Chapter 40 Electrolytes

Potassium

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

daily weights

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

hypokalemia.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

1 unit over 2 to 3 hours, no longer than 4 hours

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

remove iv

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Metabolic alkalosis

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

decreased potassium

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Cryoprecipitate

A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer?

decreased blood volume and intracellular dehydration

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

hypotonic Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

cardiac irregularities

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

renin.

A decrease in arterial blood pressure will result in the release of:

Renin

A decrease in arterial blood pressure will result in the release of: thrombus. insulin. protein. renin.

3,000

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

apricots

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Avoid salty or excessively sweet fluids.

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?" What would the nurse include as a suggestion for this client?

Discontinue the IV.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?

Discontinue the IV and relocate it to another spot.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Infants

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

Size of Catheter administration location of iv catheter

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

2,600 mL

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

Ensure that the prescribed solution is clear and transparent.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Banana

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

banana

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

"You won't have to endure any more needlesticks."

A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?

Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated, notify the primary care provider immediately.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

distended neck veins

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

60 drops/mL

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

50 gtt/min

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

Changing the dressing on a client's peripheral IV site

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?

the band members should drink large amounts of water.

A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:

placing the tourniquet on the upper arm for 2 minutes

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

replacement of fluids for those lost from vomiting and diarrhea.

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

a winged

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

total parenteral nutrition.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

Offer small amounts of preferred beverage frequently.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options.

Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. Cleanse the site with chlorhexidine. Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. Insert the needle gently. Release the tourniquet. Stabilize the catheter or needle.

Not wearing gloves when preforming the intervention

As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action?

aldosterone.

How is control over the extracellular concentration of potassium within the human body is exerted?

Muscle weakness, fatigue, and dysrhythmias

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

cardiac function

Potassium is needed for neural, muscle, and:

Hypokalemia

Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 5.75 mg/dL (1.8 mEq/L) Based on these levels, the nurse would identify which imbalance?

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

83 mL/hr

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

"Let me refer you to the blood bank so they can provide you with information."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

O negative

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

Cardiac dysrhythmias

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?

"I received a blood transfusion in the United Kingdom."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

-H2CO3 level in the blood decreases -pH becomes more alkaline -Blood level of CO2 decreases -Decreased respirations -Carbon dioxide retention -Carbonic acid formed

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2.

sodium, chloride, and bicarbonate.

The primary extracellular electrolytes are:

glomerulus

The process of filtration begins at the:

phlebitis.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

Arterial blood gas

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Apply a warm compress.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

chloride

Which is a common anion?

Acute Confusion related to cerebral edema

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which statement most accurately describes the process of osmosis?

Potassium is needed for neural, muscle, and:

cardiac function

extracellular fluid volume excess

dema happens when there is which fluid volume imbalance?

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 Hypovolemia refers to a state of low extracellular fluid volume, generally secondary to combined sodium and water loss. All living organisms must maintain an adequate fluid balance to preserve homeostasis. Water constitutes the most abundant fluid in the body, at around 50% to 60% of the body weight

correct way to prime tubing

position for priming