fluid and electrolytes
Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 30ml/hour A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 10 mL/hour A patient with a minimal urine output of 20 ml/hour
A patient with a minimal urine output of 50 mL/hour Explanation: A client with minimal urine output of 50 mL/hour provides the nurse with the information that the patient is maintaining proper fluid balance. Less then 50 ml /hour of urine output indicates dehydration and possible poor kidney function.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Dark, concentrated urine Crackles in the lung fields Distended jugular veins Cool and pale skin
Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? Chloride CO2 Sodium Potassium
Potassium Explanation: The nurse should identify potassium: 2.2 mEq/L as critical because a normal potassium level is 3.5 to 5.0 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl) and the chloride level is a bit low (normal is 100 to 110 mEq/L). Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dl) and creatinine (normal is 0.8 to 1.4 mg/dl) are within normal range.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Hegar's sign. Trousseau's sign. Homans' sign. Goodell's sign.
Trousseau's sign. Explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.
The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." "It is normal to be a little confused following surgery, and it is safe not to urinate at night." "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids."
"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." Explanation: In elderly clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.
Which nerve is implicated in the Chvostek's sign? Optic Facial Hypoglossal Spinal accessory
Facial Explanation: Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Give medications that promote fluid retention. Teach client behaviors that decrease urination. Limit sodium and water intake. Assess for dehydration.
Limit sodium and water intake. Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
