Ch 8 Fluid and Electrolytes

Which symptoms indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. A. Decreased urine B. Hypotension C. Dyspnea D. Dry mucous membranes E. Pulmonary edema F. Poor skin turgor

A, B, D, F. Lowered urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and pulmonary edema may be caused by fluid overload.

The nurse understands that the action of antidiuretic hormone (ADH) is to do what? A. Reduce blood volume B. Decrease water loss in urine C. Increase urine output D. Initiate the thirst mechanism

B. ADH is released by the posterior pituitary gland. It is mainly released in response to either a decrease in blood volume or an increased concentration of sodium or other substances in plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which IV solution will be prescribed initially? A. 3% NaCl B. 0.9% NaCl C. 5D and 0.9% NaCl D. 5D and LR

B. An IV of 0.9% sodium chloride is the most appropriate initial IV fluid for this client because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. 3% sodium chloride is a high-concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. 5% dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer solution may be appropriate fluids to infuse after 0.9% sodium chloride.

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? A. Calcium of 9.5 mg/dL B. Potassium of 7.02 mEq/L C. Bicarbonate of 22.8 mEq/L D. Phosphorus of 4.1 mg/dL

B. The normal level of serum potassium is between 3.5-5.0 mEq/L. Elevated potassium levels greater than 6 mEq/L can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4-4.4 mg/dL. The normal levels of serum calcium are usually between 8.6-10.2 mg/dl. The normal level of serum bicarbonate is between 22-26 mEq/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? A. Abdominal girth decrease B. Mucous membranes becoming drier C. HR increases from 80 to 135 D. BP rises from 130/70 to 190/80

C. Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

A nurse on the Code Blue/Arrest team responds to a code that is called for a client with hyperkalemia who is experiencing cardiac standstill. What would an appropriate immediate treatment plan include? A. Defibrillation B. Furosemide C. Sodium bicarbonate D. Anticoagulation therapy

C. Sodium bicarbonate decreases the potassium level. It works by increasing the movement of potassium from the blood into the cells. The body stores potassium inside the cells, with only a small amount in the bloodstream. Electrical defibrillation should not be applied indiscriminately to the client in asystole. This is not only fruitless but also detrimental, eliminating any possibility of recovering a rhythm. Furosemide is a diuretic commonly used for HF. There is no indication for anticoagulation therapy.

An older client develops hypokalemia, and an IV infusion containing 40 mEq of potassium is instituted. The client tells the nurse that the IV stings a little. What is the nurse's best reply? A. "I'll restart the IV in a different vein. This may help to relieve the pain" B. "Try to imagine a sunny beach with gentle waves, and soon you won't notice the discomfort" C. "You are receiving a large dose of potassium, and unfortunately it often causes a stinging sensation" D. "Some people are more sensitive to pain than others. I'll get a prescription for pain medication for you"

C. The response "You are receiving a large dose of potassium, and unfortunately it often causes a stinging sensation" validates the client's concerns and provides information. The potassium solution will be irritating to other peripheral veins as well. Although imagery may help to distract the client from discomfort, this response provides no information as to why the stinging sensation is occurring. The response "Some people are more sensitive to pain than others..." belittles the client and implies that the client is intolerant of pain. Also, pain medication is not needed in this situation.

After the nurse provides education about hydrochlorothiazide, the client will agree to notify the HCP regarding the development of which symptom? A. Insomnia B. Nasal congestion C. Increased thirst D. Generalized weakness

D. Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy. Insomnia is not known to be related to hypokalemia or hydrochlorothiazide therapy. Although a stuffy nose is unrelated to hydrochlorothiazide therapy, it can occur with other antihypertensive drugs. Increased thirst is associated with hypernatremia. Because this drug increases excretion of water and sodium in addition to potassium and chloride, hyponatremia, not hypernatremia, may occur.

An RN is teaching a student nurse how to assess for edema. Which statement made by the student indicates the need for further education? A. "Edema results in the separation of skin from pigmented and vascular tissue" B. "Pitting edema leaves an indentation on the site of application of pressure" C. "Trauma or impaired venous return should be suspected in clients with edema" D. "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given"

D. The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site will leave an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.