CHAPTER 28 - FLUID AND ELECTROLYTES - PrepU
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 3.5 cm H2O 12 cm H2O 9.5 cm H2O 5 cm H2O
3.5 cm H2O p. 869 Rationale: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
A client who is n.p.o. prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and extracellular overhydration increased blood volume and intracellular dehydration decreased blood volume and intracellular dehydration decreased blood volume and extracellular overhydration
decreased blood volume and intracellular dehydration p. 872-873 Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.
A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to: 60 degrees 90 degrees 30 degrees 45 degrees
45 degrees p. 869, Figure 28-12 Explanation: When measuring jugular venous distention, the nurse would elevate the head of the client's bed to 45 degrees so that the sternal angle is 5 cm above the right atrium. Any other elevation would lead to inaccurate results.
What is the lab test commonly used in the assessment and treatment of acid-base balance? Urinalysis Complete blood count Arterial blood gas Chemistry I
Arterial blood gas p. 855, text and Table 28-4 Rationale: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine.
The student nurse asks, "what it interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid outside cells." "Fluid in the tissue space between and around cells."
"Fluid in the tissue space between and around cells." p. 848 Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? - Compare the client's intake with the normal range of adult fluid intake. - Report the exact milliliter of intake to the physician's office nurse. - Ensure that the information is included in the verbal end-of-shift report. - Compare the total intake and output of fluids for the 24 hours.
- Compare the total intake and output of fluids for the 24 hours. p. 866 Rationale: The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time.
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 500 1,000 3,000 3,750
3,000 p. 867 Rationale: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? Processed meat Bread products Dairy products Apricots
Apricots p. 856 Rationale: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order? Tell the client and family to increase oral intake. Decide how much fluid to increase every 8 hours. Divide the intake so the largest amount is at night. Explain to the client why this is needed.
Explain to the client why this is needed p. 871 Rationale: Several techniques are recommended to help the client drink greater than average amounts of fluids. Begin by explaining to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily amount of fluids prescribed.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Hypernatremia Hypokalemia Hyperchloremia Hypomagnesemia
Hypokalemia p. 857 Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? Intravascular Interstitial Intracellular Extracellular
Intracellular p. 847, 848 Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? Impaired Urinary Elimination Urinary Retention Impaired Skin Integrity Risk for Deficient Fluid Volume
Risk for Deficient Fluid Volume p. 870, Table 28-7 Rationale: An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights
The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.) infusion of intravenous solution eating a sandwich urination vomiting drinking milk
infusion of intravenous solution urination vomiting drinking milk p. 856-859 Rationale: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output
A client is prescribed a diuretic as part of the treatment plan for heart failure. The nurse educates the client about the drug and dietary measures to prevent complications. The nurse determines that the client needs more education when he states that he will increase his consumption of: apricots. orange juice. carrots. spinach.
spinach p. 873, Table 28-8 Explanation: The client needs to increase his consumption of potassium-containing foods such as apricots, orange juice, and carrots. Spinach is high in calcium and magnesium but not potassium.
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? "This surgery has a very low change of hemorrhage, so you will not need blood." "Let me refer you to the blood bank so they can provide you with information." "Unfortunately your own blood cannot be re-infused during surgery." "We now have artificial blood products, so giving your own blood is not necessary."
"Let me refer you to the blood bank so they can provide you with information." Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 1,500 mL/day 1,000 mL/day 3,500 mL/day 2,500 mL/day
2,500 mL/day p. 856 Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance? Hypermagnesemia Hypokalemia Hypercalcemia Hyponatremia
Hypokalemia p. 849, Table 28-2 Rationale: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L). Therefore the client has hypokalemia.
Which statement most accurately describes the process of osmosis? Solutes pass through semipermeable membranes to areas of lower concentration. Water moves from an area of lower solute concentration to an area of higher solute concentration. Water shifts from high-solute areas to areas of lower solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries.
Water moves from an area of lower solute concentration to an area of higher solute concentration. p. 851 Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis and plasma proteins facilitate colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and sodium chloride and magnesium calcium and phosphorus potassium and chloride
calcium and phosphorus p. 850 Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - metabolic acidosis - increased intracranial pressure (ICP) - cardiac irregularities - muscle weakness
cardiac irregularities p. 862, Table 28-6 Rationale: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.
Edema happens when there is which fluid volume imbalance? water excess extracellular fluid volume excess water deficit extracellular fluid volume deficit
extracellular fluid volume excess p. 853 Rationale: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? hypertonic hypotonic, followed by isotonic isotonic hypotonic
hypertonic p. 852 Explanation: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply. Diffusion Osmosis Acid-base balance Filtration Active transport
Osmosis Filtration Diffusion Active transport p. 850 Explanation: Osmosis, filtration, diffusion, and active transport maintain fluid homeostasis. Acid-base balance concerns chemical reactions in the body that influence metabolism.
The nurse is teaching a nursing student how to record strict I&O;for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." "Estimate the amount of fluid that you think was excreted into the undergarment." "You only record urine output in an adult undergarment; you do not record diarrhea output." "We do not record fluids absorbed into undergarments."
"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." p. 866 Explanation: Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL).
Which is a common anion? Chloride Magnesium Potassium Calcium
Chloride p. 849 Rationale: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? Cardiac dysrhythmias Fluid volume excess Pulmonary embolus Tetany
Cardiac dysrhythmias p. 862, Table 28-6 Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "I have never given blood before." "My blood type is B positive." "I received a blood transfusion in the United Kingdom." "My spouse would also like to donate blood."
"I received a blood transfusion in the United Kingdom." Rationale: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've been taking antacids almost every 2 hours over the past several days." "I was breathing so fast because I was so anxious and in so much pain." "I've had a GI virus for the past 3 days with severe diarrhea." "I've had a fever for the past 3 days that just doesn't seem to go away."
"I've been taking antacids almost every 2 hours over the past several days." p. 863 Rationale: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.
The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? Select all that apply. - provides a medium for transporting wastes to cells and nutrients from cells - helps maintain normal body temperature - acts as a buffer for electrolytes and nonelectrolytes - facilitates digestion and promotes elimination - provides a medium for transporting substances throughout the body - facilitates cellular metabolism and proper cellular chemical functioning
- provides a medium for transporting substances throughout the body - facilitates cellular metabolism and proper cellular chemical functioning - helps maintain normal body temperature - facilitates digestion and promotes elimination p. 847 Rationale: The functions of water include: providing a medium for transporting nutrients to cells and wastes from cells; providing a medium for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells throughout the body; facilitating cellular metabolism and proper cellular chemical functioning; acting as a solvent for electrolytes and nonelectrolytes; helping to maintain normal body temperature; facilitating digestion and promoting elimination; and acting as a tissue lubricant.
The nurse works at an agency that automatically places certain clients on intake and output (I&O;). For which client will the nurse document all I&O;? 23-year old with ulnar and radial fracture 55-year old with congestive heart failure on furosemide 34-year old whose urinary catheter was discontinued yesterday 48-year old who has had a bowel movement after surgery
55-year old with congestive heart failure on furosemide p. 863-867 Rationale: Agencies often specify the types of clients that are placed automatically on I&O;Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O;documented. The other clients do not require the nurse to document all I&O;.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Constipation related to immobility Risk for Infection related to inadequate personal hygiene Pain related to surgical incision Acute Confusion related to cerebral edema
Acute Confusion related to cerebral edema p. 861, 863 Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids.
Avoid salty or excessively sweet fluids. p. 873 Rationale: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? B positive A positive AB negative O negative
O negative p. 495 Rationale: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.
A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output? Urine Feces Perspiration Exhaled air
Perspiration p. 856, Table 28-5 Explanation: Normal urine output for 24 hours is approximately 1,500 mL if intake is normal. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. In addition to perspiration, insensible fluid loss through the skin amounts to about 300 to 400 mL per day. Loss of fluid through the gastrointestinal system in the form of feces is usually minimal, approximately 200 mL per day. Loss of water through respiration is approximately 300 mL per day.
A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium? Potassium Magnesium Sodium Phosphorus
Phosphorus p. 850 Explanation: Calcium and phosphorus typically show a reciprocal relationship such that an increase in one leads to a decrease in the other. Sodium is the major cation in the extracellular fluid. Sodium, potassium, and magnesium do not share a relationship with calcium.
The nurse is determining a site for an IV infusion. What guideline should the nurse consider? Antecubital veins should be used for long-term infusions. Veins in the leg should be used to keep the arms free for the client's use. Scalp veins should be selected for infants because of their accessibility. Veins in surgical areas should be used to increase the potency of medication.
Scalp veins should be selected for infants because of their accessibility. p. 507, Procedure 21-1 Explanation: Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication.
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply. - The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. - The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus. - The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. - The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. - Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. - The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance.
The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus. p. 850, 855 Explanation: Fluid homeostasis normally functions automatically and effectively. Almost every organ and system in the body helps in some way to maintain fluid homeostasis. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The adrenal glands secrete aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. The lungs regulate oxygen and carbon dioxide levels of the blood. Regulation of the carbon dioxide level is especially crucial in maintaining acid-base balance. Thyroxine, released by the thyroid gland, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus. Parathyroid hormone draws calcium into the blood from the bones, kidneys, and intestines. It also facilitates the movement of phosphorus from the blood to the kidneys, where it is excreted in the urine.
A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. What would the instructor likely include when describing newborns and infants? Select all that apply. The infant's kidneys are readily able to concentrate urine. Insensible fluid losses are greater in this age group. This age group loses water less readily . Water makes up a larger percentage of their body weight. Greater amounts of water are found in the extracellular fluid compartment.
Water makes up a larger percentage of their body weight. Greater amounts of water are found in the extracellular fluid compartment. Insensible fluid losses are greater in this age group. p. 853 Explanation: Infants have a proportionately larger percentage of total body weight as water (70% to 80%) than do adults (60%). A greater amount of the fluid is contained within the ECF compartment in infants than within that of adults. Because infants also have a greater surface area in relation to weight, they can lose a proportionately larger volume of fluid through the skin. Fluid requirements vary according to age, as do normal urine outputs. The infant's kidneys are immature and lack the ability to concentrate urine fully. Metabolic and respiratory rates are high in infants, contributing to increased insensible fluid loss. Fluid loss can occur very rapidly in this age group.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? - a newly admitted 88-year-old with a 2-day history of vomiting and loose stools - a 47-year-old who had a colon resection yesterday and is reporting pain - a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today - a 60-year-old who is 3 days post-myocardial infarction and has been stable.
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools p. 854, 859 Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily BUN and serum creatinine monitoring daily electrolyte monitoring daily weights output measurements
daily weights p. 868 Explanation: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.
By which route do oxygen and carbon dioxide exchange in the lung? filtration osmosis diffusion active transport
diffusion p. 851 Rationale: Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries by diffusion. Diffusion is the tendency of solutes to move freely throughout a solvent by moving from an area of higher concentration to an area of lower concentration.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching fingerprinting over sternum distended neck veins nausea and vomiting
distended neck veins p. 861 Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: fluid volume deficit. myocardial Infarction. fluid volume excess. atelectasis.
fluid volume excess p. 861 Rationale: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: hyperkalemia. hypokalemia. hypernatremia. hyponatremia.
hyponatremia p. 849, 871 Rationale: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? ordering type of solution, additive, amount of infusion, and duration regulating the rate of administration preparing solution for administration performing venipuncture
ordering type of solution, additive, amount of infusion, and duration p. 870-875 Explanation: The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The healthcare provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.
Calcium is important for which functions? Select all that apply. wound healing regulating vitamin K absorption synaptic transmission in nervous tissue membrane excitability respiratory function blood clotting
wound healing synaptic transmission in nervous tissue membrane excitability blood clotting p. 850 Explanation: Calcium is important in wound healing, synaptic transmission in nervous tissue, membrane excitability, and is essential for blood clotting.