Chapter 11, Assessment and Care of Patients with Problems of Fluid and Electrolyte Balance(questions)

An older adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. What are the immediate nursing interventions to stabilize the patient? Select all that apply A. Administering diuretics B. Administering 0.9% saline C. Administering anti-psychotics D. Administering calcium channel blockers E. Administering 5% dextrose in 0.45% sodium chloride

A, B, E

The nurse is providing care to a patient who is admitted with fluid volume overload. Which electrolyte imbalances does the nurse anticipate for this patient based on the admitting diagnosis? Select all that apply. A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hypochloremia E. Hypermagnesemia

A, B, D

Which parameters should be monitored to assess a patient's response to fluid replacement therapy? Select all that apply. A. Monitor pulse quality B. Monitor urine output C. Monitor serum bilirubin D. Monitor white blood cell count E. Monitor weight changes every 8 hours

A, B, E

Which situation can cause a patient to experience "insensible water loss?" Select all that apply. A. Fever B. Nausea C. Diarrhea D. Mechanical ventilation E. Dry, hot weather F. Increased Respiratory Rate

A, C, D, E, F

The nurse is providing care to a patient who is experiencing severe nausea, vomiting, and diarrhea. Which is the patient at risk of developing? Select all that apply. A. Dehydration B. Hypertension C. Hypokalemia D. Hypercalcemia E. Hypernatremia

A, C, E

A patient is brought in an unconscious state to the emergency department. The primary health care provider suspects dehydration and advises laboratory investigation to ascertain the cause. Which parameter in the laboratory investigations would indicate internal hemorrhage as a reason for dehydration?

Absence of hemoconcentration

A patient's electrocardiogram (ECG) demonstrates a heart rate of 52 beats/minute and prolonged PR interval with widened QRS complex, and the patient is also hypotensive. Which laboratory results are consistent with these findings?

Hyperkalemia, hypercalcemia, hypermagnesemia

Which written order does the nurse clarify with the provider when caring for a patient with a serum sodium level of 149 mEq/L?

Make the patient NPO

When planning care for a patient with hypercalcemia, which intervention does the nurse consider?

Monitor cardiac rhythm for changes- increases risk for cardiac dysrhythmias

A patient is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first?

Obtaining a pulse oximetry reading

Laboratory results for a patient with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action?

Assess the patients respiratory status

The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction?

"Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." - The student nurse requires correction when stating, "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." NPs are hormones secreted by special cells that line the atria of the heart in response to increased blood volume and blood pressure. The other statements are correct. The hypothalamus contains osmoreceptors that are sensitive to changes in blood osmolarity. Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low. ADH is released from the posterior pituitary gland in response to changes in blood osmolarity.

A patient has a serum magnesium level of 1.2 mEq/L. Which instruction by the nurse is appropriate?

"Notify me if you have diarrhea."- A serum magnesium level of 1.2 mEq/L represents mild hypomagnesemia (normal is 1.3-2.1 mEq/L) for which oral magnesium supplements are administered. Oral magnesium may lead to diarrhea; diarrhea contributes to magnesium loss. With severe hypomagnesemia, the IV route (instead of IM) is used because the IM route causes tissue damage and pain. Any medications containing phosphorus are contraindicated because they would contribute to associated hypocalcemia. Magnesium therapy does not affect the urine.

Which conditions may contribute to a patient's insensible water loss? Select all that apply. A. Severe diarrhea B. Respiratory rate of 36 bpm C. Hot, dry home environment D. Body temperature of 96.4 F E. Large volume of urinary output

A, B, C- Insensible water loss occurs through the skin, lungs, and stool

The patient with fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which changes indicate to the nurse that the diuretic resulted in overdiuresis? Select all that apply. A. Reports of fatigue B. Weight loss of 9 lbs C. Heart rate increase from 70 to 96 BPM D. Heart rate decreases from 80 to 72 BPM E. Respiratory rate decreases from 20 to 16 bpm F. Reports of light-headedness when first standing from a lying down position

A, B, C, F

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin, chlorothiazide, and oral potassium supplements. He tells the nurse that he has had flu-like symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic intravenous therapy (IV) to be started. Which IV fluid does the nurse administer?

5% dextrose in water (D5W)- 5% dextrose in water (D 5W) is an isotonic solution. 0.45% saline is a hypotonic solution, whereas 5% dextrose in 0.45% saline and 5% dextrose in lactated Ringer's solution are hypertonic solutions.

Which total urine output for the previous day would place a patient at risk for accumulating waste products?

500 mL- The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL

Which is the expected insensible water loss for a healthy adult each day?

500 to 1000 mL

Which patient is at greatest risk for hypernatremia?

54-year old who is sweating profusely

The nurse is providing care to several patients on a medical-surgical unit. Which patient is at an increased risk for insensible water loss?

A patient receiving continuous gastrointestinal suctioning postoperatively

A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. The provider has ordered fall precautions. Which interventions does the nurse implement as part of fall precautions? Select all that apply. A. Activate the bed alarm B. Orient the patient frequently C. Assess for orthostatic hypotension D. Loosely apply upper extremity wrist restraints E. Maintain a calm, dim room to reduce confusion F. Place the bed in the lowest position with the brakes locked

A, B, C, F

Which signs does the nurse expect to find when assessing a patient with fluid overload? Select all that apply. A. Weight gain B. Hypotension C. Crackles in the lungs D. Large amounts of dilute urine E. Pitting edema in ankles and feet

A, C, E- Signs of fluid overload are hypertension, hemodilution, pulmonary crackles, peripheral edema, and decreased urinary output. Rapid weight gain is the most reliable indicator of fluid retention and overload.

The nurse admits a patient with dehydration. Which electrolyte imbalances does the nurse anticipate based on this diagnosis? Select all that apply. A. Hyperkalemia B. Hypocalcemia C. Hypochloremia D. Hypernatremia E. Hypermagnesemia

A, D

When assessing patients for potential fluid imbalances, what factors does the nurse know affect the amount and distribution of body fluids? Select all that apply. A. Age B. Poverty C. Activity D. Gender E. Body fat F. Cognition

A, D, E

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure, and hypertension. His current medications are digoxin, chlorothiazide, and potassium supplements. He tells a nurse that he has had flul-ike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the patient's intravenous therapy (IV) and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication?

Added to an IV, not to exceed 20 mEq/hr

A hypertensive patient was brought to the emergency department with a heart rate of 115 beats per minute and an abnormal electrocardiogram showing a shortened QT interval. The laboratory findings of the patient show a serum calcium level of 11 mg/dL. What nursing interventions would help stabilize the patient? Select all that apply.

Administering high ceiling or loop diuretics, administering 0.9% normal saline IV

What is the preferred diuretic used for patients with hypokalemia?

Amiloride- A potassium-sparing diuretic may be prescribed to increase the urine output without increasing potassium loss. Amiloride is an example of potassium-sparing diuretic, which is preferred for patients diagnosed with hypokalemia. Furosemide, bumetanide, and chlorothaiazide are examples of high ceiling, loop, or thiazide diuretics. These loop and thiazide diuretics promote excretion of potassium along with water; therefore they are not used in patients diagnosed with hypokalemia.

Which medication may affect the assessment of a patient's fluid balance after a surgical intervention?

Angiotensin-converting enzyme inhibitor twice a day-Urine output is used as an indicator of perfusion adequacy after surgery or other procedures. Medications used to manage hypertension such angiotensin-converting enzyme (ACE) inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine. This may make it harder to use urine output as a primary measure of perfusion. Aspirin may prolong clotting. Penicillin and digoxin will not affect monitoring fluid balance postprocedure.

The nurse is caring for a group of patients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation?

Aspirin overdose

A patient receiving insulin and glucose infusion therapy for hyperkalemia now has a serum potassium level of 3.6 mEq/L. What is the nurse's first action?

Assess the patient's heart rate, rhythm, and respiratory status.

Which assessment findings will indicate the need for continuation of prescribed fluid replacement therapy in a patient diagnosed with dehydration? Select all that apply. A. Hemoglobin of 13.5 B. Pulse pressure of 28 mm HG C. Urine output of 400 mL per day D. Respiratory rate of 20 breaths per minute E. Neck veins distension when the patient is in a supine position

B, C

A patient is admitted to the intensive care unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which treatments does the nurse anticipate for this patient? Select all that apply. A. Digitalis (Lanoxin) B. Furosemide (Lasix) C. Tolvaptan (Samsca) D. Conivaptan (Vaprisol) E. Vasopressin (Pitressin) F. Norepinepherine (Levophed)

B, C, D

hich will the nurse include when documenting a patient's fluid intake for the shift? Select all that apply. A. Emesis B. Enemas C. Oral fluids D. Solid foods E. Irrigation fluids

B, C, E

Which hormones play a role in the regulation of sodium balance by the kidneys? Select all that apply. A. Cortiosol B. Aldosterone C. Angiotension D. Natriuretic Peptide (NP) E. Antidiuretic hormone (ADH)

B, D, E

The nurse is caring for a patient with metabolic alkalosis. What manifestations of metabolic alkalosis is the nurse likely to assess? Select all that apply. A. Decrease in heart rate B. Numbness around the mouth C. Increase in hand grip strength D. Presence of Kussmaul breathing E. Hyperactivity of deep tendon reflexes

B,E - Hypercalcemia occurs with alkalosis, which can cause hyperactivity of deep tendon reflexes. Alkalosis overexcites the nervous system leading to tingling or numbness around the mouth. Overstimulation of the nerves may cause contraction of skeletal muscles, but the contractions are weaker because of hypokalemia. Therefore there is a decrease in handgrip strength. Alkalosis increases myocardial irritability and increases the heart rate. Kussmaul respiration (deep and rapid involuntary breathing) is seen in metabolic acidosis with respiratory compensation.

A patient's morning laboratory results show a serum ionized calcium of 2.85 mmol/L. For what sign must the nurse assess?

Blood clotting

A patient presents with dehydration. Which parameter should be considered when deciding isotonic fluid replacement therapy for the patient?

Body temperature of 40°C for more than 8 hrs

The nurse is admitting a 78-year-old patient with severe diarrhea in the emergency department. Which assessment findings indicate that the patient may be dehydrated? Select all that apply. A. Distended neck veins B. Bounding radial pulses C. Temperature of 99.4 F D. Dizziness when standing E. Newly reported confusion

C, D, E - Postural hypotension causing dizziness may occur with dehydration. Because of decreased perfusion to the brain, confusion is common in older adults. Low-grade fever is a common result of dehydration. With dehydration, neck veins are flat, not distended; peripheral pulses are weak, not bounding.

Which are common symptoms of hypokalemia? Select all that apply. A. Paresthesia B. Bradycardia C. Shallow respirations D. Weak, thready pulse E. Musculoskeletal weakness

C, D, E- Common symptoms of hypokalemia include shallow respirations; weak, thready pulse; and musculoskeletal weakness. Paresthesia and bradycardia are symptoms of hyperkalemia.

Which drug therapies might be used to manage symptoms of hypocalcemia?

Calcium chloride

A patient has edema in both lower extremities. The patient's edema is due to which occurrence?

Changes in normal hydrostatic pressure

A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath (SOB), and 3+ pitting edema in her lower extremities. Her medications are furosemide, digoxin, and an angiotensin-converting enzyme (ACE) inhibitor. She states that she stopped taking her furosemide because she did not think that it was helping her heart failure. Her health care provider orders furosemide 5 mg IV push. Ten hours after receiving the furosemide, the patient's potassium (K+) level is 2.5 mEq/L. Knowing all of the patient's medications, what problem does the nurse anticipate in this patient?

Clinical manifestations of digoxin toxicity

A patient presents to the emergency room with confusion, altered level of consciousness, dry mouth, scaly skin, and very loose fitting shoes. Which finding in the patient's history is significant?

Decreased ingestion of solid foods such as gelatin

hich age-related change to fluid balance does the nurse anticipate when conducting a neurologic assessment for an older adult patient?

Decreased thirst reflex

The nurse is assessing an older adult patient during a scheduled health maintenance visit. Which assessment finding, related to fluid balance, does the nurse anticipate?

Decreased turgor

A patient with severe vomiting and diarrhea was brought to the emergency department in a semiconscious condition. What interventions does the nurse implement to stabilize the patient? Select all that apply. A. Monitor urine output B. Monitor the respiratory rate C. Administer the oral rehydration salts D. Monitor blood pressure and heart rate E. Administer replacement fluids IV F. Administer drugs to correct the cause of dehydration

E, F

What is the reason for relative dehydration?

Fluid shift from plasma to interstitial space

The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?

Hourly deep tendon reflexes (DTRs)

Which condition commonly occurs in patients who are on long-term furosemide therapy?

Hyponatremia

The nurse is providing care to a patient who is experiencing tachypnea. Which intervention is most appropriate to maintain the patient's fluid balance?

Increase IV fluids- The patient who is experiencing tachypnea will experience an increase in insensible water loss, increasing the risk for dehydration. The most appropriate intervention by the nurse is to increase intravenous fluids. Encouraging oral fluids is not recommended due to the increased risk for aspiration that occurs with tachypnea. Fluid restrictions and diuretics are not recommended, as these will increase the patient's risk for dehydration.

What is the defense mechanism to combat the effects of isotonic dehydration and maintain blood flow to the vital organs?

Increased blood vessel constriction- Dehydration may cause hypovolemia along with decreasing blood pressure. Vasoconstriction is a mechanism that helps to increase the blood pressure and maintain blood flow to the vital organs. The heart rate increases in a hypovolemic condition to maintain the blood flow and blood pressure to the vital organs. Peripheral resistance is increased in order to maintain blood pressure and circulation during dehydration. Increased pulmonary ventilation rate or hyperventilation causes dehydration that further leads to hypovolemia and decreased blood pressure.

Which condition is least likely to cause fluid overload?

Psychiatric disorders

Which nursing action is recommended when providing care to a patient with hypokalemia?

Question the continued administration of bumetanide- loop diuretic which contributes to potassium loss

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this patient?

Restoring the fluid balance by controlling the cause of dehydration

When caring for a patient with hyponatremia, which intervention does the nurse implement?

Small-volume intravenous infusions of 3% normal saline

Which intervention does the nurse include in caring for a patient with generalized edema who is receiving a loop diuretic?

Turning the patient every 2 hours.

Which assessment finding is likely in a patient reporting diarrhea and vomiting with an elevated body temperature of 103° F for 2 days who is brought to the emergency department?

Urine output of 350 mL/day - dry oral mucosa could be an indicator but is misleading because some drugs can cause dry oral mucosa as well

An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this patient related to the reason for admission?

What is your typical daily fluid intake and what types of fluids do you drink?

The nurse is providing care to a female patient who experienced an adverse reaction to a prescribed drug. The patient states, "My husband was on the same dose, and he didn't have any issues." Which response by the nurse is most appropriate?

Women have more fat cells, which causes differences in drug responses.

The nurse is performing discharge dietary teaching for a patient with hyperkalemia. Which statement does the nurse include in the teaching?

You may eat apples, strawberries and peaches.