Fluid and Electrolytes NCO

How would the nurse respond to a client admitted for dehydration who has an intravenous (IV) infusion of normal saline is started at 125 mL/h and one hour later begins screaming, "I can't breathe!"? Discontinue the IV and notify the health care provider. Elevate the head of the client's bed and obtain vital signs. Assess the client for allergies and change the IV to an intermittent lock. Contact the health care provider to request a prescription for a sedative.

Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Discontinuing the IV access line is unsafe because IV medications may need to be administered and restarting the IV will cause unnecessary discomfort and expense; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.

Which action would the nurse implement first for a client whose serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L)? Assess vital signs. Call the laboratory to repeat the test. Inform the cardiac arrest team to place them on alert. Perform an electrocardiogram.

It is important for the nurse to assess the client's vital signs. Vital signs provide valuable information regarding a client's cardiorespiratory status. Hyperkalemia causes cardiac dysrhythmias. After completing vital signs and performing an assessment, the nurse would contact the health care provider because medical intervention may be necessary. A repeat laboratory test will take time and probably reaffirm the original results; the client needs immediate attention. The cardiac arrest team is always on alert and will respond when called for a cardiac arrest. Taking an electrocardiogram would be an insufficient intervention.

During an 8-hour shift a client drinks two 6-oz (180-mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period? Record your answer using a whole number. mL

235 mL is the correct calculation. The client's intake was 360 mL (12 oz × 30 mL = 360 mL), and the loss was 125 mL of fluid; 360 mL - 125 mL = 235 mL.

Which factor is the most probable cause for Conn syndrome in an adult client? Genetic cause Adrenal adenoma High level of angiotensin II Elevated level of plasma renin

Conn syndrome is primary hyperaldosteronism. Excessive secretion of aldosterone by the adrenal glands due to an adrenal adenoma results in Conn syndrome. Certain types of hyperaldosteronism that are diagnosed in childhood have genetic causes. High levels of angiotensin II that are stimulated by high levels of plasma renin are a cause for secondary hyperaldosteronism.

While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above heart level. Which statement describes the rationale behind this nursing action? To promote bone density To prevent further edema To reduce pain perception To increase muscle strength

A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help reduce pain by reducing the transmission and perception of pain impulses.

Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? Providing oxygen Encouraging carbohydrates Administering fluid replacement Teaching facts about dietary principles

As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

Which length of time is the maximum that the nurse would allow an intravenous bag of solution to infuse? 6 hours 12 hours 18 hours 24 hours

After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often, such as 6 hours, 12 hours, or 18 hours.

Which action is the function of antidiuretic hormone (ADH)? Reduces blood volume Decreases water loss in urine Increases urine output Initiates the thirst mechanism

ADH is released by the posterior pituitary gland. It is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. ADH acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels? Epinephrine Glucagon Calcitonin Aldosterone

Aldosterone is mineralocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.

Which client problem would the nurse expect to decrease in response to the administration of serum albumin intravenously to a client with ascites? Confusion Urinary output Abdominal girth Serum ammonia level

An increased serum albumin level increases the osmotic effect and pulls fluid back into the intravascular compartment. This will increase renal flow and urine output, with a resulting decrease in abdominal girth. Confusion will not be impacted. Urinary output therapy will increase blood volume and blood flow to the kidney, thereby increasing urinary output. Albumin therapy has no effect on blood ammonia levels. An increased, not decreased, blood ammonia level causes hepatic encephalopathy.

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. Pulse quality Pulse pressure Bounding pulse Presence of dependent edema Neck vein distention in the upright position

Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? Rapid, thready pulse Distended jugular veins Elevated hematocrit level Increased serum sodium level

Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

Which condition would a nurse monitor for in a client who is prescribed bumetanide? Hypokalemia Hyperchloremia Hypernatremia Hypoglycemia

Bumetanide is a loop diuretic. Diuretic therapy that affects the loop of Henle increases urinary excretion of sodium, chloride, and potassium. As a result, clients are at risk for hypokalemia, hyponatremia, and hypochloremia. Additionally, hyperglycemia can occur.

Which statement regarding calcitonin is correct? It is secreted by follicular cells. Its actions are opposite to that of parathyroid hormone. It decreases phosphorous levels by increasing bone resorption. It works along with thyroid hormone to maintain normal calcium levels in blood.

Calcitonin reduces serum calcium levels, whereas parathyroid hormone increases serum calcium levels. The actions of calcitonin are opposite to that of parathyroid hormone. Calcitonin is secreted by parafollicular cells of the thyroid gland. Calcitonin decreases calcium and phosphorus levels by decreasing bone resorption. Calcitonin works along with parathyroid hormone to maintain calcium levels in blood.

One liter of 5% dextrose solution contains 50 grams of sugar. The nurse calculates that 3 L solution/day will supply approximately how many kilocalories? 400 600 800 1000

Carbohydrates provide 4 kcal/g; therefore 3 L × 50 g/L × 4 kcal/g = 600 kcal, only about a third of the basal energy needed. Four hundred kilocalories are less than the kilocalories provided by the prescribed intravenous (IV) fluid. Eight hundred kilocalories and 1000 kilocalories are more than the kilocalories provided by the prescribed IV fluid.

The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20 mm Hg. Which action made by the client is responsible for the reported ICP? Drinking lots of water Eating high-fiber foods Bending over at the waist Bending knees when lowering body

Clients without a pituitary gland ( hypophysectomy) should avoid bending at the waist because this position increases intracranial pressures. Drinking lots of water and eating high-fiber foods reduce the risk of constipation, so this should not cause increased intracranial pressure. The client should bend the knees to lower the body, which reduces the risk of increased intracranial pressures.

Which factor must the nurse determine to adjust the drip rate when administering intravenous (IV) fluids to be delivered at 80 mL/h? Total volume of fluid in the IV bag Size of the needle or catheter in the vein Drops per milliliter delivered by the infusion set Diameter of the tubing being used to instill the fluid

Different infusion sets deliver different preset numbers of drops per milliliter. Knowing this is a necessity for calculating the drip rate. Total volume of fluid in the IV bag and size of the needle or catheter in the vein do not determine the drip rate. The diameter of the tubing being used to instill the fluid determines the size of the drop, not the drip rate.

Which statement indicates the client with chronic kidney disease understands the purpose of using continuous ambulatory peritoneal dialysis (CAPD)? "The treatment provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." "The treatment exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." "The treatment decreases the need for immobility, because the fluids clear the toxins in short and intermittent periods." "The treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."

Diffusion moves particles from an area of greater concentration to an area of lesser concentration. Osmosis moves fluid from an area of lesser concentration to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane for indirect cleansing of the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.

The nurse administers two units of packed red blood cells ([RBCs] 250 mL each), followed by 500 mL of 0.9% sodium chloride. How many mL of solution has infused? Record your answer as a whole number. mL

Each bag of packed RBCs contains 250 mL, for a total of 500 mL of packed RBCs. The total amount of sodium chloride received is 500 mL. 500 + 500 = 1000 mL of solution.

Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine? Dilute urine Hematuria Concentrated urine Myoglobinuria

Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates hematuria, the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobinuria.

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? Shift of fluid into the interstitial spaces Weakening of the cell wall Increased intravascular compliance Increased intracellular fluid volume

Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathological reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? Clear breath sounds Positive pedal pulses Normal potassium level Decreased urine specific gravity

Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

Intravenous (IV) fluid replacement of 7200 mL during the first 24 hours has been prescribed for a client with severe burns. Fifty percent of fluid replacement will be administered in the first 8 hours; then the remaining 50% given over the next 16 hours. How many milliliters per hour will the nurse infuse during the first 8 hours? Record your answer using a whole number. mL/h

Fifty percent of the total volume to be infused is 3600 mL (7200/2 = 3600). The total time of infusion for this volume is 8 hours. 3600 mL/8 hours = 450 mL/h.

In which parts of the kidney are glucose and amino acids reabsorbed? Distal tubule Loop of Henle Collecting duct Proximal tubule

Glucose, amino acids, electrolytes, and bicarbonate are reabsorbed in the proximal tubule. In distal tubules, water and bicarbonate are reabsorbed, but not glucose and amino acids. Sodium and chloride are reabsorbed in the ascending limb, and water in the descending loop, of the Loop of Henle. Water is reabsorbed in the presence of antidiuretic hormone in the collecting duct.

Which would the nurse assess for if unilateral injury of the laryngeal nerve was suspected, when caring for a client immediately after a subtotal thyroidectomy? Check the throat for edema. Ask the client to say what the current time is. Elicit spasms of the facial muscles. Palpate the neck for seepage of blood.

If the laryngeal nerve is damaged during surgery, the client will be hoarse and have difficulty speaking. Checking the throat for edema does not indicate injury to the laryngeal nerve; this is part of the assessment for a compromised airway. Eliciting the Chvostek sign (spasm in the facial muscle) assesses for hypocalcemia resulting from inadvertent removal of the parathyroid glands. Palpating the neck for seepage of blood assesses for bleeding and possible hemorrhage, not laryngeal nerve injury.

Which volume of solution would be prepared when the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL

In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

Which factor would the nurse recognize as the cause when a client's intravenous (IV) infusion infiltrates? Excessive height of the IV bag Failure to secure the catheter adequately Contamination during the catheter insertion Infusion of a chemically irritating medication

Infiltration is caused by catheter displacement, which allows fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration. Infusion of a chemically irritating medication can lead to phlebitis, not infiltration.

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. Diuretics Low-salt diet Daily weight checks Fluid restriction Intake and output Oxygen administration

Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.

Which response would be given by a nurse providing discharge teaching to an older adult who was admitted to the hospital to be treated for dehydration when the client asks what to do about itchy, dry skin? "Wear plenty of warm clothes to keep moisture in the skin." "Use a moisturizer on the skin daily to help reduce itching." "Take hot tub baths only twice a week to reduce drying of the skin." "Expose the skin to the air to help reduce the sensation of itching."

Lubricating the skin with a moisturizer effectively relieves dryness and, thus, the pruritus (itching). Wearing warm clothing will not lubricate the skin or relieve pruritus. Warm or cool, not hot, tub baths will reduce itching. Exposing the skin to the air causes further drying and will not relieve pruritus.

The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? Hypokalemia and hyponatremia Hyperkalemia and hyponatremia Hypokalemia and hypernatremia Hyperkalemia and hypernatremia

Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

Which disease increases the risk of hyperkalemia? Crohn disease Cushing disease End-stage renal disease Gastroesophageal reflux disease

One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

Which hormone regulates blood levels of calcium? Parathyroid hormone (PTH) Luteinizing hormone (LH) Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH)

Parathyroid hormone (PTH) regulates the blood levels of calcium and phosphorus. LH stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. TSH stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. ACTH promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

Which information in the response of a client receiving peritoneal dialysis indicates understanding of the purpose of the procedure? Reestablishing normal kidney function Cleaning the peritoneal membrane Providing fluid for intracellular spaces Removing toxins and metabolic wastes

Peritoneal dialysis uses the peritoneum as a selectively permeable membrane for diffusion of toxins and wastes from the blood into the dialyzing solution. Peritoneal dialysis acts as a substitute for kidney function; it does not reestablish kidney function. The dialysate does not clean the peritoneal membrane; the semipermeable membrane allows toxins and wastes to pass into the dialysate within the abdominal cavity. Fluid in the abdominal cavity does not enter the intracellular compartment.

Which medication can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide

Prolonged administration of demeclocycline may cause diabetes insipidus, because this medication decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

Which clinical finding would the nurse associate with hypokalemia? Edema Muscle spasms Kussmaul respirations Muscle weakness

Serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. This can result in observable muscle weakness. Edema is associated with electrolyte imbalances, including sodium excess (hypernatremia). Muscle spasms and twitching are often seen in the setting of hypocalcemia. Kussmaul respiration is a breathing pattern characterized by deep and labored breaths in response to metabolic acidosis, especially diabetic ketoacidosis.

Which answer would a nurse give to a client receiving a hemodialysis treatment who asks which substances are being removed? Blood Sodium Glucose Bacteria

Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. Red blood cells do not pass through the semipermeable membrane during hemodialysis. Glucose does not pass through the semipermeable membrane during hemodialysis. Bacteria do not pass through the semipermeable membrane during hemodialysis.

A 2-year-old child is admitted with gastroenteritis and dehydration. Intravenous fluids are prescribed. Which is the most appropriate site for the first intravenous insertion? Scalp vein near the fontanel Venous arch on top of the foot Dorsal metacarpals of the hand Basilic vein at the antecubital fossa

The choice of first insertion site should be distal (low) on the periphery of an extremity and progress proximally (upward) toward the trunk; the upper extremities are the most appropriate sites for intravenous insertions for adults and children older than 1 year. Scalp veins are used for infants only if peripheral veins are inaccessible. Foot veins should not be used once a child is walking. The antecubital fossa should be avoided because the arm will have to be immobilized to stabilize the intravenous insertion site to prevent an infiltration.

A client is 36 hours after admission with severe burns and the nurse identifies the client's potassium level is 6.0 mEq/L (6.0 mmol/L). The nurse would recommend substituting current dietary fluids with which drink? Milk Tea Orange juice Tomato juice

The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

Which percentage of total body water is found in a premature newborn? 55% 65% 75% 85%

The total body water in a premature newborn is 85%. In full-term infants, body water ranges from 70% to 80%. The total body water in a child between the ages of 1 and 12 years is approximately 64%.

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. The nurse will set the control device to deliver how many milliliters per hour? Record your answer using a whole number. mL/h

The volume to be infused is 2000 mL. The total time of infusion is 12 hours. 2000 mL/ 12 hours = 167 mL/ hour.

The nurse administers vasopressin to a client and recalls that the medication is which type of hormone? Growth hormone Luteinizing hormone Antidiuretic hormone Thyroid-stimulating hormone

Vasopressin is an antidiuretic hormone. Somatotropin is a growth hormone. Gonadotropin is a luteinizing hormone. Thyrotropin is a thyroid-stimulating hormone.

Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Severe muscle cramps Numbness around the mouth

Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.

Which action would the nurse perform first when assessing if an intravenous (IV) infusion of a vesicant has extravasated? Elevate the IV site. Stop the infusion. Contact the prescriber. Aspirate residual medication from the IV catheter.

When an IV infusion of a vesicant extravasates, it should be stopped immediately to prevent further damage. After this action is taken, the nurse can elevate the site of IV placement, contract the provider, and aspirate any remaining medication from the IV catheter.

The nurse is educating a client about managing hypoglycemia unawareness. Which information would the nurse provide? Refrain from alternative testing sites. Use any available meter to monitor levels. Initiate continuous blood glucose monitoring. Calibrate the meter before managing hypoglycemia.

When the client is managing hypoglycemia, the same site should be used to obtain blood glucose levels. This provides consistent readings because blood glucose levels are changing rapidly. The client should use his or her meter to monitor blood glucose levels for consistency. Continuous blood glucose monitoring should be implemented when the client is stable, not during hypoglycemic episodes. The client should calibrate the meter once a day, but not when hypoglycemic. The client needs a meter that can provide instant results without waiting for tests to be performed on the meter itself.

Which hormonal deficiency causes diabetes insipidus in a client? Prolactin Thyrotropin Luteinizing hormone Antidiuretic hormone (ADH)

ADH deficiency causes diabetes insipidus. Decreased levels of prolactin may cause decreased amounts of milk secretion after birth. Decreased levels of thyrotropin cause hypothyroidism, weight gain, and lethargy. Luteinizing hormone deficiency causes menstrual abnormalities, decreased libido, and breast atrophy.

Which symptom indicates that a client with inhalation anthrax is in the fulminant stage? Fever Dry cough Mediastinitis Mild chest pain

Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. This disease has two stages of illness, the prodromal stage and the fulminant stage. The symptom of the fulminant stage is mediastinitis. The symptoms of the prodromal stage are fever, dry cough, and mild chest pain.

A client with hyperemesis gravidarum is receiving rehydration infusion therapy at home. Which is the priority nursing activity for the home health nurse? Determining fetal well-being Monitoring for signs of infection Monitoring the client for signs of electrolyte imbalance Teaching about changes in nutritional needs during pregnancy

Rehydration fluids contain only saline and dextrose; if the client continues to vomit, she will lose electrolytes. Monitoring the fetus is not the priority at this time. Although there is a risk of infection when an intravenous line is in place, this is uncommon and is not the first priority assessment. Teaching about nutritional needs is important, but is not the first priority for this client.

Which collecting structure is located at the end of the renal papilla? Calyx Capsule Renal cortex Renal columns

The calyx is a cuplike structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.

Which action will the nurse take in a client hospitalized for uncontrolled hypertension and chest pain on a daily diuretic for 2 days whose potassium level this morning is 2.7 mEq/L (2.7 mmol/L)? Send another blood sample to the laboratory to retest the serum potassium level. Notify the health care provider that the potassium level is above normal. Notify the health care provider that the potassium level is below normal. No action is required because the potassium level is within normal limits.

The health care provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because some can cause hypokalemia, whereas others spare potassium, which can cause hyperkalemia. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client? Sodium: 143 mEq/L Potassium: 2.9 mEq/L Bicarbonate: 25 mEq/L Total calcium: 10 mg/dL

The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is less than the normal level. It may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL. Thus the laboratory values of sodium (143 mEq/L), bicarbonate (25 mEq/L), and total calcium (10 mg/dL) lie in the normal range, which does not indicate hyperfunction of the adrenal gland in the client.

The nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. Which is the volume of solution the nurse would prepare? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL

The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse would prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.

The client needs to receive 1 L of intravenous fluid every 8 hours. If the equipment delivers 15 drops/mL, the nurse will regulate the flow to deliver how many drops per minute? Record your answer using a whole number. drops/minute

The prescribed dose is 1 L (1000 mL) to be infused with a total infusion time of 8 hours. The drop factor is 15 gtt/mL. Use the following formula to calculate the rate of the infusion in drops per minute. 1000mL / 8 hours x 1 hour/60 minutes x 15 drops/mL = 31 drops/minute.

Which action is promoted by vasopressin? Sodium reabsorption Reabsorption of water Tubular secretion of sodium Red blood cell production

Vasopressin is also known as an antidiuretic hormone. 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.

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? Prevent constipation Prevent dehydration Prevent vomiting Prevent electrolyte imbalance

When clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern. Constipation is usually not a concern in this situation. Although dehydration is a possible effect of an NG tube that removes gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.

Which gauge size would the nurse choose for a peripheral catheter insertion to administer saline to an infant? 14 gauge 18 gauge 20 gauge 24 gauge

A 24- to 26-gauge size is appropriate for transfusion and administration of saline in an infant. A 14 gauge is the preferred size for trauma and surgical clients requiring rapid fluid resuscitation in an adult client. An 18 gauge is the preferred size for surgery for an adult. A 20-gauge size is adequate for all therapies related to an adult client.

Which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected? Complete blood cell count Serum potassium level X-ray film of long bones Blood cultures ×3

A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood cell count, x-ray film of long bones, and blood cultures ×3 will have no significance in the diagnosis of a potassium deficit.

Which condition is a possible cause of pitting edema on the dorsum of the foot? Endocrine imbalance Excessive collagen production Fluid and electrolyte imbalance Autonomic nervous system stimulation

Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in nonpitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.

Which food would a nurse instruct the client to include in the diet when being prescribed furosemide? Liver Apples Cabbage Bananas

Furosemide is a loop diuretic that increases potassium excretion by preventing renal absorption. Bananas have a significant amount of potassium. Bananas: 450 mg; cabbage: 243 mg; liver: 73.6 mg; apples: 100 to 120 mg.

Which adverse effect would a nurse monitor for when caring for a client receiving furosemide to relieve edema? Hypernatremia Elevated blood urea nitrogen Hypokalemia Increase in the urine specific gravity

Furosemide is a potent diuretic used to provide rapid diuresis; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. Furosemide inhibits the reabsorption, not retention, of sodium. Furosemide does not affect protein metabolism and will not elevate blood urea nitrogen. Because furosemide increases water excretion relative to solutes, the specific gravity of the fluid more likely will be low.

For which reason would clients who receive intravenous (IV) fluids rather than total parenteral nutrition for gastrointestinal problems lose weight? Lack of bulk in the diet Deficient carbohydrate intake Insufficient intake of water-soluble vitamins Increasing concentrations of electrolytes in the cells

IV fluids supply minimal calories; a client receiving only IV fluids will lose weight and become malnourished. Lack of bulk in the diet is not related to weight; lack of bulk in the diet results in constipation. Vitamins are not related to weight loss. Intracellular electrolytes are not related to weight loss.

A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. Which item would the nurse keep at the bedside in case of magnesium sulfate toxicity? Oxygen Naloxone Calcium gluconate Suction equipment

The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is to try to prevent a seizure.

The client needs 8 mg of morphine sulfate to be given by injection. The vial on hand contains 10 mg of morphine per milliliter. How many milliliters will the nurse administer? Record your answer using one decimal place and include a leading zero if applicable. mL

The prescribed dose is 8 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer. 8 mg x 1 mL/10 mg = 0.8 mL.

In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? Isotonic Isomeric Hypotonic Hypertonic

Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. Isomeric relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor? Skin condition Fluid and electrolyte balance Food intake Fluid intake and output

Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea leads to alteration in fluid and electrolyte balance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

Which assessment finding indicates that sodium polystyrene sulfonate has been effective? Control of diarrhea An increase in serum sodium level An increase in serum calcium level A decrease in serum potassium level

Sodium polystyrene sulfonate is given to treat hyperkalemia. The effectiveness of the medication is determined by a decreasing serum potassium level. Sodium polystyrene sulfonate binds with the potassium in the gastrointestinal system and often causes diarrhea. Sodium retention and hypernatremia may occur as an adverse effect; this does not indicate effectiveness. Sodium polystyrene sulfonate decreases serum calcium levels in a small number of clients but does not increase calcium.

A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? Sodium Calcium Potassium Phosphorus

The muscle contraction-relaxation cycle requires an adequate serum calcium/phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. The major route of sodium excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.

Which goal would the nurse expect a client receiving treatment for bacterial cystitis to achieve before their discharge from the hospital? Understand the need to drink 4 L of water per day to prevent dehydration. Demonstrate an ability to identify dietary restrictions and plan menus. Achieve relief of clinical symptoms and maintain kidney function. Recognize signs of bleeding as a complication associated with this type of procedure.

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 treatment.

Which part of the kidney produces the hormone bradykinin? Kidney tissues Kidney parenchyma Renin-producing granular cells Juxtaglomerular cells of the arterioles

The juxtaglomerular cells of the arterioles produce the hormone bradykinin, which increases blood flow and vascular permeability. The kidney tissues produce prostaglandins that regulate internal blood flow by vasodilation or vasoconstriction. The kidney parenchyma produces erythropoietin that stimulates the bone marrow to make red blood cells. The renin-producing granular cells produce the hormone renin that raises blood pressure as a result of angiotensin and aldosterone secretion.

Which medication will the nurse expect the health care provider to prescribe to a client who had a thyroidectomy and is pale with spasms of the hand when taking the blood pressure? Calcium Magnesium Bicarbonate Potassium chloride

These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.

Which complication would the nurse suspect when the cardiac monitor shows the appearance of a U wave in a client being treated with intravenous fluids and insulin for diabetic ketoacidosis when the client develops peripheral paresthesias and shortness of breath? Hypokalemia Hypoglycemia Hypernatremia Hypercalcemia

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Symptoms of hypoglycemia are weakness, nervousness, tachycardia, diaphoresis, irritability, and pallor. Symptoms of hypernatremia are thirst, orthostatic hypotension, dry mouth, and mucous membranes, concentrated urine, tachycardia, irregular heartbeat, irritability, fatigue, lethargy, labored breathing, and muscle twitching or seizures. Symptoms of hypercalcemia are lethargy, nausea, vomiting, paresthesias, and personality changes.

Which molecule excessively accumulates in the blood to precipitate the signs and symptoms associated with a diabetic coma? Sodium bicarbonate, causing alkalosis Ketones as a result of rapid fat breakdown, causing acidosis Nitrogen from protein catabolism, causing ammonia intoxication Glucose from rapid carbohydrate metabolism, causing drowsiness

Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate. Diabetes does not interfere with removal of nitrogenous wastes. Carbohydrate metabolism is impaired in the client with diabetes.

Which action will the nurse take when caring for a client whose intravenous (IV) site is tender with erythema, warmth, and mild edema? Irrigate the IV tubing. Change the IV site. Slow the rate of the infusion. Obtain a prescription for an analgesic.

The clinical findings indicate the presence of inflammation; therefore, the IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion does not address the underlying problem and may cause worsening irritation. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.

Which number would a nurse document as the client's fluid balance after an 8-hour shift where a client has a 6-oz (180-mL) cup of tea and 360 mL of water, vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output? 240 mL -340 mL 440 mL 540 mL

440 mL is the correct calculation. The client's intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which when subtracted from 540 mL equals 440 mL. The IV fluid intake and the urinary output are equal; therefore they do not influence the final fluid balance. The options 240 mL, -340 mL, and 540 mL are incorrect calculations.

At 10:00 AM the nurse hangs a 1000-mL bag of 5% dextrose in water (D 5W) with 20 mEq of potassium chloride to be administered at 80 mL/h. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic? 15 minutes 30 minutes 45 minutes 60 minutes

An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. Minutes that are less than an hour are incorrect calculations.

Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? Increased blood urea nitrogen (BUN) and hypotension Hyperkalemia and poor skin turgor Hyponatremia and decreased urine output Polyuria and increased specific gravity of urine

Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? Crackles in the lungs Decreased heart rate Decreased blood pressure Cyanosis of nailbeds

Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

Which priority action will the nurse take after stopping an intravenous piggyback antibiotic of a client who became restless, flushed and began to wheeze shortly after initiation? Notify the primary health care provider immediately about the client's condition. Take the client's blood pressure. Obtain the client's pulse oximetry. Assess the client's respiratory status.

The client is experiencing an allergic reaction. Severe allergic reactions commonly cause respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the primary health care provider. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.

Which finding during peritoneal dialysis would the nurse act on as a sign of infection? Pain with instillation Cloudy return of dialysate Complaints of constipation Leakage of dialysate around the catheter

The cloudy return of dialysate indicates infection and should be cultured for confirmation. Pain with instillation can happen when the dialysate is not warmed. Constipation can slow the flow of dialysate. Leakage around the catheter can happen early in the new placement of the catheter and when the peritoneum contains too much fluid.

Which component of the client's nephron acts as a receptor site for the antidiuretic hormone to regulate water balance? Collecting ducts Bowman's capsule Distal convoluted tubule Proximal convoluted tubule

The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. Bowman's capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption. The proximal convoluted tubule is the site for reabsorption of sodium, chloride, water, and urea.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? Cerebral palsy Cystic fibrosis Muscular dystrophy Multiple sclerosis

The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.

Which action would the nurse include in the plan of care for a client undergoing a transsphenoidal hypophysectomy? Select all that apply. One, some, or all responses may be correct. Assessing for clear nasal drainage Maintaining strict intake and output Increasing daily dietary fiber intake Elevating the head of the bed 30 degrees Instructing on the use of an incentive spirometer

The plan of care for a client who underwent a transsphenoidal hypophysectomy would include assessing for clear nasal drainage as this is a sign of cerebrospinal fluid leak. Strict intake and output would be maintained to monitor fluid balance because the pituitary gland produces hormones that regulate fluid volume. Daily dietary fiber would be increased to reduce the risk for constipation and straining postoperatively. The head of the bed would always be elevated at least 30 degrees to decrease intracranial pressure. Any client would perform incentive spirometry after surgery.

The provider has ordered endocrine testing for a client. Arrange the steps to be followed for the urine specimen collection in the correct sequence. Note the time. Empty bladder and discard the urine. Empty bladder at the end of the timed period and add urine to the collection. The timing for the urine collection begins after this specimen.

The procedure to collect urine specimen for endocrine testing involves serial specimens collected over a timed period and begins with emptying the bladder. The initial voiding specimen should be discarded. The client should then note the time at which the specimen is discarded and then begin to collect the urine specimens. At the end of the procedure the client should empty the bladder and add that specimen to the collection.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. Which electrolyte imbalance is causing these clinical findings? Hypokalemia Hyponatremia Hyperglycemia Hypercalcemia

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Clinical manifestations of hyponatremia include nausea, malaise, and changes in mental status. Clinical manifestations of hyperglycemia include weakness, dry skin, flushing, polyuria, and thirst. Clinical manifestations of hypercalcemia include lethargy, nausea, vomiting, paresthesias, and personality changes.

Which hormone aids in regulating intestinal calcium and phosphorous absorption? Insulin Thyroxine Glucocorticoids Parathyroid hormone

Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

Administration of which medication in relation to which changes in fluid intake can help prevent complications related to uric acid nephropathy in a client with lymphosarcoma is receiving allopurinol and methotrexate? Allopurinol and restricting the fluid intake Methotrexate and restricting fluid intake Allopurinol and encouraging increased fluid intake Methotrexate and encouraging increased fluid intake

Allopurinol decreases serum uric acid levels before and during chemotherapy; increased fluid intake aids in the increased excretion of uric acid. Allopurinol and increased fluids help prevent renal tubular impairment and kidney failure because of hyperuricemia. The client should be encouraged to follow a diet that promotes urine alkalinity. If the oral route is used, administering the methotrexate after providing an antacid will limit gastric irritation, not uric acid nephropathy. Fluid intake should be increased to 2 to 3 liters per day to prevent urate deposits and calculus formation.

Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? Complete blood count Serum potassium level Arterial blood gas panel Urine osmolality test

Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (mmol/L) indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit.

Upon pressure application, which degree of edema would the nurse document for a 6-mm deep indentation? 4+ 3+ 2+ 1+

The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a edema of 3+ degree. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which cation regulates intracellular osmolarity? Sodium Potassium Calcium Calcitonin

A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

Which statement explains why metabolic acidosis develops with kidney failure? Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

Which nutrient deficiency in the pregnant adolescent may result in decreased birthweight as a consequence of low bone mineral density in the fetus? Zinc Iron Calcium Folic acid

Calcium and vitamin deficiency may result in decreased birthweight as a consequence of low bone mineral density. Zinc deficiency may not lead to a decrease in bone mineral density. Iron deficiency may lead to anemia. Folic acid deficiency may result in neural tube defects.

Which electrolyte deficiency triggers the secretion of renin? Sodium Calcium Chloride Potassium

Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which parameter is the nurse assessing? Pain tolerance Skin turgor Ecchymosis formation Tissue mass

Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

When ammonia is excreted by healthy kidneys, which mechanism usually is maintained? Osmotic pressure of the blood Acid-base balance of the body Low bacterial levels in the urine Normal red blood cell production

The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.

Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? Decrease in tissue hydrostatic pressure Increase in plasma hydrostatic pressure Increase in tissue colloid osmotic pressure Decrease in plasma colloid oncotic pressure

Because the plasma colloid oncotic pressure is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.

Which concern when caring for a client prescribed furosemide 40 mg every day in conjunction with digoxin would prompt the nurse to ask the health care provider about potassium supplements? Digoxin causes significant potassium depletion. The liver destroys potassium as digoxin is detoxified. Lasix requires adequate serum potassium to promote diuresis. Digoxin toxicity occurs rapidly in the presence of hypokalemia.

Furosemide promotes potassium excretion, and low potassium (hypokalemia) increases cardiac excitability. Digoxin is more likely to cause dysrhythmias when potassium is low. Digoxin does not affect potassium excretion. Furosemide causes potassium excretion. Potassium is excreted by the kidneys, not destroyed by the liver. Furosemide causes diuresis and consequent potassium loss regardless of the serum potassium level.

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute will the nurse administer? Record your answer using a whole number. gtts/min

The prescribed rate is 125 mL/h. The drop factor of the tubing is 10 gtt/mL. Use the flow rate equation to determine the appropriate flow rate in drops/minute. 125 mL/h x 10 gtts/mL x 1h/60 min = 20.8 gtts/min (round up to 21 gtts/min)

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism

The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

An intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride needs to be administered over 20 minutes. The nurse will set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number. mL/h

The volume to be infused is 50 mL. The time of infusion needs to be converted to mL/h for the infusion pump. 50 mL/20 minutes x 60 minutes/1h = 150 mL/h.

When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider ? Equal Unrelated Inversely related Directly proportional

There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

A child who has a history of a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonephritis. How can the nurse obtain the most accurate information on the status of the child's edema? Weighing daily Observing body changes Measuring intake and output Monitoring electrolyte values

Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb (1 kg). Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.