Fluids and Electrolytes
An older adult patient is admitted to the emergency department for hypovolemia. After 500 mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: blood pressure of 167/88 mm Hg, heart rate 110 beats per minute, and crackles bilaterally. What should the nurse determine from this situation? A - The patient has been properly hydrated B - the patient is showing signs of hypervolemic C - the patient is showing no change in condition D - the patient continues to be hypovolemic
B too much fluid too quickly, fluids should be stopped immediately and MD notified
The nurse is caring for a patient with hypervolemia and hyponatremia. What assessment finding should the nurse anticipate? A - weight loss and thirst B - confusion and hypertension C - irregular pulse and shortness of breath D - clammy, pale, skin and seizures
B confusion can be a sign of cerebral edema as seen with hyponatremia. Hypertension is a sign of hypervolemia making this correct.
The nurse is admitting a patient in the emergency department with new onset of confusion. The laboratory report shows Na 120 mEq/L; K 5.0 mEq/L; urine specific gravity 1.038. Which intervention is the highest priority? A - place on cardiac monitor B - pad the side rails of the bed C - keep accurate I & O D - fall precautions
B the sodium level is very low and the risk for seizures is very high. Implementing seizure precautions is the priority
The nurse is caring for a patient with diabetic ketoacidosis. The blood pressure is 88/50 with a mean arterial pressure (MAP) of 63 mm Hg, heart rate is 109, and respiratory rate is 26 with a pulse oximetry of 98%. The arterial blood gases show a pH of 7.26, and the serum potassium is 5.9 g/mL. What is the nurse's priority action? A - apply oxygen B - administer 0.9% NaCl 500mL over 1 hour C - polystyrene sulfonate to lower potassium D - encourage oral fluids
B this is the priority intervention because the MAP is below 65 which means that vital organs are not being perfused
The nurse is caring for an older adult who is unable to swallow and receiving a hypertonic nutritional supplement through an enteral tube. The nurse notes that the laboratory report shows hypernatremia. What action should the nurse take? A - administer a hypertonic saline solution IV at a rate of 1mL/kg/hr B - monitor the weight and serum sodium level of the patient daily C - monitor for changes in the level of consciousness, respiratory effort, and muscle control D - administer IV glucose at 2-3ml/kg/hr
B when caring for a patient receiving hypertonic enteral feeding, the nurse should monitor the weight and serum sodium level daily for hypernatremia and fluid volume deficit.
A patient has 3+ pedal and periorbital edema and a normal blood pressure. After reviewing the medication administration record, the nurse recognizes that which prescriptions will reduce the edema? Select all that apply. A - 0.9% NaCl over 2hr for SBP < 90mmHg B - Albumin 25g/100mL IV over 4hr. One time dose. C - Furosemide 40mg IV. One time dose. D - Compression stockings E - KCl 10mEq/100mL 0.9% NaCl IV over 2 hr
B - albumin is a colloid protein that pulls fluid from the extravascular space into the intravascular space because of its high oncotic pressure C - this loop diuretic will help eliminate excess fluid from the body via the kidneys and reduce edema D - the use of compression stockings will reduce dependent edema from elevated hydrostatic pressure in the lower extremities
The nurse is caring for a patient with ascites, edema, and crackles in the lung bases secondary to chronic cirrhosis. Blood pressure is 88/56, heart rate is 110. The serum sodium is 149 mEq/L; potassium is 3.5 mEq/L. The nurse SBARs the provider with this information. Which prescriptions would be appropriate for the nurse to request? Select all that apply. A - 0.9% NaCl for hypotension B - Albumin 25 % infusion for edema C - oxygen per nasal cannula D - high sodium diet for sodium level E - spironolactone orally for edema
B- this colloid protein would pull fluid from the third space back into the vascular space and improve blood pressure. C - since the patient has crackles, oxygenation is a concern despite 98%.
A patient comes into the emergency department after being knocked unconscious from a car accident. He is disoriented and is vomiting. The CT scan shows cerebral edema. Which fluid should the nurse request from the practitioner for rehydration? A - 5% D5W B - Lactated Ringers C - D5 0.45% NaCl D - 5% albumin
C This hypertonic solution will move the fluids into the vascular space, decreasing cerebral edema and increasing vascular hydration
The nurse is teaching a patient about prescribed dietary changes. Which food should the nurse suggest avoiding for a renal diet that includes low sodium, low potassium, and high calcium? A - chicken breast with green salad B - halibut and rice C - plain cheese pizza D - turkey breast with homeade dressing
C this contains 450-1200mg of sodium in 4 oz and should be avoided
A client is given a prescription for bumetanide. Which electrolyte imbalance should the nurse monitor for? Hypokalemia Hypercholeremia Hypernatremia Hypoglycemia
Hypokalemia - med is a loop diuretic
The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning? A - The patient feels lightheaded when getting out of bed B - The patient has tremors when stretching arms out straight C - The patient has bone pain and joint stiffness D - The patient feels palpitations and has an irregular pulse
D A low potassium level or hypokalemia cause cardiac arrhythmia and prolonged PR interval. This places the patient at risk for developing lethal dysrhythmias.
A patient with hyperkalemia asks the nurse how it happened since they do not take any potassium supplements. The nurse reviews the admission medications. What is most likely the cause of the hyperkalemia? A - multivitamin with iron daily B - Furosemide 20mg tablet C - dioctyl sodium sultosuccinate 100mg tablet D - Digoxin 0.25mg
D Digoxin and digitalis glycosides increase potassium levels becuase of the decreased sodium potassium ATPase activity
The nurse is caring for a patient with celiac disease who lacks vitamin D absorption. What conclusion can the nurse make with this assessment finding? A - the patient is severely dehydrated B - this is a normal finding C - The magnesium level is high D - the patient has a low Ca level
D This positive Trousseau sign is consistent with hypocalcemia. A lack of vitamin D absorption will decrease calcium levels.
The nurse is caring for a patient with ascites from liver failure receiving IV albumin. What response will the nurse anticipate if the medicine is effective? A - peripheral edema will increase B - urine output will decrease C - blood pressure will decrease D - abdominal girth with decrease
D albumin will pull fluid from abdomen into the vascular space, decreasing abdominal girth and ascites fluid
A registered nurse is caring for a patient experiencing fluid volume excess. Which assessment finding is anticipated? A - dry mucous membranes B - oliguria C - concentrated urine output D - edema
D edema is a sign of fluid excess outside the vascular space in the tissues
The nurse is monitoring the adequacy of IV fluid replacement in a client during the first 2-3 days after sustaining full thickness burns from the trunk to the right thigh. Which assessment will provide the nurse with the most significant data? daily weights urinary output Q1hr blood pressure Q15min extent of peripheral edema Q4
Urinary output every hour a client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume and is the most reliable, immediately available information to assess fluid needs. although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine
Which clinical manifestations would the nurse expect in a client with hypokalemia thirst anorexia leg cramps rapid, thready pulse dry mucous membranes
anorexia leg cramps thirst and dry mucous membranes are associated with hypernatremia rapid/thready pulse is associated with dehydration and hyponatremia
Which finding supports the diagnosis of hyperfunctioning adrenal glands? Na+ 130 HCO3 24 BUN 12 K+ 2.8
K+ 2.8 hyperaldosteronism causes sodium and water retention and potassium excretion
A client who is s/p thyroidectomy is having their blood pressure taken, when the nurse notices they are pale and their hand is spasming. what medication would the nurse anticipate being ordered? magneseium bicarb calcium potassium chloride
calcium r/t s/s of hypocalcemia and being s/p thyroidectomy. +Chvostek and peripheral paresthesias
Which clinical manifestations would the nurse observe in a client with a calcium level of 11.3 muscle tremors abdominal cramps increased peristalsis cardiac dysrhythmias hypoactive bowels
cardiac dysrhythmias and hypoactive bowel sounds
Which outcome would be the priority for a cachetic, dehydrated adolescent who has taken enemas and laxatives several times a week and has engaged in self induced vomiting? identify personal strengths control impulse behaviors correct electrolyte imbalances develop a contract for treatment goals
correct electrolyte imbalances physical needs must be met first
When caring for a client in late hypovolemic shock, which will the nurse anticipate? hypokalemia respiratory alkalosis metabolic acidosis low PCO2
metabolic acidosis due to the build up of lactic acid
which clinical manifestations would the nurse expect in a client admitted with dehydration? oliguria dyspnea hypotension lung crackles tenting skin turgor
oliguria, hypotension, tenting skin
Which electrolyte is the most important in the interstitial fluid? sodium potassium calcium chloride
potassium
the nurse is caring for a patient who has sustained serious burns on a large area of skin. Which nursing intervention is the initial priority? alleviating pain preventing infection replacing blood loss restoring fluid volume
restoring fluid volume in the first 48 hours is the priority
Which action would assist in the prevention of developing renal calculi and urinary stasis in a bedridden client? maintaining bedrest after discharge voiding at least every hour consuming 2-3L of fluid every day limiting fluids to 1L/day
2-3L of fluid/day
The nurse is caring for a patient with hypovolemia from a prolonged high fever with tachypnea. What assessment finding should the nurse anticipate? A - Weak, rapid pulse B - 2+ pedal edema, bilaterally C - Moist mucous membranes D - Jugular venous distention
A Rationale: The patient experiencing hypovolemia will become tachycardic as the heart rate increases to compensate for the decreased cardiac output.
The nurse is caring for a patient with a severed limb who was involved in a motorcycle accident. A tourniquet was placed on the limb before transport to the hospital, but the blood loss was significant. Which solution should the nurse infuse at a high rate of administration? A - 0.9% NaCl B - 0.45% NaCl C - D5 0.45% NaCl D - 3% NaCl
A Since there was a large blood loss, the patient is likely hypovolemic. An isotonic solution is needed to restore the vascular volume
A nurse reviews the recent laboratory report for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which action should the nurse take next? K+: 5.1 mEq/L Na: 128 mEq/L Mg: 1.5 mEq/L Ca: 8.0 mg/dL Phos: 4.7mg/dL Cl: 96mEq/L A- pad the siderails of the bed and place suction at the bedside B - Contact the provider and request a cardiac monitor C - assess for a Trousseau and Chvostek sign each shift D - Encourage oral fluid and monitor I &O
A a patient with hyponatremia is at risk for confusion and neurological deterioration that can lead to seizures from cerebral edema. Additionally, the bed should be in the lowest position.
The nurse is delivering 0.9% NaCl at 100 mL/hr to a patient admitted yesterday. Which assessment change should the nurse report to the healthcare provider? A - bilateral crackles in the lungs B - blood pressure 112/76mmhg C - pain at IV site D - increased urine output
A crackles indicate fluid has shifted into the lungs which can create oxygenation problems. A focused respiratory assessment should be completed before notifying MD
The nurse is caring for a patient in metabolic acidosis with a potassium level of 6.0 mEq/L. What is the nurse's priority action? A - place the patient on EKG monitor B - obtain a baseline weight C - deliver spironolactone orally D - assess level of consciousness
A the risk for cardiac dysrhythmias is significant and the EKG monitor will help to determine how the cardiac muscle is tolerating the hyperkalemic state
The nurse is admitting a patient with confusion and hallucinations. The laboratory report shows hyponatremia, normal potassium, hypomagnesemia, and hypocalcemia. What priority actions should the nurse take? Select all that apply. A - complete a neuro assessment B - assess for an irregular pulse C - implement fall precautions D - determine how much alcohol the patient drinks. E - evaluate for tremors and muscle weakness
A - besides the confusion and hallucinations, the patient is hyponatremic which can also cause cerebral edema and deterioration of mental status B - although the potassium is WNL, the magnesium is low which can cause PVCs C - r/t confusion, hallucinations, and hyponatremia D - hypomag is often seen with alcoholism. E - possible result r/t electrolyte imbalance and needs a baseline assessment.
The nurse is caring for an older adult who is confused and disoriented after taking twice her normal dose of furosemide for the last week. Which priority actions should the nurse take as the patient arrives to the emergency department? Select all that apply. A - lower the head of bed B - assess lung sounds C - obtain a blood pressure D - place a cardiac monitor E - initiate fall precautions
A - furosemide is a loop diuretic that will cause hypovolemia. Lowering the head of the bed will improve cerebral perfusion. B C - risk for hypokalemia r/t lasix D
The nurse is assessing a patient with a positive Chvostek's sign. Which actions are a priority? Select all that apply. A- assess lung sounds B - request a soft diet C - evaluate phosphorus level D - assess for thrombosis and clots E - monitor for cardiac dysrhythmias
A - hypocalcemia can cause wheezing and bronchospasms B -hypocalcemia can cause swallowing difficult and pt is at risk for aspiration C - calcium and phos inversely related. If Ca is low, Phos is likely high E - hypocalcemia can cause prolonged QT interval and predispose to ventricle dysrhythmias
The nurse is caring for a patient with tachycardia and hypotension secondary to polyuria from hyperglycemia. Which prescriptions on the medication administration record should the nurse implement? Select all that apply. A - 0.9% NaCl 1000mL over 2hr B - Albumin 25G in 100mL IV over 4hr One time dose C - Mannitol 20G IV one time dose D - 0.45% NaCl 100mL/hr IV E - D50 0.9% NaCl at 50ml/hr IV
A - this is an isotonic solition that will increase fluid in the vascular space and help raise blood pressure B - albumin is a colloid protein that pulls fluid from the extravascular space into the intravascular space because of its high oncotic pressure. It will help increase blood pressure and improve perfusion
The nurse is completing discharge instructions for a patient with hyperphosphatemia secondary to chronic renal failure. Which statement by the nurse is correct? A- you should increase your intake of water and fruit juice daily B - I encourage you to explore foods high in calcium and low in phosphorus C - you will want to limit intake of potassium rich foods like spinach and bananas D - it is important to increase your intake of sodium rich foods like processed meats and canned soups
B Often the best way to correct hyperphosphatemia is to correct the hypocalcemia that accompanies it. Increased dietary calcium with phosphate binders can also help.
The nurse is caring for a patient with a bowel obstruction who has been vomiting at home for 3 days before coming to the hospital. Which priority prescription should the nurse request when contacting the healthcare provider? A - Hydroxyethyl starch B - Lactated Ringers C - Dextran D - Mannitol
B LR is an isotonic solution that creates no fluid shift while increasing vascular volume when a patient is dehydrated from vomiting.
The nurse is caring for a patient with adrenal cortex insufficiency (Addison's disease) with a lack of aldosterone production. Which electrolyte should the nurse monitor most closely? A - magnesium B - sodium C - calcium D - phosphorus
B aldosterone release causes increase of sodium. When there is a lack of aldosterone, there is a lack of sodium causing hyponatremia. It will also elevate serum potassium.
Which clinical manifestations would the nurse observe in a client with a calcium level of 6.4 muscle tremors abdominal cramps increased peristalsis cardiac dysrhythmias hypoactive bowels
abdominal cramps increased peristalsis muscle tremors
Which clinical manifestations appear when a patient has inadequate fluid volume decreased urine output hypotension dyspnea dry MM lung crackles poor skin turgor
decreased urine output hypotension dry MM poor skin turgor
When caring for a client with hypokalemia, which EKG changes will the nurse expect to find? inverted P waves flat T waves absence of U waves elevated ST segment
flattened T waves - indicating a problem with ventricular repolarization, a process involved in muscle contraction. P waves may peak, U waves are present, and ST segment is depressed