160 exam 1
Attributes in collaboration with the nurse
1. understand how professional roles/responsibilities support pt. care 2. organize and communicate information w/pt.'s families that is not profession specific 3. understand you are not solely the only nurse involved in your pt. care, rely on others 4. engage w/other professionals in shared decision making that support collaborative practice and team effectiveness
The registered nurse (RN) administers intravenous fluids to a client who was in a motorcycle accident. Which assessments made by the nurse would be appropriate based on the principle of right task of delegation? 1. Environmental conditions 2. Resources required for drug administration 3. Institutional policies of drug administration 4. Client's condition prior to drug administration
3. Right task of delegation includes information on whether the task performed would be appropriate based on institutional policies. Assessing if the environmental conditions are conducive for completing the task determines right circumstance of delegation. Right circumstance of delegation also includes the assessments of resources and equipment available for performing the task. Assessing the client's condition prior to drug administration may not be an appropriate intervention of the nurse under right task of delegation. Test-Taking Tip: There are five rights of delegation. Look for the answer that mainly focuses on right of supervision.
What term began to be used in the 1960s to describe case management? 1. Process control 2. Risk management 3. Quality improvement 4. Utilization management
4. In the 1960s, insurers began to use nursing case management (NCM) as a strategy to manage the needs of complex clients who require coordination over the course of treatment. Acute care hospitals used nurses in this role under the term "utilization management." Process control is not a recognized term for client management. Risk management is a process to manage safety. Quality improvement is a process of ensuring high quality safe client care.
obligatory urine output per day
400-600mL/day
For which health care team role are the principles of the delegation process outlined according to the American Nurses Association (ANA)? A. Registered nurse B. Licensed practical nurse C. Licensed vocational nurse D. Unlicensed nursing personnel
A Registered nurse The ANA has outlined the principles of the delegation process for registered nurses. Licensed practical nurses, licensed vocational nurses, and unlicensed nursing personnel are the delegatees and do not manage the delegation process.
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? A. Allows excess tissue fluid to be excreted B. Helps to control the volume of food intake and thus weight C. Aids the weakened heart muscle to contract and improves cardiac output D. Assists in reducing potassium accumulation that occurs when sodium intake is high
A. Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
A nurse manager is presenting an organizational overview to new nurses during orientation. Which of the following features, common to all organizations, would be included in this overview? A. Policies and procedures for the organization B. Salaries and benefits for employees C. Floor plan of each unit D. Professional development activities
A. Common features of all organizations include having personnel, a purpose, customs, and policies and procedures. Salaries and benefits are human resource features that vary with agencies. The floor plan is not part of an organizational overview. Professional development is often part of an organization but is dependent on the mission of the agency.
The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? A. Crackles in lungs B. Supple skin turgor C. Urine output of 240 mL over 8 hours D. Increase in blood pressure from 110/76 to 124/68 mm Hg
A. Crackles in lungs Crackles in the lungs indicate the client is overloaded with fluids. The nurse should notify the primary healthcare provider to slow or discontinue the IV fluid. Supple skin turgor is a normal finding indicating that the IV fluid is working. A urine output of 240 mL in 8 hours is adequate. Therefore simply having a urine output of 30 mL/hr is not an indication that the IV fluid should be decreased or discontinued; it demonstrates that the kidneys are adequately perfused. An increase in blood pressure is to be expected with administration of fluid.
A nurse manager is describing the type of employee typically employed by a health care organization. In addition to knowledge and skills, which of the following characteristics is common in health care professionals? A. A strong allegiance to professional values. B. A strong desire to meet organizational goals. C. A strong ability to follow lines of authority. D. A strong preference for following rules.
A. Health professionals tend to have strong allegiances to their licensing or professional values, a trait that readily transfers to meeting a health organization's values to provide care. Health professionals are accountable to professional boards, although there is also accountability to meet employer expectations as long as there is not a conflict with the professional expectations. Health professionals follow authority but only in alignment with their professional values. Health professionals value creativity and innovation, which at times means adapting rules to meet patient goals rather than blindly following rules.
The nurse is admitting an older adult with left-sided heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse anticipates which of the following orders? A. Furosemide (Lasix) 20 mg PO now B. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/h C. IV Dextrose 5% at 125 ml/h D. IV D KCl 20 mEq at 125 ml/h
A. Lasix is a diuretic, which will assist in relieving extracellular fluid volume (ECV) excess, which is the major consideration with left-sided heart failure. The remaining options are incorrect because IV fluids may place an additional load on the failing heart.
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? A. Lethargy and constipation from hypercalcemia B. Positive Trousseau's sign from hypercalcemia C. Lethargy and constipation from hypocalcemia D. Positive Trousseau's sign from hypocalcemia
A. Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate levels
A. Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.
Which of the following are examples of health care organizations (HCO)? A. State and county hospitals B. State board of nursing C. National Institute of Health (NIH) D. United States Department of Health and Human Services (USDHHS)
A. State and county hospitals are examples of HCOs. The purpose of HCOs is to help others by providing health care services. This distinguishes an HCO as a service-oriented organization distinct from other organizations with health-related purposes. The state board of nursing, NIH, and USDHHS are examples government and state organizations.
A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema? A. Weighing daily B. Observing body changes C. Measuring intake and output D. Monitoring electrolyte values
A. Weighing daily Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb (1 kg). Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.
The nursing manager issued orders to take the utmost care of a client with myocardial infarction and expects the staff to obey and follow the rules immediately. Which type of decision making is the manager using? A. Autocratic B. Optimizing C. Laissez-faire D. Bureaucratic
A. autocratic The autocratic method results in rapid decision-making and is more appropriate in a crisis situation. Optimizing decision making is when the nurse considers both pros and cons of each position. Laissez-faire is a "hands-off" approach, which is taken by manager who chooses to do nothing when intervention is indicated. The bureaucratic style is focused on organizational rules and policies.
A new nurse manager is reviewing the attributes of a health care organization. Which of the following attributes would be expected for a health care organization? Select all that apply. A. Providing care for underserved minority patients B. Providing transportation to work sites C. Providing child care for unemployed parents seeking work D. The organizational chart of staffing breakdowns from each department E. Usage of the facility by surrounding residents
A.D.E. All health care organizations provide health care services, have a specialized work force, and rely on trust from the public to use their services. Transportation and child care are not major attributes of a health care facility, although these benefits may be provided by social organizations that work with unemployed persons.
Fluid volume excess nursing interventions
Assess respiratory status, assess cardiac status, monitor daily weight, monitor I/O, restrict fluid intake, restrict sodium intake, administer diuretics (lasix, hydrochlorothiazide, spironolactone)
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? A. Extracellular fluid volume (ECV) excess B. Extracellular fluid volume (ECV) deficit C. Hypokalemia D. Hyperkalemia E. Hypocalcemia F. Hypercalcemia
B. C. E. Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? A. Sodium B. Calcium C. Potassium D. Phosphorus
B. Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.
Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's
B. D5W
A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? A. Weight gain B. Dehydration C. Hyperactivity D. Hyperglycemia
B. Dehydration The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.
What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Hypertonic C. Isotonic D. Colloid
B. Hypertonic
A 70-year-old client needs to undergo heart surgery but cannot afford it. The client seeks the assistance of a nurse. Which is the preferred program that the nurse may suggest? A. Medicaid B. Medicare C. Managed care organization D. Preferred care organization
B. Medicare The nurse should discuss the Medicare program to this client. This health insurance program is designed for clients 65 years of age and older. There are four parts of Medicare; part A takes care of the medical, surgical, and psychiatric costs. Medicaid is a state-operated program that provides long-term care to low-income families and disabled older clients. The nurse may suggest this program in case of disabilities, but Medicare is the preferred choice. Managed care organizations (MCO) provide comprehensive preventive and treatment services to a specific group of voluntarily enrolled people. Preferred care organizations (PCO) narrow down the list of hospitals, physicians, and healthcare providers preferred by the member. PCO and MCO members need to pay from his or her own pocket in order to afford these facilities.
When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B. Pulmonary Edema
The nurse understands that the structure of HCOs consists of which of the following? A. Informal rules B. Formal rules C. Bureaucracy D. Systems theory
B. Structure is the collective of formal rules and policies that govern organizational practices and that promote the effective management of materials and resources. Informal rules are not conducive to structure. Bureaucracy and systems theory are related to theoretical links.
Who is responsible for establishing systems to monitor and verify the competency requirements related to delegation in an organization? A. Primary healthcare team B. Chief nursing officers (CNOs) C. American Nursing Association D. National Council of State Boards of Nursing (NCSBN)
B. The chief nursing officers (CNOs) are accountable and responsible for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation. The primary healthcare team may not establish the principles of delegation. The American Nursing Association and National Council of State Boards of Nursing (NCSBN) mainly helped in outlining the principles of delegation to the registered nurse (RN).
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? A. Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. B. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. C. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. D. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.
B. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.
A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? A. Serum sodium B. Serum potassium C. Serum total calcium D. Serum magnesium
B. The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiologic availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.
The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? A. X-ray reports B. Severity of pain C. Results of blood work D. Family caregiver interview
B. The primary source of information during an assessment is the client. The nurse gathers information about the client's pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client's family caregiver is a secondary source of information.
A registered nurse is educating a nursing student about assault. What information should the registered nurse provide? A. "Assault refers to any action of intentional touching without consent." B. "A procedure performed without the consent of the client is considered assault." C. "Assault refers to any action that places a client in apprehension of harmful contact without consent." D. "Threatening a client before performing a medical procedure is not considered assault."
C. Assault does not require actual physical contact. Any action that places the client in apprehension of a harmful contact without consent is considered to be assault. Battery refers to any action of intentional touching without consent. Medical procedures performed without the consent of the client are considered to be battery.
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? A. Ensuring the client's skin integrity B. Reviewing the preoperative instructions C. Administering general anesthetic to the client D. Placing the client in the correct position on the operating table
C. Administering general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation.
A nurse manager is reviewing patient satisfaction surveys and notices several comments that the unit environment is "cold" and "uncaring." Which of the following actions by the manager would best help the organization to improve its image with the public? A. Forward the surveys to housekeeping with a request to keep the rooms less cluttered. B. Request that patients be admitted to newer sections of the hospital. C. Ask staff for suggestions to improve the unit environment. D. Send copies of the surveys to the administration and wait for directions on how what to do.
C. Health care organizations rely on public trust to perform their mission of providing care. Staff interact with patients daily and often receive input from patients and their families about the overall organization. Forwarding the surveys to other departments does not address the responsibility to acknowledge problems and search for solutions. Not using a unit that has identified problems does not allow the organization to improve care and increase the public trust.
A client is receiving furosemide to relieve edema. The nurse should monitor the client for which response to the medication? A. Hypernatremia B. Low blood urea nitrogen C. Hypokalemia D. Increase in the urine specific gravity
C. Hypokalemia Furosemide is a potent diuretic used to provide rapid diuresis; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. Furosemide inhibits the reabsorption, not retention, of sodium. Furosemide does not affect protein metabolism. With edema, the specific gravity of the fluid more likely will be low.
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis
C. Isotonic
After teaching a family member how to administer subcutaneous enoxaparin sodium, how should a nurse evaluate the effectiveness of the training? A. Return demonstration on a manikin B. Verbalization of the side effects of the medication C. Observing the family member administering enoxaparin sodium to the client D. Correctly verbalizing all necessary steps in enoxaparin sodium administration
C. Observing the family member administering enoxaparin sodium to the client The best way to evaluate the effectiveness of the teaching is to observe the family member administering the medication to the client. The family member may be able to perform a subcutaneous injection on a manikin but fear hurting the family member. Knowing the side effects of enoxaparin sodium is important, but it does not provide any information as to the family member's ability to administer the medication. The family member may be able to verbalize all the steps but fear puncturing the skin with the needle.
A nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor? A. Urea B. Chloride C. Potassium D. Creatinine
C. Potassium, a gastrointestinal (GI) constituent, moves quickly through the GI tract of a client with diarrhea and is not absorbed; therefore, serum potassium can become dangerously low and cause cardiac dysrhythmias. Blood urea nitrogen is unaffected by diarrhea; with diarrhea there is a loss of potassium, sodium, and water. Hypochloremia usually is the result of excessive vomiting or gastric decompression. Creatinine reflects muscle and renal function and remains stable unless the client is extremely hemoconcentrated.
Which of the following programs is overseen by the state health department services? A. Administration of Medicare reimbursement rates and eligibility determination B. Programs involving citizens in the local community, including sanitation and communicable disease contact tracing C. Disaster response, health care financing and administration of programs such as Medicaid, and establishment of health codes D. Monitoring of drugs and over-the-counter products available for sale and use by consumers
C. The public health system at the state level is responsible for standing ready to prevent or respond to disasters, both human caused and natural; overseeing health care financing and the administration of programs such as Medicaid and the State Children's Health Insurance Program; providing mental health and professional education; establishing health codes; licensing facilities and personnel; regulating the insurance industry; and providing direct assistance to local health departments, such as ongoing health needs assessment.
The nurse is working with a patient who has been complaining of nausea and diarrhea. The nurse suspects dehydration. Which sign does the nurse expect to see? A. Flat neck veins when upright B. Decreased patellar reflexes C. Positive Trousseau sign D. Jugular vein distension
C. Trousseau sign is likely present in patients who have diarrhea or dehydration because dehydration can cause increased neuromuscular excitability. Flat neck veins when upright is incorrect because flat neck veins are not an expected finding in patient with diarrhea. Decreased patellar reflexes is incorrect because the reflexes would likely be increased or hyper in patients with diarrhea and dehydration. Jugular vein distension is incorrect because jugular vein distension is a sign of excess fluid volume.
A client refuses to go to the twice-a-day prescribed sessions in physical therapy. How might the nurse best approach this problem? A. Having the client observe the progress of a more cooperative client with the same problem B. Being the client's advocate and asking the primary healthcare provider whether therapy can be decreased to once daily C. Ensuring that pain medication is administered to the client before the scheduled physical therapy sessions D. Planning a conference with the client, the physical therapist, and the nurse present to discuss the client's feelings
D. Planning a conference with the client, the physical therapist, and the nurse present to discuss the client's feelings includes the client in the problem-solving process. Having the client observe the progress of a more cooperative client with the same problem, being the client's advocate and asking the primary healthcare provider whether therapy can be decreased to once daily, and ensuring that pain medication is administered to the client before the scheduled physical therapy sessions do not include the client in the problem-solving process; more data should be obtained from the client before deciding on an intervention, which may or may not be appropriate.
Which definition of delegation given by the nurse is correct? A. Activities undertaken by a group of people who have common interests B. Transfer of both accountability and task responsibility from one person to another C. An organized and innovative plan that helps an organization achieve its objectives D. Process for the nurse to direct another person to perform nursing tasks and activities
D. The American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN) collaboratively defined delegation as the "process for the nurse to direct another person to perform nursing tasks and activities." Collective actions are the "activities that are undertaken by a group of people who have common interests." Transferring both accountability and responsibility from one person to another is referred to as an assignment. Strategy is an "organized and innovative plan that assists an organization to achieve the objectives."
Which solution below is NOT a hypertonic solution? A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS)
D. 0.33% saline (1/3 NS)
A nurse manager feels that the overall work environment of his hospital is positive, and he recommends that the organization apply for Magnet© status, which recognizes excellence in nursing practice. Which of the following is an internal environmental factor present in a unit that would need to be changed to qualify for Magnet status? A. A setting where staff are creative in meeting quality care indicators. B. A unit where new programs are researched, implemented, and evaluated by staff. C. A unit where collaboration among disciplines is encouraged and reinforced in evaluations. D. A unit where feedback on staff concerns is given anonymously.
D. A Magnet organization exhibits engagement and participation of staff, especially nursing staff; a setting where feedback is given anonymously does not indicate a climate where staff members feel safe to openly share concerns and suggest solutions. Allowing staff to be creative and participate in projects fosters a sense of empowerment and commitment. Collaboration among disciplines is expected and encourages accountability.
A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal? A. High fluid intake B. Increased intake of calcium C. Inadequate kidney function D. Accelerated bone demineralization
D. Accelerated bone demineralization Calcium that has left the bones as a response to prolonged inactivity enters the blood and may precipitate in the kidneys, forming calculi. Increased fluid intake is helpful in preventing this condition by preventing urinary stasis. Calcium intake usually is limited to prevent the increased risk for calculi. Calculi may develop despite adequate kidney function; kidney function may be impaired by the presence of calculi and urinary tract infections associated with urinary stasis or repeated catheterizations.
The nurse suspects that a patient has a decreased cellular volume with a possible electrolyte imbalance. The provider has ordered blood chemistry laboratory tests. What is the most important nursing intervention for this patient until laboratory results confirm this suspicion? A. Raise bedside rails because of potential decreased level of consciousness and confusion. B. Examine sacral area and patient's heels for skin breakdown caused by potential edema. C. Establish seizure precautions because of potential muscle twitching, cramps, and seizures. D. Institute fall precautions because of potential postural hypotension and weak leg muscles.
D. Electrolyte imbalances are abnormal plasma concentrations of electrolytes such as K+, Ca++, and Mg++. Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Options A, B, and C are incorrect because decreased cellular volume does not cause edema, decreased level of consciousness, or seizures.
_______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic
D. Hypertonic
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? A. "I should drink a lot of tap water today." B. "I need to take more calcium tablets today." C. "I should avoid fruits with potassium in them." D. "I need to drink liquids with some sodium in them."
D. Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.
Hypertonic -Definition -Fluid types -Uses -Side effects
Definition- excessive concentration of solution Fluid types- 3% saline 5% saline 10% dextrose in water 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in Lactated Ringers Uses- hyponatremia, cerebral edema S/E- cell is going to shrink, fluid overload-pulmonary edema
Hypotonic -Definition -Fluid types -Uses -Side effects -Contraindications
Definition-Lower concentration of solutions Fluid types- 0.45% saline (1/2 NS) 0.22% saline (1/4 NS) 0.33% saline (1/3 NS) Uses- hydrate cells (diabetic ketoacidosis, hyperglycemia) S/E- cause cells to lyse, depletes the circulatory system causing hypovolemia Contraindications- increased intracranial pressure, burns/trauma (already hypovolemic)
Isotonic fluids -Definition -Fluid types -Uses
Definiton-equal concentration of solution Fluid types- 0.9% saline (NS) 5% dextrose in water (D5W)*after dextrose is metabolized it becomes hypotonic 5% dextrose in 0.22% saline Lactated Ringers Uses- Increase extracellular fluid volume caused by blood loss, dehydration (vomiting, diarrhea), surgery
Hemoconcentration
Electrolyte levels are high and water is low Indicates dehydration (high and dry)
Hemodilution
Electrolyte levels are low and water level is high Fluid volume overload, CHF (low and liquidy)
Fluid volume excess (hypervolemia) Assessments
Labs: decreased serum electrolytes, metabolic acidosis, decreased BUN, decreased specific gravity Physical assessment: WET (Weight gain, Wet lungs, Edema, Trouble breathing). Ascites, hemodilution, bounding pulse, jugular vein distention, crackles in the lungs, pulmonary edema, dysrhthmias, acidosis, tachypnea, dyspnea, visual disturbances, muscle weakness, increased urine output if not kidney related, decreased urine output if kidney related, pale cool skin, pitting edema
fluid volume deficit/hypovolemia Assessments
Labs: increased serum sodium, elevated BUN, high specific gravity Physical: DRY (Decreased BP, Decreased urine, Really tired, Really fast HR, You look for shock) Hypotension, tachycardia, dyspnea, flattened neck veins, diminished peripheral pulses, dysrhthmias, lethargy, coma, decreased urine output.
A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline
The answer is A: 3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.
________ fluids remove water from the extracellular space into the intracellular space. A. Hypotonic B. Hypertonic C. Isotonic D. Colloids
The answer is A: Hypotonic
Which patient below would NOT be a candidate for a hypotonic solution? A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct
The answer is A: Patient with increased intracranial pressure
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline
The answer is C: 0.45% Saline
Which condition below could lead to cell lysis, if not properly monitored? A. Isotonicity B. Hypertonicity C. Hypotonicity D. None of the options are correct
The answer is C: Hypotonicity
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline
The answer is D: 0.9% Normal Saline
Isotonic fluids cause shifting of water from the extracellular space to the intracellular space. True False
The answer is FALSE. HYPOTONIC fluids cause shifting of water from the extracellular space to the intracellular space (not isotonic)
D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution. True False
The answer is TRUE. D5W is classified as a ISOTONIC fluid BUT after adminstration the body metabolizes the dextrose and the fluid left over is a hypotonic solution.
Fluid volume excess priority nursing diagnosis
excess fluid volume risk for impaired skin integrity risk for impaired gas exchange risk for complications: hypervolemia
fluid volume deficit/hypovolemia interventions
fluid replacement with electrolytes, monitor urine output, monitor cardiovascular and respiratory status, prepare to administer vasopressin, monitor weight, monitor kidney function Meds: fluid replacements, (in case of shock- vasoconstrictors, norepinephrine (levophed), dopamine)
5 rights of delegation
right task right circumstance right person right direction/communication right supervision/evaluation
insensible water loss
the loss of water not noticeable by a person, such as through evaporation from the skin and exhalation from the lungs during breathing salivation, drainage, skin, lungs, GI secretions 500-1000mL/day