PrepU-Fluid & Electrolyte Balance
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
"I sleep on three pillows each night."
An initial bolus of crystalloid fluid replacement for a child in shock is 20 ml/kg. The nurse is preparing to administer how many milliliters of fluid for a child weighing 30 kg?
600 mls
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?
A 52-year-old with diarrhea
A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems?
Decompensated heart failure with pulmonary edema
A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?
Deficient fluid volume related to nausea and vomiting
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Echocardiogram
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
Edema and inflammation
A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?
Elevating the hand and wrapping it in a warm towel
A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate hydration before the anesthetic is administered.
A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
Fluid intake should be about equal to the urine output
Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?
Hypertonic
The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure?
Jugular vein distention (JVD)
The preferred preparation for treating hypothyroidism includes which of the following?
Levothyroxine (Synthroid)
A patient admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which of the following electrocardiographic (ECG) characteristics is commonly associated with this laboratory finding?
Peaked T waves
The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?
Potassium level of 3.1
A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs?
Pulmonary congestion
What is the primary goal of nursing care during the emergent phase after a burn injury?
Replace lost fluids.
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
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.
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient?
Volume expanders
A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
Weigh the child before breakfast.
A client has been taking furosemide for 2 days. The nurse should assess the client for:
a decreased potassium level.
Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?
canned tomato juice
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
cardiac arrest.
When caring for the pregnant client with hyperemesis gravidarum, the nurse would further assess the client for which problem?
dehydration
A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with the diagnosis include:
easy wrinkling of the skin and sunken eyes.
A client is admitted with peritonitis. The priority of nursing care for this client is:
fluid and electrolyte balance.
A client diagnosed with heart failure presents with the following assessment data: temperature 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; pulse oximeter reading of 89%. Following the completion of your assessment, you prioritize your findings. Which findings indicate a need for immediate attention?
lung congestion
Immediately after surgery to create an ileostomy, which goal has the highest priority?
maintaining fluid and electrolyte balance
A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L). The physician orders an I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq (20 mmol/L) of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to:
meet physiologic needs.
The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?
noisy respirations
The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order:
ondansetron (Zofran)
Which of the following is a correct route of administration for potassium?
oral
Which of these clients in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?
A client who is pale and diaphoretic with a heart rate of 115 beats/minute
A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
Distended neck veins
You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?
Gradual unexplained weight gain
(see full question) When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality?
Hyperkalemia
A multiparous client thought to be at 14 weeks' gestation based on uterine size has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for:
Ketones
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted.
The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?
Offer small, frequent feedings
When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following?
Orthopnea
The nurse is discussing cardiac hemodynamics with a nursing student, who understands the following formula: CO = HR X SV (cardiac output equals heart rate times stroke volume). The student asks what determines stroke volume. The correct response by the nurse is which of the following?
Stroke volume depends on three factors: preload, afterload, and contractility
Which oncologic emergency involves the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH)?
Syndrome of inappropriate antidiuretic hormone release (SIADH)
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which complication?
fluid imbalances
A nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to:
fluid overload.
The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder?
heart failure
A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?
hyperkalemia
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.
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
(see full question) When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?
poor skin turgor
A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?
"You should rest, increase your fluids, and take Ibuprofen."
Which of the following is considered an isotonic solution?
0.9% normal saline
When fluid intake is normal, the specific gravity of urine should be which of the following?
1.010 to 1.025
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
Dependent edema.
Acute dialysis is indicated in which situation?
Impending pulmonary edema
Several of the patients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which of the following statements suggests that the patient requires further teaching?
"I make sure to limit how much I drink so that I don't have accidents."
A client with diabetes whose husband recently died reports elevated blood glucose levels. She admits she is barely eating anything; she does not feel hungry. How will the nurse best respond to this client?
"Often with stress, glucose level increases because the body needs more energy."
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
"What daily activities were you able to do 6 months ago compared with the present?"
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.
The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. What is the fluid total to be infused and recorded at 1200? Record your answer using a whole number.
13 1000 to 1030 = 4 mL (hourly rate 8), 1030 to 1100 = 3 mL (hourly rate 6 mL), 1100 to 1200 = 6 mL (hourly rate 6 mL). 4 + 3 + 6 = 13.
A client has been prescribed hydrochlorothiazide to treat heart failure. The nurse should tell the client to report:
muscle weakness
What finding should the nurse interpret as indicating that a child is receiving too much IV fluid too rapidly?
moist crackles in the lung fields
Which of the following is a characteristic of right-sided heart failure
JVD
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?
Pancreatitis
Parents who bring a 3-week-old neonate to the hospital report that he's been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm:
pyloric stenosis
A patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). To ensure early intervention, the nurse monitors laboratory values and urine output for which of the following adverse reactions?
renal
A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
sodium
Which of the following is the most accurate indicator of fluid loss or gain?
weight
The client has received chemotherapy and 1 week later is at home experiencing nausea and vomiting. The first action of the nurse is to recommend
Taking prescribed ondansetron (Zofran)
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
The client says his rings have become tight and are difficult to remove.
For a client with anorexia nervosa, which goal takes the highest priority?
The client will establish adequate daily nutritional intake.
Who is responsible for maintaining the proper flow rate of the IV solution?
The nurse
When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality?
Hyperkalemia
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances?
Hypokalemia
A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas—pH 7.46, PCO2 45 mm Hg (6.0 kPA), PO2 95 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first?
5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h
A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number.
83 1,000 mL/12 hours = 83 mL/hour
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 73-year-old male client was admitted to your hospital unit after 2days of vomiting and diarrhea. His wife became alarmed when he demonstrated confusion and elevated temperature and reported "dry mouth."You suspect the client is experiencing which of the following conditions?
Dehydration
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and
Aldosterone
A client has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next?
Check the client's potassium level
A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention?
Encourage meticulous handwashing by the client and visitors.
Which of the following medications is categorized as a loop diuretic?
Furosemide (Lasix)
The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL
Glucose level
The nurse is providing instructions to the client prior to an intravenous pyelogram. Which statement by the client indicates teaching was effective?
I will feel a warm sensation as the dye is injected."
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.
A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?
Jugular venous distention
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted
(see full question) A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted.
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
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.
Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?
Osmosis
A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?
Pulmonary edema
A client has been diagnosed with heart failure. One of the main overall objectives of management of heart failure is which of the following?
Reduce the workload on the heart
A 58-year-old woman 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
A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important?
Serve the client's menu choices in a supervised area and observe her 1 hour after each meal.
A client has noticed increased incidence of constipation since he broke his ankle and cannot complete his daily 3-mile walk. As his home care nurse, you complete your assessment and discuss the potential causes. During your client education session, what do you explain as the mechanical cause of his constipation?
Stool remaining in the large intestine too long
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?
To dehydrate the brain and reduce cerebral edema
The nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which electrolyte imbalance is a common cause of digoxin toxicity?
hypokalemia
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.
After a head injury, a child experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of:
hypokalemia.
The nurse is caring for a 10-year-old child who is newly diagnosed with type 1 diabetes mellitus. The nurse is teaching the parents how to recognize signs and symptoms of hyperglycemia. Which of the following is most important for the nurse to include as an initial symptom of hyperglycemia?
increased thirst
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
(see full question) Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?
Hypertonic
A client is in hypovolemic shock. In which position should the nurse place the client?
supine with the legs elevated 15 degrees
Which indicates hypovolemic shock in a client who has had a 15% blood loss?
systolic blood pressure less than 90 mm Hg
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
Which of the following is a key diagnostic indicator of heart failure?
BNP
A nurse is caring for a patient who has a PICC line. Which nursing action is recommended?
Flush using normal saline and/or heparin solution according to facility policy.
A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately?
The LPN pours the urine into a graduated measuring container
