Chapter39 Fluid and Electrolyte Imbalances
What is the reason for relative dehydration? Too much fluid loss Too little fluid intake Fluid shift from plasma to interstitial space Fluid shift from interstitial space to plasma
C Dehydration without actual loss of total body water, such as when the fluid shifts from plasma to the interstitial space, is called relative dehydration. Too much fluid loss is the decrease in the total body water, leading to dehydration. Too little fluid intake also causes an actual decrease in the total water content of the body, which results in dehydration. A fluid shift from the interstitial space to the plasma causes an increase in plasma volume, which is a condition known as hypervolemia.
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.
Which assessment findings will indicate the need for continuation of prescribed fluid replacement therapy in a patient diagnosed with dehydration? Hemoglobin of 13.5 g/dL Pulse pressure of 28 mm Hg Urine output of 400 mL per day Respiratory rate of 20 breaths per minute Neck veins distention when the patient is in a supine position
B, C Pulse pressure below 40 mm Hg and urine output below 500 mL are abnormal and require continuation of the fluid replacement therapy. Hemoglobin of 13.5 g/dL is within the normal range. Respiratory rate of 20 breaths per minute is also a normal finding. Neck veins distention is evidence of fluid overload.
The nurse manager of the medical-surgical unit assigns which patient to the LPN/LVN? 44-year-old admitted with dehydration who has a heart rate of 126 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home 64-year-old admitted yesterday with heart failure who still has dependent pedal edema 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea
C Because the patient with heart failure is the most stable of the four patients, this patient is most appropriate to assign to the LPN/LVN. Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a patient indicate that he or she is unstable and should be cared for by RN staff members.
How much fluid should a healthy adult consume each day to maintain adequate urine output? 2 L/day 2.3 L/day 2.6 L/day 2.9 L/day
B Most healthy adults take in about 2300 mL of fluid each day, which is equivalent to 2.3 L/day. The other figures do not accurately account for the amount of daily fluid from food and liquids.
Which is an age-related change that impacts fluid balance? Loss of skin elasticity Adrenal hypertrophy Increased thirst reflex Increased muscle mass
A
A patient's electrocardiogram demonstrates a heart rate of 52 beats/min, prolonged PR interval with widened QRS complex, and the patient is also hypotensive. The nurse reviews the morning labs for which conditions? Hyperkalemia, hypercalcemia, hypermagnesemia Hypokalemia, hypocalcemia, hypermagnesemia Hypocalcemia, hyperkalemia, hypernatremia Hypernatremia, hypercalcemia, hypophosphatemia
A Cardiovascular changes are consistent with elevated potassium, calcium, and magnesium. These signs and symptoms may progress to life-threatening cardiac emergency. Although hypocalcemia can interfere with cardiac contractility, hypokalemia and hypophosphatemia do not.
What is the preferred diuretic used for patients with hypokalemia? Amiloride Furosemide Bumetanide Chlorthiazide
A Diuretics that increase the kidney excretion of potassium can cause hypokalemia. A potassium sparing diuretic may be prescribed to increase the urine output without increasing potassium loss. Amiloride is an example of potassium sparing diuretic, which is preferred for patients diagnosed with hypokalemia. Furosemide, bumetanide, and chlorthaiazide are examples of high ceiling, loop, or thiazide diuretics. These loop and thiazide diuretics promote excretion of potassium along with water; therefore, they are not used in patients diagnosed with hypokalemia.
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
What parameter does the nurse assess for in a postoperative patient to determine perfusion adequacy? Urine output Blood volume Blood pressure Glomerular filtration rate
A Hemorrhage is a risk factor in postoperative patients. The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs, which is why urine output is used to measure the perfusion adequacy after surgery. Blood volume, blood pressure, or glomerular filtration rate are not indicators of perfusion adequacy in postoperative patients.
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 primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient? Hyperkalemia Hyperglycemia Hypernatremia Hypercalcemia
A Hyperkalemia is a condition where serum potassium levels are high. Potassium movement into the cells is enhanced by insulin. Intravenous administration of 100 mL 10% to 20% glucose with 10 to 20 units of regular insulin helps decrease serum potassium levels. Insulin increases the activity of sodium-potassium pumps, which decreases serum potassium levels temporarily by moving potassium from the extracellular fluid to the cells. This therapy is prescribed as an add-on therapy along with diuretics in a hyperkalemic patient. Conditions such as hyperglycemia, hypernatremia, and hypercalcemia cannot be managed with this insulin and glucose therapy.
How is isotonic dehydration defined? Fluids and electrolytes are lost from the body in equal amounts. Fluids are lost from the body in greater quantities than electrolytes. Electrolytes are lost from the body in greater quantities than fluids. Fluids and electrolytes are lost from the body, but only water is used to replace losses.
A Isotonic dehydration is when fluids and electrolytes are lost in equal quantities. Hypertonic dehydration occurs when fluids are lost in greater quantities than electrolytes. Hypotonic dehydration occurs when electrolytes are lost in greater quantities than fluids, or when fluid and electrolyte losses are replaced by water only.
Which total urine output for the previous day would place a patient at risk for accumulating waste products? 500 mL 700 mL 900 mL 1100 mL
A The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. 700 mL, 900 mL, and 1100 mL of total urine output will not place the patient at risk for accumulating waste products.
The RN is assessing a 70-year-old patient admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? Patient behavior that changes from anxious and restless to lethargic and confused Deep furrows on the surface of the tongue Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched 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.
Which condition would stimulate the renin-angiotensin II to maintain fluid balance within the body? Shock Hypoglycemia Hypercalcemia Water intoxication
A The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs. This is why urine output is used as an indicator of perfusion adequacy after surgery or any time the patient has undergone an invasive procedure and is at risk for hemorrhage. Hypoglycemia, hypercalcemia, and water intoxication are not conditions that stimulate the renin-angiotensin II to maintain fluid balance within the body.
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
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).
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.
The nurse is caring for a patient with dehydration. Which task can be delegated to unlicensed assistive personnel (UAP)? Offering 2-4 ounces of fluid to the patient every hour. Calculating the IV fluid rate necessary to replace lost fluids. Administering prescribed antidiarrheal medications to stop fluid losses. Assessing the patient every hour for neurologic or cardiovascular changes.
A Unlicensed assistive personnel (UAP) can aid in encouraging patients who are dehydrated to consume the necessary fluids. Calculating IV fluid rates, administering medications, and performing assessments are out of the scope of practice for UAPs.
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? Hyponatremia Hypokalemia Hypercalcemia Hypochloremia 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? Assess for orthostatic hypotension. Orient the patient frequently. Loosely apply upper-extremity wrist restraints. Maintain a calm, dim room to reduce confusion. Place the bed in the lowest position with brakes locked. 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.
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.
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.
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? 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? 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? Intake of 5-6g/day of sodium Intake of 2-4g/day of sodium Intake of 3-5g/day of sodium 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? "Increase your intake of water each day to increase urine output." "Limit your intake of sodium to decrease the water you are retaining." "Foods rich in potassium, such as bananas, will increase urine output." "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.
A hypertensive patient was brought to the emergency department with a heart rate of 115 beats per minute and an abnormal electrocardiogram showing a shortened QT interval. The laboratory findings of the patient show a serum calcium level of 11 mg/dL. What nursing interventions would help stabilize the patient? Administering thiazide diuretics Administering high ceiling or loop diuretics Administering 0.9% normal saline intravenously Administering Ringer's lactate solution intravenously Administering non-steroidal, anti-inflammatory agents
B, C Hypercalcemia clinically manifests as serum calcium levels above 10.5 mg/dL. This condition can be managed by using loop diuretics such as furosemide, which promote the excretion of calcium. One cause of hypercalcemia is dehydration, which can be well managed by administering 0.9% normal saline intravenously. Thiazide diuretics do not promote the excretion of calcium and thus are not suitable treatments for hypercalcemia. Ringer's lactate solution contains calcium; administering this solution does not help decrease the serum calcium levels. Administering non-steroidal, anti-inflammatory agents prevents hypercalcemia by calcium resorption from the bone; however, it does not treat hypercalcemia.
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? Monitoring the respiratory rate Monitoring the urine output of the patient Assessing the sodium and potassium values Checking the urine for correct specific gravity 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? Daily weights are a poor indicator of fluid loss or gain. Diuretics can lead to fluid and electrolyte imbalances. Diuretics increase fluid retention. Laxatives can lead to fluid imbalance. 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.
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? 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? 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.
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? Hyperkalemia Hypercalcemia Hyponatremia 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
Which electrolyte imbalance should be anticipated and monitored in a patient with hyperphosphatemia? Hypernatremia Hypokalemia Hypocalcemia 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? Blood pressure Pulse Respirations 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.
What is the primary assessment in evaluating the effectiveness of diuretic therapy? Blood pressure Respiratory rate Urinary output Skin turgor
C Since the most direct effect of a diuretic is diuresis, urinary output is the most reliable indicator of its effectiveness. Blood pressure, respiratory rate, and skin turgor all reflect volume status, but are not the primary evaluation of diuretic administration.
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.
The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? 24-hour urine output Asking the patient about feeling depressed Hourly deep tendon reflexes (DTRs) 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
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.
On the second day of caring for a patient with generalized edema, which change best reflects that the administered diuretic is effective? Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr Respiratory rate decrease from 24 to 20 Weight loss of 6 pounds 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? Absent T waves Elevated P waves Prolonged PR intervals 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.
The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit. Which lab result is severely abnormal? Potassium, 3.5 mEq/L Sodium, 137 mEq/L Chloride, 107 mEq/L Magnesium, 6.2 mEq/L
D A magnesium level of 6.2 mEq/L is greatly elevated. Patients with severe hypermagnesemia are in grave danger of cardiac arrest. The normal magnesium level is 1.3-2.1 mEq/L. The sodium and potassium results are within normal limits. The chloride level is just slightly elevated, with the normal range being between 98-106 mEq/L.
An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this patient related to the reason for admission? What is your typical urinary elimination pattern and amount? How is your appetite? Have you noticed a change in the tightness of your shoes? What is your typical daily fluid intake and what types of fluids do you drink?
D Asking the patient about the amount and types of fluids will provide additional information as to how the patient deals with incontinence through fluid management and possible causes for the dehydration. Asking the patient about appetite, urinary pattern, and tightness of shoes is not helpful in assessing the patient's current health problem.
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? Dialysis/home care Geriatric/rehabilitation Medical-surgical 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.
A 5-year-old child is brought into the emergency department with persistent vomiting and diarrhea. The child's parents state that the child has lost 4 pounds since the symptoms began. Based on this information, approximately how much fluid has the child lost? 500 milliliters 1 liter 1.5 liters 2 liters
D One pound of body weight is approximately equal to 500 mL of fluid. With a weight change of 4 pounds, the child has lost approximately 2 liters of fluid.
Which assessment finding is consistent with fluid overload? Heart murmurs Decreased pulse rate Decreased respiratory rate 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.
A patient presents to the emergency room with confusion, altered level of consciousness, dry mouth, scaly skin, and very loose fitting shoes. Which finding in the patient's history is significant? Unusual increase in body weight Decreased exposure to higher altitudes Decreased sense of thirst in the patient Decreased ingestion of solid foods such as gelatin
D The patient whose shoes are suddenly loose may be dehydrated. Dehydration is manifested as changes in mental status such as confusion and altered levels of consciousness, dry mouth, scaly skin and an elevated serum osmolarity. If the patient stopped eating foods that are liquid at room temperature, such as gelatin, there may be concerns about dehydration. Weight gain that is proportional to fluid loss is not an indication of dehydration. Patients with decreased exposure to higher altitudes are at a lower risk of dehydration. A decreased sense of thirst in patients may not be a sign of dehydration.
Which consequence of fluid overload may result in seizures, coma, and death? Decreased hematocrit Decreased hemoglobin Decreased serum proteins Decreased serum sodium and potassium levels
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.
Which condition is least likely to cause fluid overload? Heart failure Kidney failure Diabetes insipidus Psychiatric disorders
Diabetes insipidus Diabetes insipidus is manifested as polyuria, which means the passage of frequent and large amounts of urine, leading to dehydration. Heart failure is manifested as peripheral edema, which refers to the retention of fluid in the lower extremities of the body. Kidney failure is manifested as decreasing or no production of urine, which causes retention of fluids in the body, resulting in fluid overload. Psychiatric disorders may lead to polydipsia, which may lead also to fluid overload.
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).
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling? Dry oral mucous membranes Orthostatic blood pressure changes Pulse rate of 72 beats/min and bounding Serum potassium level of 4.0 mEq/L
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.
Laboratory results for a patient with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action? Assess the patient's respiratory status. Establish intravenous access. Notify the provider of laboratory results. Assess for orthostatic hypotension
assess the pts resp. status Hyponatremia may present with neuromuscular changes including muscle weakness of the legs, arms, and respiratory muscles. The nurse should assess the respiratory effectiveness of a patient with hyponatremia as a priority. Obtaining assessment data is important when calling the provider in addition to reporting the laboratory result. Establishing IV access and assessing for orthostatic hypotension are important, but are lower-priority interventions.
