Elimination and Fluid/Electrolyte
The nurse is listening for bowel sounds in a postoperative client. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The client asks the nurse why this is happening. What is the nurse's best response?
"Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel"
The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse would explain why this practice should be changed?
"If you continue to ignore the urge to defecate, it may lead to diminished reflex and hard stool"
Upon palpation, the nurse notices that the bladder is firm and distended; the client expresses an urge to urinate. The nurse should follow up by asking
"When was at the last time you voided?"
The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Which nurse response is most appropriate?
"You should bring the infant in to be seen by the health care provider?"
The client presents to the emergency room with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially?
0.9% normal saline
The client has a condom catheter ordered to be placed. Put in order how each of the following should be performed.
1. Clean and dry the penis. 2. Apply skin protecting cream and allow to dry. 3.Wrap the adhesive spirally around the shaft of the penis. 4.Placed the rolled condom over the glans penis and unroll it gently over the penis. 5.Attach a large leg drainage bag to reduce frequency of the bag emptying.
A client is being seen in the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The health care provider has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have been successful?
40 mL per hour
The nurse emptied 2,000mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000mL at the beginning of the shift. There was 1,800mL left in the bag eight hours later. Which is the correct urine output at the end of the eight hours? (Only need to place number in answer)
800 mL
3% Saline 5% Saline 10% Dextrose in Water (D10W) 5% Dextrose in 0.9% Saline 5% Dextrose in 0.45% saline 5% Dextrose in Lactated Ringer's
Hypertonic solutions
0.45% Saline (1/2 NS) 0.225% Saline (1/4 NS) 0.33% saline (1/3 NS)
Hypotonic solutions
What are the principles of fluid balance in infants?
Infants have a greater percent of fluid in the extracellular compartment compared to adults; Answers: therefore, they have greater and more rapid fluid losses.
The client's laboratory report today indicates a potassium of 2.5 m/Eq/L, and the nurse has notified the health care provider and received new orders. Nursing assessment indicates that the heart rhythm is irregular. What is the most important nursing intervention for this patient now?
Institute fall precautions due to potential orthostatic hypotension and weak leg muscles.
A client's serum sodium level is 150 mg/dL. Which interventions should the nurse plan for this client? Select all that apply.
Instruct the client regarding a low sodium diet Administer diuretics as prescribed
0.9% Saline 5% dextrose in water (D5W) 5% Dextrose in 0.225% saline (D5W1/4NS) Lactated Ringer's
Isotonic solutions
Which fluid does the nurse anticipate will be administered for the client experiencing isotonic dehydration?
Lactated ringer's
The client is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
Monitor diarrhea, charting amount, character and consistency Administer diphenoxylate and atropine as ordered Offer banana and pedialiyte to client
The client who has undergone surgery has a nasogastric tube in place and an IV running at 150mL/hr. Which date should be reported to the health care provider?
On auscultation, crackles and rhonchi in all lung fields are noted
Which action does the nurse use to obtain a urine sample in a toddler?
Place a clear plastic, self adhering bag (urine bag) to the genitalia area
You are providing nursing care for a client admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP?
Providing the client with a clean catch urine sample container
The nurse is caring for a client with a retention catheter. The nurse finds that the drainage bag is lying on the floor when she enters the room to assess the client. Which nursing diagnosis would be appropriate for this client?
Risk for Infection related to improper handling
The nurse has just received a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. The nurse is reviewing the assignment and determines that which child is at greatest risk for dehydration?
a 15 month old child with tachypnea
The nurse knows that a bowel elimination schedule would be most beneficial in the plan of care for which client?
a 70-year-old client with stool incontinence
When caring for a client diagnosed with urinary retention, the nurse would anticipate an order for
a urinary catheter
The nurse checks the results of lab tests for the client and notes that the potassium level is 2.8 mEq/L. The nurse assesses the client for
a weak, irregular pulse
The client being admitted from the emergency department is diagnosed with a fecal impaction. Which intervention should be implemented?
administer an oil retention enema
The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first?
assess the continuous irrigation catheter for patency
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all that apply.
blood pressure of 90/40 temperature of 102 degrees Farenheit tenting of the skin
The nurse notes that a client is receiving Lactate Ringer's when the orders state that the IV solution should be D5W. What is the first thing the nurse should do?
change the solution to D5W
The nurse assess the client and has determined possible fluid overload from which assessment?
client's complains of being short of breath and auscultation results in bilateral crackles
The nurse checking the laboratory results of a client with renal calculi notes that the creatinine level is 3.5 mg/dL and the BUN is 45 mg/dL. In light of these results, which action should the nurse take first? Normal creatinine levels are 0.6 - 1.2 mg/dL Normal BUN levels are 7-20 mg/dL
contact the health care provider to report the results
A client has experienced vomiting and diarrhea for several days. The nurse understands that the nursing interventions should include safety precautions because hypovolemia can lead to:
decreased cerebral circulation ad postural hypotension
A nurse is caring for a client who is experiencing diarrhea. About which physiological response to diarrhea should the nurse be most concerned?
dehydration
A nurse is caring for a group of clients. Which client factor should the nurse identify as placing a client at risk for bowel incontinence?
disordered on time, place, and person
A 6 month old has severe diarrhea. The nurse admitting the infant understands the major problem associated with severe diarrhea is
electrolyte and fluid loss
The nurse is caring for a client who has suffered a spinal cord injury and is concerned about the client's elimination status. What is the nurse's best action?
establish a bowel and bladder program with the client
Which information about a client is communicated when a nurse documents that the client has polyuria?
excreting excessive amount of urine
The nurse is caring for a client who has been receiving intravenous fluids at 250mL/hr. The nurse assesses that the client has crackles, shortness of breath, and jugular vein distention. The nurse would recognize these findings as an indication of which complication of IV fluid therapy?
fluid volume excess
The health care provider's orders read flush NG tube with 30-50 mL 0.9 % isotonic saline solution for irrigation q2h prn. The nurse knows that saline solution is used instead of water because:
flushing with water can deplete electrolytes in the stomach
A nurse notifies the health care provider immediately if a client with an indwelling catheter
has not collected any urine in the drainage bag in the last 2 hours
The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should the nurse identify as supporting the diagnosis of dehydration?
hematocrit 53%
During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
history of frequency UTI's a fecal impaction perineal skin irritation fluid intake of less than 1000ml/day
Solution used to raise serum osmolality. This solution will pull fluids intracellular and ind interstitial into the blood vessels
hypertonic solution
A nurse is performing an assessment on a client who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding?
hypoactive bowel sounds
Solution used when the cell is dehydrated and fluids need to be put back intracellularly
hypotonic solution
The client complans she voids spontaneously without recognizing the need to void, how should the RN document her current urinary pattern?
incontinence
Solution used to increase the EXTRACELLULAR fluid volume due to blood loss, surgery, dehydration, fluid loss that has been lost extracellularly
isotonic solution
The nurse should place the client in which position when preparing to administer an enema?
left sims position
Which adaptation is most significant in indicating the presence of a fecal impaction?
liquid fecal seepage with no passage of stool
The nurse is caring for a client with chronic constipation. The nurse is aware that which may be causes of constipation?
opioid use chronic laxative use bedrest low fiber foods
An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling?
orthostatic blood pressure changes
The client is admitted with a hematocrit of 30% and a serum level of 152mEq/L. Which condition is a cause of these findings?
over hydration
A client asks about treatment for urge urinary incontinence. The nurse's best response is to advise the client to
perform pelvic floor exercises
The nurse is assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the health care provider?
positive trousseau's sign in client with acute pancreatitis
The nurse assesses the client which results in oxygen saturation level of 90%; serum sodium of 14 mEq/L; and serum potassium of 3 mEq/L. The nurse reports the findings to the healthcare provider and receives several prescriptions. Which prescription should the nurse question?
potassium chloride 40 mEq IV push now
The nurse is caring for a cancer client who presents with anorexia, blood pressure 100/60, elevated white blood cell count and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to
replace fluid, electrolyte, and nutrient in the client
A nurse is planning care for a client with fluid volume overload and hyponatremia. Which of the following should be included in this client's plan of care?
restrict fluids
A client is diagnosed with severe hyponatremia. The nurse realizes this client will mostly likely need which of the following precautions implemented?
seizure
The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?
serum potassium
What action by the nurse can help limit common side effects of morphine sulfate 10 mg every 4 hours prn for moderate pain?
teach the client to eat foods such as fruit, oatmeal, beans, and whole wheat spaghetti
The client has developed C.Difficile diarrhea. What assessments should the nurse use to detect a fluid deficit in the client? Select all that apply.
testing for skin tenting measure rate and character of pulse observe for flatness of neck veins when supine
The nurse places the client in hypovolemic shock into what position?
trendellburg
A nurse identifies that the client has tarry stools. Which problem should the nurse conclude that the client is experiencing?
upper gastrointestinal bleeding
A client is admitted to the emergency department because of hypertension and oliguria. For which additional clinical manifestation associated with this cluster of information should the nurse assess the client?
weight gain
The female client with chronic renal failure is receiving hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience:
weight loss