NCLEX RN Prep U Fluid & Electrolyte Balance

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. 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.

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) 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.

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance?

hypernatremia Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures.

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

- Numbness - Muscle twitching and spasms - Tingling When the parathyroid gland is removed, the body may not produce enough parathyroid hormone to regulate calcium and phosphorous levels. The symptoms of hypocalcemia include peripheral numbness, tingling, and muscle spasms. Aphasia is not a symptom of calcium depletion. Polyuria and polydipsia are symptoms of diabetes mellitus.

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 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 who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/hour. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number.

25 To administer IV fluids at 100 mL/hour using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula: 100 mL/60 min × 15 gtts/1 mL = 25 gtt/min.

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. 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.

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do?

Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed.

A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored?

Blood urea nitrogen (BUN) BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN), 100 mg/dL, serum creatinine 6.5 mg/dL, potassium 6.1 mEq/L, and lethargy. Which of the following is the priority nursing assessment?

Cardiac rhythm Manifestations of CKD result from loss of the renal regulatory functions of filtering metabolic waste products and maintaining fluid and electrolyte balance. These laboratory results indicate CKD, but the most significant result is the potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum creatinine level ranges from 0.7 to 1.5 mg/dL.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures 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:

Dependent edema. 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.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. Which of the following is the best nursing intervention?

Elevate the head of the bed to 30 to 45 degrees and reassess JVD Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

A client is scheduled for a creatinine clearance test. What should the nurse do?

Instruct the client about the need to collect urine for 24 hours. A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to force fluids.

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

Ketones in urine. Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.

The nurse is teaching the client with an ileal conduit how to prevent a urinary tract infection. Which measure would be most effective?

Maintain a daily fluid intake of 2,000 to 3,000 mL. Maintaining a fluid intake of 2,000 to 3,000 mL/day is likely to be most effective in preventing urinary tract infection. A high fluid intake results in high urine output, which prevents urinary stasis and bacterial growth. Avoiding people with respiratory tract infections will not prevent urinary tract infections. Clean, not sterile, technique is used to change the appliance. An ileal conduit stoma is not irrigated.

The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client reports headache and nausea. Based on the serum laboratory results below, how would the nurse interpret the client's acid-base balance?

Metabolic acidosis. This client has metabolic acidosis, which typically manifests with a low pH, low bicarbonate level, normal to low PaCO2, and normal PaO2. The client's serum electrolyte levels also support metabolic acidosis, which include an elevated potassium level, normal to elevated chloride level, and normal calcium level. The client's anion gap of 30 mEq/L is high, also indicative of metabolic acidosis. This kind of metabolic acidosis occurs with diabetic ketoacidosis and other disorders.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Normal saline solution as this is considered an isotonic solution Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect?

Number of wet diapers the in the last 24 hours A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. Number of stools may indicate diarrhea, but is less accurate in determining dehydration status. Number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and cap refill are more essential with a cardiac issue.

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?

Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose. The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded, so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

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:

Trousseau's sign. 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.

When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of:

encouraging fluids. The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.

Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?

evaluating laboratory results for electrolytes IV solutions are prescribed based upon the fluid and electrolyte status of the client, so laboratory results should be monitored first. Safety recommendations are for standard premixed solutions. If solutions are not premixed, additives are completed by the pharmacy, not at the bedside. Potassium chloride is never given by IV push because this could be fatal. Administration guidelines require no more than 10 mEq (10 mmol/L) of potassium chloride be infused per hour on a general medical-surgical unit. An infusion device or pump is required for safe administration.

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 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.

When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 mL/day, which fluid should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst?

ice chips The most appropriate and effective choice would be ice chips because they help moisten the mouth and lips while keeping fluid intake low. However, ice chips must still be counted as intake with the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fluid intake low.

The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?

noisy respirations A serious complication of IV therapy is fluid overload. Noisy respirations can develop as a result of pulmonary congestion. Additional symptoms of fluid overload include dyspnea, crackles, hypertension, bounding pulse, and distended neck veins.

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom?

passage of a liquid stool with a watery ring The mother demonstrates understanding of the discharge instructions when she says that she should contact the HCP if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

phosphorus PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?

urine output During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and daily body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP is not used. After the first 48 to 72 hours, urine output is a less reliable guide to fluid needs. The victim enters the diuretic phase as edema reabsorption occurs, and urine output increases dramatically.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client?

urine output greater than 35 mL/hour A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

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: 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. 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.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

Observe the puncture site for swelling and bleeding. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

Which laboratory value supports a diagnosis of pyelonephritis?

Pyuria Pyelonephritis is diagnosed by the presence of pyuria, leukocytosis, hematuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Myoglobinuria is seen with any disease process that destroys muscle. Ketonuria indicates a diabetic state. Because the client with pyelonephritis typically has signs of infection, the WBC count is more likely to be high rather than low.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?

Urine output of 250 ml/24 hours ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

Which intervention provides the most accurate information about an infant's hydration status?

Weighing the infant daily Weighing an infant daily provides the most accurate information about the infant's hydration status. Vital signs, intake and output, and electrolyte levels provide helpful information about an infant's hydration status, but they aren't as accurate as weighing daily.

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value?

The BUN is elevated because your daughter is dehydrated." A client with anorexia nervosa will have an elevated BUN as a result of dehydration. A decreased BUN isn't associated with anorexia nervosa or with hypothyroidism. An elevated BUN isn't associated with hypoglycemia. A client with anorexia nervosa will have hyperglycemia related to a drastic decrease in nutritional intake. A decreased BUN value isn't associated with anorexia nervosa or with hypertension. A client with anorexia nervosa will have hypotension caused by impaired cardiac functioning.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

The health care provider (HCP) prescribes intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before hanging the IV fluids with potassium chloride, which assessments would be most important?

ability to void Potassium chloride is readily excreted in the urine. Before hanging IV fluids with potassium chloride, the nurse should ascertain whether the child can void; if not, potassium chloride may build up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous potassium replacement therapy to evaluate for these changes. Having a stool daily is important, but because potassium is primarily excreted in the urine, the child's ability to void must be verified. Serum calcium levels do not indicate the child's ability to tolerate potassium replacement.

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for:

hypokalemia Loss of electrolytes from the gastrointestinal tract through vomiting, diarrhea, or nasogastric suction is a common cause of potassium loss, resulting in hypokalemia. Hypermagnesemia does not result from excessive loss of gastrointestinal fluids. Common causes of hypernatremia are water loss (as in diabetes insipidus or osmotic diuresis) and excessive sodium intake. Common causes of hypocalcemia include chronic renal failure, elevated phosphorus concentration, and primary hypoparathyroidism.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion. Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.