Fluid & Electrolytes
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.) A. vomiting B. drinking milk C. urination D. eating a sandwich E. infusion of intravenous solution
A, B, C & E Explanation: 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.
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? A. Hypothalamus B. Cerebellum C. Brainstem D. Thalamus
A. Hypothalamus Explanation: Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus
Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? A. Infant B. School-age child C. Adolescent D. Young adult
A. Infant Explanation: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances.
A priority nursing intervention for a client with hypervolemia involves which of the following? A. Monitoring respiratory status for signs and symptoms of pulmonary complications. B. Encouraging the client to consume sodium-free fluids. C. Drawing a blood sample for typing and crossmatching. D. Establishing I.V. access with a large-bore catheter.
A. Monitoring respiratory status for signs and symptoms of pulmonary complications Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. Potassium B. Phosphorous C. Sodium D. Chloride
A. Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesiu
The primary extracellular electrolytes are: A. sodium, chloride, and bicarbonate. B. magnesium, sulfate, and carbon. C. phosphorous, calcium, and phosphate. D. potassium, phosphate, and sulfate.
A. sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? A. Lactated Ringer solution B. 0.45% NaCl C. 0.9% NaCl D. 5% NaCl
B. 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? A. 500 ml B. 1 L C. 1500 ml D. 1250 ml
B. 1 L Explanation: A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
Which electrolyte is a major anion in body fluid? A. Calcium B. Chloride C. Sodium D. Potassium
B. Chloride Explanation: Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are cations.
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? A. Summer allergies B. Insensible fluid loss C. Cardiovascular compromise D. Lung function
B. Insensible fluid loss Explanation: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? A. Three ounces of sliced ham, beets, and a salad B. Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad C. A frozen, packaged low-fat dinner with a side salad D. Tomato juice, low-fat cottage cheese, and three slices of bacon
B. Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Explanation: Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.
Which is considered an isotonic solution? A. 3% NaCl B. Dextran in NS C. 0.9% NS D. 0.45% NS
C. 0.9% NS Explanation: An isotonic solution is 0.9% normal saline (NaCl). Dextran in normal saline is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? A. <136 mOsm/kg B. 350-544 mOsm/kg C. 275-300 mOsm/kg D. >408 mOsm/kg
C. 275-300 mOsm/kg Explanation: In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c)
A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of: A. 230 mOsm/kg. B. 250 mOsm/kg. C. 280 mOsm/kg. D. 210 mOsm/kg.
C. 280 mOsm/kg. Explanation: Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? A. Magnesium B. Potassium C. Calcium D. Phosphorus
C. Calcium Explanation: Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? A. Headache B. Seizures C. Confusion D. Hallucinations
C. Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? A. Vital signs B. Intake and output C. Weight D. Edema
C. The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: A.respiratory rate. B. neuromuscular function. C. electrocardiogram (ECG) results. D. bowel sounds.
C. electrocardiogram (ECG) results Explanation: Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? A. 5% glucose in normal saline solution B. 0.9% sodium chloride C. 5% glucose in water D. 0. 45% sodium chloride
D. 0.45% Sodium chloride Explanation: Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.
What foods can the nurse recommend for the patient with hypokalemia? A. Nuts and legumes B. Green, leafy vegetables C. Milk and yogurt D. Fruits such as bananas and apricots
D. Fruits such as bananas and apricots Explanation: Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains (Crawford & Harris, 2011b).
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? A. Hyperkalemia B. Hypokalemia C. Hypocalcemia D. Hypercalcemia
D. Hypercalcemia Explanation: The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
Which is a correct route of administration for potassium? A. Subcutaneous B. Intramuscular C. IV (intravenous) push D. Oral
D. Oral Explanation: Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A. Serum creatinine level of 0.4 mg/dl B. Hematocrit of 52% C. Serum blood urea nitrogen (BUN) level of 8.6 mg/dl D. Serum sodium level of 124 mEq/L
D. Serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? A. Potassium level of 3.8 mEq/L B. Sodium level of 137 mEq/L C. Potassium level of 6 mEq/L D. Sodium level of 150 mEq/L
D. Sodium level of 150 mEq/L Explanation: Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.
What percentage of potassium excreted daily leaves the body by way of the kidneys? A. 40 B. 80 C. 20 D. 60
B. 80 Explanation: To maintain the potassium balance, the renal system must function, because 80% of the potassium excreted daily leaves the body by way of the kidneys. The other numerical values are incorrect.
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? A. An increased sense of thirst B. Cardiac volume intolerance C. Increase in nephrons in the kidneys D. Increased renal blood flow
B. Cardiac volume intolerance Explanation: The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? A. Tetany and increased blood urea nitrogen (BUN) levels C. Confusion and seizures C. Flaccidity and thirst D. Sunken eyeballs and spasticity
C. Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? A. Specific gravity of 1.02 B. Absence of protein C. Absence of glucose D. Urine pH of 3.0
D. Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? A. 115 mEq/L B. 160 mEq/L C. 145 mEq/L D. 130 mEq/L
A. 115 mEq/L Explanation: Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A. Rapid respiration B. Elevated blood pressure C. Subnormal temperature D. Low heart rate
B. Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? A. Phosphorus B. Calcium C. Magnesium D. Potassium
C. Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.
Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? A. A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL) B. An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction C. A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery D. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use
D. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Hypomagnesemia is particularly troublesome during treatment of alcohol withdrawal. Therefore, the serum magnesium level should be routinely measured in patients undergoing withdrawal from alcohol. TPN, heart disease, and lymphoma are not identified as central risk factors for the development of hypomagnesemia.
Which is the most common cause of symptomatic hypomagnesemia? A. Alcoholism B. Burns C. Intravenous drug use D. Sedentary lifestyle
A. Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia
Early signs of hypervolemia include A. moist breath sounds. B. thirst. C. increased breathing effort and weight gain. D. a decrease in blood pressure.
C. increased breathing effort and weight gain. Explanation: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? A. Urine becomes more diluted. B. The client has a decreased sensation of thirst. C. The frequency of voiding increases. D. The renal system retains more water.
D. The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? A. Jugular vein distention B. Polyuria C. Weight loss D. Tetanic contractions
A. Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
Which is an insensible mechanism of fluid loss? A. Urination B. Nausea C. Bowel elimination D. Breathing
D. Breathing Explanation: Loss of fluid from sweat or diaphoresis is referred to as insensible loss because it is unnoticeable and immeasurable. Losses from urination and bowel elimination are measurable. Nausea does not result in fluid loss, however if the client would develop emesis ( vomiting) this would be considered loss of body fluids and would need measured.
The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? A. "I will not salt my food; instead I'll use salt substitute." B. "I need to check to see whether my cola beverage has potassium in it." C. "I'll drink cranberry juice with my breakfast instead of coffee." D. "Bananas have a lot of potassium in them; I'll stop buying them."
A. "I will not salt my food; instead I'll use salt substitute." Explanation: The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. A. Drink water as an inexpensive way to meet fluid needs B. Drink carbonated beverages to help balance fluid volume. C. Drink caffeinated beverages to retain fluid. D. Respond to thirst E. Drink at least eight glasses of fluid each day.
A. Drink water as an expensive way to meet fluid needs D. Respond to thirst E. Drink at least eight glasses of fluid each day Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.
Clients diagnosed with hypervolemia should avoid sweet or dry food because it A. increases the client's desire to consume fluid. B. can lead to weight gain. C. an cause dehydration. D. obstructs water elimination.
A. Increases the clients desire to consume fluid Explanation: The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? A. Limit salt and water intake B. Teach client behaviors that decrease urination C. Assess for dehydration D. Give medications that promote fluid retention
A. Limit salt and water intake Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you? A. Start IV fluids and blood products B. Restrict fluids C. Administer a diuretic D. Increase sodium intake
A. Start IV fluids and blood products Explanation: This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? A. Provide oral care every 2-3 hours. B. Assess the client's weight daily for trends. C. Teach the client about increased fluid intake. D. Monitor for signs and symptoms of dehydration.
A.Provide oral care every 2-3 hours. Explanation: Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? A. Hypovolemia B. Dehydration C. Hypervolemia D. Fluid volume excess
B. Dehydration Explanation: The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? A. Confusion and decreased level of consciousness B. Fatigue, cramps, and weakness C. Shortness of breath, rales, and peripheral edema D. Dysphagia, tetany, and emotional lability
B. Fatigue, cramps and weakness Explanation: A serum potassium level of 2.7 mEq/L constitutes hypokalemia. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), arrhythmias, and increased sensitivity to digitalis. Respiratory symptoms, dysphagia, and tetany are not typically associated with hypokalemi
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? A. Similar causes are present in both conditions B. In dehydration, only extracellular is depleted. C Hypovolemia contains only low blood volume. D. Both conditions result in abnormal laboratory studies.
B. In dehydration, only extracellular is depleted. Explanation: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? A. Weight loss of 4 lb B. Irregular heart rate C. Blood pressure 96/53 mm Hg D. Mild confusion
B. Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? A.5% Dextrose in NS B. Lactated Ringers C. 0.45% NS D. 10% dextrose in water
B. Lactated Ringers Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? A. Filtration B. Osmosis C. Active transport D. Evaporation
B. Osmosis Explanation: Osmosis is the movement of water through a semipermeable membrane; one that allows some but not all substances in a solution to pass through from a diluted area to a more concentrated area. Filtration promotes the movement of fluid and some dissolved substances through a semipermeable membrane according to pressure differences. Evaporation is the process of converting water into a vapor. Active transport requires the energy source ATP to drive dissolved chemicals from an area of low concentration to an area of higher concentration; the opposite of passive diffusion.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? A. Magnesium:2 mEq/L B. Potassium: 5.8 mEq/L C. Sodium: 138 mEq/L D. Calcium: 10 mg/dL
B. Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? A. Potassium B. Sodium C. Calcium D. Magnesium
B. Sodium Explanation: Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.
A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? A. Hyperactive bowel sounds. B. Tingling or twitching sensation in the fingers C. Dyspnea and laryngospasm D. Confusion and depression
B. Tingling or twitching sensation in the fingers Explanation: All the choices are signs and symptoms of hypocalcemia, but tetany is the most characteristic manifestation that occurs when the calcium level is less than 4.4 mg/dL
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: A. diaphoresis B. muscle weakness C. constipation D. tremors.
B. muscle weakness. Explanation: Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? A. Distended jugular veins B. Crackles in the lung fields C. Dark, concentrated urine D. Cool and pale skin
C. Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? A. Hypokalemia B. Hypomagnesemia C. Hypocalcemia D. Dehydration
C. Hypocalcemia Explanation: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? A. "A good breakfast for me will include milk and a couple of bananas." B. "I will take a potassium supplement daily as prescribed." C. "I will be sure to buy frozen vegetables when I grocery shop." " D. "I can use laxatives and enemas but only once a week."
D. "I can use laxatives and enemas but only once a week." Explanation: The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.
Below which serum sodium concentration might convulsions or coma occur? A. 145 mEq/L (145 mmol/L B. 140 mEq/L (140 mmol/L) C. 142 mEq/L (142 mmol/L) D. 135 mEq/L (135 mmol/L)
D. 135 mEq/L (135 mmol/L) Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A. A 72-year-old with a total knee repair B. A 65-year-old with a myocardial infarction C. A 7-year-old with a fracture tibia D. A 52-year-old with diarrhea
D. A 52-year-old with diarrhea Explanation: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? (Select all that apply.) A. Urine osmolality of greater than 450 mOsm/kg B. Urine positive for blood C. BUN: serum creatinine ratio of greater than 12.1 D. Hematocrit level of greater than 47% E. Urine specific gravity of 1.027
D. Hematocrit level of greater than 47% E. Urine specific gravity of 1.027 A. Urine osmolality of greater than 450 mOsm/kg Explanation: Hypovolemia is associated with a hematocrit level that is greater than normal because there is a decreased plasma volume and a BUN elevated out of proportion to the serum creatinine (ratio greater than 20:1). Urine specific gravity is increased in relation to the kidneys' attempt to conserve water. Urine osmolality can be greater than 450 mOsm/kg because the kidneys try to compensate by conserving water. Hypovolemia is not associated with blood in the urine.
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A. Hyperkalemia B. Hypernatremia C. Hypophosphatemia D. Hypokalemia
D. Hypokalemia Explanation: Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? A. No, start with the sodium chloride IV. B. Yes, along with the hypotonic IV. C. Yes, this will correct the sodium deficit. D. No, sodium intake should be restricted.
D. No, sodium intake should be restricted Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets
The calcium concentration in the blood is regulated by which mechanism? A. Adrenal gland B. Androgens C. Thyroid hormone (TH) D. Parathyroid hormone (PTH)
D. Parathyroid hormone (PTH) Explanation: The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? A. Anascara B. Hypovolemia C. Pitting-edema D. Third-spacing
D. Third-spacing Explanation: Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anascara is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the A. client may be developing hyperaldosteronism. B. client has a history of alcohol abuse. C. client's diet is lacking in calcium-rich food products. D. malignancy is causing the electrolyte imbalance.
D. malignancy is causing the electrolyte imbalance. Explanation: The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? A. Muscle weakness B. Negative Chvostek sign C. Presence of Trousseau sign D. Slurred speech
Presence of Trousseau sign Explanation: After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia