Med Surg Ch 11 - Fluid & Electrolyte
The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? Select all that apply. Apples Bananas ACE inhibitors Grapes Salt substitute
Bananas ACE inhibitors Salt substitute While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.Apples and grapes are considered lower potassium-containing foods.
1. Which food items selected by a client who must restrict potassium because of a continuing risk for hyperkalemia indicates to the nurse that more teaching is needed? a. Strawberries, Cheerios, eggs b. Cantaloupe, broccoli, sweet potatoes c. Apple pie, black coffee with sugar, carrot sticks d. Whole wheat toast with butter, canned pineapple chunks
ANS: B As indicated in 11-6, the fruits and vegetable selected by the client are all rich sources of potassium and must be avoided. Cereals, grains, bread, eggs, berries, apples, pineapples, carrots, and black coffee are low in potassium.
The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? Monitoring urine output encouraging sodium rich fluids and foods throughout the day instructing the client not to ambulate without assistance assessing deep tendon reflexes
instructing the client not to ambulate without assistance Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.Monitoring urine output needs to be done but is not the priority action in this situation. Generally, fluid is restricted, rather than sodium rich foods offered, to minimize the hyponatremia. While the nurse may assess muscle strength and deep tendon reflex responses, safety is the priority.
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L) A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest
A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) The most appropriate client for the nurse to assign to the LPV/LVN is the 76-year-old adult with poor skin turgor and a serum osmolarity of 300 mOsm/kg (300 mmol/kg). Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates normal fluid balance. This client is the most stable of the four clients described.The 44-year-old with CHF who has gained 3 pounds (1.4 kg) since the previous day requires additional assessments and interventions which should be performed by an RN. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L (6.0 mmol/L) has a risk for dysrhythmia and instability. Assessments and interventions performed by an RN are also needed on this client. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, requiring ongoing assessments and interventions by an RN.
Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A client admitted with dehydration who has a heart rate of 126 beats/min A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home A client admitted yesterday with heart failure with dependent pedal edema A client who has just been admitted with severe nausea, vomiting, and diarrhea
A client admitted yesterday with heart failure with dependent pedal edema The most appropriate client to assign to the LPN/LVN is the 64-year-old client admitted yesterday with heart failure and dependent pedal edema. This client is the most stable of all the four clients.Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable. Care must be given by the RN who can carry out assessments, prescriptions, and participate interdisciplinary collaboration as needed.
After receiving change-of-shift report, which client does the RN assess first? A client with nausea and vomiting who complains of abdominal cramps A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL
A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia. Immediate interventions are needed.The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems which are not urgent at this time.
1. When evaluating the hydration status of a new 84-year-old nursing home client, the nurse observes tenting of the skin on the back of the client's hand. What is the nurse's best action? a. Assess the skin turgor on the client's forehead. b. Ask the client when he or she last had anything to drink. c. Examine the client's dependent body areas, especially the ankles. d. Document this observation in the client's record as the only action.
ANS: A Skin turgor and hydration status cannot be accurately assessed on an older adult's hands because of age-related loss of elastic tissue in this area. Areas that more accurately show turgor and hydration status on an older adult are the skin of the forehead and the chest.
1. For which clients is it most important for the nurse to check frequently for dehydration? (Select all that apply.) a. 24-year-old athlete who is NPO for 4 hours awaiting an appendectomy b. 42-year-old client who has diabetes insipidus c. 56-year-old client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) d. 68-year-old client with poorly controlled type 2 diabetes mellitus e. 72-year-old client taking 80 mg of furosemide orally every day f. 74-year-old undergoing a bowel preparation with multiple enemas before colon surgery
ANS: B, D, E, F The 24-year-old athlete is highly unlikely to become dehydrated from being NPO for 4 hours. The client with SIADH retains water and is at greater risk for fluid overload rather than dehydration. The client with diabetes insipidus is at great risk for dehydration because the kidneys do not respond to ADH or to high blood osmolarity. Urine output is huge and the adult can dehydrate quickly. Any adult with type 2 diabetes mellitus that is poorly controlled is at high risk for dehydration because the body's response to high blood glucose levels is to pull fluid from the interstitial and intracellular spaces and increase urine output. Furosemide is a very effective loop diuretic that greatly increases urine output. 80 mg is a higher than average dose. Multiple enemas can greatly increase fluid lose from the GI tract and cause dehydration.
1. What immediate response does the nurse expect as a result of infusing 1 liter of an isotonic intravenous solution into a client over a 3-hour time period if urine output remains at 100 mL per hour? a. Extracellular fluid (ECF) osmolarity increases; body weight increases. b. Extracellular fluid (ECF) osmolarity decreases; body weight decreases. c. Extracellular fluid (ECF) osmolarity is unchanged; body weight increases. d. Extracellular fluid (ECF) osmolarity is unchanged; body weight decreases.
ANS: C Isotonic solutions have the same tonicity as plasma and other extracellular fluids. Therefore, the intravenous fluid would not change the ECF osmolarity. When 1000 mL are infused within 3 hours and the client only urinates 300 mL, the extra fluid would increase the client's weight. Remember that 1 liter of fluid is equal to 2.2 lb.
1. A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs and symptoms indicate to the nurse that this therapy is effective? a. The client reports hand swelling. b. Bowel sounds are present in all four abdominal quadrants. c. Serum potassium level has decreased from 4.4 mEq/L (mmol/L) to 4.2 mEq/L (mmol/L). d. Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg.
ANS: D Where sodium goes, water follows. Clients with severe hyponatremia are most often hypovolemic and hypotensive because fluid does not stay in the plasma volume when sodium levels are low. The plasma volume leaks into the interstitial space, which leads to edema formation. Having the blood pressure increase is the best nonlaboratory indicator that the treatment is effective.
A patient with severe hypokalemia from an accidental overdose of furosemide is to receiving IV potassium replacement through a peripheral inserted central catheter placed in the right upper arm. The ordered IV solution contains 120 mEq (mmol) of potassium chloride in 1000 mL of normal saline to be infused at a rate of 150 mL/hour. 1. Should this solution be infused using a pump or controller? Why or why not? 2. How many mEq (mmol) of potassium per hour will the patient receiving at this rate? 3. Is this rate permissible? Explain your rationale. 4. What parameter changes would indicate to you that the patient is responding well to this therapy? 5. What changes should you assess for to determine whether the patient is becoming hyperkalemic?
ANS: It should be given by pump or controller even though this is a central line into a high flow vein. Potassium is a severe tissue irritant. Tissues damaged by potassium can become necrotic and slough, causing loss of function and requiring reconstructive surgery. In addition, IV potassium solutions irritate veins and can cause phlebitis. ANS: 120 in 1000 mL = 0.12 mEq/mL (mmol/mL) × 150 = 18 mEq/hr (mmol/hr) ANS: It is very high, above the recommended 5-10/hr but within the maximum that TJC allows at 18 mEq/hr (mmol/hr). ANS: Expected responses to this therapy are a pulse oximetry that either stays the same or increases along with respirations that are deeper and slower. The serum potassium level should rise, and the urine output increase. Bowel sounds return and the patient should be able to expel flatus. Look up the ECG changes. ANS: Cardiac changes are often the first indications of higher than normal potassium levels. These include bradycardia, hypotension, and ECG changes of tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes (and possible ectopic beats).
The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply. Assess daily weights. Encourage consumption of citrus fruits. Weigh the client weekly. Monitor serum potassium. Discourage intake of spinach. Monitor for bradycardia.
Assess daily weights. Encourage consumption of citrus fruits. Monitor serum potassium. Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client must be weighed at the same time each day, using the same scale and wearing approximately the same amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.
The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? Monitoring 24-hour urine output Asking the client about feeling depressed Assessing the blood pressure hourly Monitoring the serum calcium levels
Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom of hypermagnesemia during magnesium infusion.Most clients who have fluid and electrolyte problems will be monitored for intake and output, and will not immediately indicate problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.
The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply. Blood serum glucose Blood pressure Pulse rate and quality Urinary output Urine specific gravity
Blood pressure Pulse rate and quality Urinary output Urine specific gravity The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.Blood glucose changes do not have a direct relation to a client's hydration status; lactated ringers are free from glucose.
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? Calcium level of 9.5 mg/dL (2.4 mmol/L) Magnesium level of 4.1 mEq/L (2.1 mmol/L) Potassium level of 6.0 mEq/L (6.0 mmol/L) Sodium level of 120 mEq/L (120 mmol/L)
Calcium level of 9.5 mg/dL (2.4 mmol/L) The client with a calcium level of 9.5 mg/dL (2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is 1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose risk for dysrhythmia, and a sodium level of 120 mEq/L (120 mmol/L) may cause serious cerebral dysfunction requiring assessments and/or interventions by the RN.
An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? Assesses for dry oral mucous membranes Checks for orthostatic blood pressure changes Notes pulse rate is 72 beats/min and bounding Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)
Checks for orthostatic blood pressure changes When caring an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure. Blood pressure measured with the client lying, then sitting, and finally standing is done to detect orthostatic or postural changes. During low blood volume states, especially when standing, insufficient blood flow to the brain may cause hypotension and tachycardia upon arising. This may cause light-headedness and dizziness, which increases the risk for falls, especially in older adults.Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does ensure safety for ambulation nor assess for fall risk.
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? Client behavior that changes from anxious to lethargic Deep furrows on the surface of the tongue Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched Urine output of 950 mL for the past 24 hours
Client behavior that changes from anxious to lethargic Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.
The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? Restrict the client's intake of sodium Administer a diuretic Monitor the serum osmolarity Encourage fluid intake
Encourage fluid intake When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.Hypernatremia and fluid loss typically occur in tandem in the older adult. Restricting sodium does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid volume deficit the client is experiencing. Monitoring the osmolarity will detect an abnormality, but not resolve the problem.
A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? Select all that apply. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution Use a vein in the hand for better flow Use an IV pump to deliver the medication Check IV access for blood return after the infusion Push the medication over 5 minutes
Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution Use an IV pump to deliver the medication Best practice technique for administering IV potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an adequate blood return before administering potassium-containing solutions.
The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? Insulin atropine Sodium polystyrene sulfonate (Kayexalate) potassium phosphate
Insulin The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water. This may be prescribed to promote movement of potassium from the blood into the intracellular fluid.While atropine will treat bradycardia, it does not address the underlying cause of bradycardia which is likely hyperkalemia. Sodium polystyrene sulfonate (Kayexalate)may be used for hyperkalemia, but it will not act quickly enough in an emergency. Additional potassium such as contained in potassium phosphate will make the client's condition more critical.
The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? Assessing oral mucosa for dryness Choosing appropriate oral fluids Monitoring skin turgor for tenting Offering fluids to drink every hour
Offering fluids to drink every hour Offering oral fluids every hour is within the scope of practice for a UAP.Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor would be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.
The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) Oral calcium supplements to a client with severe osteoporosis Oral phosphorus supplements to a client with acute hypophosphatemia Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)
Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum potassium levels can cause life-threatening dysrhythmias.The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.
A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? Monitor for hyperactive reflexes prepare for endotracheal intubation Institute teaching on avoiding magnesium rich foods Place the client on a cardiac monitor
Place the client on a cardiac monitor Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress at this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium excess is determined.
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply. Place the client on bed rest. Evaluate the electrolyte levels. Administer the ordered diuretic. assess for orthostatic hypotension. initiate cardiac monitoring
Place the client on bed rest. Evaluate the electrolyte levels. assess for orthostatic hypotension. initiate cardiac monitoring Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.
A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? Select all that apply. History of liver disease Use of salt substitute Use of an ACE inhibitor Potassium-sparing diuretics Prescription for insulin
Use of salt substitute Use of an ACE inhibitor Potassium-sparing diuretics When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking insulin would lower the potassium level.
The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? "The client's PT and INR may be prolonged while taking this medication." "The client may develop hypoglycemia during treatment." "Inverted T waves and a U wave may appear on the ECG." "I need to tell the client to avoid salt substitutes."
"Inverted T waves and a U wave may appear on the ECG." The nursing student understands the side effects of Bumex when commenting that inverted T waves and a U wave may appear on the EKG. Hypokalemia may cause depressed ST segments, flat or inverted T waves or the presence of a U wave on the ECG as well as dysrhythmias. High-ceiling (loop) diuretics, such as furosemide (Lasix, furosemide), promote loss of water, sodium, and potassium.PT and INR are typically prolonged with therapy with warfarin (Coumadin) or individuals with liver disease. Hypoglycemia may occur with oral hypoglycemic medications or insulin. Salt substitutes are typically avoided when the client has hyperkalemia or is taking an ACE inhibitor because many substitutes contain potassium chloride.
The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? "Be careful not to overload them with too many oral fluids." "Offer fluids that they prefer frequently and on a regular schedule." "Restrict their fluids if they are incontinent." "Wake them every 2 hours during the night with a drink."
"Offer fluids that they prefer frequently and on a regular schedule." The long-term care nurse teaches the UAPs to frequently offer older adults fluids that they prefer and on a regular basis. Because of the decreased thirst mechanism, older adults can become dehydrated and must be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer.Risk of overhydration, especially with oral fluids, is minimal. Fluids would never be restricted even if the client is incontinent. Restricting fluids to incontinent clients is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids. However, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).
The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? "I can gain 2 pounds (1 kg) of water a day without risk." "I should call my provider if I gain more than 1 pound (0.5 kg) a week." "Weighing myself daily can determine if my caloric intake is adequate." "Weighing myself daily can reveal increased fluid retention."
"Weighing myself daily can reveal increased fluid retention." The client with CHF should weigh himself daily to observe for increasing fluid retention, which may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound (0.5 kg) of weight gained (after the first half-pound [0.2 kg]) equates to 500 mL of retained water. The client must be weighed at the same time every day (before breakfast), and on the same scale.The client would call the primary care provider if more than 1 or 2 pounds (0.5 or 1 kg) are gained in a 24-hour period or if more than 3 pounds (1.4 kg) are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.
The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? Peripheral edema Crackles ½ way up the lung fields Serum osmolarity of 294 mOsm/kg (294 mmol/kg) Urine output of 1300 mL over 24 hours
Crackles ½ way up the lung fields The nurse needs to report to the PCP crackles heard ½ way up the lung fields when assessed on a client with SIADH receiving an infusion of 3% saline. When a hyperosmotic IV solution such as 3% saline is infused, the interstitial fluid is pulled into the circulation in an attempt to dilute the blood. As a result, the plasma volume expands. The nurse needs to evaluate the client for fluid volume excess and symptoms of heart failure including crackles.Peripheral edema may occur with SIADH. A serum osmolarity of 294 mOsm/kg (294 mmol/kg) is normal. A urine output of 1300 mL over 24 hours is considered normal.
The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? Administer sodium polystyrene sulfonate (Kayexalate) orally. Ensure that a potassium-restricted diet is ordered. Place the client on a cardiac monitor. Teach the client about foods that are high in potassium.
Place the client on a cardiac monitor. The nurse must first place this client on a monitor. Because hyperkalemia can lead to life-threatening bradycardia, placing the client on a cardiac monitor permits early intervention in the event of dysrhythmias.Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.
The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? Consulting with a health care provider about a client's laboratory results Infusing 500 mL of normal saline over 60 minutes Monitoring IV fluid to maintain the drip rate at 75 mL/hr Providing oral care every 1 to 2 hours
Providing oral care every 1 to 2 hours Appropriate intervention by an UAP to a client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent oral care is important for a client with fluid volume deficit.Consulting with a primary care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would be performed by licensed personnel.
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? Draws blood for laboratory tests Elevates the head of the bed Places the extremities in a dependent position Puts the client in a side-lying position
Elevates the head of the bed The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be performed first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? Heart rate Blood pressure (BP) Increases in edema Sodium level
Heart rate The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be expected in this scenario unless fluid volume deficit is present.
A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? Assessment of muscle tone and strength Education about potassium-rich foods Instruction on the proper use of drugs Measurement of the client's weight
Measurement of the client's weight The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of care has been effective.Assessment, education, and instruction are higher-level nursing actions within the scope of practice of the professional nurse.
The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? LPN/LVN who has floated from the hospital's long-term care unit LPN/LVN who frequently administers medications to multiple clients RN who has floated from the intensive care unit RN who usually works as a diabetes educator
RN who has floated from the intensive care unit The RN who has floated from the intensive care unit needs to care for this clinically unstable woman with uncontrolled diabetes. The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock from osmotic diuresis. The RN from the intensive care unit will have extensive experience caring for clients with hypovolemia, hyperglycemia, and fluid volume deficit/shock.The LPN/LVN who has floated from the long-term care unit or who frequently administers medications to multiple clients will not be as familiar with care for critically ill clients, or qualified to care for this clinically unstable client. Although the resource on diabetes is helpful, the RN who works as a diabetes educator will not be as familiar with care for acutely or critically ill clients.
Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? The client's potassium level is 5.1 mEq/L (5.1 mmol/L). The client's heart rate is 101 beats per minute. The client is free from adventitious breath sounds. The client has experienced a weight gain of 1 pound (0.5 kg).
The client is free from adventitious breath sounds. The nurse recognizes that Furosemide is effective when the client is free from adventitious breath sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight loss with resolution of edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels such as hypokalemia are side effects of furosemide, not therapeutic effects. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly indicate the medication has been effective. Weight loss, rather than weight gain, is often the effect of Furosemide, caused by the diuresis.
The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) The client whose potassium is 6.2 mEq/L (6.2 mmol/L) The client with a sodium level of 143 mEq/L (143 mmol/L)
The client whose potassium is 6.2 mEq/L (6.2 mmol/L) The first client the nurse sees with electrolyte and blood chemistry abnormalities is the client whose potassium is 6.2 mEq/L (6.2 mmol/L). A potassium value of 6.2 mEq/L (6.2 mmol/L) is elevated and the client has potential for cardiac dysrhythmias.A random or casual glucose, taken at any time of day, is elevated if ≥200mg/dL (>11.1mmol/L); a random value of 123 mg/dL (6.9 mmol/L) does not require intervention. The other clients with a magnesium value of 2.1 mEq/L (1.0 mmol/L) and a sodium value of 143 mEq/L (143 mmol/L) demonstrate normal laboratory values and do not require intervention.
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply. Use a potassium infusion prepared by a registered pharmacist. Assess for burning or redness during infusion. Infuse at a rate of no more than 10 mEq per hour. Administer only through a central venous catheter. Administer by IV push only during cardiac arrest.
Use a potassium infusion prepared by a registered pharmacist. Assess for burning or redness during infusion. Infuse at a rate of no more than 10 mEq per hour. Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstance where potassium is given by IV push.
The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? Ask the client how much fluid was consumed yesterday. Place an indwelling catheter to measure urine output. Auscultate the lungs for adventitious sounds. Weigh the client daily, at the same time.
Weigh the client daily, at the same time. When assessing fluid balance on a client with heart failure the nurse must weigh the client at the same time every day. Changes in daily weights are the best indicators of fluid losses or gains. A weight change of 1 pound (0.5 kg) corresponds to a fluid volume change of about 500 mL therefore the weight must be compared to intake and output.The nurse must weigh the client rather than rely on client estimate or memory. An indwelling catheter poses a risk for catheter associated urinary tract infection, and is reserved for specific reasons. Auscultating for adventitious lung sounds or crackles will demonstrate fluid overload, but may not immediately show up.