Ch. 13 and 14

Renin acts to produce this, which causes some vasoconstriction

angiotensin I

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? 72-year-old taking the diuretic spironolactone for control of hypertension 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis Insulin increases the activity of the sodium-potassium pump and forces more potassium from the extracellular fluid into the intracellular fluid. Although this is a desired response when managing hyperkalemia, the drug can cause hypokalemia in a client whose serum potassium level is initially normal. Spironolactone is a potassium-sparing diuretic that has the potential to raise serum potassium levels, not lower them. Ringer's lactate contains potassium and would not dilute serum potassium below normal. Infusions of red blood cells usually raise serum potassium levels, not lower them, because some blood cells are damaged during the infusion and release intracellular potassium.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

ANS: A Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) Increased pulse rate Distended neck veins Decreased blood pressure Warm and pink skin Skeletal muscle weakness Visual disturbances

ANS: A,B,E,F

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

ANS: B All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated w/ abdominal pain

ANS: B Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

ANS: B This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

ANS: C IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones d. Administers bisphosphonates as prescribed.

ANS: D Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? Hold the next dose of the prescribed antidiarrheal drug Assess bowel sounds in all four abdominal quadrants Assess the client's response to the Chvostek test Increase the IV flow rate of the normal saline infusion

Assess the client's response to the Chvostek test Severe diarrhea can cause excessive calcium loss and result in hypocalcemia. Symptoms of hypocalcemia include tingling of the lips and mouth, muscle cramps (especially in the presence of hypoxia), positive responses to the Trousseaus' and Chvostek's test, and seizures. It is critical to identify whether the client has hypocalcemia before the condition progresses to seizures. Holding the drug may make the hypocalcemia worse. Listening to bowel sounds will no provide new information. Increasing the IV flow rate of normal saline will not help identify the problem or improve the serum calcium level.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) Testing skin turgor Asking about any abdominal pain Assessing cognition Checking deep tendon reflexes Monitoring urine output Checking for the presence of fever

Assessing cognition Monitoring urine output The serum sodium is extremely low, which makes depolarization slower and cell membranes less excitable. It also can cause cerebral edema to form, leading to confusion and seizure activity. When sodium levels become very low, coma and death may occur. Assessing cognition and checking deep tendon reflexes are the most important assessment data to obtain. Monitoring urine output needs to be done but is not the priority action in this situation. Assessing skin turgor, presence of abdominal pain, and fever are not an urgent assessment to prevent immediate harm.

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? Monitoring 24-hour urine output Monitoring the serum calcium levels Assessing the blood pressure hourly Asking the client whether a headache is present

Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. 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.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL Serum sodium level of 128 mEq/L (128 mmol/L) Blood osmolality of 250 mOsm/kg (250 mmol/kg)

BE

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. Blood pressure Deep tendon reflexes Hand-grip strength Pulse rate and quality Skin turgor Urine output

Blood pressure Pulse rate and quality Urine output The most important body fluid compartment to maintain for function is the plasma volume of circulating blood. The most reliable indicators for effectiveness of IV fluid replacement to increase this volume are blood pressure and pulse. Urine output is also very sensitive to changes in plasma volume and is a reliable indicator of adequacy of fluid replacement therapy. Skin turgor changes do not occur quickly enough to use for evaluation of fluid replacement adequacy. Hand-grip strength and deep tendon reflex changes are less reliable and are affected by other factors.

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? Urge the client to drink more water. Notify the primary health care provider. Assess the client's deep tendon reflexes. Document the finding as the only action.

Document the finding as the only action. The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

Osmolarity levels <270 mEq/L could mean

Fluid overload; hyponatremia; hypoproteinemia; malnutrition

Mg2+ levels >2.6 mEq/L could mean

Hypermagnesemia; kidney disease; hypothyroidism; adrenal insufficiency

Na+ levels >145 mEq/L could mean

Hypernatremia; dehydration; kidney disease; hypercortisolism

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure

Increased osmotic pressure; increased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Vegan diet Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Past history of hepatitis A

Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Potential causes of hyperkalemia include excessive use of salt substitutes (which contain high levels of potassium), chronic kidney disease (which prevents adequate excretion of potassium), daily use of a potassium-sparing diuretic (reduces potassium excretion), and the use of an angiotensin converting enzyme inhibitor. Neither a vegan diet nor previous illness with hepatitis A is associated with development of hyperkalemia.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? Nose and ears have a slightly yellow-tinged appearance. Neck veins are now distended in the sitting position. Breath sounds can be heard in the right lower lung lobe. Weight is unchanged from that obtained yesterday.

Neck veins are now distended in the sitting position. Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? Chvostek sign is negative. Respiratory rate is 22 breaths/min. Pulse rate is 76 beats/min and regular. Hematocrit is 42%.

Pulse rate is 76 beats/min and regular. Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management.

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) Red meat Cereal Citrus fruit Salt substitutes Eggs Bread

Red meat Citrus fruit Salt substitutes While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

Fluid and electrolyte balance in older adults

Skin becomes an unreliable indicator of fluid status due to loss of elasticity and turgor dec. concentrating capacity: inc. water loss dec. muscle mass: dec. total body water (especially women) adrenal atrophy: risk for hyponatremia and hyperkalemia dec. thirst reflex

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) Tops of the forearms Skin of the shins Skin of the forehead Skin over the abdomen Skin over the sternum Back of the hand

Skin of the forehead Skin over the sternum Assess skin turgor in an older client by pinching the skin over the sternum or on the forehead, rather than on the back of the hand. With aging the skin loses elasticity and tents on hands and arms even when the client is well hydrated and thus, changes in these areas are not reliable indicators of hydration status.Many older clients have dry flaky skin on the shins regardless of hydration status. The skin of the abdomen is looser in older clients and also is not a reliable skin area to check hydration status.

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? Sodium 132 mEq/L (mmol/L) Potassium 3.5 mEq/L (mmol/L) Sodium 148 mEq/L (mmol/L) Potassium 5.3 mEq/L (mmol/L)

Sodium 148 mEq/L (mmol/L) Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value greater than 145 mEq/L (mmol/L). In option A, the serum potassium is normal. In options C, the serum potassium value is above normal and indicates hyperkalemia. In option B, the serum sodium value is low, reflecting hyponatremia.

Antidiuretic hormone (ADH), or vasopressin

helps control fluid and electrolyte balance osmoreceptors in the hypothalamus detect change in blood osmolrity Increased blood osmolarity triggers ADH release from the posterior pituitary gland, ends up diluting the blood with more water When blood osmolarity decreases with low plasma sodium levels, the osmoreceptors swell slightly and inhibit ADH release

Aldosterone

helps control fluid and electrolyte balance secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are low prevents both water and sodium loss increases blood osmolarity and blood volume and also promotes kidney potassium excretion ACE inhibitors dec. release of this and dec. these effects

Natriuretic peptides (NPs)

helps control fluid and electrolyte balance secreted in response to increased blood volume and blood pressure binds to receptors in the nephrons, creating effects that are opposite of aldosterone. Kidney reabsorption of sodium is inhibited at the same time that urine output is increased. The outcome is decreased circulating blood volume and decreased blood osmolarity.

Causes of dehydration

- Hemorrhage - Vomiting - Diarrhea - Profuse salivation - Fistulas - Ileostomy - Profuse diaphoresis - Burns - Severe wounds - Long-term NPO status - Diuretic therapy - GI suction - Hyperventilation - Renal failure - Diabetes insipidus - Difficulty swallowing - Impaired thirst - Unconsciousness - Fever - Impaired motor function

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? 12 mEq (mmol) 15 mEq (mmol) 18 mEq (mmol) 20 mEq (mmol)

15 mEq (mmol) 100 in 1000 mL = 0.10 mEq/mL (mmol/mL) x 150 = 15 mEq/hr (mmol/hr)

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? 3000 6300 9300 7000

3000 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL).

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A 26 year old with hyperparathyroidism A 70 year old who has alcoholism and malnutrition A 40 year old taking tetracycline for an infection A 35 year old athlete taking NSAIDs for joint pain

A 70 year old who has alcoholism and malnutrition Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia.

After receiving the change-of-shift report, which client does the nurse assess first? A 67 year old with nausea and vomiting who reports abdominal cramps. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

A 57 year old receiving 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 and may require immediate action. All other clients listed have less urgent problems and do not require immediate assessment.

Which client will the nurse consider to be at greatest risk for dehydration? A 75-year-old woman with chronic back pain A 25-year-old woman taking oral contraceptives A 75-year-old man who has a vitamin deficiency A 25-year-old man who has frequent esophageal reflux

A 75-year-old woman with chronic back pain Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) Reports of palpitations Slow, shallow respirations Orthostatic hypotension Paralytic ileus Skeletal muscle weakness Tall, peaked T waves on ECG

AEF

Promotes vasodilation; acts as a diuretic that causes sodium loss and diminishes the thrist mechanism

Atrial Natriuretic peptide

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. Calcium Chloride Hydrogen Potassium Sodium Sulfate

Calcium Potassium Within cells and the blood, magnesium levels are related to the levels of potassium and calcium and help maintain proper balance of these electrolytes

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? Checking pulse oximetry Measuring blood pressure Listening to bowel sounds in all four quadrants Observing the ECG for flat T-waves

Checking pulse oximetry Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) Assessing for furrows on the tongue to determine dryness of oral mucous membranes Comparing blood pressure measurements in the lying, sitting, and standing positions Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

Comparing blood pressure measurements in the lying, sitting, and standing positions When caring for an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure changes. Comparisons of blood pressures obtained with the client lying, then sitting, and finally standing can detect postural changes. If the standing blood pressure is significantly lower than that obtained while the client was in the lying or sitting positions, insufficient blood flow to the brain may cause hypotension with light-headedness and dizziness, which increase the risk for falls.Comparing apical to radial pulse rates does not provide information to detect degree of dehydration. Although assessment of oral mucous membranes can detect symptoms of dehydration, it does not provide information for falls risk. Dehydration usually results in an elevated serum potassium level, not a decreased level.

K+ levels >5.0 mEq/L could mean

Hyperkalemia; dehydration; kidney disease; acidosis; adrenal insufficiency; crush injuries

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? Decreased blood volume; increased blood osmolarity Increased blood volume; decreased blood osmolarity Decreased blood volume; decreased blood osmolarity Increased blood volume; increased blood osmolarity

Decreased blood volume; decreased blood osmolarity The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity.

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? Deflating the blood pressure cuff and giving the client oxygen Documenting the finding as the only action Initiating the Rapid Response Team Placing the client in the high-Fowler position and increasing the IV flow rate

Deflating the blood pressure cuff and giving the client oxygen Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau sign. Initiating the Rapid Response Team is a good second action. Placing the client in high-Fowler position will not help the hypocalcemia.

Osmolarity levels >300 mEq/L could mean

Dehydration; hypernatremia; hyperglycemia

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? Asking about the use of sugar substitutes. Determining what drugs are taken daily Measuring the client's response to Chvostek testing Asking about a history of kidney disease

Determining what drugs are taken daily The serum potassium level is low and the client has hypokalemia. Misuse or overuse of diuretics, especially high ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia among older adults or clients with eating disorders. Sugar substitutes do not change serum potassium levels. A positive Chvostek sign or test occurs with hypocalcemia but not with hypokalemia. Kidney disease is associated with hyperkalemia.

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? Checking for presence of dependent edema Assessing blood pressure Measuring intake and output Elevating the head of the bed

Elevating the head of the bed Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? Serum chloride level is 100 mEq/L (mmol/L) Blood urea nitrogen (BUN) is elevated Arterial blood pH is 7.37 Hematocrit is 29% (0.29 volume fraction)

Hematocrit is 29% (0.29 volume fraction) When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia. The chloride level is normal. Elevated levels are associated with dehydration and reduced kidney function. The arterial pH is normal.

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? Pulse pressure has decreased. Client reports feeling hungry. Hematocrit is 58% (0.58 volume fraction). Hourly urine output is greater than 15 mL.

Hourly urine output is greater than 15 mL. The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status.

Ca++ levels >10.5 mg/dL could mean

Hypercalcemia; hyperthyroidism; hyperparathyroidism

Cl- levels >106 mEq/L could mean

Hyperchloremia; metabolic acidosis; respiratory alkalosis; hypercortisolism

Ca++ levels <9.0 mg/dL could mean

Hypocalcemia; vitamin D deficiency; hypothyroidism; hypoparathyroidism; kidney disease; excessive intake of phosphorus-containing food

Cl- levels <98 mEq/L could mean

Hypochloremia; fluid overload; excessive vomiting or diarrhea; adrenal insufficiency; diuretic therapy

K+ levels <3.5 mEq/L could mean

Hypokalemia; fluid overload; diuretic therapy; alkalosis; insulin administration; hyperaldosteronism

Mg2+ levels <1.8 mEq/L could mean

Hypomagnesemia; malnutrition; alcoholism; ketoacidosis

Na+ levels <136 mEq/L could mean

Hyponatremia; fluid overload; liver disease; adrenal insufficiency

Dehydration nursing interventions

I&O Q8 hrs Daily weight (use same clothes, same scale, etc.) Pulse quality and pressure Closely monitor vitals Q4 hrs Check skin turgor, mucous membranes, urine output, mental status Measures to minimize fluid loss (don't give lasix) Parenteral and Oral fluids Delegate AP to offer fluids (pedialyte) at least Q1-2 hrs Give drugs prescribed to correct the underlying cause of the dehydration (e.g., antiemetics, antidiarrheals, antibiotics, antipyretics) unless H.Pylori

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? Teaching the client which foods to avoid Administering sodium polystyrene sulfonate orally Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet Initiating continuous cardiac monitoring

Initiating continuous cardiac monitoring The client has hyperkalemia. The nurse must initiate continuous cardiac monitoring for this client because hyperkalemia can lead to life-threatening bradycardia and other dysrhythmias, including tall, peaked T waves; prolonged PR intervals; flat or absent P waves; wide QRS complexes; and possible ectopic beats. Monitoring allows the nurse to determine whether therapy is effective or if the client's condition is worsening. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about which foods to avoid are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

BLOOD (PLASMA) VOLUME AND INTRACELLULAR FLUID ARE __________ TO KEEP IN BALANCE

MOST IMPORTANT

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period? Plasma volume osmolarity increases; blood pressure increases Plasma volume osmolarity decreases; blood pressure increases Plasma volume osmolarity increases; blood pressure decreases Plasma volume osmolarity decreases; blood pressure decreases

Plasma volume osmolarity increases; blood pressure increases A 3% saline solution is hypertonic to body fluids and would immediately increase the osmolarity of the plasma volume, making it somewhat hypertonic to other body fluids. Not only does the 500 mL increase the plasma volume to raise blood pressure, the increased osmolarity of the plasma would cause the interstitial fluid to move into the plasma volume, contributing to blood pressure increase.

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? Deep tendon reflexes Oxygen saturation Pulse rate and rhythm Respiratory rate and depth

Pulse rate and rhythm Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias. It is the most important assessment to perform for a client with an elevated serum potassium level. Respiratory rate and depth are more affected by hypokalemia because of the accompanying muscle weakness. The reduction then affects oxygen saturation. Although deep tendon reflexes may be increased with hyperkalemia, cardiac changes are more critical.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? Reports having a bowel movement daily. ECG shows an inverted T wave. Fasting blood glucose level is 106 mg/dL. Two lb weight gain during the past week.

Reports having a bowel movement daily. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

ph: 7.12 PCO2: 90 HCO3: 22 uncompensated or compensated

Respiratory acidosis uncompensated

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? Foot and ankle Forehead Sacrum Chest

Sacrum In a client who is confined to bed, the most dependent area is the sacrum. This is the area that will show skin turgor changes first for dependent edema. The forehead, chest, and feet are not dependent what a client is in a recumbent position.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? Shortened QT-interval Absent P wave Prominent U wave Inverted T waves

Shortened QT-interval Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow.

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? The client has calf muscle cramping. The serum chloride level is low. The urine specific gravity is high. The hematocrit is 52%.

The hematocrit is 52%. The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium, or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration.

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) Keeping the client NPO during drug treatment Pushing the drug as a bolus slowly over 5 minutes Using an IV controller to deliver the drug Checking IV access for blood return after the infusion Initiating the IV in a hand vein for rapid access Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Using an IV controller to deliver the drug Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution Best practice technique for administering parenteral potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller device must be used to deliver the drug to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest. IV potassium must be infused via a large vein with a high volume of flow, avoiding the hand. Potassium is not to be infused or pushed as a bolus to prevent cardiac. Assessing the IV access for placement and an adequate blood return is performed before administering potassium-containing solutions. It is not necessary or good practice to keep the client NPO during parenteral potassium administration.

adrenal cortex releases this to counteract hypovolemia in response to increased plasma potassium levels

aldosterone

First sign of dehydration in an older adult

confusion

Which people have less total body water?

elderly, obese

Causes of fluid overload

excessive fluid replacement, late phase kidney failure, HF, long-term corticosteroid therapy, SIADH, psychiatric polydipsia, water intoxication

S/S of dehydration

inc. HR and resp rate pallor/cyanosis weak peripheral pulses b/c blood goes to central organs postural/orthostatic hypotension dizziness flat neck and hand veins dry, scaly skin that remains tenting (over sternum or forehead) LOC dry/sticky/cracked mucous membranes low fever

Angiotensin II

increases blood pressure by stimulating kidneys to reabsorb more water and by releasing aldosterone

Electrolyte balance occurs when dietary intake of electrolytes matches

kidney electrolyte excretion or reabsorption.

ph: 7.59 Pao2: 90 PaCO2: 42 HCO3 39

metabolic Alkalosis

Adults at greatest risk for severe imbalances are

older patients, patients with chronic kidney or endocrine disorders, and those who are taking drugs that alter fluid and electrolyte balance.

ACE-Inhibitors effects on body

reduce angiotensin II, reduce aldosterone, less vasoconstriction, less peripheral resistance

responds to decreased renal perfusion caused by a decrease in extracellular volume

renin

ph: 7.45 PCO2: 30 HCO3: 22 compensated or uncompensated?

respiratory alkalosis compensated

Dehydration measurements and labs

urine output <500 mL specific gravity greater than 1.030 weight loss over a half pound per day is fluid loss elevated levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen