Fluid and Electrolyte Imbalance

Older adults and fluid electrolyte imbalance

1. they have decreased renal and respiratory functioning 2. thirst is depressed, highly encourage fluids 3. poor skin turgor due to decreased skin elasticity in older adults 4. because older adults are confused, the signs and symptoms of fluid and electrolyte imbalance may be subtle or atypical. 5. Routine procedures (laxatives before colon Xray) may induce serious fluid volume deficits in older adults

Normal Serum Sodium Level

135-145 mEq/L

Normal serum potassium

3.5-5.0 mEq/L

Hyponatremia

<135 mEq/L deficient sodium in the blood

What is the condition in which bicarbonate ions are abnormally low, and hydrogen ions are excess? a. acidosis b. alkalosis c. anasarca d. edema

Acidosis

The nurse is preparing a client for testing to determine acidosis or alkalosis. Which of the following laboratory tests would be ordered? A)CBC B)Clotting factors C)ABG D)LFT

C)ABG

The nurse is caring for a client who is diagnosed with respiratory acidosis. Which of the following is a recommended nursing intervention for this client? A) Notify the healthcare provider of skin changes. B) Lower the head of the client's bed. C) Administer prescribed antibiotics. D) Administer ordered oxygen.

D) Administer ordered oxygen.

Decreased pH

Metabolic acidosis

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value? a. ST elevations b. peaked P waves c. Prominent U waves d. narrow peaked T waves

Narrow, peaked T waves A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

Phosphorus

P

Sacral edema

Swelling around the low back in bedridden patients

The nurse is obtaining data from a client with fluid volume excess. When the nurse presses against the lower left leg, a slight indent remains for a second. How should this be documented. a. Anasarca b. +1 pitting edema c. +3pitting edema d. +4pitting edema

b. +1 pitting edema

A nurse assessing a client documents +4 pitting edema in several different locations. What condition is commonly associated with +4 pitting edema? a) Sacral edema b) Dependent edema c) Anasarca d) Pulmonary edema

c) Anasarca

What is the condition in which blood is more basic than normal due to loss of body acids? a. anasarca b. acidosis c. alkalosis d. edema

c. alkalosis

The RN reviews the results of the ABG values with the licensed practical nurse and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the lab results report? a. pH 7.50, PCO2 52 mm Hg b. pH 7.35, PCO2 40 mm Hg c. pH 7.25, PCO2 50 mm Hg d. pH 7.50, PCO2 30 mm Hg

c. pH 7.25, PCO2 50 mm Hg

What serum sodium level confirms a diagnosis of hyponatremia? a) 150 mEq/L b) 145 mEq/L c) 135 mEq/L d) 130 mEq/L

d) 130 mEq/L

Which client condition poses a highest risk for the development of respiratory acidosis? a) Renal disease b) Hyperventilating c) Excessive gastric sunctioning d) Chronic emphysema

d) Chronic emphysema

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take? a) Perform Allen's test. b) Prepare the client for dialysis. c) Administer insulin as prescribed. d) Encourage the client to slow down breathing.

d) Encourage the client to slow down breathing.

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record? a) Apnea b) Bradypnea c) Cheyne Strokes d) Kussmaul's respiratory

d) Kussmaul's respiratory

Hypo means Hypotension poor skin turgor Low urine specific gravity

deficit

pulmonary edema

fluid in the air sacs and bronchioles

Hyperkalemia

high potassium levels >5.0 mEq/L

Excess production of antidiuretic hormone causes salt retention in excess of water retention. Group of answer choices True or False

True

A nurse is collecting data from a client who has pancreatitis. The client ABG's indicate metabolic acidosis. Which of the following findings should the nurse expect? SATA A. Tachycardia B. Hypertension C. Bounding pulses D. Insomnia E. Dysrhythmias F. Tachypnea

A. Tachycardia E. Dysrhythmias F. Tachypnea

Write the correct sequence: 1. Administer oxygen to the client as ordered 2. Notify the healthcare provider of respiratory changes 3. Give stimulants or narcotic antagonists as ordered 4. Elevate the head end of the bed as ordered

2, 4, 1, 3

Which client should this nurse monitor closely for an increased risk for developing edema? A 30 - year - old client with a prolonged fever A 16 - year - old client diagnosed with anorexia nervosa A 20 - year - old client who is vomiting excessively A 78 - year - old client diagnosed with liver cirrhosis

A 78 - year - old client diagnosed with liver cirrhosis

Where can skin turgor be tested?

Clavical, sternum, hand

Skin tenting is an indication of __________.

Dehydration

ND Poor skin turgor

Dehydration RT high sodium intake

hydrogen ion concentration

H+

altered mental status

Metabolic acidosis

Convulsions

Metabolic alkalosis

Excessive gastric suctioning or vomiting can cause? a. Respiratory alkalosis b.Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis

Metabolic alkalosis

Hypotension

Metabolic alkalosis

Phosphate

PO4

carbon dioxide in arterial blood

PaCO2

is the major electrolyte in the intracellular fluid.

Potassium

diminished or excessive urinary output

RISK for electrolyte imbalance RT too much/ not enough sodium.

oral lesions

RISK for nutritional imbalance RT pt refusing to eat due to sore mouth

Increased carbon dioxide in the blood is seen in a condition called __________ acidosis.

Respiratory

Irritability, panic

Respiratory Alkalosis

Increased pCO2

Respiratory acidosis

Muscle twitching, tetany, tremors indicate

Respiratory alkalosis

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? a. The client with cirrhosis b. The client with an ileostomy c. The client with Kisney failure d. The client with decreased kidney function

The client with a ileostomy Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, HF, or decreased kidney function is at risk for fluid volume excess.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? a. The client with sepsis b. the client with cirrhosis c. The client with Kidney failure d. The client with diabetes mellitus

The client with diabetes mellitus Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? a. the client with watery diarrhea b. the client with diabetes insipidus c. the client with inadequate d. the client with the syndrome of inappropriate secretion of antidiuretic hormone

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can occur secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

Blood Oxygen Saturation

The level in your blood . Aslo SaO2. It is measured by an oximeter. a

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition? a. diarrhea b. traumatic burn c. Cushing's syndrome d. Overuse of laxatives

Traumatic burn A serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia

An excess of serum bicarbonate causes metabolic alkalosis. Group of answer choices True or False

True

Edematous skin is friable and prone to breakdown. Group of answer choices True or False

True

dependent edema

a fluid accumulation in the tissues influenced by gravity; usually greater in the lower extremities than in tissue levels above the level of the heart

Which hormone is known to control the level of potassium in the body? a) Aldosterone b) Calcitonin c) Parathormone d) Antidiuretic hormone

a) Aldosterone

A nurse is assessing a client with a chronic liver disorder. The client has hypertension, ascites, and extremity edema on examination. Which is the most probable nursing diagnosis? a) Excess fluid volume b) Impaired urinary elimination c) Deficient fluid volume d) Impaired tissue integrity

a) Excess fluid volume

The nurse caring for a postoperative client documents the following data: flush dry skin, dry mucous membranes, hypotension, and lethargy. The client states that he is thirsty and requests waters. Which medical condition is supported by this data? a) Hypernatremia b) Hyperkalemia c) Hypercalcemia d) Hypermagnesemia

a) Hypernatremia

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? a. An increase in blood pressure b. rapid weight loss c. a weak therapy pulse d. flat hand and neck veins

a. An increase in blood pressure

A client is at risk for FVE related to heart failure. What information can the nurse provide to the client to assist with prevention of this occurrence? a. Comply with diuretic therapy b. Maintain high sodium diet c. Increase level of of potassium in the diet d. Drink 8-10 glasses of fluid per day

a. Comply with diuretic therapy

A client is hyperventilating and has a pH of 7.52 and a PCO2 of 68 mm Hg. What intervention by the nurse will assist in correcting this acid-base imbalance? a. Have the client use a rebreather mask b. Administer oxygen c. Administer lactated Ringers IV d. Elevate the head of the bed

a. Have the client use a rebreather mask

The nurse is observing a client with a calcium level of 4.2 mEq/L. What clinical manifestations may correlate with this level? Select all that apply? a. Paresthesia b. Hypotension c. Muscular weakness d. Depressed reflexes e. Tetany

a. Paresthesia b. Hypotension e. Tetany

A client with a pH level below 7.0 and an above normal pCO2 has a condition called? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis

a. Respiratory acidosis

Hyperventilation can cause? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis

a. Respiratory alkalosis

ascites

accumulation of fluid in the abdominal cavity

Generalized body edema is called _________.

anasarca

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? a) A sodium level of 145 mEq/L (145 mmol/L) b) A potassium level of 3.0 mEq/L (3.0 mmol/L) c) A magnesium level of 1.3 mEq/L (0.65 mmol/L) d) A phosphorus level of 3.0 mg/dL (0.97 mmol/L)

b) A potassium level of 3.0 mEq/L (3.0 mmol/L)

A nurse is assessing a client who has developed a pathologic fracture of the right tibia due to primary hypoparathyroidism. Which electrolyte disturbance should the nurse monitor for? a) Hypokalemia b) Hypocalcemia c) Hypochloremia d) Hyponatremia

b) Hypocalcemia

A client diagnosed with left sided heart failure develops rapid, shallow respirations, shortness of breath, and cough. What immediate action should the nurse take? Group of answer choices a) Give the client a cough expectorant b) Ask the client to breathe into a paper bag c) Auscultate chest and report to healthcare provider d) Start intravenous fluids and monitor

c) Auscultate chest and report to healthcare provide

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

c) Respiratory acidosis

A client is admitted with vomiting and diarrhea and the nurse observes a potassium level of 2.9 mEq/L. What is an appropriate nursing action? a. Administer lactated ringers IV at 150 mL/hr b. No intervention is required its within normal values c. Administer potassium supplementation IV as ordered d. Administer sodium polystyrene to promote potassium excretion

c. Administer potassium supplementation IV as ordered

A nurse is giving dietary recommendations to a client who is diagnosed with Vitamin D deficiency and plains of tingling in the fingers and toes and muscle twitching. Which should be increased in the diet? a) Chloride b) Sodium c) Magnesium d) Calcium

d) Calcium

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance? a) Metabolic acidosis b) Respiratory acidosis c) Metabolic alkalosis d) Respiratory alkalosis

d) Respiratory alkalosis

Which clients would the nurse determine is at risk for development of metabolic alkalosis? SATA. a. A client with emphysema b. A client who is hyperventilating c. A client with chronic kidney disease d. A client who has been vomiting for two days e. A client receiving oral furosemide 40 mg daily f. A client admitted with acetylsalicylic acid overdose

d. A client who has been vomiting for two days e. A client receiving oral furosemide 40 mg daily

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? a. The client with Addison's disease b. the client with metabolic acidosis c. the client with intestinal obstruction d. The client receiving nasogastric suction

d. The client receiving nasogastric suction Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

pitting edema

edema that retains an imprint when touched

Hyper means Rales: Crackles; wet crackling noise in lungs Dependent edema

excess

Diaphoresis

excessive sweating

A nurse is observing an older adult client RBC. Which of following findings as a manifestation of fluid volume excess and report to the charge nurse? SATA A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A. Dyspnea B. Edema D. Hypertension E. Weakness

The nurse is reading the laboratory results for a client who is diagnosed with metabolic alkalosis secondary to excessive antacid administration. Which of the following describes this condition? A) HCO3-> ± 26 mEq/L B)¯ CO2< 35 C)¯ HCO3-< ± 22 mEq/L D) CO2> 45

A) HCO3-> ± 26 mEq/L

A 42-year-old male client with chronic renal disorder is being discharged from the healthcare facility. Which of the following instructions should the nurse give regarding home care? A) Monitor fluid intake and output. B) Allow feet to dangle at least 3 hours per day. C) Check the weight on a weekly basis. D) Keep client on complete bed rest.

A) Monitor fluid intake and output.

Which of the following acid-base imbalances, if not corrected, could lead to the need for mechanical ventilation? A)Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis.

A)Respiratory acidosis

A nurse is collecting data from who has serum potassium level 5.4 mEq/L. Which of following manifestations should the nurse expect? SATA A. ECG constipation B. Constipation C. Polyuria D. Hypotension E. Tachycardia

A. ECG constipation D. Hypotension

A nurse is caring for a client who has a serum sodium level of 133 mEq/L and a serum potassium level 3.4 mEq/L. Which of the following treatment is a risk factor for these laboratory findings? A. Three tap water enemas B. 0.95 sodium chloride IV C. Dextrose 5% in water with 20 mEq of K IV D. Spironolactone therapy

A. Three tap water enemas

A nurse is caring for a client who was in motor-vehicle crash. The client reports chest pain and difficulty breathing. A chest x-ray indicates that the client has pneumothorax. Which of the following ABG results should the nurse expect? A. pH 7.06, PaCO2-52 mmHg, HCO3- 24 mEq/L B. PH 7.42, PaCO2-38 mmHg, HCO3-23 mEq/ L C. pH 7.20, PaCO2- 39mmHg, HCO3-18 mEq/L D. pH 7.58, PaCO2- 38 mmHg, HCO3- 29 mEq/l

A. pH 7.06, PaCO2-52 mmHg, HCO3- 24 mEq/L respiratory acidosis

When assessing skin turgor in a client, the nurse observes that the skin remains elevated for about 2 seconds. How would the nurse document the skin tenting? A)+1 B) +2 C) +3 D) +4

B) +2

The nurse checking a client's laboratory results notes that the client has respiratory alkalosis. Which of the following is a recommended nursing intervention for this condition? A)Administering oxygen B) Breathing into a paper bag C) Administering bicarbonate D) IV infusion of lactated Ringer's solution

B) Breathing into a paper bag

A 65-year-old client is diagnosed with congestive heart failure with edema due to fluid retention. Which of the following may cause retention of fluid in the body? A) Elevated protein levels B) Increased venous pressure C) Elevated osmotic pressure D) Increased excretion of sodium

B) Increased venous pressure

A nurse is caring for a client who has a nasogastric tube low intermittent suctioning. The nurse should monitor the client for which following imbalances. SATA A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypomagnesemia E. Hyperkalemia

B. Hyponatremia D. Hypomagnesemia

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? a. milk b. spinach c. Butter d. collard greens

Butter Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

The nurse is caring for a 67-year-old male client who is diagnosed with fluid volume excess. Which of the following is a common cause of this condition? A) Too-slow administration of IV fluids containing sodium B) Increased urine output as occurs with kidney disorders C) Excess ingestion of sodium from table salt or medications containing sodium D) Inability of the body to conserve and reuse water by concentrating urine

C) Excess ingestion of sodium from table salt or medications containing sodium

A nurse is documenting the electrolyte report of a client on diuretic therapy for congestive heart failure. The report is as follows: sodium, 142 mEq/L; potassium, 2.5 mEq/L; calcium, 5 mEq/L; and chloride, 98 mEq/L. Which of the following electrolyte disturbances should the nurse report to the physician? A) Hyponatremia B) Hypochloremia C) Hypokalemia D) Hypocalcemia

C) Hypokalemia

A diabetic client is admitted to a healthcare facility for diarrhea, nausea, vomiting, and altered mental status. The arterial blood gas (ABG) report of the client shows decreased pH and decreased HCO3-. What immediate action should the nurse take? A) Give a bicarbonate infusion. B) Give Ringer's solution. C) Notify the physician. D)Apply a rebreathing mask.

C) Notify the physician

A nurse is collection data from a client who has hypomagnesemia. Which of the following techniques should the nurse use to check for Chvosteck sign? A. Apply a blood pressure cuff to the client's arm B. Place the stethoscope's bell over the client carotid artery C. Tap lightly on the client's cheek D. Ask the client to lower her chin to her chest

C. Tap lightly on the client's cheek

A nurse is caring for a client has confusion and lethargy. The client was unresponsive at home, with an empty bottle of aspirin lying next to her bed. Vital signs are blood pressure 104/72 mm Hg, Heart Rate 116/ min and regular, and respiratory rat 42/ min with deep respirations. Which of the following arterial blood gas (ABG) results should the nurse expect? A. pH-7.68, PaCO2 38 mm Hg ,HCO3 -28 mEq/L B. pH -7.48, PaCO2-28 mmHg, HCO3- 23 mEq/L C. pH- 7.16, PaCO2-38 mmHg, HCO3-18 mEq/L D. pH-7.58, PaCO2- 38 mmHg, HCO3-29 mEq/L

C. pH- 7.16, PaCO2-38 mmHg, HCO3-18 mEq/L indicate metabolic acidosis

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client? a. calcitonin b. calcium chloride c. calcium gluconate d. large doses of vitamin D

Calcitonin (Miacalcin) Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

Calcitriol is a regulator of __________ metabolism.

Calcium

A 25-year-old client is admitted to a healthcare facility with complaints of fever, vomiting, and watery diarrhea for 2 days. On examination, the client has dry skin, delayed skin turgor, and hypotension. What is the most likely nursing diagnosis? A) Impaired urinary elimination B) Acute gastroenteritis C) Infective diarrhea D) Deficient fluid volume

D) Deficient fluid volume

The nurse is caring for a chronic alcoholic who is being aggressively treated with diuretic therapy. Which of the following electrolyte imbalances may typically occur with this treatment of alcoholism? A) Hyperphosphatemia B) Hyperkalemia C) Hypernatremia D) Hypomagnesemia

D) Hypomagnesemia

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action? a. document the value in the clients record b. Inform the registered nurse of the laboratory value. c. place the laboratory results form in the clients record d. reassure the client that the lab result is normal

Inform the registered nurse of the laboratory value. The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is experiencing hypercalcemia, and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present? a. intense thirst b. slow bounding pulse c. dry mucus membranes d. Postural blood pressure changes

Postural blood pressure changes Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

Extracellular fluid is normally maintained at neutral pH. Group of answer choices True or False

True

For which electrolyte disturbances should the nurse monitor when caring for a client diagnosed with Hodgkin disease? Group of answer choices a) Hyponatremia b) Hypercalcemia c) Hyperchloremia d) Hyperphosphatemia

a) Hyponatremia

A 16 - year- old presents at the emergency room with altered mental status, bradycardia, and cardiac dysrhythmia caused by uncontrolled diabetes mellitus. What acid-base imbalance is most likely occurring in this client? Group of answer choices a) Metabolic acidosis b) Respiratory acidosis c) Metabolic alkalosis d) Respiratory alkalosis

a) Metabolic acidosis

A nurse is caring for a client admitted to the healthcare facility with narcotic overdose. The client has shallow respirations, tremors, headache, weakness, altered sensorium, and fruity-smelling breath. According to the arterial blood gas evaluation, the client's pH is decreased and PCO2 is increased. Which acid-base imbalance has occurred? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

a) Metabolic acidosis

An assessment indicates that the client's skin rebound from slight pressure in slightly less than 2 seconds. How should the nurse document this finding? a) No edema present b) + 1 pitting edema c) + 2 pitting edema d) Nonpitting edema present

b) + 1 pitting edema

The nurse is collecting data about a new patient's fluid and electrolyte balance during an initial comprehensive assessment. Which of the following are possible indicators of fluid and electrolyte imbalances? Select all that apply. A) Poor skin turgor B) Decreased heart rate C) Hunger D) Changes in respiratory pattern E) Equal intake and output F) Changes in urine volume

A) Poor skin turgor D) Changes in respiratory pattern F) Changes in urine volume

A nurse is collecting data from a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following should the nurse identify as manifestation of fluid volume deficit? SATA A. Decreased skin turgor B. Concentrate urine C. Bradycardia D. Low-grade fever E. Tachypnea

A. Decreased skin turgor B. Concentrate urine D. Low-grade fever E. Tachypnea

A nurse is caring for a client who has metabolic acidosis. Which of the following components of the client's medical history should the nurse identify as a risk factor for this acid-base imbalance? A. Diabetic ketoacidosis B. Sleep apnea C. Asthma D. Pulmonary Edema

A. Diabetic ketoacidosis

A nurse is collection data from a client who has hyperkalemia. Which of the following disorders is a risk factor for this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart Failure C. Aldosterone excess D. Excessive sweating

A. Diabetic ketoacidosis

A client with complaints of frequent and increased urination is diagnosed with diabetes insipidus. The electrolyte report of the client is as follows: sodium, 150 mEq/L; potassium, 4.5 mEq/L; calcium, 5.2 mEq/L; and chloride, 96 mEq/L. The client is reported to have hypernatremia. The physician instructs the nurse to modify the diet accordingly. What dietary restriction should the nurse recommend in the diet plan for this client? A) Potassium B)Calcium C) Chloride D) Sodium

D) Sodium

Hyponatremia is the term used for a decrease in serum potassium level. Group of answer choices True or False

False

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance? a. twitching b. positive Trousseaus's sign c. Hyperactive bowel sounds d. Generalized muscle weakness

Generalized muscle weakness Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? a. Gurguling respirations b. Increased blood pressure c. decrease Hematocrit levels d. Increased specific gravity of urine

Increased specific gravity of the urine Clients taking diuretics on a long-term basis are at risk for fluid volume deficit.

A client admitted to the healthcare facility for salicylate overdosage has deep respirations with rapid breathing, lightheadedness, dizziness, and paresthesia. On examination, Chvostek and Trousseau signs are positive. The client's pH is increased and PCO2 is decreased on arterial blood gas evaluation. Which acid-base imbalance should the nurse document for this client? a) Respiratory alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Metabolic alkalosis

a) Respiratory alkalosis

A client is receiving long term thiazide diuretic therapy for hypertension. What should the nurse monitor for in this client? (Select all that apply.) Group of answer choices a) Signs of potassium deficit b) Signs of fluid volume excess c) Signs of acid base imbalance d) Signs of dehydration e) Signa of hypernatremia

a) Signs of potassium deficit c) Signs of acid base imbalance d) Signs of dehydration

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which? a) Ulnar circulation b) Carotid circulation c) Femoral circulation d) Brachial circulation

a) Ulnar circulation

A nurse is teaching a client who chronic renal failure who is being cared for at home and the client 's family about how to handle edematous areas. Which of the following should be included in the client and family teaching? (Select all that apply.) Group of answer choices a) Compression of edematous body part b) Careful handling of edematous skin c) Frequent position changing d) Monitoring for tenting of skin e) Elevation of edematous body part

b) Careful handling of edematous skin c) Frequent position changing e) Elevation of edematous body part

A client who self medicated for constipation presents to a healthcare facility with complaints of weakness and has diminished deep tendon reflexes and hypotension on examination. The laboratory results reveal a serum magnesium level of 3 mEq/L. What immediate action should the nurse take? a) Decrease magnesium intake b) Connect to cardiac monitor c) Give calcium gluconate d) Increase oral fluids

b) Connect to cardiac monitor

What is the preferred route of electrolyte administration when the oral route is contraindicated? a) Intramuscular b) Intravenous c) Subcutaneous d) Intradermal

b) Intravenous

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? a. The client with draining wound b. the client with urinary catheter c. The client with fast respiratory rate d. The client with nasogastric tube low suction

Client with a fast respiratory rate Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

Which of the following clinical features should a nurse look for in a client with metabolic alkalosis? (Select all that apply.) Group of answer choices a) Hyperreflexia b) Rapid breathing c) Convulsions d) Tetany e) Hypertension

a) Hyperreflexia c) Convulsions d) Tetany

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

b) Metabolic alkalosis

Calcium

Ca

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

a) Metabolic acidosis

The nurse caring for older adults in a nursing home keeps in mind the factors predisposing older adults to fluid and electrolyte imbalances when planning care. Which of the following accurately describe these factors? A)Increased renal functioning B) Depressed thirst mechanism C) Atypical or subtle confusion D) Self-medication with analgesics E) Decreased elasticity of skin F) Incontinence

B) Depressed thirst mechanism C) Atypical or subtle confusion E) Decreased elasticity of skin F) Incontinence

3. The nurse is caring for a client with fluid volume excess who has edematous skin. Which of the following is an appropriate nursing consideration for this client? A) Keep the client in the same position to avoid irritating the skin. B) Elevate an edematous part to a position higher than the heart's level. C) Limit mouth care to prevent the formation of ulcers. D) Perform skin care at least every 4 hours.

B) Elevate an edematous part to a position higher than the heart's level.

A client is diagnosed with hypocalcemia. Which of the following conditions most commonly causes this condition? A) Cancer B) Parathyroid hormone deficit C) Primary hyperparathyroidism D) Immobilization

B) Parathyroid hormone deficit

Which of the following is a major electrolyte in ECF that influences the distribution of water and maintains acid-base balance and nerve function? A) Potassium B) Sodium C) Calcium D) Phosphorus

B) Sodium

A nurse is checking ABG results for a client who has vomited repeatedly during the past 24hr. Which following acid-base imbalances should the nurse expect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis

A nurse is caring for an older adult client in a long-term care facility who is dehydrated. Which of following actions should the nurse take? A. Initiate fluid restriction to limit the client's intake B. Observe for indication of peripheral edema C. Encourage the client to promote oxygenation by ambulating D. Monitor for orthostatic hypotension

D. Monitor for orthostatic hypotension

A nurse is collecting data from a client who is dehydrated from a client who is dehydrated due to fluid volume deficit. Which of the following findings should the nurse expect? A. Moist skin B. Distended neck veins C. Increased urinary output D. Thready pulses

D. Thready pulses

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level? a. Prolonged bed rest b. adrenal insufficiency c. Hyperparathyroidism d. Excessive ingestion of Vitamin D

Prolonged bed rest The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 8.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bedrest is hypocalcemia.