Saunders Fluid & Electrolyte Practice Questions-EXAM 2

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?

0.9% sodium chloride Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? A client with ulcerative colitis A client with Cushing's syndrome A client admitted 6 hours ago with a 40% burn injury A client who has a history of long-term laxative abuse

A client admitted 6 hours ago with a 40% burn injury Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1. Tetany 2. Tremors 3. Areflexia 4. Muscular excitability

Areflexia. Rationale: Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)?

DEHYDRATION, PHYSIOLOGICAL STRESS DECREASED BLOOD VOLUME. Rationale: ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value?

HYPERKALEMIA Tall peaked T wave Widened QRS complexes

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L (3.0 mmol/L) Rationale: The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? 1. Pour the aspirate into the NG tube through a syringe with the plunger removed. 2. Dilute with water and inject into the NG tube by putting pressure on the plunger. 3. Discard properly and record as output on the client's intake and output (I&O) record. 4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

Pour the aspirate into the NG tube through a syringe with the plunger removed. After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and should not be discarded.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value?

Prolonged QT interval Prolonged ST segment

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply

Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

The client who has sustained a traumatic burn. Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics ---HYPONATREMIA Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume?

The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

Twitching Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction.

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? 1. Tremors 2. Hyperactive reflexes 3. Respiratory depression 4. No specific signs or symptoms because this value is a normal level

Respiratory depression Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

1. Client with a major burn 2. Client with an ischemic stroke 3. Client with Laënnec's cirrhosis 4. Client with chronic kidney disease Client with an ischemic stroke. Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity

Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

Malnutrition Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1. Monitor the client for dysrhythmias. 2. Encourage increased intake of phosphate antacids. 3. Discontinue any magnesium-containing medications. 4. Encourage intake of foods such as ground beef, eggs, or chicken breast.

Monitor the client for dysrhythmias. Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.