Fluid and Electrolyte Practice Questions
Cardiac arrest Too rapid administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyperkalemia will not lead to acidosis. Psychoticlike reactions do not occur with hyperkalemia. Hyperkalemia usually causes nausea, vomiting, and diarrhea, which may result in dehydration; in this instance, fluid will shift from interstitial spaces to the intravascular compartment. With edema, the fluid shift occurs in the opposite direction.
A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1 Acidosis 2 Cardiac arrest 3 Psychoticlike reactions 4 Edema of the extremities
2 Orange 3 Banana 5 Dried fruit
A nurse advises a client receiving furosemide about potassium intake. Which fruits should the nurse encourage the client to eat? Select all that apply. 1 Apple 2 Orange 3 Banana 4 Pineapple 5 Dried fruit
Client has increased plasma hydrostatic pressure. In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.
A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1 Client has decreased plasma colloid osmotic pressure. 2 Client has increased tissue colloid osmotic pressure. 3 Client has increased plasma hydrostatic pressure. 4 Client has decreased tissue hydrostatic pressure.
Protein The waste products of protein metabolism are the main cause of uremia. The degree of protein restriction is determined by the severity of the disease. Fluid restriction may be necessary to prevent edema, heart failure, or hypertension; fluid intake does not directly influence uremia. Sodium is restricted to control fluid retention, not uremia. Potassium is restricted to prevent hyperkalemia, not uremia.
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? 1 Fluid 2 Protein 3 Sodium 4 Potassium
"The patient has dehydration because of a decrease in blood aldosterone concentrations." Addison's disease is caused by a reduction in the glucocorticoid, mineralocorticoid, and androgenic hormones in the blood. The mineralocorticoid aldosterone regulates sodium and potassium balance in the blood. A decrease in blood aldosterone concentrations results in dehydration because the hormone aldosterone is used to regulate the balance of salt and water. Addison's disease leads to weight loss and is not characterized by the deposition of fat in the body. Cushing's syndrome leads to muscle weakness from potassium loss. Addison's disease leads to weight loss because of decreased, not increased, carbohydrate metabolism.
A nursing student is caring for an older adult patient with Addison's disease. The nursing instructor asks the student about the characteristics that can be observed in patients with Addison's disease. What is the best answer given by the student? 1 "The patient has weight gain because of the deposition of excess fat in the body." 2 "The patient has muscle weakness because of increased carbohydrate metabolism." 3 "The patient has hypokalemia because of a decrease in blood potassium concentrations." 4 "The patient has dehydration because of a decrease in blood aldosterone concentrations."
Lethargy and constipation from hypercalcemia Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? A Lethargy and constipation from hypercalcemia B Positive Trousseau's sign from hypercalcemia C Lethargy and constipation from hypocalcemia D Positive Trousseau's sign from hypocalcemia
"I will report any abdominal distress." Potassium supplements can cause gastrointestinal ulceration and bleeding. Most salt substitutes contain potassium, and their use with potassium supplements can cause hyperkalemia. Because they can be irritating to the stomach, potassium supplements should not be taken on an empty stomach. An increase in urine output is the therapeutic effect of diuretic therapy, not potassium supplements. An adverse effect of potassium supplements is oliguria.
Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood? 1 "I will report any abdominal distress." 2 "I should use salt substitutes with my food." 3 "The drug must be taken on an empty stomach." 4 "The dosage is correct if my urine output increases."
Oliguria ONLY one that is hypo
The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? 1 Oliguria 2 Crackles 3 Dyspnea 4 Bounding pulse
0.50 lb
When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed: A 0.25 lb B 0.50 lb C 1 lb D 1 kg
Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.
Which assessment finding in a client signifies a mild form of hypocalcemia? 1 Seizures 2 Hand spasms 3 Severe muscle cramps 4 Numbness around the mouth
Addison's disease Abrupt withdrawal of glucocorticoid medication causes a rapid drop in cortisol levels and may lead to Addison's disease. Cataracts, osteoporosis, and Cushing's syndrome are effects of long-term corticosteroid use.
Which condition would a nurse expect in a patient who abruptly withdraws from a glucocorticoid medication? 1 Cataracts 2 Osteoporosis 3 Addison's disease 4 Cushing's syndrome
Height and weight Glucocorticoid therapy can cause growth suppression in children receiving long-term adrenal drug therapy. Therefore the nurse would obtain baseline height and weight and monitor these values throughout treatment. Visual acuity can be affected in patients with glaucoma taking glucocorticoids. Bone density is affected in older patients. Blood glucose levels are affected in patients with diabetes mellitus receiving glucocorticoids.
Which information would the nurse obtain prior to giving glucocorticoids to a 10-year-old patient? 1 Visual acuity 2 Bone density 3 Blood glucose 4 Height and weight
Administer temporary glucocorticoid replacement therapy. MOST correct answer
Which nursing care should be provided to a client who has undergone unilateral adrenalectomy? 1 Offer a high-sodium diet. 2 Encourage the client to use saliva-inducing agents 3 Instruct the client to wear a medical alert bracelet. 4 Administer temporary glucocorticoid replacement therapy.
Its actions are opposite to that of parathyroid hormone.
Which statement regarding calcitonin is correct? 1 It is secreted by follicular cells. 2 Its actions are opposite to that of parathyroid hormone. 3 It decreases phosphorous levels by increasing bone resorption. 4 It works along with thyroid hormone to maintain normal calcium levels in blood.
Hypotension Signs of adrenal insufficiency and crisis include hypotension, fatigue, nausea, and vomiting. Prednisone and other glucocorticoids can cause edema, increased appetite, and hyperglycemia as side effects.
Which symptom would the nurse assess for in a patient taking prednisone that suggests adrenal crisis? 1 Edema 2 Hypotension 3 Hypoglycemia 4 Increased appetite
Sodium and chloride levels
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? 1 Sodium and chloride levels 2 Bicarbonate and sulfate levels 3 Magnesium and protein levels 4 Calcium and phosphate levels
Hyporeflexia
A client is taking furosemide. At each clinic visit, the nurse should assess for what adverse effect? 1 Rapid weight loss 2 Xanthopsia 3 Hyporeflexia 4 Bronchospasm
increase urine output
A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in: A decreased sodium reabsorption B increased sodium reabsorption C decreased urine output D increase urine output
1 Lethargy 2 Thready, weak pulse 3 Muscle weakness
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. 1 Lethargy 2 Thready, weak pulse 3 Muscle weakness 4 Hyperactive deep tendon reflexes 5 Numbness and tingling of the hands and feet
Slow IV rate and restricted fluid intake When albumin is administered slowly and oral fluid intake is restricted, fluid moves from the interstitial spaces into the circulatory system so it can be eliminated by the kidneys. Administration should not exceed 5 to 10 mL/min. Oral fluids are restricted to facilitate the optimal effects of the albumin, which shifts fluids from the interstitial spaces to the intravascular compartment. Rapid administration may cause circulatory overload; fluid is restricted, not withheld. Unrestricted fluid intake will limit the shift of fluid from the interstitial to the intravascular compartment, interfering with the optimal effects of the albumin.
A client with ascites is scheduled to receive albumin. To have the greatest therapeutic effect, the nurse expects what infusion rate and what oral fluid intake? 1 Slow intravenous (IV) rate and liberal fluid intake 2 Slow IV rate and restricted fluid intake 3 Rapid IV rate and withheld fluid intake 4 Rapid IV rate and moderate fluid intake
Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased carbon dioxide level
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products
Whole blood products
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? 1 5% Dextrose and lactated Ringer solution 2 0.9% normal saline solution 3 Total parenteral nutrition 4 Whole blood products
Positive Trousseau sign Trousseau sign is likely present in patients who have diarrhea or dehydration because dehydration can cause increased neuromuscular excitability. Flat neck veins when upright is incorrect because flat neck veins are not an expected finding in patient with diarrhea. Decreased patellar reflexes is incorrect because the reflexes would likely be increased or hyper in patients with diarrhea and dehydration. Jugular vein distension is incorrect because jugular vein distension is a sign of excess fluid volume.
The nurse is working with a patient who has been complaining of nausea and diarrhea. The nurse suspects dehydration. Which sign does the nurse expect to see? A. Flat neck veins when upright B. Decreased patellar reflexes C. Positive Trousseau sign D. Jugular vein distension
Abdominal distention Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.
What clinical finding indicates to the nurse that a client may have hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul breathing 4 Abdominal distention
Urinary output every hour circulating volume and is more reliable
A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. The nurse is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? 1 Weight every day 2 Urinary output every hour 3 Blood pressure every 15 minutes 4 Extent of peripheral edema every 4 hours
Extracellular fluid volume (ECV) deficit Hypokalemia Hypocalcemia Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? A Extracellular fluid volume (ECV) excess B Extracellular fluid volume (ECV) deficit C Hypokalemia D Hyperkalemia E Hypocalcemia F Hypercalcemia
Furosemide (Lasix) 20 mg PO now Lasix is a diuretic, which will assist in relieving extracellular fluid volume (ECV) excess, which is the major consideration with left-sided heart failure. The remaining options are incorrect because IV fluids may place an additional load on the failing heart.
The nurse is admitting an older adult with left-sided heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse anticipates which of the following orders? A Furosemide (Lasix) 20 mg PO now B Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/h C IV Dextrose 5% at 125 ml/h D IV D KCl 20 mEq at 125 ml/h
Achieve relief of symptoms and maintain kidney function Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.
The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? 1 Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration 2 Be able to identify dietary restrictions and plan menus 3 Achieve relief of symptoms and maintain kidney function 4 Recognize signs of bleeding, a complication associated with this type of procedure
2 Low sodium diet 3 Daily abdominal girth measurements 5 Daily weights In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms, and often these clients are on a fluid restriction. Taking daily weights is the most reliable indicator of fluid retention.
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. 1 High protein diet 2 Low sodium diet 3 Daily abdominal girth measurements 4 Encourage increased by mouth fluid intake 5 Daily weights
Institute fall precautions because of potential postural hypotension and weak leg muscles. Electrolyte imbalances are abnormal plasma concentrations of electrolytes such as K+, Ca++, and Mg++. Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Options A, B, and C are incorrect because decreased cellular volume does not cause edema, decreased level of consciousness, or seizures.
The nurse suspects that a patient has a decreased cellular volume with a possible electrolyte imbalance. The provider has ordered blood chemistry laboratory tests. What is the most important nursing intervention for this patient until laboratory results confirm this suspicion? A. Raise bedside rails because of potential decreased level of consciousness and confusion. B. Examine sacral area and patient's heels for skin breakdown caused by potential edema. C. Establish seizure precautions because of potential muscle twitching, cramps, and seizures. D. Institute fall precautions because of potential postural hypotension and weak leg muscles.
3 Diarrhea 4 Weakness 5 Dysrhythmias
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias
Reabsorbs water into the capillaries Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).
What is the action of vasopressin? 1 Promotes sodium reabsorption 2 Reabsorbs water into the capillaries 3 Promotes tubular secretion of sodium 4 Stimulates bone marrow to make red blood cells
Serum potassium levels for hypokalemia Fludrocortisone has mineralocorticoid properties, which can result in potassium excretion and lead to hypokalemia. It can also cause sodium and fluid retention, leading to hypernatremia and fluid volume excess. Calcium levels are not a concern.
When assessing for potential side effects of fludrocortisone, which assessment is a priority for the nurse to monitor? 1 Serum calcium levels for hypercalcemia 2 Serum potassium levels for hypokalemia 3 Serum sodium levels for potential hyponatremia 4 Intake and output for potential fluid volume deficit
1 Isotonic exercises 2 Intravenous fluids 3 Oxygen by nasal cannula 4 Cold compresses to affected areas Because the kidneys of children with sickle cell anemia do not concentrate urine as well as do healthy kidneys, it is important to maintain adequate hydration. Hydration with IV fluids supplementing oral fluids can minimize the occurrence of a crisis because hemodilution helps prevent sickling. During a VOC bed rest is preferred, with the only exercise being passive range of motion. Oxygen may be used if the child has respiratory distress, but it does not help resolve a VOC because it decreases erythropoiesis. Cold compresses are contraindicated because cold causes vasoconstriction. Heat usually is applied to the affected areas.
A 10-year-old child with sickle cell anemia is admitted to the unit in vaso-occlusive crisis (VOC). After the child has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?
3 It will compensate for both insensible and expected output over the next 24 hours. Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.
A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? 1 It equals the expected urinary output for the next 24 hours. 2 It will prevent the development of pneumonia and a high fever. 3 It will compensate for both insensible and expected output over the next 24 hours. 4 It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.
Stable vital signs The beginning of the acute phase of burn recovery (36 to 48 hours after the injury) is evident by hemodynamic stability, which is reflected in stable vital signs. As fluid returns to the intravascular compartment, increased renal blood flow and diuresis occur. During the acute phase of burn recovery, potassium moves back into cells, decreasing, not increasing, serum potassium levels. Fluid returns to the intravascular compartment during the acute phase of burn recovery, and intravascular deficits do not occur.
A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? 1 Stable vital signs 2 Decreased urinary output 3 High serum potassium levels 4 Reduced intravascular fluid volume
Reduced peripheral pulses Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.
A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? 1 Warm, flushed skin 2 Increased pulse pressure 3 Lethargy with confusion 4 Reduced peripheral pulses
Flabby muscles With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue; muscle weakness; and soft, flabby muscles. 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; low calcium levels allow sodium to move into excitable cells, increasing depolarization and nerve excitability. Anxiety and irritability are associated with hyperkalemia. Hyperkalemia affects the nervous and muscular systems; fatigue, weakness, and lethargy are associated with hypokalemia. Decreased gastrointestinal motility occurs with hypokalemia; abdominal cramping is associated with hyperkalemia and is caused by hyperactivity of smooth muscles.
A client is receiving furosemide. For which sign of hypokalemia should the nurse monitor the client? 1 Chvostek sign 2 Flabby muscles 3 Anxious behavior 4 Abdominal cramping
Urinary Output K level IV access Before administering IV potassium, the urinary output must be normal. If the urine output is low, a potassium infusion may damage renal cells. The last serum potassium level should also be checked to ensure potassium replacement is appropriate. A patent IV access is essential because potassium is very irritating and painful to subcutaneous tissue. The infusion of KCL 40 mEq in 100 mL of 5% dextrose and water has no direct effect on deep tendon reflexes, bowel movement patterns, or arterial blood gases. Therefore these items are not required to be assessed before administration of this medication.
A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. 1 Urinary output 2 Deep tendon reflexes 3 Last bowel movement 4 Arterial blood gas results 5 Last serum potassium level 6 Patency of the intravenous access
Headache and crackles Cerebral edema caused by hypervolemia may cause a headache. Crackles on lung auscultation indicate the presence of fluid in the alveoli (pulmonary edema). Increased fluid volume in the intravascular compartment (overhydration) will cause the pulse to feel full and bounding. The blood pressure will increase, not decrease, with hypervolemia. Dizziness when standing up occurs when pooling of blood in the peripheral vessels causes orthostatic (postural) hypotension.
A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply. 1 Headache 2 Thready pulse 3 Decreased blood pressure 4 Dizziness when standing up 5 Crackles on lung auscultation
Limited water reabsorption caused by removal of intestine The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? 1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy 4 Limited water reabsorption caused by removal of intestine
Assessing urinary intake and output
A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit? A Assessing urinary intake and output B Obtaining the client's weight weekly at different times of the day C Monitoring arterial blood gas (ABG) results D Maintaining I.V. therapy at the keep-vein-open rate
Decreased urine specific gravity
A dehydrated 15-month-old toddler is admitted to the pediatric unit with a diagnosis of intractable diarrhea. After several days of treatment the child is reevaluated. Which finding indicates to the nurse that the child's hydration status has improved? 1 Increased heart rate 2 Decreased blood pressure 3 Increased capillary refill time 4 Decreased urine specific gravity
Slowing of a previously rapid pulse The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Decreasing CVP readings indicate hypovolemia. Urinary output of 15 to 20 mL/hr indicates inadequate kidney perfusion; if fluid replacement is adequate, the urinary output should be more than 30 mL/hr. A hematocrit level increasing from 50% to 55% indicates hypovolemia and hemoconcentration.
A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate? 1 Decreasing central venous pressure (CVP) readings 2 Hematocrit level increasing from 50% to 55% 3 Slowing of a previously rapid pulse 4 Urinary output of 15 to 20 mL/hr
Hypotension After an adrenalectomy, adrenal insufficiency causes hypotension because of fluid and electrolyte alterations. Hypoglycemia, not hyperglycemia, may be a problem stemming from the loss of glucocorticoids. Hyponatremia may occur because of the lack of mineralocorticoid production. Potassium, not sodium, ions may be retained because of the lack of mineralocorticoids.
A nurse is caring for a client who had an adrenalectomy. What clinical response should the nurse monitor while steroid therapy is being regulated? 1 Hypotension 2 Hyperglycemia 3 Sodium retention 4 Potassium excretion
Expecting an increase in the oral fluid intake Diuretics cause dehydration, increasing the BUN; increasing fluid intake will result in a decrease in the BUN level. Although sending the client's urine for analysis should be done, it will not change the client's hydration status. Although the client should be on strict intake and output, it will not change the client's hydration status. Sodium restriction will not lower the BUN level; in addition, nutritionists only make suggestions to the primary healthcare provider regarding interventions. The primary healthcare provider is the professional legally responsible for prescribing a sodium-restricted diet.
A nurse is caring for a client who has a prescription for a 2-gram sodium diet and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) 42 mg/dL (15.2 mmol/L) and creatinine 1.1 mg/dL (97 mcmol/L). Considering the assessment findings, what is the most appropriate intervention by the nurse? 1 Sending the client's urine for analysis 2 Expecting an increase in the oral fluid intake 3 Placing the client on strict intake and output measurements 4 Notifying a nutritionist/dietitian so that sodium can be restricted further
Muscle weakness and cardiac dysrhythmias abdn cramping = hyperkalemia
A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? 1 Tingling of the fingertips and toes 2 Dry and sticky mucous membranes 3 Abdominal cramping and irritability 4 Muscle weakness and cardiac dysrhythmias
Hematocrit (Hct)
A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? 1 Blood urea nitrogen (BUN) 2 Sedimentation rate 3 Hematocrit (Hct) 4 Blood pH
Shortness of breath with crackles
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy? 1 Bleeding at the infusion site 2 Shortness of breath with crackles 3 Feeling of warmth throughout the body 4 Infiltration at the catheter insertion site
Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.
A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? 1 Alkalosis 2 Renal failure 3 Hypervolemia 4 Pulmonary edema
Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.
A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech
Urinary output of 4 mL over 2 hours
A nurse who is assigned to care for a 6-month-old infant with diarrhea is reviewing the infant's medical history, assessment findings, laboratory reports, and practitioner prescriptions. The infant weighs 15½ lb (7 kg). The healthcare provider has written a prescription for potassium chloride to be added to the IV fluids. What assessment finding signals the nurse to question this prescription? 1 Incessant crying 2 Inadequate tissue turgor 3 Urinary output of 4 mL over 2 hours 4 Oral fluid intake of 12 mL over 8 hours
Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? A Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. B Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. C Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. D Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.
"I need to drink liquids with some sodium in them." Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? A "I should drink a lot of tap water today." B "I need to take more calcium tablets today." C "I should avoid fruits with potassium in them." D "I need to drink liquids with some sodium in them."
Serum Potassium The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiologic availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.
A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? A Serum sodium B Serum potassium C Serum total calcium D Serum magnesium
Administering IV and oral fluids
A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included the care plan of Mark for his patient? A Administering I.V. and oral fluids B Clustering necessary activities throughout the day C Assessing color, odor, and amount of sputum D Monitoring serum albumin and total protein levels
Heart rate increases from 80 to 135 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.
During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1 Abdominal girth decrease 2 Mucous membranes becoming drier 3 Heart rate increases from 80 to 135 4 Blood pressure rises from 130/70 to 190/80
Hyperkalemia and hyponatremia
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? 1 Hypokalemia and hyponatremia 2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia
