Fluid & Electrolytes Nur 252 PassPoint Quizzes
The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?
Correct response: hypokalemia Explanation: Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.
A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. What is the best nursing intervention?
Correct response: Elevate the head of the bed to 30 to 45 degrees and reassess JVD. Explanation: Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.
The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. How much fluid should the nurse tell the client to drink?
Correct response: at least 3,000 mL of fluids daily Explanation: Instructions should be as specific as possible, and the nurse should avoid general statements such as "as much as possible." A specific goal is most useful. A mix of fluids will increase the likelihood of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 L more than she usually drinks if her intake was inadequate to begin with.
Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?
Correct response: daily weight Explanation: Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss.
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?
Correct response: hypokalemia Explanation: Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.
