Prep U Fluid and Electrolytes

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: Intermittent claudication. Dyspnea. Dependent edema. Crackles.

Dependent edema Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? The client may be developing hypocalcemia. The client is experiencing a reaction to meperidine. The client has a nutritional imbalance. The client needs a muscle relaxant to promote rest.

The client may be developing hypocalcemia. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of fingers and lips, and irritability. Meperidine may cause tremors or seizures as an adverse effect, but not muscle twitching. Muscle twitching is not caused by a nutritional deficit, nor does it indicate that the client needs a muscle relaxant.

A client is receiving total parenteral nutrition (TPN), and the nurse is concerned about the complication of fluid volume overload. Which nursing action is most appropriate in the administration of TPN to prevent this complication? Use an infusion pump to administer the TPN solution. Weigh the client every day. Reduce the ordered flow rate by half. Continuously monitor the infusion rate.

Use an infusion pump to administer the TPN solution. Complications of TPN include fluid overload, electrolyte imbalances, infection, hyperglycemia and hypoglycemia, air embolism, and pneumothorax. A nurse should use an infusion pump to administer TPN to help prevent fluid overload. Although weighing the client every day would alert the nurse to possible fluid overload, it is more appropriate for the nurse to prevent fluid overload by using an infusion pump. The nurse does not need to continuously monitor the infusion rate once the pump is set. The nurse should not decrease the prescribed flow rate, thus preventing the administration of the ordered nutrition.

A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the priority for the nurse? collecting strict intake and output administering IV fluids begin oral rehydration start on a bland diet of bananas, rice, applesauce, and toast (BRAT diet)

administering IV fluids Severe vomiting and diarrhea cause fluid and electrolyte imbalances. Water loss can be greater than sodium loss, causing dangerously high serum sodium levels. Other electrolyte imbalances can occur that may require replacement. Potassium should not be administered until urine output is determined. Monitoring strict intake and output is important, but it assesses dehydration status rather than correcting it. Oral rehydration is started only after fluid and electrolyte corrections have been made. The BRAT diet is no longer recommended for children.

A client is experiencing hypovolemic shock. Which assessments best assist in evaluating the client's fluid status? Select all that apply. blood pressure hemoglobin level heart rate respiratory rate skin turgor daily weight

blood pressure heart rate respiratory rate skin turgor daily weight With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. As compensatory mechanisms, heart and respiratory rates generally increase with both fluid volume deficit and overload, making those assessments essential. Skin turgor and daily weights are essential assessments in the client with any fluid imbalance. The hemoglobin level reflects red blood cell concentration, not overall fluid status.

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first? intravenous fluid hydration acetaminophen orally as needed small volume nebulizer breathing treatments regular diet

intravenous fluid hydration Both the history and physical assessment support a client who is dehydrated. I.V. fluids would assist with rehydration and liquifying secretions. Although the pneumonia is important to treat aggressively, hydration is the priority.

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. normal saline with ultralente insulin. 5% dextrose in water with NPH insulin. 5% dextrose in water with PZI insulin.

normal saline with regular insulin. 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 client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used? to prevent signs of hypovolemic shock and restore circulation to maintain appropriate glucose levels in the blood to restore sodium stores that were lost from the burns to improve skin integrity and maintain a barrier

to prevent signs of hypovolemic shock and restore circulation Lactated Ringer's is infused to restore circulating fluid volume and prevent signs of hypovolemic shock. Intravenous administration of dextrose to restore glucose is not the priority at this time. Lactated Ringer's will not affect sodium, and this is not a priority. The client has severe burns, so improving skin integrity is not an issue at this time.

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first? Administer 1 liter 0.9% saline IV. Draw a complete blood count with hematocrit and hemoglobin. Obtain an abdominal X-ray. Insert an indwelling urinary catheter.

Administer 1 liter 0.9% saline IV. The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol? Encourage a high fluid intake. Omit carbonated fluids. Give foods that are high in potassium. Limit foods that are high in natural sugar.

Encourage a high fluid intake. 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

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Monitor the laboratory values. Observe neurologic function every 15 minutes. Observe the puncture site for swelling and bleeding. Monitor skin warmth and turgor.

Observe the puncture site for swelling and bleeding. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? preventing wound infections evaluating vital signs frequently maintaining fluid and electrolyte balance managing the child's pain

Maintaining fluid and electrolyte balance Although monitoring vital signs frequently is important, for the first few days the primary concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury and are lost. These must be replaced. Once the child's fluid and electrolyte status has been addressed and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the child's pain can be initiated.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do? Monitor laboratory values daily for elevated thyroid-stimulating hormone. Observe for swelling of the neck, tracheal deviation, and severe pain. Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? sunken fontanel decreased pulse rate increased blood pressure low urine specific gravity

Sunken fontanel In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? jugular vein distention right upper quadrant pain bibasilar crackles dependent edema

bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? blood urea nitrogen (BUN) level of 22 mg/dl (1.2 mmol/L) serum creatinine level of 1.2 mg/dl (0.1 mmol/L) temperature of 100.2° F (37.8° C) urine output of 250 ml/24 hours

urine output of 250 ml/24 hours ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow? Serve the client a regular diet. Order a high-fiber diet. Encourage plenty of fluids. Avoid dairy products.

Encourage plenty of fluids. The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply. Pain medication has been administered orally and was effective. This is a severe burn and nerve endings have been destroyed. This is a superficial burn, so no pain is present. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary. This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.