F &E
The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome? decreased abdominal girth increased caloric intake increased respiratory rate decreased heart rate
decreased abdominal girth Explanation: Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet? apples canned tomato juice whole wheat bread beef tenderloin
Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb. How many grams would the nurse administer? Record your answer as a whole number.
12 Explanation: First, convert the client's weight from pounds to kilograms: 132 lb ÷ 2.2 lb/kg = 60 kg. Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms: 0.2g/kg X 60 kg = 12 g.
A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first? Administer 1 liter 0.9% saline IV. Draw a complete blood count (CBC) with hematocrit and hemoglobin. Obtain an abdominal x-ray. Insert an indwelling urinary catheter.
Administer 1 liter 0.9% saline IV. Explanation: The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels
Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: Intermittent claudication. Dyspnea. Dependent edema. Crackles.
Dependent edema. Explanation: Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? K+, 3.2; Cl-, 92; Na+, 120 K+, 3.4; Cl-, 120; Na+, 140 K+, 3.5; Cl-, 90; Na+, 145 K+, 5.5; Cl-, 110; Na+, 130
K+, 3.2; Cl-, 92; Na+, 120 Explanation: Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. For these reasons, persistent vomiting can lead to hypokalemia, hypochloremia, and hyponatremia. The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are consistent with persistent vomiting. Each of the other options includes at least two serum electrolyte levels that are normal or high. These are not consistent with persistent vomiting.
The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess? Potassium level Calcium level Magnesium level Chloride level
Potassium level Explanation: Vomiting, diarrhea, and NG suction are all common causes of hypokalemia.
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Blood pressure of 120/64 to 130/72 mm Hg Sodium level of [142 mEq/L (142 mmol/L)]
Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Explanation: Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.
Which adverse effects occur when there is too rapid an infusion of TPN solution? negative nitrogen balance circulatory overload hypoglycemia hypokalemia
circulatory overload Explanation: Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which complication
fluid imbalances Explanation: Clients receiving TPN are at risk for a number of complications, including fluid imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary hypertension, and orthostatic hypotension are not complications of TPN.
For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate: hypocalcemia. hypercalcemia. hypokalemia. hyperkalemia.
hypocalcemia. Explanation: A client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal of or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren't present with hypercalcemia, hypokalemia, or hyperkalemia.
A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for: confusion. muscle cramping. edema. tremors.
muscle cramping. Explanation: Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.
A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals: worsening dyspnea. gastric distention. nausea and vomiting. a temperature of 102° F (38.9° C).
worsening dyspnea. Explanation: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A urine output consistently above 40 ml/hour (40 mL/hour) A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias
A urine output consistently above 40 ml/hour (40 mL/hour) Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.
x A nurse is planning to administer a sodium polystyrene sulfonate enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema should include having the client: retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea. retain the enema for 60 minutes to allow for sodium exchange; diarrhea isn't necessary to reduce the potassium level. retain the enema for 60 minutes to allow for glucose exchange; diarrhea isn't necessary to reduce the potassium level
retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. Explanation: Sodium polystyrene sulfonate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, sodium polystyrene sulfonate must be in contact with the bowel for at least 30 minutes. Sorbitol in the sodium polystyrene sulfonate enema causes diarrhea, which increases potassium loss and decreases the potential for sodium polystyrene sulfonate retention.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? Increase daily fluid intake to at least 2 to 3 L. Strain urine at home regularly. Eliminate dairy products from the diet. Follow measures to alkalinize the urine.
Increase daily fluid intake to at least 2 to 3 L. Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.
