Prep U Module 1

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

hypertonic 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 school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.

250 2,000 mL/8 hours = 250 mL/hour

Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?

K+, 3.2; Cl-, 92; Na+, 120 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 child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the priority for the nurse?

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.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated?

diabetes insipidus Diabetes insipidus is characterized by a great thirst (polydipsia) and large amounts of dilute, watery urine with a specific gravity of 1.001 to 1.005. Diabetes mellitus presents with polydipsia, polyuria, and polyphagia, but the client also has hyperglycemia. Diabetic ketoacidosis presents with weight loss, polyuria, and polydipsia, and the client has severe acidosis. A client with SIADH cannot excrete dilute urine; the client retains fluid and develops a sodium deficiency.

A client is experiencing hypovolemic shock. Which assessments best assist in evaluating the client's fluid status? Select all that apply.

heart rate respiratory rate skin turgor daily weight blood pressure 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.

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. 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 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." 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.

A 13-month-old client is admitted to the pediatric unit with gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal dehydration. Which nursing interventions are correct to prevent further dehydration? Select all that apply.

Monitor the intravenous (IV) solution per the physician's order. Encourage the child to eat non-salty soups and broth. Give clear liquids in small amounts. A child experiencing nausea and vomiting would not be able to tolerate a regular diet. The child should be given sips of clear liquids, and the diet should be advanced as tolerated. Non-salty soups and broths are appropriate clear liquids. Milk should not be given, because it can worsen the child's diarrhea. The nurse should monitor IV fluids, which are administered to maintain the fluid status and help to rehydrate the child. Solid foods may be withheld throughout the acute phase; however, clear fluids should be encouraged in small amounts (3 to 4 tablespoons [45 to 60 mL] every half hour).

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

encouraging increased fluid intake During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

Which action has the highest priority in the care of a client with chronic renal failure?

Maintain a low-sodium diet. It is appropriate for the client to be on a low-sodium diet to help decrease fluid retention. Dry skin and pruritus are common in renal failure. Lotions are used to relieve the dry skin, and antihistamines may be used to control itching; corticosteroids are not used. Pain is not a major problem in chronic renal failure, but analgesics that are excreted by the kidneys must be avoided. It is not necessary to measure abdominal girth daily because ascites is not a clinical problem in renal failure.

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 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 client is admitted with a diagnosis of viral gastroenteritis. The client has an elevated blood urea nitrogen and creatinine and is oliguric with a blood pressure of 74/30 mmHg. Which order from the healthcare provider should the nurse carry out first?

Administer intravenous fluids. The client demonstrates evidence of prerenal acute kidney injury caused by hypovolemia. Intravenous fluids will be ordered to improve renal perfusion, and this is the nurse's priority to prevent permanent kidney damage. The IV fluids increase the glomerular filtration rate, which will result in increase in urine output and a decrease in BUN and creatinine levels. After initiating IV fluids, the nurse can administer medications such as antiemetics or antipyretics PRN. Stool samples can be collected whenever they are provided by the client.

A client in the intensive care unit has a critically low potassium level of 1.9 mEq/l (mmol/l). What would be the best way to replace this client's potassium?

Administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each The nurse should administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each to safely and rapidly correct this client's potassium. IV potassium will be absorbed more fully and more quickly than oral potassium replacement. Potassium should never be given as an IV bolus, as it can result in severe cardiac dysrhythmias and sudden death. Sodium polystyrene is used in the treatment of hyperkalemia, and lowers potassium levels, so it is not indicated for this client.

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. 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 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) 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.

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

Hypertonic A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic.

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. 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 is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment?

Monitor fluid intake and output. A sunken fontanelle in an alert child would most commonly suggest a concern with dehydration. Monitoring intake and output can help determine whether the child is receiving adequate hydration and can lead to planning further actions that could correct the situation.

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 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 client receiving peritoneal dialysis in the home is suspected of having peritonitis. Which finding should the nurse expect to assess in this client? Select all that apply.

abdominal pain rebound tenderness hypotension A client receiving peritoneal dialysis is at risk for developing peritonitis. Manifestations of peritonitis include diffuse abdominal pain and rebound tenderness. Hypotension can occur if the infection continues. Weight loss and extreme thirst are not signs of peritonitis.

Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

auscultation of moist crackles An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.

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?

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.

Which adverse effect occurs when there is too rapid an infusion of TPN solution?

circulatory overload Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and

phosphorus PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

urine output greater than 30 ml/hour 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 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." 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.

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

Cardiac Rhythm Manifestations of CKD result from loss of the renal regulatory functions of filtering metabolic waste products and maintaining fluid and electrolyte balance. These laboratory results indicate CKD, but the most significant result is the potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum creatinine level ranges from 0.7 to 1.5 mg/dL.

A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next?

Clamp the catheter for 20 minutes. Taking a large amount of urine from the bladder over a short period of time puts the client at risk for hypovolemic shock. The other options would not prevent hypovolemic shock. The only way to gradually remove urine is to clamp and unclamp the catheter.

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. 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.

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an intravenous line with dextrose in 5% water infusing at 40 ml/hour and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters would the nurse calculate as urine? Record your answer as a whole number.

During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml X 8 hour = 1,600 ml/8 hour). The nurse would subtract this amount from the total volume in the drainage bag to determine the urine output (2,780 ml - 1,600 ml = 1,180 ml).

What discharge instructions should the nurse give the parents of an infant with a temporary colostomy?

Give the infant plenty of liquids to drink. Because of decreased fluid reabsorption from the colon, the child with a colostomy benefits from a liberal fluid intake. Infants also dehydrate more quickly than adults do because of immature kidneys, larger body surface area, and more fluid in the extracellular spaces. Therefore, the parents need instructions about giving the infant plenty of liquids to drink.Tap water flushes of the stoma are contraindicated in infants because of the risk for absorption of free water and the potential for fluid overload.An appliance should be fitted over the stoma for stool collection to help prevent skin breakdown.The stoma should always be reddish-pink and moist. A dusky-red stoma may indicate impaired circulation to the area.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

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 client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?

Increase daily fluid intake to at least 2 to 3 L. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

lood administration is ordered for a client receiving chemotherapy. The nurse is obtaining all supplies needed for infusion. Which intravenous solution is obtained?

Normal Saline Normal saline solution (0.9 NS) is the only fluid compatible with blood administration. Lactated Ringers and dextrose solutions are not infused with blood products due to compatibility.

A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action?

Offer the client proportioned fluids in the day and less during the night. The client and nurse should make a fluid schedule that takes into consideration factors such as periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding night fluids will decrease risk for aspiration. Other answers do not provide the client with autonomy of care, and good sleep patterns are essential for overall health.

The nurse is recording information in the electronic health record for a client with dehydration who is at risk for skin breakdown. Which documentation demonstrates an area of insensible fluid loss for this client?

Temperature Insensible fluid loss is is loss of water from the body that is not easily measured, such as from the respiratory system, skin, and stool. The client with a fever of 102.5° Fahrenheit (39.2° Celsius) has insensible fluid loss through the skin. Fluid loss can occur through the lungs, but the client's respiratory rate is within normal limits, as are the blood pressure and heart rate. Urine output and chest tube drainage represent sensible fluid loss, as these outputs can be measured.

A client with ulcerative colitis is scheduled for a bowel resection. The client is receiving parenteral nutrition prior to surgery. Which is the best explanation for the nurse to give the client about the need for parenteral nutrition?

The client has lost 15% of body weight and has prolonged diarrhea. Clients with ulcerative colitis are often in a poor physical state because of loss of weight, improper absorption, and loss of fluids and electrolytes. Diarrhea and weight loss signify nutrient losses and deficiencies. The client needs to have a good nutritional status prior to surgery to promote recovery and wound healing. The other answers are incorrect because the client's desire to have surgery as soon as possible is not as important as being in a positive nitrogen balance and good nutritional state. Nutrients are not absorbed through the colon, but through the small intestine. Fluids, electrolytes, and acid-base balance do not need to be corrected by parenteral nutrition.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?

blood chemistry of serum lactate Measuring blood chemistry of lactate can indicate sepsis. Lactate is a byproduct of ineffective cellular metabolism. The other answers are incorrect because dextrose is not a fluid volume expander and the rate is too low. Vitals would be monitored more frequently in sepsis. The other lab values are liver function tests.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's

blood pressure. With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

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 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.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?

elevating the hand and wrapping it in a warm towel Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

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 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.

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

hypocalcemia Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

increased serum amylase and lipase levels Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode?

jitteriness Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl (2.2 mmol/L). A hyperalert state suggests neurologic irritability and isn't associated with blood glucose levels. A positive Babinski's reflex is a normal finding in neonates and isn't associated with hypoglycemia. A serum glucose level of 60 mg/dl (3.3 mmol/L) is a normal level.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?

limiting fluid intake During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?

low sodium A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

A client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

metabolic acidosis The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) − (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for?

muscle cramping 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.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to

prevent seizures. The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

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 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.

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 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.

The nurse is caring for a 12-month-old infant with dehydration and metabolic acidosis. What assessment finding does the nurse document as congruent with dehydration and metabolic acidosis?

tachypnea The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate carbon dioxide by increasing alveolar ventilation through deep, rapid respirations. The cardiovascular symptoms the nurse would observe would be poor perfusion, weak pulses, and tachycardia, not bradycardia. The child may also be hypotensive, but unless there is a respiratory disorder or polycythemia, the nurse would not expect to see cyanosis.

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 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. The client has severe burns, so improving skin integrity is not an issue at this time.

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?

urine output at 0.5 mL/kg/hour Hourly urine output is often used as an indicator of effective fluid resuscitation, with about 0.5 mL/kg/hr for an adult considered adequate. Blood pressure changes are less reliable because significant hypotension does not develop until volume losses exceed 30%. Degree of orientation is not used as an indicator of adequate fluid resuscitation. If fluid resuscitation is adequate, the heart rate should be lower than 120 beats/minute or in the upper limits of normal for the client's age. However, the fear, anxiety, and pain that accompany burn injuries often increase the heart rate.

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?

weighing the diaper before and after micturition Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV administration of lactated Ringer's The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

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.

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. 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.

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)?

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 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 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.

The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure?

bilateral edema of the feet and ankles A client with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), may experience symptoms that are similar to those of left-sided heart failure, such as dyspnea on exertion. However, without other risk factors, the client with COPD is at risk for right-sided, not left-sided, heart failure. Bilateral edema of the feet and ankles would not occur with chronic bronchitis but is evidence of right-sided heart failure due to the resistance to venous return to the right side of the heart. Bilateral crackles that clear with coughing would occur with chronic bronchitis. Note that pulmonary edema is not expected with right-sided heart failure. Nail clubbing develops in chronic bronchitis because of chronic oxygen deprivation and is not evidence of heart failure.

Which symptom is an early indication that the client's serum potassium level is below normal?

muscle weakness in the legs An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby. If hypokalemia progresses, respiratory muscles become involved and the client becomes apneic. Hypokalemia also causes ECG changes. Diarrhea is common in hyperkalemia. Sticky mucous membranes are common in hypernatremia. Tingling in the fingers and around the mouth occurs in hypocalcemia.

A 6-month-old infant is assessed to have 4% volume depletion related to a gastrointestinal illness. What intervention would the nurse recommend to the parents based on the infant's condition?

oral electrolyte replacement solutions, breast milk, or lactose-free formula A volume depletion of 4% is considered mild and is based on total body water loss calculated via percentage of weight loss. In cases of mild hypovolemia, oral electrolyte replacement solutions, breast milk, or lactose-free formula may be given in small amounts. IV fluids are usually reserved for clients experiencing moderate to severe hypovolemia, and the treatment requires hospitalization. Fruit juices, carbonated soft drinks, and the BRAT diet, all of which are high in carbohydrates and low in electrolytes, are not recommended.

Which indicates hypovolemic shock in a client who has had a 15% blood loss?

systolic blood pressure less than 90 mm Hg 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.

The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend?

Continue with breast milk or lactose-free formula. Water, breast milk, and lactose-free formula are low-sodium fluids that are often used during maintenance fluid therapy. Fruit juices, carbonated soft drinks, and gelatin have a high carbohydrate content, very low electrolyte content, and high osmolarity, so they are not used to manage diarrhea. Caffeinated soda is a mild diuretic, so its use may lead to increased loss of water and sodium. Chicken or beef broth has excessive sodium and inadequate carbohydrate content. The BRAT (bananas, rice, applesauce, and toast or tea) diet has little nutritional value.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the health care provider will order diuretic therapy, restrict fluid intake, and provide sodium replacement to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?

cerebral edema Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

muscle weakness and a weak, irregular pulse The serum potassium level of 3.2 mEq/L is an indication of hypokalemia. Only 2% of the potassium is found in the extracellular fluid, and it is primarily responsible for neuromuscular activity. Muscle weakness and heart irregularities would be evident with hypokalemia. Potassium deficit is caused by diarrhea. Tetany and tremors are associated with hypocalcemia. Headaches and poor tissue turgor are associated with hyponatremia.

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a urine output consistently above 40 ml/hour (40 mL/hour) In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

The rate at which IV fluids are infused is based on the burn client's:

total body weight and BSA burned. During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.