Fluid and Electrolytes Q'S

The nurse is teaching older adult patients how to prevent fluid volume deficit. Which information should the nurse include? Answer "Avoid extreme temperatures." "Decrease fluid intake." "Increase sodium in the diet." "Take diuretics daily."

"Avoid extreme temperatures." Exposure to extreme temperatures such as heat can cause the patient to sweat and experience insensible fluid loss. Decreasing the amount of fluid intake and taking diuretics will cause fluid loss. Increasing sodium in the diet will cause fluid volume excess. Fluid imbalances can occur in older adult patients due to: Decreased thirst mechanism. Decreased kidney function. Reduced fluid reserves. Increased levels of atrial natriuretic factor (ANF).

The nurse is caring for a patient with a fluid volume excess (FVE) secondary to heart failure. The nurse should request a collaborative therapy consult for which specialist? Answer Dietitian Social worker Exercise physiologist Home care nurse

Dietitian Patients with FVE due to heart failure are advised to follow a low-sodium diet, and would benefit from a consultation with a dietitian or nutritionist to discuss the specifics. Social workers, exercise physiologists, and home care nurses are not typically required in the care of a patient with FVE.

A patient in the 28th week of pregnancy is suspected of developing preeclampsia. Which potential complication should the nurse anticipate when planning care for this patient? Answer Heart failure Dehydration Cirrhosis Sodium imbalance

Heart failure Preeclampsia during pregnancy puts a woman at risk for fluid volume excess. Without prompt treatment and resolution of the fluid imbalance, the woman is at risk for developing heart failure due to the increased workload associated with pumping excess blood volume. Fluid volume excess is not associated with dehydration, cirrhosis, or sodium imbalance. Additional Learning Fluid volume excess is associated with: -Heart failure. -Pulmonary edema. -Cerebral edema. -Plasma dilution causing a decreased hematocrit and BUN. -Ascites. -Edema and anasarca.

The nurse is documenting a patient's fluid output. Which fluid should the nurse include in this calculation? Answer Liquid feces Parenteral fluids Irrigants Tube feeding

Liquid feces Liquid feces is considered output. Parenteral fluids, irrigants, and tube feedings are considered input.

A patient has a low serum sodium level. Which intervention should the nurse expect to be prescribed for this patient? Answer 0.9% saline IV infusion Heparin injection Oral furosemide IV vasopressin

0.9% saline IV infusion Normal saline, or 0.9% saline, solution contains the sodium chloride necessary to treat the hyponatremia. Heparin is an anticoagulant and has a potential side effect of hyponatremia. Furosemide blocks sodium and water reabsorption, possibly causing further hyponatremia. Vasopressin is a vasoconstrictor that can cause fluid retention, which could exacerbate hyponatremia as dilutional hyponatremia. Medications and Fluids Used to Correct Fluid & Electrolyte Imbalances Electrolyte supplements Sodium chloride (sodium supplement) Potassium chloride (potassium supplement) Colloids Serum albumin Dextran 40 Crystalloids 5% dextrose and water Normal saline solution Lactated Ringer's solution 5% dextrose and ½ normal saline solution Diuretics Furosemide Hydrochlorothiazide Spironolactone (Aldactone)

A patient with altered renal function has an elevated potassium level. Which prescription should the nurse question before administering to this patient? Answer Administration of a diuretic Electrocardiogram every 12 hours Administration of insulin and glucose together Serum electrolytes every 8 hours

Administration of a diuretic With normal renal function, diuretics are sometimes used to treat hyperkalemia. However, they cannot be used when a patient has abnormal renal excretion. Routine electrocardiograms (ECGs) and serum electrolytes are important to monitor for worsening hyperkalemia or cardiac dysrhythmias. Administration of insulin and glucose together is a common medication combination for hyperkalemia. Additional Learning Management of hyperkalemia includes: Administration of sodium polystyrene sulfonate orally or by enema. Calcium gluconate. Insulin and glucose. Diuretics in case of normal renal excretion.

An older adult patient with electrolyte imbalances is concerned about repeated episodes of dehydration. Which physiological change that contributes to electrolyte imbalances in older adult patients should the nurse explain? Answer Decreased thirst sensation Decreased insensible water loss in warm weather Increased need for vitamins and minerals Increased renin and aldosterone secretion

Decreased thirst sensation Older adult patients often experience a reduced sense of thirst, which makes it more likely for them to become dehydrated, because they may not drink as much water as needed. Older adult patients also tend to lose more insensible water in warm weather. Older adult patients do not have an increased need for vitamins or minerals and may have decreased renin or aldosterone secretion. Older adults are at higher risk for electrolyte disturbances due to several physiological changes, including: Reduced glomerular filtration. Decreased ability to concentrate urine. Decreased total body water. Decreased thirst sensation. Greater insensible loss in warm weather. Reduced renin and aldosterone secretion. Increased atrial natriuretic peptide (ANP). Use of diuretics or other medications.

The nurse is caring for a patient with severe diarrhea. Which assessment data should indicate to the nurse that additional intervention is required for this patient? Answer Elevated hematocrit level Blood pressure of 120/74 mmHg Heart rate of 72 beats/min Urine output of 50 mL/hr

Elevated hematocrit level An elevated hematocrit indicates dehydration caused by intravascular volume loss and hemoconcentration. The other data indicate the fluid volume deficit has resolved. Additional Learning When caring for a patient with dehydration, the nurse must evaluate the patient's progress toward meeting the desired outcomes. Expected outcomes include: -The patient has water and electrolytes that are in balance as measured by serum electrolytes, hematocrit, and assessment findings. -Urinary output is within normal limits. -Fluid intake is adequate to meet maintenance needs. -Vital signs are within normal limits.

The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. For which imbalance should the nurse assess this​ client? A. Fluid overload B. Fluid deficit C. Hypernatremia D. Hyperkalemia

A. Fluid overload The client receiving intravenous​ (IV) colloids or any IV fluid is at risk for fluid overload. It​ is, therefore, important to monitor the client for manifestations of fluid overload. Fluid​ deficit, hyperkalemia, and hypernatremia do not typically result when infusing colloids.

The nurse is caring for a hospitalized client who is experiencing​ anxiety-related hyperventilation. When calculating the​ client's intake and​ output, where would the nurse anticipate the need for an adjustment in fluid​ loss? A. Feces B. Urine C. Sweat D. Insensible loss

D. Insensible loss With increased​ respirations, the client will experience a​ greater-than-normal insensible loss of fluid through the lungs. Hyperventilation will not affect the amount of fluid lost through the​ urine, sweat, or feces.

A patient presents with noticeable lower extremity swelling and periorbital edema. Which collaborative thearpy should the nurse anticipate? Answer Loop diuretic Electrocardiogram Sodium replacement therapy Elevating the head of the bed

Loop diuretic Significant edema and periorbital edema signifies that the patient may be suffering from fluid volume excess (FVE). The nurse should anticipate the healthcare provider ordering a diuretic to help reduce extra fluid. The patient may be placed on a sodium-restricted diet, not given sodium replacement therapy. Performing an electrocardiogram (ECG) is not likely indicated except for a severe imbalance or concurrent electrolyte imbalances. Elevating the head of the bed is an independent nursing intervention, not a healthcare provider order. When evaluating a patient for fluid volume excess, the nurse should include: Patient interview. Physical exam. Checking for edema (no edema to severe pitting edema). Periorbital or scrotal edema (normal is no edema). Intake/output. Character of the pulse. Neck vein distention. Auscultation of the dependent lung fields (abnormal is crackles in the lower lobes). Accessory muscle use (normal is no accessory muscle use). Serum electrolytes and serum osmolality (both usually normal even with FVE). Hematocrit and hemoglobin (may be decreased with FVE). Renal and liver function to determine the cause of FVE.

A patient has a serum potassium level of 7.4 mEq/L. Which medication should the nurse anticipate being prescribed for this patient? Answer Oral sodium polystyrene sulfonate Intravenous potassium supplementation Oral glucose Corticosteroid

Oral sodium polystyrene sulfonate Hyperkalemia is a potassium level above 5.2 mEq/L. Oral sodium polystyrene sulfonate is used to help reduce the potassium level. Further potassium supplementation would only further increase the potassium level. The healthcare provider may prescribe glucose and insulin together, but never glucose alone. Corticosteroids are not used to treat hyperkalemia. Management of hyperkalemia includes: Administration of sodium polystyrene sulfonate orally or by enema. Calcium gluconate. Insulin and glucose. Diuretics in case of normal renal excretion.

A patient is experiencing signs of a decrease in extravascular volume. Which should the nurse expect the patient to experience in response to this drop in volume? Answer Stimulation of the thirst center Increasing kidney function Decreasing secretion of insulin Stimulation of thyroid function

Stimulation of the thirst center In order to temporarily respond to decreased extracellular volume, the hypothalamus will be stimulated to initiate thirst. Increasing kidney function would cause more fluid volume loss. Decreased secretion of insulin and stimulation of thyroid function would not decrease extracellular fluid volume.

The nurse is teaching a patient taking a loop diuretic about prevention of fluid volume excess. Which should the nurse include in this teaching session? Answer "You should perform daily weights." "You will need to increase the dose of the medication." "You can eat a banana each day." "You should decrease fluid intake."

"You should perform daily weights." Daily weights are the best indicator of fluid imbalance. The patient should not increase the amount of diuretic medication because that can cause fluid volume deficit. Bananas provide a source of potassium for the patient and bear no impact on fluid balance. Decreasing fluid intake could promote a fluid volume deficit and would be incorrect advice.

The nurse is teaching parents about fluid replacement in an infant who has been vomiting. Which statement made by the parents should indicate to the nurse that further teaching is required? Answer "I will withhold oral fluids until the vomiting stops." "Oral fluid replacement is the preferred method of fluid replacement." "When fluid loss is minimal, water may be sufficient to use for replacement." "With fluid loss due to diarrhea or vomiting, a rehydrating solution with electrolytes may be needed."

"I will withhold oral fluids until the vomiting stops." Oral fluid replacement is preferred when treating fluid volume deficit. Water may be acceptable, a rehydrating solution may be necessary, and oral fluid replacement is preferred.

The nurse is reviewing patient assignment data to begin planning care for the day. Which patient should the nurse identify as being at the greatest risk for developing fluid volume excess? Answer A patient with cirrhosis A patient scheduled for oral surgery A patient who overuses laxatives A patient experiencing nausea and vomiting

A patient with cirrhosis A patient with liver cirrhosis is at greatest risk for developing fluid volume excess. Patients with nausea and vomiting, overuse of laxatives, or oral surgery are not at risk for developing fluid volume excess. Risk factors associated with excess fluid volume include: Preeclampsia in pregnancy. Heart disease. Kidney dysfunction. Diabetes and peripheral vascular disease. Hypertension. IV therapy if infusion rate and solution are not carefully monitored.

The nurse is administering a blood transfusion to a client who is hemorrhaging. In which fluid compartment should the nurse identify that the client is experiencing a​ deficit? A. Intravascular fluid B. Intracellular fluid C. Transcellular fluid D. Interstitial fluid

A. Intravascular fluid Blood loss causes a deficit in the intravascular fluid​ compartment, which is a subcompartment of extracellular fluid​ (ECF). Transcellular and interstitial​ fluids, along with​ lymph, make up the other compartments of ECF. Intracellular fluid is the other major fluid compartment in the body.

The nurse is caring for a client with suspected fluid volume excess. Which change in the serum osmolality should the nurse use as confirmation of this health​ problem? A. Remains the same B. Slight increase C. Slight decrease D. Large increase

A. Remains the same During fluid volume​ excess, the body retains both sodium and water. This causes the blood serum to remain isotonic and serum osmolality to remain the same.

A client with dehydration secondary to poor fluid intake has a 1 kg weight loss and voids 20 mL in the last hour. Which action should the nurse take​ first? A. Infuse 100 mL of normal saline per the standing order B. Discuss a fluid challenge with the healthcare provider C. Document these normal findings D. Encourage to increase oral intake of water

B. Discuss a fluid challenge with the healthcare provider The weight loss and low urine output indicate fluid volume deficit. These findings indicate the need for a fluid challenge. A fluid challenge may be performed to evaluate fluid volume when urine output is low and cardiac or renal function is questionable. A fluid challenge helps to prevent fluid volume overload resulting from IV fluid therapy when cardiac or renal function is compromised. These are not normal findings and require intervention. Drinking water or administration of 100 mL of normal saline are not appropriate interventions for this client.

The nurse is caring for a client with third spacing. Which information should the nurse use to explain this health problem to the​ client's family? A. ​"Fluid leaves the body through increased​ urination." B. ​"Fluid in the blood vessels is unavailable for the body to​ use." C. ​"Fluid moves into the fatty tissue under the​ skin." D. ​"Fluid moves into the space in the body​ cells."

B. ​"Fluid in the blood vessels is unavailable for the body to​ use." In third​ spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may move into the peritoneal space or​ pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss that can be attributed to third spacing may be difficult to detect because the​ client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.

correct, Study Plan 6.1.5 The nurse prepares intravenous fluid for a client. Which mechanism should the nurse recall that represents the movement of fluid across cell membranes from an area of less concentration to an area of higher​ concentration? A. Filtration B. Active transport C. Osmosis D. Diffusion

C. Osmosis Osmosis is the movement of water across cell​ membranes, from the​ less-concentrated solution to the​ more-concentrated solution. Filtration is the process by which fluid and solutes move together across a membrane from one compartment to another. Active transport is a process by which substances move across the cell membrane and must combine with a carrier for​ transportation, requiring metabolic energy. With​ diffusion, the molecules move from a solution of higher concentration to a solution of lower concentration.

The nurse instructs a client with fluid volume excess about dietary choices. Which meal choice should indicate to the nurse that teaching was​ effective? A. ​Eggs, sausage,​ grits, and white bread B. Egg​ whites, turkey​ bacon, oatmeal, and wheat toast C. ​Eggs, ham, mixed​ fruit, and wheat bread D. Egg​ whites, ham,​ grits, and white bread

B. Egg​ whites, turkey​ bacon, oatmeal, and wheat toast A meal of egg​ whites, turkey​ bacon, oatmeal, and wheat toast is the best choice to decrease the amount of​ sodium, because turkey bacon has the least amount of sodium. Choices that contain​ sausage, bacon, or ham are high in sodium and should be avoided

The nurse is caring for a patient who is experiencing orthostatic hypotension secondary to fluid volume deficit (FVD). Which action by the patient requires immediate follow-up by the nurse? Answer Getting out of bed straight to standing Drinking 1500 mL each day Sitting in a recliner instead of lying in bed Weighing themselves every day

Getting out of bed straight to standing A patient with a FVD is at risk for orthostatic hypotension, dizziness, and falling. The nurse should teach the patient to get up and transition slowly from lying down to sitting to standing, instead of going straight to standing. Drinking at least 1500 mL each day, sitting in a recliner, and weighing themselves daily are all appropriate interventions for someone suffering from a FVD. Additional Learning When caring for a patient with FVE, the nurse should be sure to include the following in the physical examination: -Checking for edema (no edema to severe pitting edema). -Periorbital or scrotal edema (normal is no edema). Intake/output. -Character of the pulse. -Neck vein distention. -Auscultation of the dependent lung fields (abnormal is crackles in the lower lobes). -Accessory muscle use (normal is no accessory muscle use). Grading a pitting edema on a scale of 1 to 4, with 1 plus corresponding to 2 mm, 2 plus corresponding to 4 mm, 3 plus to 6 mm, and 4 plus to 8 mm.-

A patient seeks medical attention for symptoms that are occurring since drinking large amounts of water after running a marathon. Which assessment should the nurse make a priority for this patient? Answer Level of consciousness Reflexes Eye accommodation Skin turgor

Level of consciousness The patient with water intoxication is experiencing a fluid volume excess and likely low electrolyte levels. Measuring blood pressure, auscultating lung sounds, and assessing level of consciousness are all priority assessments for the nurse to perform. Reflexes and skin turgor are important to evaluate, because they can give information about electrolyte and fluid levels, but they are not the priority assessment. Palpating the area around the eyes, not testing for accommodation, is a priority for this patient. When treating a patient for acute fluid overload, the nurse should be prepared for interventions that include: -Administering diuretics. -Elevating the head of the bed. -Monitoring vital signs and oxygen saturation. -Administering oxygen as needed. -Measuring daily weights. -Accurate measuring of I&O. -Instituting temporary fluid restrictions.

The nurse is caring for a patient with hypochloremia. Which dietary change should the nurse recommend to this patient? Answer "Add salt to your diet." "Follow a low-sodium diet." "Take regular calcium supplements." "Restrict fluids."

"Add salt to your diet." Hypochloremia is a low serum chloride level. Interventions include adding more salt to the diet, addressing the cause of the hypochloremia, and adding chloride to IV fluids (if hospitalized). Reducing sodium intake, adding calcium supplements, or restricting fluids are not recommended for this health problem.

The nurse is teaching a patient about maintenance of fluid and electrolyte balance. Which patient statement indicates an understanding of the modifiable risk factor with the most direct effect on calcium balance? Answer "I should exercise to help me to maintain an appropriate calcium balance." "I need to manage my stress level to help keep a good calcium level." "I should maintain adequate fluid intake for better calcium balance." "I need to take my diuretic medication as directed to maintain the appropriate calcium level."

"I should exercise to help me to maintain an appropriate calcium balance." Regular weight-bearing exercise helps maintain calcium balance. Stress, fluid intake, and diuretics can all affect fluid and electrolyte balance in a general way, but they do not specifically target calcium.

A client is experiencing severe diarrhea. Which data should indicate to the nurse that the client is experiencing fluid volume​ deficit? (Select all that​ apply.) A. Poor skin turgor B. Increased urine output C. Orthostatic hypotension D. Weight gain E. Increased heart rate

A. Poor skin turgor C. Orthostatic hypotension E. Increased heart rate Orthostatic​ hypotension, increased heart​ rate, and poor skin turgor are acute manifestations of fluid volume deficit. Increases in urine output and weight gain are not acute manifestations of fluid volume deficit.

The nurse is caring for an older client. Which early sign of a fluid volume deficit should the nurse identify in this​ client? A. Brittle hair B. Poor skin turgor C. Change in mental status D. Dry skin

C. Change in mental status Change in mental status or mentation is an early sign of FVD in the older adult. Skin turgor can be difficult to assess due to normal changes with aging. Dry skin and brittle hair are signs of chronic dehydration.

The nurse is performing an assessment on a client with fluid volume excess. Which finding should the nurse identify that supports fluid volume​ excess? (Select all that​ apply.) A. Tenting of skin B. Thirst C. Weight gain D. Crackles on auscultation E. Pitting edema

C. Weight gain D. Crackles on auscultation E. Pitting edema Pitting​ edema, weight​ gain, and crackles in the lungs upon auscultation are indicative of fluid volume excess. Tenting of skin and thirst are found in fluid volume deficit.

A patient with confusion and hyperreflexia has a serum sodium level of 162 mEq/L. The nurse should plan this patient's care based on which health problem? Answer Hypernatremia Hyponatremia Fluid volume excess Fluid volume deficit

Hypernatremia The normal range of serum sodium level is from 135-145 mEq/L. A high value indicates hypernatremia. Hyponatremia is a low serum sodium level. There is insufficient information to diagnose either FVE or FVD.

The nurse is reviewing the medication record of a patient admitted with dehydration. Which medication type should cause the nurse concern? Answer Antipsychotic Selective serotonin reuptake inhibitor Nonsteroidal anti-inflammatory drug Antibiotic

Antipsychotic Patients with dehydration are likely to develop electrolyte imbalances as the body attempts to compensate for the lost fluid. Individuals taking antipsychotic agents are often at risk for alterations in fluid intake due to the effect on thirst mechanisms. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics are not associated with fluid or electrolyte imbalances and do not affect fluid balance.

A client is receiving hemodialysis for renal failure. Which clinical information should indicate to the nurse that the client is experiencing an excess in fluid​ volume? (Select all that​ apply.) A. Weight gain of 2 kg B. Blood pressure​ 172/90 mmHg C. Pulse of 62 bpm D. Temperature 100.1degreesF E. Full and bounding pulse

​A. Weight gain of 2 kg B. Blood pressure​ 172/90 mmHg E. Full and bounding pulse Rationale: Pulse​ volume, blood​ pressure, and body weight all increase with fluid volume excess. Temperature and pulse rate both increase with fluid volume deficit.

A nurse is unable to secure an intravenous access site due to severe dehydration. Which prescription should the nurse expect to replace this patient's fluid deficit? Answer "Administer fluids via hypodermoclysis." "Administer sodium supplements." "Administer oral fluid replacement." "Administer diuretics."

"Administer fluids via hypodermoclysis." When IV access is problematic, fluids can be administered subcutaneously, using a method called hypodermoclysis. Diuretics are used to treat fluid volume excess, not dehydration. Oral fluid replacement is ordered for mild dehydration, not severe dehydration. Fluid replacement, not sodium supplements, would be anticipated.

A patient on fluid restriction is experiencing severe thirst. Which suggestion should the nurse provide to this patient? Answer "Chew sugarless gum." "Drink a small glass of water." "Eat a bowl of soup." "Have a piece of watermelon."

"Chew sugarless gum." Patients on fluid-restricted diets must be careful about every ounce of fluid they take in. They can try chewing sugarless gum or sucking on some ice chips if they get thirsty. Drinking extra water is not appropriate because it can precipitate fluid volume excess (FVE). Eating soup or some fruits and vegetables can also be an extra source of fluid. Sodium and fluid restrictions are required for a patient with FVE. This may include: -Placing allowed amounts of fluid in a small glass instead of a large one. -Offering ice chips. -Being aware of the water content in some fruits, vegetables, and foods (such as soup). -Providing frequent mouth and oral care. -Using sugarless gum to reduce thirst. -Watching out for salt in nonprescription drugs (analgesics, cough medicines, antacids), toothpastes, and mouthwashes. -Using salt substitutes sparingly. -Using herbs, spices, lemon juice, vinegar, and wine for flavoring instead of salt. -Being aware that processed foods are often high in salt.-

The mother of a 2-month-old infant is concerned that the baby is becoming dehydrated because of the number of wet diapers. Which recommendation should the nurse make to this mother? Answer "Continue with breast milk or formula only; it provides all of the hydration that an infant needs." "Try giving 1-2 cups of water each day to increase hydration levels." "Add a little extra water to the formula to increase fluid levels." "Administer 0.5 cup of oral rehydration solution."

"Continue with breast milk or formula only; it provides all of the hydration that an infant needs." Breast milk or formula should be the only source of fluids for a young infant. Newborns and young infants are at risk for fluid volume excess (FVE) due to immature kidneys and filtering mechanism. Extra water, even in mixed formula, or oral rehydration solutions are not necessary for an infant. A few teaching points when infants suffer from fluid loss or dehydration include the following: Water should be given slowly, sparingly, and only during extremely hot weather. Symptoms of FVE include a change in behavior and drowsiness. FVE can also be associated with serious injury or illness; it tends to occur in the pediatric intensive care unit because intervention includes the use of fluids, and balancing intake is difficult. Treatment includes limiting fluid intake and use of diuretics if the FVE is severe.

The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte imbalances, which statement or question is the most important for the nurse to ask? Answer "Describe what you eat and drink on a typical day." "Are you currently being treated for joint problems?" "Have you recently had a cold?" "Describe your anxiety level on a typical day."

"Describe what you eat and drink on a typical day." It is important for the nurse to consider socioeconomic factors affecting food and fluid intake when assessing a patient's risk for fluid and electrolyte imbalances, especially with a vulnerable population such as the homeless. Asking a patient to describe a typical day's food and fluid intake will help the nurse determine if a patient's oral intake is adequate. Joint problems and minor respiratory infections are not primary risk factors for fluid and electrolyte imbalances. It would be more important for the nurse to ask about kidney or thyroid disease, diabetes, or hypertension and acute conditions that cause fluid loss, such as gastroenteritis. Asking about anxiety is too general when assessing a patient's fluid and electrolyte status, because some anxiety is to be expected in a homeless patient. Areas to focus on during health interview include: Current and past medical history. Medications and treatments. Food and fluid intake. Fluid output. Fluid and electrolyte imbalances.

The nurse provides teaching to a patient with excess fluid volume. Which patient statement indicates the need for further teaching? Answer "I should read food labels to note fiber content." "I will elevate legs and feet when sitting." "I will learn to safely self-administer diuretics after discharge." "I should sit in the Fowler position if dyspnea or orthopnea is present."

"I should read food labels to note fiber content." For a patient with fluid volume excess, the patient should understand the importance of monitoring fluid intake to stay within fluid restrictions, monitoring weight daily and reporting significant increases to the healthcare provider, and elevating the legs and feet to reduce dependent edema. The patient should read labels on food products for sodium content. Caffeinated drinks produce a diuretic effect and would not need to be reduced. Nursing interventions for the patient with fluid volume excess (FVE) vary depending on the patient's specific needs and treatment. However, interventions generally include: Weighing the patient daily. Maintaining I&O records. Administering oral fluids carefully. Performing oral hygiene at least every 2 hours. Teaching the patient and significant others about a sodium-restricted diet. Administering prescribed diuretics and monitoring the patient's response to therapy. Reporting significant changes in serum electrolytes or osmolality.

A patient with severe heat exhaustion asks what type of fluid is in the intravenous infusion. Which response should the nurse provide? Answer "I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." "I'm giving you a solution that is a lot like your blood. It will replace the fluid you lost." "I'm giving you a solution that has proteins in it. It will help replace the fluid you lost." "I'm giving you a solution with a drug that will keep you from losing water."

"I'm giving you a solution that is a lot like the fluid outside your cells. It will replace the fluid you lost." Crystalloid solutions are given intravenously to patients like this who have lost fluids from excessive sweating, inadequate intake, or insensible water loss. Crystalloid solutions mimic the body's extracellular fluid and replace lost fluids. Colloid solutions resemble blood more closely, because they contain proteins and other large molecules, and are given in cases of excessive blood loss. Crystalloid solutions do not contain a drug that causes a person to retain water.

parent asks how a 4-month-old infant with frequent vomiting can become dehydrated. Which response by the nurse is the best response to this query? Answer "Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a smaller body water percentage than adults, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." "Infants have a low body surface area, so they lose fluid more easily than adults and it is easy for them to get dehydrated." "Infants have a smaller percentage of their body water outside their cells than adults, so it is easy for them to get dehydrated."

"Infants need to take in a lot of fluid, so if they lose a lot of fluid through vomiting, it is easy for them to get dehydrated." Infants have a proportionally higher body water percentage, higher fluid requirements, higher body surface area, and lower intracellular fluid volume than adults, all of which make them more prone to dehydration. If the infant is unable to adequately take in enough fluids due to vomiting, dehydration can happen rapidly. Fluid and electrolyte imbalance issues can occur in infants and small children due to: Burns. Higher respiratory rate. Illnesses. Dehydration . Heat-related illness. Immature kidney function in children less than 1 year of age.

The nurse reviews information received during hand-off communication about a group of assigned patients. Which patient should the nurse closely monitor for signs of fluid volume deficit? Answer A 37-year-old patient with chronic diarrhea A 56-year-old patient with kidney failure A 21-year-old patient with acute water intoxication A 63-year-old patient with hypertension

A 37-year-old patient with chronic diarrhea Fluid volume deficit, or dehydration, can occur when excessive amounts of fluids are lost through diarrhea or vomiting. Kidney failure causes water retention, leading to fluid volume excess, not deficit. Water intoxication results from excessive fluid intake and also leads to fluid volume excess. Fluid volume excess, not deficit, can result in hypertension. Additional Learning There are many causes for fluid volume deficit. -Excessive fluid loss from diarrhea or vomiting are the most common causes of dehydration, but other causes of fluid loss include: Excessive renal loss of water and sodium. Diuretics. Renal disorders. Endocrine disorders. Water and sodium loss from sweating. Heavy exercise. Hot outdoor temperature. Hemorrhage. Chronic abuse of laxatives or enemas.

A patient is prescribed daily weights. Which information should the nurse recall as the purpose of daily weights to evaluate fluid balance? Answer A gain or loss of 5-8% of body weight can represent fluid imbalance. Daily weights will not reflect fluid imbalance unless greater than 20% of body weight is affected. Though blood pressure is always a better indicator of fluid imbalance, daily weight is a good adjunct measure. Daily weights are only required for patients taking cardiac medications.

A gain or loss of 5-8% of body weight can represent fluid imbalance. A change in weight of 5-8% (gain or loss) can represent fluid imbalance. A change in body weight greater than 20% would be problematic and more serious than fluid imbalance. Blood pressure can represent alterations in fluid imbalance, but it is not always the best indicator of changes in fluid status. Daily weights are required in many patients, regardless of the medications taken. Assessment of fluid balance should include: -Daily weight. -Vital signs. I-ntake and output of fluids and food. Diagnostic tests such as serum electrolytes, CBC, serum osmolality, and urine specific gravity.

A nurse is caring for a client who has lost a large percentage of circulating body fluids as a result of excessive diuresis. Which medication would the nurse anticipate this client​ needing? A. Crystalloid B. Colloid C. Diuretic D. Electrolyte supplement

A. Crystalloid Colloids expand fluid volume by the replacement of proteins or other large molecules. Diuretics are used to promote urine​ output, particularly associated with fluid overload. Electrolyte supplements are used to replace lost electrolytes. Crystalloids contain both electrolytes and other substances that mimic the​ body's extracellular fluid. These medications will assist in the replacement of depleted fluids while promoting urine output.

A client with nausea and vomiting has orthostatic​ hypotension, dry​ skin, flat neck​ veins, and a urine specific gravity of 1.060. Which diagnosis should the nurse use to guide this​ client's care? A. Fluid​ Volume: Deficient B. Tissue​ Perfusion: Peripheral, Ineffective​ (NANDA-I ©2014) C. Gas​ Exchange, Impaired D. Skin​ Integrity, Impaired

A. Fluid​ Volume: Deficient The​ client's symptoms and urine specific gravity indicate deficient fluid volume. The other diagnoses are not the priority for the client at this time.

The nurse is assessing a client with fluid volume deficit. Which finding should the nurse identify that supports fluid volume​ deficit? A. Increased hematocrit B. Edema C. Wheezes upon auscultation D. Weight gain

A. Increased hematocrit Increased hematocrit is a finding consistent with fluid volume deficit. Edema and weight gain are consistent with fluid volume overload. Wheezes upon auscultation of the lungs is not related to fluid imbalances.

A client is experiencing symptoms of severe gastroenteritis. Which intravenous fluid order should the nurse anticipate being prescribed for this​ client? A. Lactated Ringers B. ​5% dextrose in​ 0.45% NaCl C. ​5% dextrose in water D. ​0.45% NaCl

A. Lactated Ringers clients with dehydration secondary to gastroenteritis​ (vomiting and/or​ diarrhea) are experiencing isotonic fluid loss and require isotonic electrolyte​ replacement, which includes either lactated Ringer or normal saline. A solution of​ 5% dextrose in​ 0.45% NaCl,​ 5% dextrose in​ water, and​ 0.45% NaCl is used to treat total body water​ deficits, not isotonic fluid loss.

A pregnant client telephones the clinic for help because of vomiting for over 15 hours and is feeling lightheaded and dizzy. Which advice should the nurse provide to this​ client? A. ​"Head to the local emergency​ department." B. ​"See your healthcare provider for a prescription for an​ antiemetic." C. ​"Drink one fourth cup of oral rehydration fluid every 15dash 20 minutes until vomiting​ stops." D. ​"Switch from water to ginger ale or ginger tea to prevent​ nausea."

A. ​"Head to the local emergency​ department." Pregnant clients with hyperemesis gravidarum are at significant risk for electrolyte imbalances. The client should be directed to the emergency department for evaluation and rehydration. Oral rehydration fluids and ginger products will likely not be effective to rehydrate the client. An antiemetic may be effective to minimize​ nausea, but it does not address the immediate issue of the potential electrolyte imbalance.

The nurse reviews intake and output with a graduate nurse. Which statement by the graduate nurse should cause the nurse​ concern? A. ​"I would not count ice cream as fluid intake because it is​ frozen." B. ​"Any time the client​ vomits, I need to add that number to the​ output." C. ​"I should document the amount of tube irrigation as​ intake." D. ​"I would need to record liquid feces as​ output."

A. ​"I would not count ice cream as fluid intake because it is​ frozen." Accurate measurement and recording of fluid​ I&O provides important data about the​ client's fluid balance. Ice cream would be considered intake because it is a food that becomes liquid at room temperature. The other answers are appropriate. Other intake includes all oral​ fluids, ice​ chips, IV​ fluids, IV​ medications, tube​ feedings, and catheter or tube irrigants. Output would include urinary​ output, vomitus, liquid​ feces, tube​ drainage, and wound drainage.

A client is experiencing​ fatigue, headache, and nausea and vomiting and has a decrease in deep tendon reflexes. Which electrolyte imbalance should the nurse suspect is causing this​ client's symptoms? A. Hypomagnesemia B. Hypercalcemia C. Hypokalemia D. Hyperchloremia

B. Hypercalcemia Hypercalcemia is an increase in serum calcium level. Clinical manifestations of this condition include​ fatigue, weakness, decreased tendon​ reflexes, headache, impaired​ cognition, anorexia, nausea and​ vomiting, lethargy,​ polyuria, muscle​ weakness, constipation, and cardiac dysrhythmias.​ Hypomagnesemia, hyperchloremia, and hypokalemia do not produce these clinical manifestations.

A client is admitted with​ end-stage renal disease and a potassium level of 7.1​ mEq/L. The nurse anticipates which medication to be used to treat the electrolyte​ imbalance? A. Sodium B. Insulin and glucose C. Lactated Ringer D. Magnesium

B. Insulin and glucose A level of 7.1​ mEq/L is a​ critically-high potassium level. Hyperkalemia is manifested by​ tall, peaked T waves and widened​ QRS, dysrhythmias, cardiac​ arrest, nausea and​ vomiting, abdominal​ cramping, diarrhea, and paresthesia. Pharmacologic treatment consists of administration of insulin and​ glucose, administration of calcium​ gluconate, and sodium polystyrene sulfonate​ (Kayexalate) orally or by enema. Diuretics may be indicated if renal excretion is normal. The other options are not appropriate prescriptions for a client experiencing hyperkalemia.

A client with heart failure has distended neck​ veins, dependent​ edema, and respiratory crackles on assessment. Which prescription should the nurse anticipate being prescribed for this​ client? A. Continuous EKG monitoring B. Intravenous Lasix 20 mg now C. Infuse 1000 mL of normal saline D. Chest​ x-ray

B. Intravenous Lasix 20 mg now The client is demonstrating signs of fluid volume excess. Treatment of this disorder includes diuretics to remove excess fluid. Normal saline would exacerbate this​ client's health problem. A chest​ x-ray may be required if the diuretic does not help remove excess fluid from the lungs. Continuous EKG monitoring does not address excess fluid.

The school nurse notes that a​ school-age child is experiencing mild heat exhaustion after playing outside during recess. Which recommendation should the nurse make to help prevent future occurrences of​ heat-related illness? A. Teach children to drink water only before recess. B. Move afternoon recess to a cooler morning hour. C. Encourage children to drink water when they feel thirsty. D. Provide a time for children to rest after recess.

B. Move afternoon recess to a cooler morning hour. To prevent​ heat-related illness, it would be best to move recess from the hottest part of the day to a cooler part of the day. Children should be encouraged to take frequent water breaks and drink before they begin to feel​ thirsty, not just when they feel thirsty or only before recess. Children should also be encouraged to take frequent rest breaks during​ recess, not just afterward.

The nurse is completing a physical assessment with a client. On which part of the body should the nurse focus when determining fluid and electrolyte​ status? (Select all that​ apply.) A. Ears B. Oral cavity C. Skin D. Endocrine system E. Cardiovascular system

B. Oral cavity C. Skin E. Cardiovascular system Physical assessment for fluid and electrolyte status focuses on the​ skin, oral cavity and mucous​ membranes, eyes, cardiovascular and respiratory​ systems, and neurologic and muscular status. The ears and endocrine system are not a focus of fluid and electrolyte status assessment.

The nurse reviews a list of clients waiting to be seen in a community health clinic. Which client should the nurse identify as experiencing the most common cause of an electrolyte imbalance in​ adolescents? A. A​ 14-year-old male who is losing water through increased insensible water loss B. A​ 16-year-old female participating in heavy exercise to lose weight for a school dance C. A​ 17-year-old female with diarrhea after gastroenteritis D. A​ 16-year-old male who is not drinking enough at wrestling practice

C. A​ 17-year-old female with diarrhea after gastroenteritis The most common reason for electrolyte imbalances and FVD in children and adolescents is diarrhea or gastroenteritis. Heavy​ exercise, insensible​ loss, and not drinking enough are also potential causes of electrolyte imbalance and​ FVD, but they are not the prominent reasons in adolescents.

The nurse is determining a​ client's fluid balance. Which method should the nurse use to identify this​ client's fluid volume excess or​ deficit? A. Blood pressure B. Skin turgor C. Daily weight D. Intake and output

C. Daily weight Daily weight is the best indicator of fluid volume excess or deficit. Skin​ turgor, blood​ pressure, and intake and output are assessments that would be included in the care of a client with fluid​ imbalances, but daily weight is the best indicator of changes in fluid status.

The nurse reviews the care needs for a group of clients. Which condition should the nurse realize occurs from a fluid volume​ deficit? A. Kidney failure B. Hypertension C. Diarrhea D. Water intoxication

C. Diarrhea Fluid volume​ deficit, or​ dehydration, can occur when excessive amounts of fluids are lost through diarrhea or vomiting. Kidney failure causes water​ retention, leading to fluid volume​ excess, not deficit. Water intoxication results from excessive fluid intake and leads to fluid volume excess. Fluid volume​ excess, not​ deficit, can result in hypertension.

The nurse plans care for a client with fluid volume deficit. Which direction should the nurse provide to nursing assistive personnel about turning and repositioning this​ client? A. Every 90 minutes B. Every 30 minutes C. Every 120 minutes D. Every 180 minutes

C. Every 120 minutes Turning the client every 2 hours​ (120 minutes) and monitoring for evidence of skin breakdown are nursing interventions to prevent alterations in skin integrity. 30 minutes is too often and would be very disruptive to the client. 90 minutes is also too soon. 180 minutes is too long and poses a risk to the​ client's skin.

The healthcare provider prescribes calcium gluconate for a client. For which electrolyte imbalance should the nurse assess this​ client? A. Hypochloremia B. Hyponatremia C. Hypermagnesemia D. Hypernatremia

C. Hypermagnesemia Calcium gluconate is used to treat hypermagnesemia. Hypernatremia is treated with fluid replacement. Hypochloremia is treated by increasing dietary salt and adding chloride to the IV fluid. Hyponatremia is treated by increasing dietary sodium and administering​ sodium-containing IV fluids.

The nurse is assessing a young child in the community clinic. Which sign indicates to the nurse that the child is experiencing mild​ dehydration? A. ​Cool, dry skin B. Concentrated urine C. Restless D. Dry mucous membranes

C. Restless Mild dehydration can be difficult to detect in young children because they tend to not show any​ symptoms, though they may be alert or restless. Mucous membranes and skin tends to remain warm and moist and urine does not always appear concentrated.

The nurse is reviewing the fluid needs for a group of clients. Which characteristic of the intracellular fluid compartment of the body should the nurse​ identify? A. Makes about one third of total body fluid in adults B. Divides into​ intravascular, interstitial, and transcellular fluids C. Serves as a medium for metabolic processes D. Includes cerebrospinal and peritoneal fluids

C. Serves as a medium for metabolic processes The intracellular fluid compartment makes up about two thirds of total body fluid in adults and is found within cells. It is a medium for metabolic processes. Extracellular fluid makes up the other one third of total body fluid and is divided into​ intravascular, interstitial, and transcellular fluids. Cerebrospinal and peritoneal fluids are examples of transcellular fluids.

The nurse is preparing material on fluid compartments in the body. Which fluids should the nurse identify as the components of extracellular​ fluid? A. ​Intracellular, interstitial, and intravascular fluids B. ​Intravascular, interstitial, and intracellular fluids C. ​Intravascular, interstitial, and transcellular fluids D. ​Transcellular, intracellular, and extracellular fluids

C. ​Intravascular, interstitial, and transcellular fluids Rationale: Body fluids found outside of the cell include​ intravascular, interstitial, and transcellular fluids.​ Conversely, intracellular fluids are found inside the cell.

A patient is experiencing a fluid imbalance caused by excessive blood loss. Which fluid should the nurse expect to be prescribed for this patient? Answer Colloid Crystalloid Electrolytes Oral fluids

Colloid Fluids are replaced in an attempt to put back what is lost, so blood loss is replaced with blood transfusions, albumins, or other large-molecule protein solutions (colloids). Fluids lost secondary to excessive diuresis, perspiration, inadequate intake, or insensible water losses are replaced by using crystalloids.

A patient has a severe fluid deficit caused by hypovolemia. Which fluid should the nurse expect to be prescribed for this patient? Answer Crystalloid Colloid Oral water Ice chips

Crystalloid Fluids are replaced in an attempt to put back what is lost, so blood loss is replaced with blood transfusions, albumins, or other large-molecule protein solutions (colloids). Fluids lost secondary to excessive diuresis, perspiration, inadequate intake, or insensible water losses are replaced by using crystalloids.

A client is prescribed furosemide. Which information should the nurse provide about this​ medication? A. Take the medication at bedtime. B. Increase sodium intake. C. Decrease potassium in the diet. D. Check weight daily.

D. Check weight daily. Daily weight is recommended for a client taking furosemide. Increasing sodium intake and decreasing potassium intake can lead to fluid and electrolyte imbalances. It would be recommended to take furosemide in the morning due to the diuresis effect of the medication.

A client has a serum sodium level of 140​ mEq/L, hematocrit level of​ 31%, and generalized edema. Which intervention should the nurse make a priority for this​ client? A. Prepare to administer a blood transfusion B. Encourage to drink ginger ale C. Increase sodium intake in the diet D. Restrict fluid intake

D. Restrict fluid intake The​ client's laboratory values and symptoms indicate excessive fluid volume. The priority would be to restrict fluid. The other actions are not appropriate for excessive fluid volume.

The nurse is evaluating the laboratory work of a client who is receiving replacement therapy for hypokalemia. Which value should the nurse identify that evaluates the effectiveness of the replacement​ therapy? A. Serum calcium 9.2​ mEq/L B. Serum chloride 100​ mEq/L C. Serum potassium 2.3​ mEq/L D. Serum potassium 4.2​ mEq/L

D. Serum potassium 4.2​ mEq/L Hypokalemia is a potassium level less than 3.5​ mEq/L. A serum potassium of 4.2​ mEq/L indicates improvement in hypokalemia. Serum chloride and serum calcium are not used to evaluate potassium level.

The nurse is assessing the urinalysis of a client with fluid volume deficit. On which component of the urinalysis should the nurse focus to determine the​ client's fluid​ balance? A. Glucose B. Leukocyte esterase C. Nitrites D. Specific gravity

D. Specific gravity Specific gravity measures the concentration of urine. Glucose found in the urine is indicative of diabetes mellitus. Nitrites in the urine indicate a possible bacterial infection. Leukocyte esterase also can be indicative of a possible bacterial infection.

The nurse is teaching a marathon runner about the importance of maintaining fluid and electrolyte balance. Which situation puts runners at a higher risk for fluid and electrolyte​ imbalances? A. The increase of protein intake prior to a race B. The significant loss of water during a lengthy exercise session C. The additional calcium taken by using calcium tablets to strengthen bones D. The use of electrolyte replacement fluids during a race

D. The use of electrolyte replacement fluids during a race It is common for athletes to use electrolyte replacement fluids during exercise. The nurse should be sure that the athlete understands that these fluids could alter the delicate balance of individual electrolytes. Supplemental protein and calcium intake do not typically affect fluid and electrolyte balance. Although water is lost during​ sweating, it does not usually create issues during exercise.

A patient with fluid volume excess has hypokalemia. Which collaborative therapy should the nurse expect to implement for this patient? Answer Diuretic Oral fluid solution Isotonic electrolyte solution Heparin

Diuretic Diuretics are used to remove excess fluid. A specific diuretic that does not remove potassium will be prescribed. Oral fluids, isotonic electrolyte solutions, and heparin are not appropriate for this patient's health problem.

he nurse is performing an assessment on a patient who has had nothing by mouth since the previous evening. Which manifestation related to the patient's fluid restriction should be of concern to the nurse? Answer Dry mucous membranes Edema Increased blood pressure Bounding pulse

Dry mucous membranes Oral fluid restriction can cause dehydration. The nurse should monitor for manifestations of dehydration such as dry mucous membranes, increased hematocrit, and tenting skin. Edema, increased blood pressure, and bounding pulse are manifestations of fluid volume excess, not deficit.

The nurse is caring for a client admitted for dehydration. Which assessment finding confirms the​ diagnosis? A. ​Dry, sticky mucous membranes B. Polyuria C. Bradycardia D. Increase in tongue size

Dry, sticky mucous membranes are an assessment finding indicating fluid loss over an extended period of time. The client would have decreased urine​ output, not​ polyuria; tachycardia, not​ bradycardia; and decreased tongue​ size, not increased.

A patient with weakness and fatigue has hypotension. The patient reports having run a marathon the day before. Which health problem should the nurse suspect is occurring with this patient? Answer Fluid volume deficit Fluid volume excess Hypertension Hypoglycemia

Fluid volume deficit Fluid volume deficit is associated with lethargy, tachycardia, weakness, and tachypnea. Fluid volume excess causes rapid weight gain over a short amount of time, bounding pulse, distended neck veins, cough, and shortness of breath. Hypertension and hypoglycemia do not cause these symptoms. The symptoms of dehydration will vary depending on its severity. They may include: Thirst. Lethargy. Dry mucous membranes. Reduced or absent urine output. Weakness. Hypotension. Tachycardia. Tachypnea. Decreased cardiac output. If dehydration is not resolved, it will ultimately lead to coma and death.

The nurse prepares to assess patients arriving at the clinic for routine prenatal care. Which factor should the nurse identify that contributes to fluid and electrolyte imbalances in pregnant patients? Answer Hyperemesis gravidarum Increased vascular volume Decreased kidney function Decreased thirst mechanism

Hyperemesis gravidarum Hyperemesis gravidarum can cause fluid and electrolyte imbalances. It is a disorder that involves an extreme amount of vomiting during pregnancy. Increased intravascular volume is expected during pregnancy. Decreased kidney function and decreased thirst mechanism are not causes of fluid imbalance in pregnant women.

A patient had the following during the previous shift: emesis 75 mL, urine output 725 mL, water 240 mL, IV fluids 650 mL, and IV medication 100 mL. Which intake and output values should the nurse document for this patient? Answer Intake 990 mL, output 800 mL Intake 950 mL, output 840 mL Intake 890 mL, output 900 mL Intake 940 mL, output 850 mL

Intake 990 mL, output 800 mL Output consists of urine and emesis and this totals 800 mL for this patient. IV fluids, IV medication, and water are counted as intake and this totals 990 mL for this patient. Accurate intake and output is important to determine if the amount of intake is proportional to the amount of output, because this is objective and can be measured. This must be considered when looking at insensible fluid losses, as well. Previous

The healthcare provider prescribes a patient a diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. For which class of diuretic should the nurse prepare teaching for this patient? Answer Loop Osmotic Thiazide Potassium sparing

Loop Loop diuretics inhibit sodium and chloride reabsorption in the ascending loop of Henle. Thiazide diuretics promote the excretion of sodium, chloride, potassium, and water by decreasing absorption in the distal tubule. Potassium-sparing diuretics promote excretion of sodium and water by inhibiting sodium-potassium exchange in the distal tubule. Osmotic diuretics do not inhibit sodium and chloride reabsorption in the ascending loop of Henle. There are several different types of medications that can be used to treat FVE. Diuretics help the body get rid of excess fluid from the body. There are three types of diuretics: -Loop diuretics act on the ascending loop of Henle. -Thiazide diuretics act on the distal convoluted tubule. -Potassium-sparing diuretics act on the distal nephron.

A young child has been experiencing vomiting and diarrhea for several days. Which rehydration solution should the nurse recommend to this patient's mother? Answer Pedialyte Water Diet ginger ale Apple juice

Pedialyte Pedialyte is an oral rehydration solution that contains both fluids and electrolytes in the correct proportions. A child who has been vomiting with diarrhea for several days needs replacement of both fluid and electrolytes. Water does not contain necessary electrolytes. Sugar facilitates sodium reabsorption during rehydration, so diet ginger ale would not help this child. Undiluted apple juice can actually worsen diarrhea, so it must be diluted with water before giving it to a child with diarrhea and/or vomiting. Fluid replacement is necessary for children with dehydration due to diarrhea or vomiting, and is not as simple as just giving them a glass of water. Oral rehydration solutions (ORS) such as Pedialyte are ideal. Water does not contain needed electrolytes that may be lost during diarrhea. Do not give full-strength apple juice or soda due to the risk of worsening diarrhea. Diet ORS do not contain sugar, which is necessary to promote sodium reabsorption. Start with a tablespoon of liquid at a time and progress to greater amounts as tolerated. If oral fluid replacement is not successful at replacing lost fluids and electrolytes, intravenous fluids may be necessary.

The nurse is caring for a patient who was prescribed a loop diuretic. Which patient data indicates a need for further follow-up with the healthcare provider? Answer Periorbital edema Normal hemoglobin level Normal skin temperature and without edema Weight loss of 6 lb

Periorbital edema Periorbital edema is a strong indicator of fluid volume excess (FVE) and indicates that the diuretic therapy is not effective. A normal hemoglobin level and normal skin without edema are normal findings and indicate a stabilization of fluid balance. A weight loss of 6 lb is an expected finding and indicates the medication is having the desired therapeutic effect. When evaluating a patient for fluid volume excess, the nurse should include: Patient interview. Physical exam. Checking for edema (no edema to severe pitting edema). Periorbital or scrotal edema (normal is no edema). Intake/output. Character of the pulse. Neck vein distention. Auscultation of the dependent lung fields (abnormal is crackles in the lower lobes). Accessory muscle use (normal is no accessory muscle use). Serum electrolytes and serum osmolality (both usually normal even with FVE). Hematocrit and hemoglobin (may be decreased with FVE). Renal and liver function to determine the cause of FVE.

The nurse observes a new graduate nurse provide care to a patient with an elevated sodium level. For which action performed by the graduate nurse should the nurse preceptor intervene? Answer Provided bouillon and crackers for an afternoon snack Involved patient in meal planning Initiated safety precautions to avoid falls due to dizziness Used an infusion pump for the administration of IV fluids

Provided bouillon and crackers for an afternoon snack Administration of bouillon and crackers is not appropriate for the patient's health problem because these food items are high in sodium. Involving the patient in meal planning, teaching the patient to avoid falls secondary to dizziness, and administering IV fluids using an infusion pump are important interventions when caring for a patient with an electrolyte imbalance. Nursing interventions to address electrolyte imbalances are specific to the electrolyte that is out of balance, and usually involve replacing deficits or eliminating excess. General interventions include: -Monitoring sodium, potassium, chloride, and magnesium levels daily (monitoring more frequently if levels are significantly elevated or decreased). -Monitoring I&O as indicated by agency policy. -Observing for signs and symptoms of dehydration. -Observing for signs and symptoms of fluid and electrolyte excess or deficiency. -Providing nutritional teaching to maintain balance despite the side effects of medication therapy (e.g., foods high in potassium in patients receiving furosemide or thiazide diuretics). -Providing teaching for parents, teachers, coaches, and caregivers regarding early recognition of symptoms of dehydration and the need for ongoing fluid replacement. -Including the need for water as well as electrolyte solutions. -Incorporating cultural or ethnic principles into the nutritional teaching for patients who are at risk for fluid and electrolyte imbalance.

The nurse reviews the medical record of an older adult patient. Which health problem should the nurse identify that increases the patient's risk for fluid volume excess? Answer Renal failure Prolonged vomiting Severe burns after an accident Dysphagia

Renal failure Renal failure puts the patient at risk for developing fluid volume excess. Prolonged vomiting, severe burns, and dysphagia are associated with a risk of developing fluid volume deficit, not excess. Risk factors associated with excess fluid volume include: Preeclampsia in pregnancy. Heart disease. Kidney dysfunction. Diabetes and peripheral vascular disease. Hypertension. IV therapy if infusion rate and solution are not carefully monitored.

The nurse is assessing a patient with fluid volume overload. Which mechanism should the nurse understand assists in the regulation of body fluids? Answer Renin-angiotensin-aldosterone pathway Release of cortisol from the adrenal gland Suppression of epinephrine from the adrenal gland Erythropoietin release from the kidney

Renin-angiotensin-aldosterone pathway The renin-angiotensin-aldosterone pathway is one of the mechanisms used to maintain fluid balance in the body. Cortisol and epinephrine are stress hormones that are not related to the maintenance of body fluids. Erythropoiesis is the process to stimulate red blood cell production. This process would be stimulated to increase oxygenation but not to maintain the balance of body fluids. Mechanisms for Homeostasis Kidneys regulate and filter waste. Cardiovascular and respiratory systems ensure adequate oxygen is available for use and use fluid and electrolytes as appropriate. The immune system destroys pathogens. Hormones such as ADH, the renin-angiotensin-aldosterone pathway, and ANF (atrial natriuretic factor) maintain and control vascular volume.

The nurse is planning care for a patient with heart failure (HF). Which physiological change should the nurse identify as causing this patient to be at risk for fluid retention? Answer Retention of water and sodium Decrease in antidiuretic hormone and aldosterone Impaired renal excretion of potassium Low serum osmolality level that stimulates the thirst center

Retention of water and sodium Fluid volume excess results from conditions that cause retention of water and sodium. Impaired renal excretion of potassium is not related to fluid volume excess. There will be an increase in antidiuretic hormone (ADH) and aldosterone when the stress response is activated with fluid volume excess. An increase in serum osmolality, not a low serum osmolality, stimulates the thirst center, which could affect fluid volume. Fluid volume excess usually results from conditions that cause retention of sodium and water. These conditions include: Heart failure. Cirrhosis of the liver. Renal failure. Adrenal gland disorders. Administration of corticosteroids. Stress conditions causing a release of ADH and aldosterone. Excessive intake of sodium-rich foods. Medications that cause sodium retention. Administration of IV fluids that contain sod

A young child with increasing lethargy and sleepiness is suspected of having a fluid volume deficit. Which microorganism should the nurse suspect is causing this patient's symptoms? Answer Rotavirus E. coli Salmonella Shigella

Rotavirus One of the primary causes of gastroenteritis in young children is rotavirus. E. coli, Salmonella, and Shigella are not common causes of gastroenteritis and fluid loss in young children. Children are at greater risk for developing fluid volume deficit for several reasons, including: Diarrhea due to gastroenteritis. Increased respiratory rate that causes insensible water loss. Higher risk of fever, which increases metabolic rate and water demand. Excess exercise and activity. Lack of feelings of thirst.

The nurse prepares an educational program for colleagues about intracellular and extracellular fluid compartments. Which solutes or electrolytes that are predominantly found within the intracellular and extracellular fluids, should the nurse explain help with transmitting nerve impulses and contracting muscles? Answer Sodium and potassium Albumin and magnesium Chloride and phosphate Calcium and bicarbonate

Sodium and potassium Sodium and potassium are found in both intracellular and extracellular fluid and are involved in transmitting nerve impulses and contracting muscles. Albumin is a protein found in cellular fluid but plays no role in transmitting nerve impulses or contracting muscles. Magnesium is involved with relaxing muscle contractions. Calcium and phosphate are involved in teeth and bone formation. Phosphate is involved with nerve function but does not transmit nerve impulses. Chloride and bicarbonate are involved with acid-base balance.

A patient reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which manifestation should the nurse expect to find during assessment? Answer Tachycardia Ascites Dyspnea Warm, flushed skin

Tachycardia When a patient experiences a deficiency in fluid volume, the heart rate will increase (tachycardia) in an attempt to improve circulation. Ascites and dyspnea are frequently noted with fluid volume excess. Warm, flushed skin is typically seen with a fever.

The nurse discusses how active transport differs from other transport processes with colleagues. Which statement should the nurse include? Answer "Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike diffusion, active transport moves solutes from a solution with a higher concentration of solutes to a less concentrated solution." "Unlike osmosis, active transport moves water from a solution with a lower concentration of solutes to a more concentrated solution." "Unlike osmosis, active transport moves water from a solution with a higher concentration of solutes to a less concentrated solution."

Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated solution." Unlike diffusion, active transport moves solutes against their concentration gradients from a solution with a lower concentration to a more concentrated solution. Active transport does not move water, only solutes. Osmosis is the movement of water from a solution with a lower concentration of solutes to a more concentrated solution.

The nurse is reviewing laboratory values for a patient with hyperthyroidism. Which component of the urinalysis should the nurse use to help determine the patient's fluid status? Answer Urine specific gravity Ketones Nitrites Glucose

Urine specific gravity Specific gravity is an indicator of urine concentration that can be performed quickly and easily by nursing personnel. Normal specific gravity ranges from 1.005 to 1.030 (usually 1.015-1.024). When the concentration of solutes in the urine is high, the specific gravity rises. In very dilute urine with few solutes, it is abnormally low. Ketones are found in the urine when the body is breaking down fats to have an alternate form of energy. Nitrites found in the urine are usually related to an infection. Glucose found in the urine can indicate elevated blood sugar.

The nurse is providing discharge teaching for an older adult patient with a new diagnosis of heart failure. Which symptom should the nurse instruct the patient to immediately report to the healthcare provider? Answer Weight gain of 5 lb in a week Dry mouth Dizziness when standing Urine output of 320 mL in 8 hours

Weight gain of 5 lb in a week A weight gain of 5 lb in a week indicates that the patient is retaining fluid or experiencing fluid volume excess. This can indicate worsening cardiac function. Dry mouth and dizziness when standing are signs of dehydration, not fluid volume excess. Urine output of 320 mL per 8 hours is within the normal range. Teaching points for a patient with fluid volume excess include: -Proper administration of prescribed medications. -Fluid and sodium restrictions. -Importance of following up with the healthcare provider as ordered. -Sitting in the Fowler position to promote comfort and ventilation. -The use of diuretics. -Taking daily weight. -Signs that the patient needs to call the healthcare provider or go to the emergency department.