PrepU Med Surg: Fluid & Electrolyte Balance

Place the steps in the order when a nurse would be flushing a peripheral intravenous access device.

1. Cleanse the end cap with an antimicrobial swab. 2. Insert the saline flush syringe into the cap on the extension tubing. 3. Pull back on saline flush syringe to aspirate the catheter for blood return. 4. Instill saline solution over 1 minute. 5. Remove the syringe and reclamp the extension tubing. 6. Remove gloves and perform hand hygiene.

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem?

Abnormally high salt loss through perspiration

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

A client with renal insufficiency is admitted to the hospital with pneumonia. The client is being treated with gentamicin. Which laboratory value should be closely monitored?

Blood urea nitrogen (BUN)

A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?

Children with iron-deficiency anemia are more susceptible to infection than are other children

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?

Prevent the development of ketosis

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?

Daily weight

When assessing a client diagnosed with third spacing, a nurse should expect to assess manifestation?

Decreased blood pressure

A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Ensure adequate hydration before the anesthetic is administered

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

Intake and output

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

Jitteriness

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

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

Maintain a low-sodium diet

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?

Metabolic alkalosis

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 client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority?

Neurological status

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms?

Numbness Muscle twitching and spasms Tingling

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

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

When caring for a client with preeclampsia during labor, the nurse should:

Restrict the amount of fluid administered

The student nurse is planning to care for an intravenous (I.V.) site for a client receiving chemotherapy. Which outcome would demonstrate that the student understands the concepts of I.V. care?

Rotate the insertion site every 72 hours

A client was admitted for intracranial hemorrhage four days ago. Morning laboratory results demonstrate a low serum sodium of 121 mEq/L, a low serum osmolality of 256 mOsm/kg, a high urine osmolality of 588 mOsm/kg, and a high urine sodium of 89 mmol/L. Vital signs are stable. Urine output is high, averaging greater than 100 cc/hr. Which nursing interventions should the nurse include when planning care for a client with cerebral salt wasting (CSW) syndrome?

Sodium and fluid replacement

The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client?

The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L

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.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?

The client voids 500 mL of urine

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane (NPH) insulin to be taken before breakfast. At about 4:30 p.m. (1630), the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

The isophane (NPH) insulin is peaking (Hypoglycemia)

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

Total body weight and BSA burned

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first?

Verify that the infant has urinated

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider?

Wearing gown and gloves when working in the room

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

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

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 nurse plans care for a child with sickle cell disease in vasoocclusive crisis. The nurse includes increasing fluid intake in the list of interventions because the nurse understand that:

Decreased blood viscosity prevents the sickling process

A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug?

Deep tendon reflexes

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

Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol?

Encourage a high fluid intake

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

Hypercalcemia

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

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

Increased urine output