NMNC 1110 EAQ 7: Fluid and Electrolytes
The nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. Which is the volume of solution the nurse would prepare?
250 to 350 mL
Which degree of edema will result in a 6-mm deep indentation upon pressure application?
3+
Which percentage of total body water is found in a premature newborn?
85%
Which action would the nurse include in the plan of care for a client undergoing a transsphenoidal hypophysectomy? Select all that apply. One, some, or all responses may be correct.
- Assessing for clear nasal drainage - Maintaining strict intake and output - Increasing daily dietary fiber intake - Elevating the head of the bed 30 degrees - Instructing on the use of an incentive spirometer
The health care provider prescribes a blood transfusion for a client with esophageal varices. Place the following nursing actions in the correct order.
1. Check the client's vital signs. 2. Establish intravenous (IV) access with IV normal saline. 3. Verify the blood product with another nurse against the client's identification (ID) bracelet. 4. Monitor the client's vital signs and status according to agency policy.
An intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride needs to be administered over 20 minutes. The nurse will set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number. ___ mL/h
150
At 10:00 AM the nurse hangs a 1000-mL bag of 5% dextrose in water (D 5W) with 20 mEq of potassium chloride to be administered at 80 mL/h. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic?
60 minutes
One liter of 5% dextrose solution contains 50 grams of sugar. The nurse calculates that 3 L solution/day will supply approximately how many kilocalories?
600
A pregnant client with severe preeclampsia is receiving intravenous magnesium sulfate. Which item would the nurse keep at the bedside in case of magnesium sulfate toxicity?
Calcium gluconate
When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest?
Cantaloupe
Which finding during peritoneal dialysis would the nurse act on as a sign of infection?
Cloudy return of dialysate
The nurse assesses a client's intravenous (IV) site. Which clinical finding leads the nurse to conclude that the IV has infiltrated, rather than caused inflammation?
Coolness
The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome?
Fluid and electrolyte balance
The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury?
Hyperkalemia and hyponatremia
A client is receiving furosemide to relieve edema. The nurse will monitor the client for which adverse effect?
Hypokalemia
Which part of the kidney produces the hormone bradykinin?
Juxtaglomerular cells of the arterioles
Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with a diabetic coma?
Ketones as a result of rapid fat breakdown, causing acidosis
In which components of the nephron unit does furosemide decrease fluid reabsorption? Select all that apply. One, some, or all responses may be correct.
Loop of Henle Distal tubules Proximal tubules
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day?
Maintaining potassium levels
A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next?
Notify the health care provider that the potassium level is below normal.
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion?
Plasma proteins moving out of the intravascular compartment
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
Shift of fluid into the interstitial spaces
Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure?
Sodium
Twenty minutes after an infusion of packed red blood cells begins, the client complains of chest pain, difficulty breathing, and feeling cold. Which is the first action the nurse will take?
Stop the tranfusion.
While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above heart level. Which statement provides the reason behind this nursing intervention?
To prevent further edema
Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder?
Cystic fibrosis
Which is the action of an antidiuretic hormone (ADH)?
Decreases water loss in urine
Which relationship between a client's burned body surface area and fluid loss would the nurse consider when evaluating fluid loss in a client with burns?
Directly proportional
Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct.
Duiretics Low-salt diet Daily weight checks Fluid restriction Intake and output Oxygen administration
A child who has a history of a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonephritis. How can the nurse obtain the most accurate information on the status of the child's edema?
Weighing daily
