EAQ Fluid and Electrolytes - Concept
On the first day after a mastectomy, a nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. The client asks why she has to do these exercises. What is the best response by the nurse?
"They will help stimulate peripheral circulation."
A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.
*Decreased heart rate *Decreased bowel sounds
A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply.
*Providing mechanical ventilation *Administering sodium bicarbonate
During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem?
Hypocalcemia; increase her intake of milk
A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection?
Maintain the prescribed hydration
A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?
Potassium
What is the purpose of administering intravenous (IV) fluids as prescribed while performing detoxification of an alcoholic client?
To correct the client's fluid and electrolyte imbalance
What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse?
24 hours
A client who is dehydrated is to receive an intravenous (IV) solution of normal saline to be infused at 175 mL/hr. The drop factor of the IV set is 15 gtts/mL. At what drop rate should the nurse adjust the flow to provide the prescribed solution? Record your answer using a whole number. __________ gtts/min
44
Which client should a nurse consider the greatest risk for developing hypernatremia?
A 63-year-old who has had watery diarrhea since traveling abroad
A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. What is the primary cause of the client's ascites?
A decrease in plasma protein to maintain adequate capillary-tissue circulation
A client is receiving hydrochlorothiazide (HCTZ). What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy?
Blood pressure
A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the child health unit for corrective surgery. What is the primary objective of preoperative care for this infant?
Correcting fluid and electrolyte imbalances
A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates?
Discontinue the infusion.
A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care?
Ensuring a large fluid intake
A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies which factor may have contributed to the development of the calculi?
History of hyperparathyroidism
A client who is suspected of having Cushing syndrome is admitted to the hospital. What does the nurse plan to monitor this client for?
Hypokalemia
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 and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing?
Hyponatremia
Which hormonal disorder may be suspected when positive Chvostek and Trousseau signs are assessed?
Hypoparathyroidism
A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care?
Increased pressure in the portal vein
A nurse finds it difficult to obtain intravenous (IV) access to administer electrolytes to a 2-year-old child suffering from severe diarrhea. Which other route of administration should the nurse try?
Intraosseous
A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider?
Urine output of 20 to 30 mL/hr
A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply.
*Lethargy *Thready, weak pulse *Muscle weakness
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb (11 kg) who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age?
10 to 20 mL
An adolescent is hospitalized with multiple internal injuries after an automobile collision. The adolescent is being kept NPO and is receiving an IV infusion at 125 mL/hr and an antibiotic reconstituted in 10 mL of normal saline every 6 hours (6 am, 12 pm, 6 pm, 12 am). What is the intake from 7 am to 3 pm? Record your answer using a whole number.__________ mL
1010
