EXAM 2 (Fluid & Electrolytes)

Place the populations in order from LEAST total body water to MOST total body water (Adult males, Infants, Newborns, Adult Females, Older adults)

Older adults> adult females> adult males> infants> newborns

Landon McCabe brings his 4-month-old daughter, June, to the urgent care clinic. June has been vomiting every few hours for the past 12 hours & feeding poorly. After noting June's dry mouth & lack of tears, the nurse diagnoses June with mild dehydration. After you teach Mr. McCabe about rehydrating June, he asks, "How did June get dehydrated so quickly?" What is the best response for you to give Mr. McCabe?

"Infants have a low body surface area, so they lose fluid more easily than adults & it is easy for them to get dehydrated"

A client is admitted with end stage renal disease and a potassium level 7.1. The nurse anticipate which medication prescription from the healthcare provider?

Calcium Gluconate 1.5g IV

The nurse is caring for a client admitted for dehydration. What assessment finding indicates a loss of fluid over a period of time? -Polyuria -Increased in tongue size -Dry, Sticky Mucous Membranes -Bradycardia

Dry, Sticky Mucous Membranes

How often should the nurse reposition a PT with fluid volume deficit? -every 90 mins -every 120 mins -every 30 mins -every 180 mins

Every 120 minutes (2 hours)

Which modifiable risk factor has the most direct effect on calcium balance? -stress -diuretics -exercise -fluid intake

Exercise

47 yr old Sally, who is experiencing fluid retention due to acute renal failure. After several days of treatment, she shows no improvement in her fluid volume excess. You ask if she's drinking fluids other than those permitted by her healthcare provider & she replies "No but I do like to suck on ice chips during the day." You review her record & see that ice chips have not been documented. Which clinical measurement should you correct immediately? -Daily weight -Vital Signs -Fluid Output -Fluid Intake

Fluid Intake

Nurse is monitoring the fluid & electrolyte of PT receiving IV colloids. Nurse understands that it is priority to monitor the client for manifestations of which imbalance? -fluid over load -hyperkalemia -hypernatremia -fluid deficit

Fluid Overload

nurse is reviewing laboratory values for a PT with hyperthyroidism. Which component of the complete blood count will be most useful to the nurse in determining PT fluid status? -hematocrit -platelet count -RBC count -WBC count

hematocrit

Which electrolyte imbalance is treated with calcium gluconate? -hyponatremia -hyperkalemia -hypochloremia -hypernatremia

hyperkalemia

Nurse is caring for a hospitalized PT who is experiencing anxiety-related hyperventilation. To account for client's hyperventilation when recording the client's fluid I&O, the nurse should adjust the amount of fluid lost through which route? -sweat -urine -feces -insensible loss

insensible loss

which diagnostic test assesses kidney function? -hematocrit -serum creatinine -serum osmolality -hemoglobin

serum creatinine

A client is admitted for diarrhea. Which laboratory value indicates that the client is experiencing dehydration? -Hemoglobin, 9.0g/dL -Hematocrit, 57% Sodium, 132 mEq/L -Yrine Specific Gravity, 1.000

Hematocrit, 57%

When engaging client in the plan of care for end stage renal disease, to what should nurse pay particular attention? -Meal planning when dietary modifications are required -Monitoring I&O -Weighing client daily -Medication regimens & side effects

Meal planning when dietary modifications are required

While providing discharge to PT who has frequent episodes of fluid volume excess requiring hospitalization. He will take lasix after discharge. Which statement indicates PT needs additional information? -"it is important to change positions frequently" -"i will eat banana everyday" -i will wear shoes that fit well & not go barefoot" -i will weight myself weekly & notify health care provider if i gain more than 1 pound"

"I will weigh myself weekly & notify health care provider if i gain more than 1 pound"

You are administering IV crystalloid solutions to 26 yr old Marco, who suffered severe heat exhaustion at an outdoor concert. Mr. Ramirez asks, "What is this stuff you're giving me?" What is the best response for you to give him? -"I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost" -"I'm giving you a solution that has proteins in it. It will help replace the fluids you lost" -I'm giving you a solution with a drug that will keep you from losing water" -"I'm giving you a solution that is a lot like your blood it will replace the fluid you lost"

"I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid lost."

Nurse is reviewing the medication record of a PT with dehydration. Which medication would cause the nurse concern? -Vasodilator -Selective serotonin reuptake inhibitor (SSRI) -Benzodiazeprine -Nonsterodial ant-inflammatory drug (NSAID)

-Benzodiazeprine

Physical assessment for fluid & electrolyte status focuses on which part of the body? (select all that apply.) -endocrine system -cardiovascular system -skin -oral cavity -ears

-Cardiovascular system -Skin -Oral cavity

Nurse is unable to secure an IV access site due to severe dehydration. Which order does the nurse anticipate receiving from the healthcare provider? -diuretics -oral fluid replacement -sodium supplements -hypodermoclysis

-Hypodermoclysis (fluids administered subcutaneously)

You are assessing an 8 year old at school, after he complains of feeling dizzy during recess on a hot, sunny day. You note manifestations of mild heat exhaustion, perform first aid, & notify child's parents to follow up w/ their HCP. What is the best recommendation for you to make to the principal of school to help prevent future occurrences of heat-related illness? -Teach children to drink water only before recess -Encourage children to drink water when they feel thirsty -Move afternoon recess to a cooler morning hour -Provide a time for children to rest after recess

-Move afternoon recess to a cooler morning hour

The nurse is caring for a client who is experiencing diarrhea. Which data indicates that the client is experiencing fluid volume deficit? (Select all that apply) -Orthostatic Hypotension -Weight gain -Increased Heart Rate -Poor Skin Turgor -Increased Urine Output

-Orthostatic Hypotension -Increased Heart Rate -Poor Skin Turgor

Which electrolyte is regulated by aldosterone? (select all that apply.) -calcium -sodium -magnesium -potassium -chloride

-Sodium -Potassium -Chloride

The nurse is planning care for a client who has congestive heart failure & is experiencing generalized edema. Which interventions will the nurse plan for the client who is at risk for altered skin integrity secondary to edema? (select all that apply) -Turning the client every 2 hours -Instructing the client to stand slowly -Observing mental status -Monitoring for evidence of skin breakdown -Obtaining daily weight

-Turning the client every 2 hours -Monitoring for evidence of skin breakdown

Which clinical measurements elevates with fluid volume excess? (select all that apply.) -body weight -blood pressure -temperature -pulse rate -pulse volume

-body weight -blood pressure -pulse volume

The nurse is monitoring PT who has undergone a thyroidectomy. The nurse suspects the parathyroid glands may have been inadvertently removed if imbalances are seen in which serum electrolyte level? (select all that apply) -potassium -chloride -sodium -calcium -magnesium

-calcium -magnesium

Which interventions would you include in a plan of care for a PT with fluid volume excess? (select all that apply.) -elevating legs & feet when sitting -keeping track of how many cups of fluid drink -reducing intake of caffeinated drinks -reading food labels to note fiber content -monitoring daily weights

-elevating legs & feet when sitting -keeping track of how many cups of fluid they drink -monitoring daily weight

Nurse is providing education to a volunteer group who are planting trees in a park on a hot, sunny day. What teaching should the nurse provide about avoiding heat-related illness? (select all that apply.) -take frequent rest breaks -wear lightweight clothes -older adults are less at risk -avoid participating in tree planting if ill -drink water when they feel thirsty

-take frequent rest breaks -wear lightweight clothes -avoid participating in tree planting if ill

Fluid volume deficit can result from which conditions? (select all that apply) -water intoxication -vomiting -fever -diarrhea -kidney failure

-vomiting -fever -diarrhea

The nurse is reviewing the I&O records of PT. Which entry in the intake record would cause the nurse's concern (select all that apply). -tube feedings -vomitus -intravenous medication -tube drainage -parenteral fluids

-vomitus -tube drainage

What is the result of the fluid in third spacing? -fluid returns to intracellular space -fluid is excreted from the body through stimulation of urine production -fluid from the vascular space becomes unavailable for physiological functioning -fluid shifts into the subcutaneous tissue

Fluid from the vascular space becomes unavailable for physiological functioning

Which fluid or electrolyte imbalance is best treated with dialysis? -hyponatremia -fluid volume deficit -blood loss -hyperkalemia

Hyperkalemia

What is the most common electrolyte disorder in the general population? -hyperkalemia -hypokalemia -hypernatremia -hyponatremia

Hyponatremia

The nurse is planning care for a client admitted for dehydration. Which asessment finding indicates that current interventions are not improving the client's hydration status? -Weight gain of 1.2 kg -Hypotension -Warm, dry skin -Urine output of 40 mL/hr

Hypotension

PT has been determined to have fluid volume excess. Lab values indicate he is experiencing hypokalemia. Which therapy do you anticipated will be prescribed? -isotonic electrolyte solution -loop diuretics -oral fluid solutions -potassium-spacing diuretics

Potassium-sparing diuretics

Which is a characteristic of the intracellular fluid compartment of the body? -includes cerebrospinal & peritoneal fluid -divides into intravascular, interstitial fluids -is a medium for metabolic processes -makes about 1/3 of total body fluid in adults

is a medium for metabolic processes

When ADH & aldosterone are secreted, what change occurs in the body? -sodium & water are retained by the kidneys -third-spacing shifting occurs -intracellular fluid is depleted -urine output is increased

sodium & water are retained by the kidneys

PT reports experiencing vomiting & diarrhea for the past 2 days, resulting in 5% weight loss. In addition to diminished skin turgor, which assessment would you expect to note with PT? -dyspnea -tachycardia -warm, flushed skin -ascites

tachycardia