Nursing Fund Week 10
The nurse is reviewing the intake and output (I&O) records of a client. Which entry in the intake record would cause the nurse concern? (Select all that apply.)
*Tube drainage ***Vomitus
The student nurse is assisting the nurse in administering intravenous normal saline to a dehydrated client. The nurse explains to the student that active transport is essential in maintaining sodium and potassium ion concentrations in the body's fluid compartments. The student asks how active transport differs from other transport processes. What is the best response by thenurse?
-"Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." Unlike diffusion, active transport moves solutes against their concentration gradients from a solution with a lower concentration to a more concentrated solution. Active transport does not move water, only solutes. Osmosis is the movement of water from a solution with a lower concentration of solutes to a more concentrated solution.
The nurse is monitoring a client who has undergone a thyroidectomy. The nurse suspects the parathyroid glands may have been inadvertently removed if imbalances are seen in which serum electrolyte level? (Select all that apply.)
***Magnesium ***Calcium
The nurse is providing education to a group of volunteers who are planting trees in a city park on a hot, sunny day. What teaching should the nurse provide about avoiding heat-related illness?(Select all that apply.)
***Take frequent rest breaks ***Avoid participating in the tree planting if ill ***Wear lightweight clothes
The nurse is performing an assessment on a client who has had nothing by mouth since the previous evening. Which manifestation related to the client's fluid restriction would be of concern to the nurse? (Select all that apply.)
-Dry mucous membranes -Tenting skin -Increased hematocrit Rationale: Oral fluid restriction can cause dehydration. The nurse should monitor for manifestations of dehydration such as dry mucous membranes, increased hematocrit, and tenting skin. Edema and increased blood pressure are manifestations of fluid volume excess, not deficit.
The nurse is administering a blood transfusion to a client who is hemorrhaging. The nurse identifies that the client is experiencing a deficit in which body fluid compartment?
-Intravascular Rationale: Blood loss causes a deficit in the intravascular fluid compartment, which is a subcompartment of extracellular fluid (ECF). Transcellular and interstitial fluids, along with lymph, make up the other compartments of ECF. Intracellular fluid is the other major fluid compartment in the body.
An emergency room nurse is assessing a client who overhydrated during a marathon. Which assessment is essential for the nurse to perform during the physical examination? (Select all thatapply.)
-LOC -BP -Lung sounds
The nurse is caring for a client with hyponatremia. What are independent interventions that the nurse can perform to help manage the client's electrolyte imbalance? (Select all that apply.)
-Monitor intake and output -Weigh client daily -Involve client in meal planning Rationale Monitoring intake and output, weighing the client daily, and involving the client in meal planning are all independent interventions that the nurse can perform to help manage the client's hyponatremia. Administering oral and intravenous sodium supplements are collaborative interventions that can only be carried out with a healthcare provider's orders.
Which electrolyte is regulated by aldosterone? (Select all that apply.)
-Sodium -Potassium -Chloride
Fluid volume deficit can result from which conditions? (Select all that apply.)
-vomiting -fever -diarrhea
Based on Mrs. Toppum's lab values and clinical manifestations, the health care provider orders furosemide (Lasix) 80 mg intravenous (IV) push every 12 hours times two doses and digoxin 0.25 mg PO daily. The nurse is preparing to administer the furosemide to Mrs. Toppum via her INT. The order is to administer 80 mg IV push. Furosemide 10 mg/mL is available for administration. How many milliliters of furosemide will the nurse administer to Mrs. Toppum? Please limit your answer to a numeral. Record your answer rounding to the nearest whole number.
8.0 (with margin: 0.0) The answer may be calculated using the following formula: Desired Dose x Quantity on Hand = Dose Dose on Hand 80 mg x 1 mL = 8 mL 10 mg
The nurse is reviewing client data to begin planning care. Which client is at greatest risk for developing fluid volume excess?
A client admitted for cirrhosis A client admitted for liver cirrhosis is at greatest risk for developing fluid volume excess. Clients admitted for nausea and vomiting, overuse of laxatives, or oral surgery are not at risk for developing fluid volume excess.
You are preparing to administer digoxin (Lanoxin) to Mrs. Toppum as ordered. You know you need to complete which assessment prior to administering digoxin?
Assess apical pulse You should assess Mrs. Toppum's apical pulse prior to administration of digoxin. If her pulse rate is greater than 60 beats/min, you can administer the medication as prescribed. Digoxin is a cardiac glycoside and slows the conduction from the SA to the AV node, thereby slowing the heart rate. Administering digoxin to a client with a heart rate below 60 beats/min can result in a dysrhythmia and SA or AV heart block. Apical pulse should be used instead of radial pulse because it assures an accurate reading. You would also want to assess her potassium level, because a potassium level of 6 mEq/L or greater and digoxin level of 3 mg/mL or greater indicate digoxin toxicity, which would require you to hold the dose and notify the health care provider. Hematocrit measures the number of RBC in volume of whole blood and will not inform your assessment related to digoxin level. Respiratory rate does not affect the administration or dosage of digoxin.
The nurse is caring for a client with a fluid volume deficit. Which nursing intervention addresses the client's potential for poor perfusion?
Assessing client's nail beds Rationale Fluid and electrolyte balance is related to several nursing concepts, including perfusion, cellular regulation, and cognition. Fluid volume loss can lead to decreased perfusion, so the nurse should assess pulses, nail beds, and color to assure that perfusion is adequate. Monitoring for signs of blood loss and administering whole blood are interventions targeted toward hemorrhage (cellular regulation) rather than poor perfusion. Checking the client's temperature helps to determine the client's thermoregulation status, not perfusion
Mrs. Toppum has an uneventful night. In the morning, her lab results come back, and her lab values are: sodium 140 mEq/L, potassium 2.5 mEq/L, hemoglobin 17 g/dL, hematocrit 27%, serum creatinine 0.2 mg/dL, and BUN 4 mg/dL. EKG revealed sinus tachycardia. Ongoing assessment: T 99.3°F, P 99 beats/min, R 28 breaths/min, and BP 147/90 mmHg. Bowel sound present all four quadrants, intake 800 mL and output 1,000 mL over 24 hours. While reviewing Mrs. Toppum's lab values, which results would support a diagnosis of fluid retention? Select all that apply.
BUN 4 mg/dL Hematocrit 27% Potassium 2.5 mEq/L Hematocrit, potassium, BUN, and hemoglobin values will be lower in the client with fluid retention due to hemodilution. A sodium level of 140 mEq/L is normal. Clients with fluid retention will retain water and sodium, so a change in sodium level is not anticipated. A hemoglobin level of 17 g/dL is elevated and may indicate dehydration, because the number of red blood cells may be the same but the blood volume may be decreased. Normal hemoglobin level for females is 11.7-16.1 g/dL.
In preparation for Mrs. Toppum's discharge, the dietitian receives an order to discuss food choices with her. Mrs. Toppum is reluctant to discuss her eating habits, because she has never had this problem before. A review of recent food choices while dining out places Mrs. Toppum at risk for possible reoccurrence of fluid retention. The dietitian shows Mrs. Toppum a sample menu from a local restaurant to help her begin planning her meals more conscientiously. Which meal selection would be appropriate for Mrs. Toppum?
Beef, brown rice, spinach Beef, brown rice, and spinach are low sodium foods that will not cause client to retain fluid. Fettucine alfredo can be high in sodium content because of the sauce. Tossed salad can consist of watery vegetables that may facilitate fluid retention. Ham, mayonnaise used in potato salad, and V-8 juice all contain sodium and may place client at risk for fluid retention. Canned tuna that is mixed in water and broccoli possess a high water content, and those food options may increase Mrs. Toppum's risk for fluid retention. Processed cheddar cheese has a high sodium content and may increase Mrs. Toppum's risk for fluid retention. Mrs. Toppum should read nutrition labels for sodium content and meet with the dietitian when warranted. The health care provider may place client on fluid restriction to decrease the amount of free water.
The nurse is reviewing the medication record of a client admitted with dehydration. Which medication would cause the nurse concern?
Benzodiazepine
A client is admitted with end stage renal disease and a potassium level of 7.1. The nurse anticipates which medication prescription from the healthcare provider?
Calcium gluconate
The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte imbalances, which question is most important for the nurse to ask?
Describe what you eat and drink on a typical day?" Rationale It is important for the nurse to consider socioeconomic factors affecting food and fluid intake when assessing a client's risk for fluid and electrolyte imbalances, especially with a vulnerable population like the homeless. Asking a client to describe a typical day's food and fluid intake will help the nurse determine if a client's oral intake is adequate. Joint problems and minor respiratory infections are not primary risk factors for fluid and electrolyte imbalances. It would be more important for the nurse to ask about kidney or thyroid disease, diabetes, or hypertension and acute conditions that cause fluid loss such as gastroenteritis. Asking about anxiety is too general when assessing a client's fluid and electrolyte status, as some anxiety is to be expected in a homeless client.
The nurse is completing discharge teaching with a client diagnosed with congestive heart failure. Which symptoms will the nurse teach the client to immediately report to the healthcare provider? (Select all that apply.)
Cough with increased sputum production The client with congestive heart failure it at risk for developing fluid volume excess. Weight gain of more than 5 pounds in a week and a cough with increased sputum production are indications of excess fluid volume, and the healthcare provider must be notified of these findings. Dizziness when standing and a dry mouth are not signs of fluid volume excess and do not need to be reported to the healthcare provider. A urine output of 320 mL in 8 hours is not a finding that needs to be reported to the healthcare provider.
A client admitted for nausea and vomiting has a urine-specific gravity of 1.061. Upon assessment of the client, the nurse finds that the client is experiencing orthostatic hypotension and has dry skin and flat neck veins. What is the priority nursing diagnosis for this client when planning care?
Deficient fluid volume Fluid volume deficit can be caused by nausea and vomiting with assessment findings of orthostatic hypotension, dry skin, and flat neck veins, which will lead to the priority nursing diagnosis of deficient fluid volume. The client is demonstrating fluid volume deficit. Therefore, ineffective tissue perfusion, impaired gas exchange, and impaired skin integrity are not priority nursing diagnoses for this client.
What is the result of the fluid in third spacing?
Fluid from the vascular space becomes unavailable for physiological functioning. In third spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may locate into the peritoneal space or pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss attributable to third spacing may be difficult to detect because the client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.
You are caring for 47-year-old Savita Patel, who is experiencing fluid retention due to acute renal failure. After several days of treatment, Ms. Patel shows no improvement in her fluid volume excess. You ask Ms. Patel if she is drinking fluids other than those permitted by her healthcare provider, and she replies, "No, but I do like to suck on ice chips during the day." You review Ms. Patel's medical record and see that the ice chips have not been documented. Which clinical measurement should you correct immediately?
Fluid intake
The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. The nurse understands that it is priority to monitor the client for manifestations of whichimbalance?
Fluid overload
The nurse is reviewing laboratory values for a client with hyperthyroidism. Which component of the complete blood count will be most useful to the nurse in determining the client's fluid status?
Hematocrit
Mrs. Toppum is receiving furosemide (Lasix), a drug that will rapidly increase urinary output when injected directly into the bloodstream. Which assessment finding should you review to determine the effectiveness of furosemide 80 mg IV dose?
Hourly urine output Mrs. Toppum is receiving furosemide (Lasix), a drug that will rapidly increase urinary output when injected directly into the bloodstream. Which assessment finding should you review to determine the effectiveness of furosemide 80 mg IV dose?
Which electrolyte imbalance is treated with calcium gluconate?
Hyperkalemia Calcium gluconate is used to treat hyperkalemia. Hypernatremia is treated with fluid replacement. Hypochloremia is treated with increasing dietary salt and adding chloride to the IV fluid. Hyponatremia is treated by increasing dietary sodium and administering sodium containing IV fluids.
A nurse is unable to secure an intravenous access site due to severe dehydration. Which order does the nurse anticipate receiving from the healthcare provider?
Hypodermoclysis
What is the most common electrolyte disorder in the general population?
Hyponatremia
You are providing discharge instructions for Mr. Dickson, who has had frequent episodes of fluid volume excess requiring hospitalization. He will continue to take furosemide (Lasix) after discharge. Which statement by Mr. Dickson would indicate that there is a need for additional instruction?
I will weigh myself weekly and notify my healthcare provider if I gain more than 1 pound." It is important for the client to weigh himself daily, not weekly, after discharge for fluid volume excess. Eating foods rich in potassium, wearing shoes that fit well and not walking barefoot, and changing positions frequently are all responses that indicate understanding of the discharge instructions provided by the nurse.
You are administering intravenous crystalloid solutions to 26-year-old Marco Ramirez, who suffered severe heat exhaustion at an outdoor concert. Mr. Ramirez asks, "What is this stuff you're giving me?" What is the best response for you to give to Mr. Ramirez?
I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost."
The nurse is caring for a client who is experiencing diarrhea. Which data indicates that the client is experiencing fluid volume deficit? (Select all that apply.)
Increased heart rate Orthostatic hypotension Poor skin turgor
The nurse is caring for a hospitalized client who is experiencing anxiety-related hyperventilation. To account for the client's hyperventilation, when recording the client's fluid intake and output, the nurse should adjust the amount of fluid lost through which route?
Insensible loss
A client experiencing hyperkalemia is scheduled for dialysis. The nurse anticipates an order for what therapy to help drive potassium back into the cells prior to dialysis?
Insulin Rationale Glucose and insulin are administered to the client with hyperkalemia to help drive potassium back into the intracellular fluid, reducing the amount of potassium in the blood. Potassium supplements would only increase the client's potassium levels. Blood transfusions are only given for major blood loss, which is not indicated for the client. Antidiuretic hormone (ADH) is administered to clients with hypernatremia due to decreased ADH production, not hyperkalemia.
The healthcare provider ordered a diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. The nurse recognizes that this medication is part of what class of diuretics?
Loop Loop diuretics inhibit sodium and chloride reabsorption in the ascending loop of Henle. Thiazide diuretics promote the excretion of sodium, chloride, potassium, and water by decreasing absorption in the distal tubule. Potassium-sparing diuretics promote excretion of sodium and water by inhibiting sodiumdash-potassium exchange in the distal tubule. Osmotic diuretics do not inhibit sodium and chloride reabsorption in the ascending loop of Henle.
You are assessing 8-year-old Kristian Davidson at school after he complained of feeling dizzy during recess on a hot, sunny day. You note manifestations of mild heatexhaustion, perform first aid, and notify Kristian's parents to follow up with their heathcare provider. What is the best recommendation for you to make to the principal of the school to help prevent future occurrences of heat-related illness?
Move afternoon recess to a cooler morning hour
In planning Mrs. Toppum's care, you consider reasons why Mrs. Toppum is retaining fluid. Which factors would increase a client's risk for retaining fluid? Select all that apply.
New onset congestive heart failure (CHF) Client receiving plasma protein Correct! Chronic liver disease Causes of fluid retention include over-infusion of intravenous fluid, chronic liver disease, heart failure, client receiving plasma protein, excess ingestion of solutes in foods, and medications. Asthma does not increase the client's risk for retaining fluid. Diabetes mellitus can result in fluid volume deficit due to body unable to utilize excess glucose which can result in osmotic diuresis (e.g., increased urination).
Mrs. Toppum reports that she is having trouble breathing. You know that a complication for fluid retention is pulmonary edema. In what order would you implement interventions for a client with pulmonary edema?
Place client in high Fowler position.- 1 Provide supplemental oxygen as ordered. 2 Check the client's blood pressure. 3 Continue nursing assessment. 4 Review the client's serum sodium, potassium, BUN, and creatinine levels. 5 Document findings. 6 Clients presenting with respiratory difficulty require immediate intervention. Placing Mrs. Toppum in a high Fowler position provides for improved lung expansion, which will allow the supplemental oxygen to be effective. After providing the oxygen per the health care provider's order, you would check Mrs. Toppum's blood pressure and then continue with the rest of your assessment. Once she is stable, you would check her lab values and document your findings. You would not leave Mrs. Toppum's bedside until she is stable.
You are providing care for James Dand, who has been determined to have fluid volume excess. Laboratory values indicate that Mr. Dand is experiencing hypokalemia. Which therapy do you anticipate will be prescribed for Mr. Hernandez based on this information?
Potassium-sparing diuretics A client experiencing fluid volume excess with hypokalemia would be prescribed potassium-sparing diuretics. Loop diuretics would be prescribed for a client with hyperkalemia. Oral fluid solutions and isotonic electrolyte solutions are appropriate therapies for a client with fluid volume deficit, not excess.
A client is admitted with a serum sodium level of 140 mEq/L, hematocrit level of 31%, and generalized edema. Which priority intervention is indicated for this client?
Restrict fluid intake This client is experiencing fluid volume excess. Therefore, the priority nursing intervention is restricting fluid intake. Preparing to administer a blood transfusion, encouraging the client to drink ginger ale, and encouraging the client to increase sodium intake are not priority nursing interventions because this client is experiencing fluid volume excess.
Which diagnostic test assesses kidney function?
Serum creatinine A diagnostic test used to assess kidney function is serum creatinine levels. Hemoglobin and hematocrit are used to assess hemoconcentration in the blood. Serum osmolality helps to differentiate isotonic fluid loss from water loss.
When ADH and aldosterone are secreted, what change occurs in the body?
Sodium and water are retained by the kidneys. The release of ADH and aldosterone causes sodium and water to be retained by the kidneys. The secretion of ADH and aldosterone are part of the renindash-angiotensindash-aldosterone system.
Mrs. Rivera reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which assessment would you expect to note with Mrs. Rivera?
Tachycardia When a client experiences a deficiency in fluid volume, the heart rate will increase (tachycardia) in an attempt to improve circulation. Warm, flushed skin is typically seen with a fever. Ascites and dyspnea are frequently noted with fluid volume excess.
Mrs. Madeline Toppum is a 57-year-old woman who is 5'6" and weighs 200 lbs. Over the past several days, she has had difficulty ambulating up stairs and performing activities of daily living. She has been unable to shower in the mornings without feeling weak and having to sit down before implementing another task. Her husband encouraged her to follow up with her health care provider, but she was too busy planning her daughter's wedding and did not make an appointment. Mrs. Toppum finally decided to call for an appointment when she started having trouble catching her breath, especially at night. The nurse at her health care provider's office instructed her to go to the emergency department. Upon arrival, she was diaphoretic, T 99.7°F, P 110 beats/min, R 32/min, and BP 160/80 mmHg. In addition, she had ankle edema and reported that her weight was 180 pounds at her physical exam two months ago. Mrs. Toppum is admitted to the intensive care unit with a diagnosis of fluid overload. The health care provider orders the following: Basic metabolic panel, liver function test, complete metabolic panel, vital signs every 4 hours, intake and output, insert indwelling Foley catheter, saline lock, chest x-ray, oxygen 2-4 liter per nasal cannula to maintain oxygen saturation above 96%, and a low-sodium diet.You are the nurse assigned to Mrs. Toppum today. You take Mrs. Toppum's health history, including her symptoms over the past few weeks. You continue your assessment, noting the following: a well-nourished woman, alert, and oriented times three. Upper extremities strong and lower extremities weak. Mrs. Toppum complains of difficulty ambulating and moving her legs freely. Lower extremities 2+ pitting edema. Lung sounds are positive for crackles on auscultation. Abdomen bowel sounds present in all four quadrants. Vital signs: T 99.3°F, P 104 beats/min, R 32 breaths/min, and BP 152/90 mmHg. Which clinical manifestations would indicate fluid retention?
Tachycardia Lung sounds: crackles 1+ pitting edema in both ankles Manifestations of fluid retention include crackles in the lungs heard on auscultation, 1+ or higher pitting edema, tachycardia, weight gain, dyspnea, full bounding pulse, and distended neck veins. Poor skin turgor and low concentrated urine will be present with fluid volume deficit. Manifestations of fluid retention include crackles in the lungs heard on auscultation, 1+ or higher pitting edema, tachycardia, weight gain, dyspnea, full bounding pulse, and distended neck veins. Poor skin turgor and low concentrated urine will be present with fluid volume deficit.
The nurse is planning care for a client who has congestive heart failure and is experiencing generalized edema. Which interventions will the nurse plan for the client who is at risk for altered skin integrity secondary to edema? (Select all that apply.)
Turning the client every 2 hours Monitoring for evidence of skin breakdown
Mrs. Toppum understands the importance of making wise food choices and indications for recent retention of fluid. Her family medical history includes hypertension, obesity, cardiac problems, and respiratory problems, so she is very focused on making better choices. Mrs. Toppum will start eating at home more and carrying lunch and a snack with her if she plans to run errands during the day. She also plans on implementing new dietary choices for the family. You are reviewing Mrs. Toppum's most recent laboratory results and assessment findings. Which finding would suggest that Mrs. Toppum's plan of care is effective?
Weight loss of 2 lbs in the last 24 hours One of the most effective measurements to assess fluid volume status is daily weight measurement. Intake and output require 2-3 days of data to get a full picture. Intake of 800 mL and output of 500 mL suggest client is retaining fluids because intake exceeds output. Hematocrit of 50% indicates client has a fluid volume deficit due to a higher concentration of RBCs in relation to circulating blood volume. A potassium level of 6 mEq/L is too high and may indicate an imbalance in fluids and electrolytes.
The nurse is planning care for a client admitted for dehydration. Which assessment finding indicates that current interventions are not improving the client's hydration status?
hypotension
Which is a characteristic of the intracellular fluid compartment of the body?
is a medium for metabolic processes
The nurse is planning care for a client admitted for congestive heart failure who has a priority problem of fluid volume excess. What is occurring in the body that places the client at risk for retaining fluids?
retention of water and sodium Fluid volume excess results from conditions that cause retention of water and sodium. Impaired renal excretion of potassium is not related to fluid volume excess. There will be an increase in ADH and aldosterone when the stress response is activated with fluid volume excess. An increase in serum osmolality stimulates the thirst center, not a low serum osmolality, which could affect fluid volume.r
Before planning your discharge teaching, you need to assess Mrs. Toppum for behaviors and modifiable risk factors that would increase her risk for fluid retention. Which statement by Mrs. Toppum indicates a need for teaching about factors that increase her risk for fluid retention?
"I use salt substitutes to season food" Salt substitutes increase clients' risk for potassium excess due to the potassium content. Drinking ten glasses of water daily will assist in maintaining fluid balance by hydrating the client. Drinking four glasses of apple juice is not a concern unless the client is experiencing diarrhea. Not adding seasoning to meals is not a concern with medication use.
Landon McCabe brings his 4-month-old daughter, June, to the urgent care clinic. June has been vomiting every few hours for the past 12 hours and feeding poorly. After noting June's dry mouth and lack of tears, the healthcare provider diagnoses June with mild dehydration. After you teach Mr. McCabe about rehydrating June, he asks, "How did June get dehydrated so quickly?" What is the best response for you to give Mr. McCabe?
"Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated."
Landon McCabe brings his 4-month-old daughter, June, to the urgent care clinic. June has been vomiting every few hours for the past 12 hours and feeding poorly. After noting June's dry mouth and lack oftears, the healthcare provider diagnoses June with mild dehydration. After you teach Mr. McCabe about rehydrating June, he asks, "How did June get dehydrated so quickly?" What is the best response for you to give Mr. McCabe?
"Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated."
The nurse is caring for a client admitted for dehydration. What assessment finding indicates a loss of fluid over a period of time?
Dry, sticky mucous membranes
A client is admitted for diarrhea. Which laboratory value indicates that the client is experiencing dehydration?
Hematocrit, 57%