325 exam 2 review
A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure? Anemia Weight loss Uremic frost Hyperkalemia
Hyperkalemia
interventions for hypernatremia
IV D5%W, administer diuretics, measure I&O, dialysis, decrease sodium intake
Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? - Serum sodium of 139 mEq/L - Serum chloride of 100 mEq/L - Serum calcium of 10.2 mg/dL - Serum potassium of 7.2 mEq/L
Serum potassium of 7.2 mEq/L
After several months of chemotherapy treatment, a client with the diagnosis of multiple myeloma comes to the emergency department because of confusion, muscle weakness, and diarrhea. The nurse reviews the client's electronic medical record. Which complication associated with chemotherapy does the nurse suspect that the client is experiencing?
Tumor lysis syndrome
risk for hyperkalemia
cardiac arrest
causes of hypovolemia
decreased intake, normal output; or normal intake, increased output
causes of hypernatremia
dehydration, diabetes insipidus, fever, Cushing's syndrome, heat exposure, excessive exercise
causes of hyponatremia
diuretics, diarrhea, congestive HF, liver disease, renal failure
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? Crohn disease Cushing disease End-stage renal disease GERD
end-stage renal disease
causes of hypervolemia
heart failure, renal failure, excessive IV fluids input > output
Irritability, as a result of heightened neuromuscular activity, is a sign of
hyperkalemia
Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and:
hyponatremia
blood pressure change that occurs because of sodium and water losses that accompany glucocorticoid and mineralocorticoid insufficiency
hypotension
Clinical manifestations of hypercalcemia
lethargy, nausea, vomiting, paresthesias, and personality changes, decreased muscle contraction
causes of hyperkalemia
trauma, renal disease, use of salt substitues, K-sparing diuretcs
if there's too much fluid, labs will show ever-increasing _______ values
BNP
fluid and electrolyte balance is the balance of what 3 factors?
- Extracellular volume - osmolality - K+ concentration
interventions for hypervolemia
diuretics, fluid restrictions, low sodium diet, I&O, daily weights, check electrolytes & renal function
in the presence of hyponatremia, _________________ results
hyperkalemia
Excess sodium intake can lead to
hypernatremia
causes of hypokalemia
loss of body fluid (vomiting, diarrhea, sweating); medications (diuretics, steroids)
spironolactone is a __________ - sparing drug
potassium
Salt substitutes usually contain __________, which can lead to __________
potassium; hyperkalemia
A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. Which factors does the nurse determine were the most likely cause of the hyponatremia? - Diabetes insipidus - Profuse diaphoresis - Excess sodium intake - Removal of the parathyroid glands - Rapid IV infusion of 5% dextrose in water
profuse diaphoresis, Rapid IV infusion of 5% dextrose in water
Administering potassium binding and excreting resin, such as sodium polystyrene sulfonate, can
reduce potassium levels
risk for hypernatremia
seizure
clinical manifestations of hypocalcemia
tetany, seizures, excess muscle contraction, n/v/d
Chvostek sign
the contraction of the facial muscles in response to a light tap over the facial nerve in front of the ear; is associated with hypocalcemia
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time?
Monitor for cardiovascular irregularities.
clinical manifestations of hypervolemia
confusion, high BP, JVD
following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia?
- dysrhythmias - muscle weakness
expected range for serum calcium
9 - 10.5 mg/dL
Clinical manifestations of hyponatremia
ALOC, nausea; malaise; changes in mental status (confusion), seizures; cellular swelling, cerebral edema; diarrhea; rapid thready pulse, reduced tendon reflexes (mainly neurologic, as water rushes to brain cells)
After an assessment, an adolescent is diagnosed with a perceived inability to ingest food. Which nursing interventions would be appropriate for identifying hyponatremia? - Monitor vital signs - Monitor fluid and electrolyte status - Monitor nutritional intake and behavior - Monitor for targeted daily calorie intake - Monitor activities for detrimental behaviors
Monitor vital signs; Monitor fluid and electrolyte status
Removal of the parathyroid glands can lead to
hypocalcemia
Foods high in potassium
potatoes, cantaloupe, bananas, avocados, oranges, dates, apricots, and raisins, spinach
A client with addisonian crisis exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies. Which responses should the nurse expect the client to exhibit?
- hyperkalemia - hyponatremia - postural hypotension
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? - Provide pretzels as a snack daily. - Restrict fluid intake to 1000 mL per day. - Assess neurologic status every 2 hours. - Administer intravenous fluid of one-half (0.45%) normal saline (NS) at 125 mL/hr.
Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
expected range for serum sodium
135 to 145 mEq/L
expected range for serum chloride
96 - 106 mEq/L
A registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? - Administering sodium polystyrene sulfonate - Avoiding potassium restriction - Monitoring glucose levels hourly - Providing potassium-sparing diuretics
Administering sodium polystyrene sulfonate
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?
Hyponatremia
interventions for hypovolemia
IV fluids according to deficit, give blood, FFP, monitor I&O, daily weights
interventions for hyperkalemia
IV reg insulin + dextrose, renal dialysis, K+ lowering meds, restricting K+ rich foods, diuretics,
lab values for hypervolemia
all values go down (more water --> lower concentration) except BNP
lab values for hypovolemia
all values go up (less water --> higher concentration) except BNP
Trousseau's sign
arm/carpal spasm associated with hypocalcemia
A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication?
cardiac arrest
interventions for hyponatremia
correct underlying cause, IV 0.9 or 3%NaCl, fluid restrictions, fix diuretics, seizure precautions
cardiovascular effects of potassium depletion
irregular, rapid, weak pulse; decreased blood pressure; flattened and inverted T waves, prominent U waves, depressed ST segments, peaked P waves, and prolonged QT intervals
clinical manifestations of hypovolemia
low BP/orthostatic hypotension, high HR, thirst, low urine output, high BUN, rapid weight loss
Hypotonic IV solutions
lower concentration than a healthy person (ex: 0.45% NaCl)
clinical manifestations of hypokalemia
muscle weakness, tingling and numbness of extremities, shortness of breath, dysrhythmias (flat T wave, U wave present), anorexia, n/v, decreased peristalsis
clinical manifestations of hyperkalemia
cardiac arrhythmias, intestinal cramps/diarrhea/vomiting, confusion, irritability, numbness, flaccid paresis, muscle weakness/twitching, areflexia, irregular HR,
A client is receiving furosemide. For which sign of hypokalemia should the nurse monitor the client? Chvostek sign Flabby muscles Anxious behavior Abdominal cramping
flabby muscles
An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid, and the serum electrolyte value demonstrates hyponatremia. What would the nurse concludes was the element that most likely contributed to the hyponatremia?
fluid intake
Hypertonic IV solutions
higher concentration than a healthy person (ex: 3% NaCl)
where sodium is most abundant
blood plasma
When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? - Thirst - Seizures - Erythema - Confusion - Constipation
seizures, confusion
isontonic IV solution
similar concentration to that of a healthy person (ex: 0.9% NaCl)
expected range for serum potassium
3.5 to 5.0 mEq/L
A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings?
Hypokalemia
clinical manifestations of hypernatremia
Thirst, dry mucous membranes
A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? - Thirst - Anorexia - Leg cramps - Rapid, thready pulse - Dry mucous membranes
anorexia, leg cramps
potassium facilitates conduction of:
nerve impulses and muscle activity
What dietary choices should the nurse instruct the client taking spironolactone to avoid increasing? - Potatoes - Red meat - Cantaloupe - Wheat bread - Flavored yogurt
potatoes, cantaloupe
active transport
the movement of materials through a cell membrane using energy
interventions for hypokalemia
treat underlying cause, supplement with potassium, encourage K+ rich foods
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? <p>A client’s laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? </p> Anorexia Vomiting Constipation Muscle weakness Irregular heart rate
vomiting, muscle weakness, irregular heart rate
Clinical manifestations of hyperglycemia
weakness, dry skin, flushing, polyuria, and thirst