, and medical-surgical units typically do not have cardiac monitoring capabilities.
Which assessment finding is consistent with fluid overload? A.Heart murmurs B.Decreased pulse rate C.Decreased respiratory rate D.Moist crackles in the lungs upon auscultation
D Patients with fluid overload will often have moist crackles in the lungs, an increased respiratory rate, and an increased pulse rate. Heart murmurs are not associated with fluid overload.
The nurse is providing teaching to a student nurse about how antidiuretic hormone (ADH) plays a central role in the reabsorption of water by the kidneys. The nursing student is correct to place the following components of the homeostatic action of ADH in the correct sequence. Use all the options. a. Stored ADH is released into circulation. b. ADH is transported along a neural pathway to the posterior pituitary gland. c. Aquaporins are inserted into tubular cell membranes. d. ADH is synthesized by cells in the supraoptic and paraventricular nuclei of the hypothalamus. e. Serum osmolality increases.
D, B, E, A, C
Which consequence of fluid overload may result in seizures, coma, and death? A. Decreased hematocrit B. Decreased hemoglobin C. Decreased serum proteins D. Decreased serum sodium and potassium levels
D. Decreased serum sodium and potassium levels Fluid overload may cause a decrease in serum electrolytes such as sodium and potassium, which can lead to seizures, coma, and death. A decrease in hematocrit due to fluid overload decreases the serum osmolarity, which may cause pulmonary edema or heart failure. A decrease in hemoglobin increases the respiratory rate to meet the oxygen needs of the body. A decrease in serum proteins decreases the serum osmolarity and may cause pulmonary edema or heart failure.
A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? Hypernatremia Hypomagnesemia Hypercalcemia Hyperphosphatemia
Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).
When an 80-year-old client who takes diuretics for management of hypertension informs the nurse she take laxatives daily to promote bowel movements, the nurse assesses the client for possible symptoms of
Hypokalemia
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?
Hyponatremia
During an assessment of an elderly client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. The nurse recognizes that what medical diagnosis may be responsible?
Hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN).
Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
Isotonic
A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?
Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43-). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.
A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following?
Lungs (The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.)
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?
Measuring weight daily
A nurse monitoring a patient's IV infusion auscultates the patient's lung sounds and finds crackles in the bases in lungs that were previously clear. What would be the appropriate intervention in this situation?
Notify primary care provider immediately for possible fluid overload
A 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?
Spinach Sardines, whole grains, and green leafy vegetables also provide calcium.
You are volunteering in the medical tent of a road race on a hot, humid day. A runner who has collapsed on the road is brought in with the following symptoms: sunken eyes, a body temperature of 100°F, and a complaint of dizziness while sitting to have his blood pressure taken (which subsides upon his lying down). These are signs of a fluid volume deficit. Which of the following treatments should be carried out first? a. Offer water by mouth. b. Begin cooling of his body by ice packs. c. Give him a transfusion of FFP. d. Give him an electrolyte solution by mouth.
d. Give him an electrolyte solution by mouth.
1. A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a."Try to drink at least six to eight glasses of water each day." b."Try to limit your fluid intake to one quart of water daily." c."Limit sugar, salt, and alcohol in your diet." d."Report side effects of medications you are taking, especially diarrhea." e."Temporarily increase foods containing caffeine for their diuretic effect." f."Weigh yourself daily and report any changes in your weight."
a, c, d, f. Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.
A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply.
a. "Try to drink at least six to eight glasses of water each day." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." f. "Weigh yourself daily and report any changes in your weight."
A nurse in a medical unit has noted that a client's potassium level is elevated at 6.1 mEq/L. The nurse has notified the physician, removed the banana from the client's lunch tray, and is performing a focused assessment. When questioned by the client for the rationale for these actions, which of the following explanations is most appropriate? a. "Your potassium level is high, and so I need you let me know if you feel numbness, tingling, or weakness." b. "Your potassium levels in the blood are higher than they should be, which brings a risk of changes in the brain function." c. "I'll need to monitor you today for signs of high potassium; tell me if you feel as if your heart is beating quickly or irregularly." d. "The amount of potassium in your blood is too high, but this can be resolved by changing the intravenous fluid you are receiving."
a. "Your potassium level is high, and so I need you let me know if you feel numbness, tingling, or weakness."
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.
a. 5% dextrose in water (D5W) d. 0.33% NaCl (¹∕³-strength normal saline) e. 0.45% NaCl (½-strength normal saline)
A patient arrives in the ED very hypovolemic related to excretion of "at least 3 gallon jugs of urine in the past 24 hours." He describes the urine as being clear-like water. The physician suspects diabetes insipidus. The nurse should be prepared to administer which of the following medications? a. Desmopressin acetate (DDAVP) b. Benadryl, an anticholinergic c. Calcium gluconate d. Prednisone
a. Desmopressin acetate (DDAVP)
Recognizing the prevalence and incidence of dehydration among older adults, a care aide at a long-term care facility is in the habit of encouraging residents to drink even though they may not feel thirsty at the time. Which of the following facts underlies the care aide's advice? a. Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high. b. The metabolic needs for both fluid and sodium in older adults differ from those of younger individuals. c. Regulation and maintenance of effective circulating volume by the kidneys is less effective in the elderly. d. The renin-angiotensin-aldosterone system (RAAS) is less able to facilitate sodium clearance in older adults.
a. Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high.
A 77-year-old female hospital patient has contracted Clostridium difficile during her stay and is experiencing severe diarrhea. Which of the following statements best conveys a risk that this woman faces? a. She is susceptible to isotonic fluid volume deficit. b. She is prone to isotonic fluid volume excess. c. She could develop third-spacing edema as a result of plasma protein losses. d. She is at risk of compensatory fluid volume overload secondary to gastrointestinal water and electrolyte losses.
a. She is susceptible to isotonic fluid volume deficit.
A 26-year-old male patient with a diagnosis of schizophrenia has been admitted with suspected hyponatremia after consuming copious quantities of tap water. Given this diagnosis, what clinical manifestations and lab results should the nurse anticipate the patient will exhibit? a. High urine specific gravity, tachycardia, and a weak, thready pulse b. Low blood pressure, dry mouth, and increased urine osmolality c. Increased hematocrit and blood urea nitrogen and seizures d. Muscle weakness, lethargy, and headaches.
d. Muscle weakness, lethargy, and headaches
A client is brought to the emergency department with complaints of shortness of breath. Assessment reveals a full, bounding pulse, severe edema, and audible crackles in lower lung fields bilaterally. What is the client's most likely diagnosis? a. Hyponatremia b. Fluid volume excess c. Electrolyte imbalance: hypocalcemia d. Hyperkalemia
b. Fluid volume excess
An 81-year-old female has a long-standing diagnosis of hypocalcemia secondary to kidney disease. She will be moving into an assisted living facility shortly. Which of the following clinical manifestations would the nursing staff at the facility likely observe in this patient? a. Loss of appetite and complaints of nausea b. Muscular spasms and complaints of tingling in the hands/feet c. High fluid intake and copious amounts of dilute urine output d. Lethargy and change in level of consciousness
b. Muscular spasms and complaints of tingling in the hands/feet
10. A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a.Encourage foods and fluids with high sodium content. b.Administer oral K supplements as ordered. c.Caution the patient about eating foods high in potassium content. d.Discuss calcium-losing aspects of nicotine and alcohol use.
b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.
A 56-year-old female hospital patient with a history of alcohol abuse is receiving intravenous (IV) phosphate replacement. Which of the following health problems will this IV therapy most likely resolve? a. The client has an accumulation of fluid in her peritoneal cavity. b. The client is acidotic and has impaired platelet function. c. The client has an irregular heart rate and a thread pulse. d. The client has abdominal spasms and hyperactive reflexes.
b. The client is acidotic and has impaired platelet function.
9. A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? a.Kidneys b.Lungs c.Adrenal glands d.Blood vessels
b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.
An ECG technician is performing an ECG on a hospital patient who has developed hypokalemia secondary to diuretic use. Which of the following manifestations of the client's health problem will the technician anticipate on the ECG? a. Irregular heart rate and a peaked T wave b. A low T wave and an absent P wave c. A prominent U wave and a flattened T wave d. A narrow QRS complex and an absent U wave
c. A prominent U wave and a flattened T wave
A 34-year-old male client has diagnoses of liver failure, ascites, and hepatic encephalopathy secondary to alcohol abuse. The client's family is questioning the care team as to why his abdomen is so large even though he is undernourished and emaciated. Which of the following statements most accurately underlies the explanation that a member of the care team would provide the family? a. An inordinate amount of interstitial fluid is accumulating his abdomen. b. The transcellular component of the intracellular fluid compartment contains far more fluid than normal. c. Normally small transcellular fluid compartment, or third space, is becoming enlarged. d. Gravity-dependent plasma is accumulating in his peritoneal cavity.
c. Normally small transcellular fluid compartment, or third space, is becoming enlarged.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes.
The nurse is caring for a client who was found after spending 2 days without food or water in the desert and was admitted through the emergency department. The client is severely dehydrated. What are reasons why the human body requires fluid? Select all that apply.
facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes Water in the body functions primarily to provide a medium for transporting nutrients to cells and wastes from cells; to provide a medium for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells throughout the body; to facilitate cellular metabolism and proper cellular chemical functioning; to act as a solvent for electrolytes and nonelectrolytes; to help maintain normal body temperature; to facilitate digestion and promote elimination; and to act as a tissue lubricant. Water does not, by itself, provide hydrogen or glucose.