HESI & NCLEX PASSPOINT: Fluid & Electrolyte Balance
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?
prevent the development of ketosis. Explanation: High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?
The client voids 500 mL of urine. Explanation: Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.
Clients who are receiving parenteral nutrition (PN) are at risk for development of which complication?
fluid imbalances Explanation: Clients receiving TPN are at risk for a number of complications, including fluid imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary hypertension, and orthostatic hypotension are not complications of TPN.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's spouse reports that the client acted confused and was extremely weak upon waking that morning. The client's blood pressure is 90/58 mm Hg, pulse is 116 beats/minute, and temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?
hydrocortisone Explanation: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.
A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?
initiating caloric and nutritional therapy as ordered Explanation: A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number.
12 Explanation: First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg.Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms:0.2g/kg X 60 kg = 12 g.
An older adult client diagnosed with end-stage renal disease (ESRD) presents with fluid volume excess. Which nursing intervention is the priority?
Assess the client's lung sounds. Explanation: All interventions are important for the client with fluid volume excess, but airway takes priority. Fluid volume excess can lead to fluid in the lungs causing respiratory difficulty.
A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client?
To prevent seizures Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors.
A client with renal insufficiency is admitted to the hospital with pneumonia. The client is being treated with gentamicin. Which laboratory value should be closely monitored?
blood urea nitrogen (BUN) Explanation: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.
The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?
decreased ability to detect thirst Explanation: The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased, and dissolved particles in the extracellular fluid compartment become more concentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and aldosterone as a normal part of aging.
The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?
hypokalemia Explanation: Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.
A nurse is caring for a client who had a prostatectomy for prostate cancer. The nurse is reviewing the client's vital signs and intake and output as documented by a nursing assistant. Which documented finding requires immediate action?
intake and output Explanation: The client has a significantly greater intake than output. This finding may indicate that the catheter is blocked and causing urine retention. The nurse should immediately irrigate the catheter and try to determine if clots are blocking the catheter. If the nurse is unable to irrigate the catheter, the healthcare provider should be notified immediately. The client's heart rate and blood pressure are normal. Although the temperature is slightly elevated, this finding is not a priority at this time.
A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for?
muscle cramping Explanation: Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.
When magnesium sulfate is administered to a client in labor, its action occurs at which site?
neural-muscular junctions Explanation: Because magnesium has chemical properties similar to those of calcium, it will assume the role of calcium at the neural muscular junction. It doesn't act on the distal renal tubules, CNS, or myocardial fibers.
The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the health care provider?
potassium: 2.2 mEq/L (2.2 mmol/L) Explanation: The nurse should identify potassium 2.2 mEq/L as critical because a normal potassium level is 3.8 to 5.5 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl). The sodium level is normal (135-145 mEq/L). The creatinine is elevated (normal is 0.8 to 1.4 mg/dl), but this would not be a priority to report at this time.
A nurse is planning to administer a sodium polystyrene sulfonate enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema should include having the client
retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. Explanation: Sodium polystyrene sulfonate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, sodium polystyrene sulfonate must be in contact with the bowel for at least 30 minutes. Sorbitol in the sodium polystyrene sulfonate enema causes diarrhea, which increases potassium loss and decreases the potential for sodium polystyrene sulfonate retention.
Which indicates hypovolemic shock in a client who has had a 15% blood loss?
systolic blood pressure less than 90 mm Hg Explanation: Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.
Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
urine output greater than 30 ml/hour Explanation: Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.
A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first?
Discontinue the I.V. infusion. Explanation: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should discontinue the infusion immediately and restart it at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold, is the appropriate treatment for inflammation.
During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is smaller now than when he was born. After teaching the mother about the infant's condition, which statement by the mother indicates that the teaching has been effective?
"It seems like the fluid is being reabsorbed." Explanation: A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis. As fluid is being absorbed, scrotal size decreases. Elevation of the infant's bottom, massage, or keeping the infant quiet or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.
A newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions?
"Notify your healthcare provider if you experiences visual changes." Explanation: Hypokalemia can exacerbate digoxin toxicity so potassium should not be limited. The client will be taught the signs and symptoms of digoxin toxicity and what needs to be reported to the healthcare provider. Visual changes and anorexia are signs of digoxin toxicity and should be reported. The heart rate will not need to be verified twice a day. Anorexia is a symptom of digoxin toxicity so if the client is anorexic that should be reported to the healthcare provider.
The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?
"There is not enough blood circulating to the kidneys." Explanation: The best answer directly and simply explains to the parents that the kidneys are not getting perfused and therefore cannot function. Acute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic. Barbiturates are cleared renally and do commonly cause oliguria after an overdose. It is also common to require hemodialysis after a severe overdose.
A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?
B-type natriuretic peptide (BNP) Explanation: The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider?
Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes. Explanation: Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child's tolerance level. Simple sugars aren't a good source of hydration because of their osmotic effects. The nurse shouldn't wait 72 hours before taking action if a child is vomiting or has diarrhea. Toddlers can become dehydrated in a short time. A physician should see a child whose vomiting or diarrhea persists for 24 to 36 hours. Wet diapers are a good source of determining hydration; however, three wet diapers each day isn't a normal finding for toddlers. A hydrated toddler should have six to eight wet diapers per day.
A client prescribed propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?
Have the client come to the clinic in order to assess the lungs. Explanation: The client needs to be assessed for the heart failure, a potential adverse effect of beta blockers. The other answer choices will not rule out the possibility of the development of pulmonary edema.
A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first?
Slow the I.V. infusion. Explanation: Because this client has fluid overload, the nurse should first slow the infusion to prevent additional fluid overload, then notify the physician and obtain further orders. Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. Discontinuing the catheter is inappropriate because the nurse may still need vascular access to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate wouldn't prevent fluid overload from recurring.
When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate?
administering fluids to the client Explanation: A client that receives an MRI with contrast will need to have fluids offered to facilitate kidney excretion of the contrast medium. There is no need to numb the client's throat for this procedure so the client's gag reflex should not be affected. There is no need to restrict the client's activity. The nurse should assess for the presence of metal implants prior to the MRI, not after.
Which client is most likely to exhibit dehydration?
an 8-month-old infant with persistent diarrhea for 24 hours Explanation: Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and replacement fluids given.Healthy young adults have a higher tolerance for fluid loss and can quickly regain their fluid balance when fluids are lost through normal activity.The 75-year-old woman who was placed on NPO status before surgery is not likely to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions present that would precipitate fluid loss.The 60-year-old client with pneumonia and a fever should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is actively losing fluids through diarrhea.
Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?
canned tomato juice Explanation: Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance?
decreased serum sodium level Explanation: SIADH is characterized by excess antidiuretic hormone (ADH, vasopressin) secretion, despite low plasma osmolality. Excess ADH causes water to be retained. As blood volume expands, plasma becomes diluted resulting in dilutional hyponatremia. Aldosterone is suppressed, resulting in increased renal sodium excretion. Water moves from the hypotonic plasma and the interstitial spaces into the cells.
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for
diaphoresis, vomiting, and diarrhea. Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.
When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of
encouraging fluids. Explanation: The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels
Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?
hypertonic Explanation: The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?
lactated Ringer's solution Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client reports headache and nausea. Based on the serum laboratory results, how would the nurse interpret the client's acid-base balance?
metabolic acidosis Explanation: This client has metabolic acidosis, which typically manifests with a low pH, low bicarbonate level, normal to low PaCO2, and normal PaO2. The client's serum electrolyte levels also support metabolic acidosis, which include an elevated potassium level, normal to elevated chloride level, and normal calcium level. The client's anion gap of 30 mEq/L is high, also indicative of metabolic acidosis. This kind of metabolic acidosis occurs with diabetic ketoacidosis and other disorders.
A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?
metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.
A child with diabetic ketoacidosis is being treated for a blood glucose level of 738 mg/dl (41.0 mmol/L). The nurse should anticipate an order for:
normal saline with regular insulin. Explanation: Short-acting regular insulin is the only insulin used for insulin infusions. Initially, normal saline is used until blood glucose levels are reduced, then a dextrose solution may be used to prevent hypoglycemia. Ultralente, NPH, and PZI insulins have a longer duration of action and shouldn't be used for continuous infusions.
A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
use of humidity in the incubator Explanation: Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss. The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the skin.
An adolescent is brought to the emergency department in a coma and is diagnosed with diabetic ketoacidosis. What is the correct action for the nurse to take?
Infuse intravenous fluids as prescribed. Explanation: Dehydration results from the osmotic diuresis associated with hyperglycemia and polyuria. The client is at risk for shock from dehydration. Chvostek sign is exhibited by clients with hypocalcemia. Calcium and sodium are not concerningly altered in the acute phase of diabetic ketoacidosis (DKA). People experiencing DKA have classic metabolic acidosis manifestations with a low bicarbonate level. Eventually, the body should try to shift toward respiratory alkalosis to compensate.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?
sodium Explanation: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.
A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
sodium Explanation: Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.
A two-year-old child is showing signs of shock. A 10 ml/kg bolus of normal saline solution is ordered. The child weighs 40 lb (18.18 kg). How many milliliters should be administered? Round your answer using a whole number.
182 Explanation: The correct formula for this calculation is: 10 ml/kg x 18.18 kg = 181.8 ml Round to 182 ml
The nurse is preparing 1,000 mL D5/N5 to deliver over 6 hours. If the infusion set administers 15 gtt/mL, what is the required flow rate in gtt/min? (Round to the nearest whole number.)
42 Explanation: The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtt/mL × 1,000 mL/6 h x 1 h/60 min = 42 gtt/min.
The health care provider (HCP) prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to be infused at 2 mL/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place.
8.2 Explanation: 4.1 kg × 2 mL/kg = 8.2 mL/hour
The nurse is completing a plan of care for a client with right-sided heart failure. In order to prevent skin breakdown, which interventions would the nurse include? Select all that apply.
Administer prescribed diuretics. Elevate bilateral legs and apply heel protectors. Maintain client on fluid restriction as ordered. Explanation: The client with excess fluid volume as evidenced by peripheral edema would have the most improvement with skin integrity by elevating both legs and using heel protectors. Maintaining the client on fluid restriction and administering diuretics will help with the decrease in fluid volume and, therefore, edema. The client will need to have rest periods and education regarding intake and output, but these will not impact skin integrity in a direct way.
While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?
Hang a new bag of D5W, and complete an incident report. Explanation: Maintenance of IV sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, solution, and tubing; these measures help prevent complications. The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify this action with another nurse. Paging the HCP is not necessary; maintaining the IV and using the correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital policy should be followed if there is a question as to whether there could have been an unknown substance in the bag that caused it to change color.
A client with leukemia received induction chemotherapy 2 days ago and is now reporting severe diarrhea, decreased urination, cardiac dysrhythmias, and paresthesia with tetany. Laboratory reports reveal hyperkalemia, hyperuricemia, and hypocalcemia. Which action would the nurse anticipate?
I.V. fluids to increase urine output and allopurinol to inhibit uric acid Explanation: The client likely has tumor lysis syndrome, which occurs when a person with cancer (such as leukemia) initiates treatment, causing the rapid destruction and breakdown of large numbers of cells. The syndrome results in the signs and symptoms noted above as well as hyperuricemia, hyperkalemia, hyperphosphatemia, renal failure, and hypocalcemia. Early recognition is important to prevent renal damage. Increased I.V. fluids will flush the cellular debris from the system while increasing urine volume and restoring alkalinity, and allopurinol will decrease production of uric acid. Fluids should not contain potassium.
A nurse is administering 50 mEq potassium chloride (KCl) in 250 mL 0.9 normal saline (NS) intravenously piggyback (I.V.PB) to a client with hypokalemia. Which action should the nurse take?
Provide continuous cardiac monitoring during the infusion. Explanation: I.V. potassium chloride (KCl) is administered at a maximal rate of 10 mEq/hour. The pump would be set for 50 mL/hour to infuse the I.V.PB over 5 hours. Rapid I.V. infusion of KCl can cause cardiac arrest. Cardiac monitoring should be provided while client is receiving potassium because of the risk for dysrhythmias.
A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation?
Reposition the child's extremity. Explanation: The most likely reason for difficulty running an IV in this age group is a positional issue of the child or extremity because of the child's activity level.
Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective?
The serum potassium is 4.0 mEq/L (4.0 mmol/L). Explanation: Following a crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated, and serum potassium levels should come back to normal. Normal serum potassium is 3.5 to 5.3, so a level in this range indicates that the medication has been effective. A weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.
A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence and has decreased the fluid intake because of the incontinence. What is the nurse's best response to the client?
"Drink eight glasses of water a day and urinate every 2 hours." Explanation: Clients who have undergone TURP need to be instructed to maintain an adequate fluid intake despite urinary dribbling or incontinence. The client should be advised to drink at least eight glasses of water a day to dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours can help decrease incidents of incontinence. Teaching the client Kegel exercises is also beneficial for strengthening sphincter tone. The nurse should not encourage the client to decrease fluids. It is not necessarily true that a decreased intake will cause renal calculi. Threatening the client with a catheter is not beneficial, and it is not the treatment of choice for a client who is experiencing incontinence from TURP.
The nurse is caring for a child with elevated serum potassium. When teaching the parents about dietary restrictions related to this condition, which of the following would be appropriate information? Select all that apply.
Do not drink orange juice. Asparagus should be avoided. Explanation: Orange juice and asparagus are high in potassium and should be avoided. Salt substitutes, dried fruit, and potatoes are also high in potassium and should not be included in the child's diet.
A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client?
Continue to maintain normal sodium intake while at home. Explanation: Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased. Reduced sodium intake can lead to lithium toxicity. Nursing is not allowed to tell a client to adjust dosages of any drugs. A low-protein snack is not reflective or needed with this drug. Avoiding participation is not a therapeutic discussion.
What is an appropriate nursing action to detect early signs of metabolic complications in a client receiving total parental nutrition (TPN)?
Monitor urine output. Explanation: Hyperosmolar hyperglycemia is a metabolic complication of TPN. Expansion of the blood volume combined with hyperglycemia may cause osmotic diuresis, presenting as increased urine output. Intake and output should be recorded so that a fluid imbalance can be readily detected. Urine can also be tested for hyperosmolar diuresis. The other choices do not support early metabolic complications, and the assessment of lung sounds reflects respiratory complications.
A client is scheduled for a creatinine clearance test. What should the nurse do to prepare the client?
Instruct the client about the need to collect urine for 24 hours. Explanation: A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to increase fluids to 3,000 mL.
Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol?
Encourage a high fluid intake. Explanation: Destruction of malignant cells during chemotherapy produces large amounts of uric acid. The child's kidneys may not be able to eliminate the uric acid, and tubular obstruction from the crystals could result in renal failure and uremia. Allopurinol interrupts the process of purine degradation to reduce uric acid buildup. The child should be encouraged to increase fluid intake to further assist in eliminating uric acid.Carbonated fluids need not be omitted when allopurinol is administered.An intake of foods high in potassium is not necessary nor is limiting foods high in natural sugar.
The nurse is caring for a client following a motor vehicle incident with head trauma. Diabetes insipidus is suspected. Which nursing intervention is appropriate?
Measure and record urinary output. Explanation: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. Blood sugar has nothing to do with diabetes insipidus.
The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take?
Report the finding to the healthcare provider. Explanation: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid that should be immediately reported to the healthcare provider. Flushing the catheter could enhance the development of an abdominal infection. The client receiving peritoneal dialysis is in renal failure and most likely is on a fluid restriction. Additional fluids will not affect the presence of cloudy dialysate. It is beyond the nurse's scope of practice to instill an additional liter of dialysate. This action could alter the client's fluid and electrolyte balance.
A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess?
Number of wet diapers the in the last 24 hours Explanation: A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. This helps to determine the severity of the dehydration. Knowing the amount of fluid intake for 24 hours also helps assess the severity of the dehydration. If the baby is bottle fed the mother could give a specific amount. If breast fed the nurse would want to know how many times fed and for how long each time. Just knowing the number of feeds in 24 hours will not give accurate information to determine dehydration status. The number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and capillary refill assessment could indicate a perfusion problem.
What is the primary goal of nursing care during the emergent phase after a burn injury?
Replace lost fluids. Explanation: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.
The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention?
low-sodium diet Explanation: In clients with fluid retention, sodium restriction may be necessary to promote fluid loss. Increasing exercise will not reduce fluid retention. Exercise will promote circulation, but will not manage the fluid retention. Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and promote improved fluid balance. Elevating the client's feet helps promote venous return and fluid reabsorption but in itself will not reduce the volume of excess fluid.
The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag. There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output?
The client's intake was 300 ml greater than output. Explanation: The nurse should conclude that the client's intake was 300 ml greater than output. To reach this conclusion, the nurse should add the nasogastric drainage (300 ml) and the urinary output (200 ml) to get an output of 500 ml. The nurse should add the amount of IV fluid that infused during the shift (300 ml) to the amount of liquid consumed (500 ml) to get 800 ml for the client's intake. The nurse should then compare the output (500 ml) to the intake (800 ml) and determine that the intake was 300 ml greater than the output (800 ml - 500 ml = 300 ml).
The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in a child with nephrotic syndrome?
decreased abdominal girth Explanation: Fluid accumulates in the abdomen and interstitial spaces due to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
The nurse plans care for a child with sickle cell disease in vasoocclusive crisis. The nurse includes increasing fluid intake in the list of interventions because the nurse understand that:
decreased blood viscosity prevents the sickling process. Explanation: Treatment of a child in vasoocclusive crisis from sickle cell disease includes measures to prevent further sickling. Sickling occurs in the presence of decreased oxygen tension and alterations in pH. The hard sickle-shaped cells catch on each other and can eventually occlude vessels; that decreases oxygenation of the area and increases the sickling process. Increasing fluids will increase hemodilution and prevent the clumps of sickle cells from occluding vessels.Children in sickle cell crisis do not lose more water than normal through diaphoresis.The life span of a normal red blood cell is 120 days; there is no way to increase this life span.Hemolysis refers to the breakdown of red blood cells, something to be avoided in a child with sickle cell disease.
A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority?
neurological status Explanation: Clients experiencing dialysis for the first time often have confusion and even seizures and should be monitored closely. Vital signs and laboratory values are important assessments but do not specifically address dialysis disequilibrium syndrome. Pain in the flank region is not associated with dialysis.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?
decreased deep tendon reflexes Explanation: Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.
The nurse is caring for a client who has returned from having a subtotal thyroidectomy. What finding would require a nurse to take immediate action?
facial muscle twitching Explanation: Facial muscle twitching is a manifestation of hypocalcemia, and the healthcare provider should be immediately notified. A shortened QT interval can be a manifestation of hypercalcemia, and diminished deep tendon reflexes can be a manifestation of hypermagnesia; both these findings should be evaluated, but they are not the priority. Incisional pain 6/10 should be addressed, but is not the priority.
A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?
hyperkalemia Explanation: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.
A nurse is caring for a client whose blood pressure has changed from 136/82 to 114/86. Which is the best nursing intervention?
increasing the rate of the intravenous fluid solution Explanation: Decreasing pulse pressure is an early manifestation of shock. The intravenous rate should be increased and the healthcare provider immediately notified. The RN is responsible for further monitoring of this client, including vital signs. Placing the client on strict intake and output and encouraging the client to increase fluids are not appropriate interventions.
The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?
noisy respirations Explanation: A serious complication of IV therapy is fluid overload. Noisy respirations can develop as a result of pulmonary congestion. Additional symptoms of fluid overload include dyspnea, crackles, hypertension, bounding pulse, and distended neck veins.
The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider?
protamine sulfate Explanation: The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit.
After being sick for three days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). Which diagnostic test will the nurse prioritize in monitoring?
serum potassium level Explanation: The nurse would prioritize the monitoring of the client's potassium level because potassium leaves the cell during periods of acidosis, causing hyperkalemia, which may cause cardiac arrhythmias. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser effect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias, which the nurse would consider a priority.
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting?
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the health care provider?
potassium: 2.2 mEq/L (2.2 mmol/L) Explanation: The nurse should identify potassium 2.2 mEq/L as critical because a normal potassium level is 3.8 to 5.5 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl). The sodium level is normal (135-145 mEq/L). The creatinine is elevated (normal is 0.8 to 1.4 mg/dl), but this would not be a priority to report at this time
A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas-pH 7.46, PCO2 45 mm Hg (6.0 kappa), PO2 95 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first?
5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h Explanation: The vital signs suggest that the client is dehydrated from the vomiting, and the nurse should first infuse the IV fluids with the addition of potassium. There is no indication that the client needs oxygen at this time since the PO2 is 95 mm Hg (12.6 kPa). Although the client has a rapid and irregular pulse, the infusion of fluids may cause the heart rate to return to normal, and the 12-lead ECG can be prescribed after starting the intravenous fluids.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?
hypotension. Explanation: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia.
When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 mL/day, which fluid should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst?
ice chips Explanation: The most appropriate and effective choice would be ice chips because they help moisten the mouth and lips while keeping fluid intake low. However, ice chips must still be counted as intake with the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fluid intake low.
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?
K+, 3.2; Cl-, 92; Na+, 120 Explanation: Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. For these reasons, persistent vomiting can lead to hypokalemia, hypochloremia, and hyponatremia.The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are consistent with persistent vomiting.Each of the other options includes at least two serum electrolyte levels that are normal or high. These are not consistent with persistent vomiting.
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
hyperkalemia. Explanation: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?
daily weight Explanation: The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.
The nurse is administering a high dose of furosemide to a client with nephrotic syndrome. What potential complication is the nurse most concerned with for the client?
electrolyte imbalance Explanation: Furosemide is a loop diuretic that can cause the excretion of potassium, sodium, and magnesium. The client receiving high doses should be monitored for electrolyte imbalance. Visual disturbances and altered levels of consciousness are not common complications. The nurse expects clients to have increased urine output with furosemide.
During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?
urine output Explanation: During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and daily body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP is not used. After the first 48 to 72 hours, urine output is a less reliable guide to fluid needs. The victim enters the diuretic phase as edema reabsorption occurs, and urine output increases dramatically.During the first 48 to 72 hours, fluid replacement is critical and is based on hourly urine output. Daily body weight does not provide enough information on which to base fluid replacement amounts.Body temperature is not a reliable guide for fluid replacement.IV fluid rates will be adjusted to keep urine output greater than 30 mL/h. Specific gravity measures the kidneys' ability to concentrate urine.
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
urine output of 20 ml/hour Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?
The urine output is greater than 35 mL/h. Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of
increasing fluid intake to prevent dehydration. Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?
metabolic alkalosis Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that appl
numbness tingling muscle twitching and spasms Explanation: When the parathyroid gland is removed, the body may not produce enough parathyroid hormone to regulate calcium and phosphorous levels. The symptoms of hypocalcemia include peripheral numbness, tingling, and muscle spasms. Aphasia is not a symptom of calcium depletion. Polyuria and polydipsia are symptoms of diabetes mellitus.
A client is admitted to the emergency department with a diagnosis of advanced anorexia nervosa. The client is 5′ 4″ (1.6 m) tall and weighs 79 lb (35.8kg). On assessment, the nurse notes blood pressure of 82/50 mm Hg; cracked and bleeding lips; and dry, yellow skin. The nurse offers the client oral fluids, and the client replies, "They'll make me even fatter." The nurse should base her next intervention on which assessment finding?
refusal of fluids Explanation: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. The client is typically hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Refusal of fluids puts the client at immediate physiologic risk. Addressing this behavior should take immediate priority over the client's dry skin, cracked lips, low body weight, and disturbed body image.
The nurse is flushing a peripheral intravenous access device. Place the steps in the order that the nurse should perform them. All options must be used.
Cleanse the end cap with an antimicrobial swab. Insert the saline flush syringe into the cap on the extension tubing. Pull back on saline flush syringe to aspirate the catheter for blood return. Instill saline solution over 1 minute. Remove the syringe and reclamp the extension tubing. Remove gloves and perform hand hygiene. Explanation: The first step is to cleanse the end cap with an antimicrobial swab to reduce the risk for contamination. The second step is to insert the saline flush syringe into the cap on the extension tubing to prepare to flush the intravenous site. The third step is to pull back on saline flush syringe to aspirate the catheter for blood return to confirm patency. The fourth step is to instill saline solution over 1 minute to maintain patency of the peripheral intravenous access device site. The fifth step is to remove the syringe from the peripheral intravenous access device because the normal saline has been administered and reclamp the extension tubing to prevent air from entering the peripheral intravenous access device. The sixth step is to remove gloves and perform hand hygiene to reduce the risk of transmission of microorganisms.
The nurse is placing an intravenous (IV) catheter in a client who has a risk of impaired skin integrity due to dehydration. Place the steps in order for this procedure. All options must be used.
Palpate and select an appropriate vein. Cleanse client's skin with an antiseptic. Hold skin taut 1-2 inches below the site. Insert catheter and observe for blood return. Stabilize catheter and flush with saline. Explanation: The client with fluid volume deficit due to dehydration would likely require an IV infusion of fluids as a treatment for this. Having an improved skin turgor with decreased dehydration will reduce the client's risk for impaired skin integrity. The client would have the catheter inserted and then flushed with saline once the appropriate vein was selected, the skin cleansed, and then the skin held taut below the site to stabilize the vein for IV insertion. Avoid touching the cleansed area to maintain this antisepsis.
The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next?
Ask another nurse to attempt to start a peripheral intravenous line. Explanation: Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.
A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug?
deep tendon reflexes Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. It is administered by IV; 4 g of a 50% solution in 250 mL D5W can be given as a bolus before the dose is titrated for continuous infusion. Magnesium sulfate is a general inhibitor of neurotransmission. As such, the two largest complications are the loss of deep tendon reflexes and the suppression of breathing. These are the priority assessments. If deep tendon reflexes decrease or the respiratory rate is 12 breaths/min or less, the medication should be discontinued and calcium gluconate administered. Magnesium sulfate is excreted entirely through the kidneys so intake and output should be evaluated hourly. The mother becomes very hot and flushed. This is a normal response. The fetal heart rate should not decrease from the drug.
The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.
prothrombin time 22 seconds ammonia 96 mg/dL (68.54 mmol/L) platelets 75,000 cells/mm3 (75 x 109/L) Explanation: The client with cirrhosis has liver dysfunction and impaired coagulation and rising ammonia levels. The prothrombin time is prolonged (normal is 10 to 13.0 seconds), and the platelet count is low (normal is 150,000 to 350,000 cells/mm3). A normal ammonia level is 15 to 45 mg/dl (10.71 to 32.13 mmol/L), and this client's level is elevated, placing the client at risk for hepatic encephalopathy. A client with cirrhosis typically has hypokalemia because of the diuretic therapy used to treat the fluid retention associated with the disease. Here, the potassium level is within normal limits (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). In cirrhosis, the albumin level is also typically low (normal is 3.5 to 5.0 g/dl or 35-50 g/L) due to alterations in protein metabolism in the liver. Levels of amylase, a pancreatic enzyme, typically increase with pancreatitis, not cirrhosis (normal level is 27 to 151 units/L or 0.45 to 2.52mkat/L).
Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem?
abnormally high salt loss through perspiration Explanation: One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Extra salt is almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.In the child with cystic fibrosis, the functioning of the sweat glands is the problem, causing abnormal amounts of salt to be lost with perspiration. The ability to concentrate urine is not the problem.Little skin pigment is not a condition associated with cystic fibrosis.A poorly functioning temperature control center is not a condition related to cystic fibrosis.
