Fluid and Electrolyte Review - PC Nursing

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."

Potassium is needed for neural, muscle and:

Cardiac Function

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

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

Intracellular fluid

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:

Replacement of fluids for those lost from vomiting and diarrhea.

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present?

The client reports using laxative substances daily. The client has been vomiting for several days. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). The client has severe iron-deficiency anemia.

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

infusion of intravenous solution serving of jello 100 mL from melted ice chips cup of ice cream ONLY fluids. No solids.

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?

Notify the primary care provider immediately for possible fluid overload

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?

The student should drink large amounts of water on practice days.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

Muscle cramping and tetany

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?

Muscle weakness, fatigue, and dysrhythmias. Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply.

Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

24s Report this Question The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

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

Acute Confusion related to cerebral edema

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

Apricots. Dairy is reach in calcium. Processed meat and bread products provide sodium.

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance?

Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.

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

Decreased potassium levels. Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

Diarrhea The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.

A client loses consciousness after strenuous exercise and needs to be admitted to a HC facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

Electrolytes

While obtaining the health history from a client, which is most appropriate for the nurse to ask the client to asses fluid balance?

How much do you typically urinate during the day?

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:

Hypokalemia The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

Hyponatremia

During an assessment of an older adult 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. Which medical diagnosis may be responsible?

Hypovolemia

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

INTRAcellular

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume?

IV therapy Nutrition management Electrolyte management

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?

Include more bananas in diet

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have?

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?

fluid volume excess and acidosis Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis.

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding?

orthostatic hypotension decreased urine output slow-filling peripheral veins The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following?

osmosis filtration diffusion active transport Osmosis, filtration, diffusion, and active transport maintain fluid homeostasis. Acid-base balance concerns chemical reactions in the body that influence metabolism.