Fluid and electrolytes wk 11

1. A nurse is caring for a postoperative patient over an 8-hour period. The patient vomits 300 ml. of greenish-yellow fluid. The patient's intravenous fluids are infusing at 125 ml per hour. The patient received 2 intermittent infusions of antibiotics each in 50 mL of solution and they were infused at a different site than the IV fluid infusion. The patient was given 8 ounces of ice chips which were retained. The patient urinated twice-250 mL and 400 mL. Which is the patient's total fluid intake at the end of the 8-hour period?

1,220 ml

25. A nurse must discontinue a patient's intravenous infusion. The nurse shuts off the infusion, washes the hands, and dons clean gloves. Place the following steps in the order in which they should be performed. 1. Apply counter-traction to the skin while loosening the tape at the 2. Apply fi rm pressure to the site with sterile gauze for two to three minutes. venipuncture site. 3. Apply a sterile dressing with tape over the venipuncture site. 4. Withdraw the needle/catheter along the line of insertion. 5. Examine the end of the needle/catheter.

1,4, 2, 5, 3

balance. What would the instructor tell the students that the average daily fluid intake for an 3. The nursing instructor is discussing with the nursing class about fluid and electrolyte adult is?

2500 mL

72. What is one process by which dissolved chemicals move from one area of the body to another?

Active transport

19. The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Beverages with alcohol or caffeine

21. The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?

Complete a head-to-toe assessment.

37. A nurse is monitoring a patient who is receiving intravenous fluid. Which clinical fi ndings indicate that the patient has a fluid overload?

Dyspnea, headache, and increased blood pressure

74. An assessment of which of the following is most important when a nurse is caring for an adult patient experiencing vomiting?

Electrolyte values

53. Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

42. Several patients are taking 2,500 mL. The nurse explains supplemental calcium daily. The nurse teaches them to maintain that this intervention is designed to prevent which complication?

Formation of kidney stones

4. Which is the best choice for an appetizer when teaching a patient about a 2-g sodium diet?

Fresh vegetable sticks

43. A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

Hypertonic solution

64. A patient exhibits an increasing blood pressure and 2-lb weight gain over 2 days. Which additional clinical manifestation can be clustered with these data?

Increase in pulse volume

9. A nurse evaluates a patient's fl uid about the ratio of the patient's fluid intake to output? balance by monitoring the patient's intake and output. Which must the nurse understand

Intake should be slightly more than the output

32. The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Kidney and liver

35. The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurologic system

66. Which should a nurse do to encourage a confused patient to drink more fluid?

Offer the patient something to drink every hour.

54. The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEg/L

58. The nurse is providing the assessment afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

Weight

29. The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

active transport

34. A patient receiving a diuretic is encouraged to increase the intake of potassium. Which foods selected by the patient indicate that the teaching is understood? Select all that apply.

cantaloupe

39. The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

dark, concentrated urine

5. A nurse is caring for a patient who has a reduced fluid intake. The nurse assesses the patient for which response to this reduced fluid intake?

decreased urine output

16. A nurse is caring for a patient who has dependent edema. Which pressure has caused the excess fl uid in the interstitial compartment?

hydrostatic pressure

48. A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. Which electrolyte imbalance does this data support?

hypernatremia

55. A patient receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea?

hypertonic

59. The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern as a result of the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, what is the nurse most concerned about?

insensible fluid loss

30. A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

kidney stones and blood clots

56. A nurse is documenting a patient's 1&0. Which should be recorded at approximately half its volume?

lce chips given by mouth

69. Hydrochlorothiazide (HCTZ), a diuretic, is prescribed for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients that contain which electrolyte?

potassium

26. When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse plans to monitor the patient routinely because an increase in these hormones will cause a decrease in which of the following?

urinary output

7. The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

🌀An elevated hematocrit 🌀Electrolyte imbalance

65. A nurse is assessing a patient's fluid status. Which assessments indicate that the patient has a defi cient fluid volume? Select all that apply.

🌀Flat neck veins blood 🌀Negative balance of intake and output 🌀Weight loss

70. A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and Points: family? Select all that apply.

🌀Respond to thirst. 🌀Drink at least eight glasses of fluid each day.

61. A 2-g sodium diet is ordered for a patient with hypertension. Which foods should the nurse teach the patient to avoid? Select all that apply.

🌀american cheese 🌀canned tuna fish

38. A patient is to receive 250 ml of 0.9% sodium chloride over 30 minutes. The nurse obtains an electronic infusion devise. At which hourly rate should the nurse set the infusion device? Record your answer using a whole number.

14 drops/min

2. A nurse is monitoring a patient who is receiving fluids intravenously. Which clinical manifestations at the insertion site indicate that the V has infi Itrated? Select all that apply.

🌀coolness 🌀swelling

28. A patient's diet is progressed from clear liquid to full liquid. Which can the nurse include on the full-liquid diet that is not included on the clear-liquid diet? Select all that apply.

🌀cream of wheat 🌀 vanilla ice cream 🌀 milk

24. A nurse is caring for a critically ill patient with a urinary retention catheter. Which hourly urine output should fi rst alert the nurse that the primary health-care provider should be notifi ed?

30 mL

73. A primary health-care provider orders 1,000 mL 0.9% sodium chloride to be infused over 6 states that the drop factor is 15, At which rate should the nurse set the IV flow rate? Record your answer using a whole number, hours. A gravity flow infusion set

42 drops/min

63. An older adult is diagnosed with congestive heart failure and pulmonary edema, and the primary health-care provider prescribed furosemide 40 mg PO twice a day. The patient has slight dysphagia as a result of a brain attack a year ago. The nurse obtains an oral solution of furosemide that states that there is 8 mg/mL. How many milliliters should the nurse administer?

5 mL

8. The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

40. The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

A drop in systolic blood pressure (15 mm Hg) upon rising

41. The nurse is caring for a client prescribed a low-sodium diet. Which food, identified as a client favorite, will the nurse discourage?

Ahot dog with catsup

71. The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a group of students. Which action by bases keeps the blood pH nearly neutral?

Bases bind with hydrogen.

11. The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate

13. Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2 30 mm Hg, and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid- base imbalance do both nurses agree is the client's current state?

Compensate d respiratory alkalosis

57. The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?

Decreased abdominal girth

15. A patient has continuous bladder irrigation. Which should the nurse do with the irrigant on the 1&O sheet when calculating the fl uid balance for this patient?

Deduct it from the total urine output.

18. A primary health-care provider orders an intravenous infusion containing potassium for a patient. Which is the most important nursing intervention before administering this solution to the patient?

Determine the presence of urinary output

6. The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted.

22. Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?

Initiate an Iv of albumin.D

44. The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location that contains the most body water?

Intracellular fluid

31. A patient in the hospital emergency department tells the nurse, "I feel lousy and I've had diarrhea for several days, I have nausea and I don't feel like eating or drinking." The nurse obtains the patient's vital signs, performs a focused physical assessment, and reviews the results of laboratory studies. Which should the nurse conclude is the patient's human response based on this information? PATIENT'S CLINICAL RECORD Vital Signs Temperature: 101.2*F, oral Pulse: 92 beats per minute, regular, thready Respirations: 26 breaths per minute, deep Blood pressure: 100/60 mm Hg Focused Physical Assessment Weight loss of 4 pounds in 3 days Tenting of the skin Laboratory Values Urine specific gravity: 1.036 Serum potassium: 5.3 mEg/L Arterial blood gases: pH 7.30 Pa CO 2:24 mEg/L HCO 3: 18 mEg/L

Metabolic acidosis

36. The client's lab values are sodium 166 mEg/L, potassium 5.0 mEg/L, chloride 115 mEg/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic acidosis

20. The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?

Metabolic alkalosis

68. A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEg/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

51. The nurse is adding the intake and output results for a client diagnosed dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

50. The nurse is caring for a client with severe hypokalemia. The physician has ordered potassium to be administered at10 mEg/hr. The client complains of burning along his vein. What should the nurse do?

Seek a physician's order to dilute the infusion.

67. A nurse suspects that an older adult may have a fl uid and electrolyte imbalance, Which assessment best reflects fluid and electrolyte balance in an older adult?

Serum laboratory values

27. The illustration refl ects a patient's upper extremity while the nurse is obtaining the patient's blood pressure. Which should the nurse do next after releasing the pressure in the sphygmomanometer cuff?

Tap over the patient's facial nerve.

23. The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH?

The lungs are not able to blow off carbon dioxide.

62. A primary health-care provider orders a patient's IV fluids to be discontinued. Which is an essential nursing intervention when discontinuing the patient's intravenous infusion?

Withdraw the intravenous catheter along the same angle of its insertion.

49. When a nurse evaluates the effectiveness of patient teaching, which food selections by a patient indicate understanding regarding an abundant source of calcium? Select all that apply.

Yogurt

33. The nurse is caring for a client with heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

elevated blood pressure

75. With which complication of the administration of intravenous fluids should the nurse slow the rate of flow of the infusion rather than stop the infusion and remove the catheter?

fluid overload

17. A nurse is caring for two patients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these patients?

fluid volume deficit

46. A nurse checks a meal tray for a patient on a clear liquid diet. Which item is acceptable on this diet?

ginger ale

10. The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

hypocalcemia

45. Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

hypomagnesemia

12. A nurse identifi es that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion?

taut and shiny

52. Which characteristics associated with touching an intravenous insertion site support the conclusion that the insertion site may be inflamed? Select all that apply.

🌀discomfort 🌀warmth 🌀firmness

60. A nurse is caring for a patient in the emergency department. The patient's ECG tracing is indicated below. For which additional responses should the nurse assess the patient that can be clustered with the results of this ECG tracing? Select all

🌀flaccid paralysis 🌀increased bowel sounds 🌀bradycardia

14. A nurse is assessing several patients for fl uid and electrolyte imbalances. Which responses are common to both excess fl uid volume and defi cient fluid volume? Select all that apply.

🌀muscle weakness 🌀mental confusion

47. A nurse assesses a patient for electrolyte imbalances. Which clinical manifestations indicate that the patient may have a potassium deficiency? Select all that apply.

🌀muscle weakness 🌀ventricular dysrhythmias