Fluid & Electrolyte Balance- RN PassPoint

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?

canned tomato juice

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?

"I should drink more water when feeling thirsty or becoming irritable."

A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number.

12

A client is to receive 1,000 mL of lactated Ringer's over 10 hours. The drip factor is 15 drops (gtt)/mL. How many gtt per minute should the client receive?

25 gtt/min

The nurse is admitting a client who takes digoxin daily, reported seeing green halos around the lights, and has not wanted to eat breakfast. The laboratory report shows that serum sodium = 135 mEq/L, potassium = 3.2 mEq/L, magnesium = 2.5 mg/dL, and calcium = 10.2 mg/dL. Which nursing action is appropriate?

Administer a potassium supplement.

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 client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:

Dependent edema.

A nurse is caring for a preschool-age client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention?

Encourage meticulous handwashing by the client and visitors.

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 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

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply.

Report signs of redness or inflammation at the site. Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Cleanse the port with alcohol wipes.

A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important?

Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal

For a client with anorexia nervosa, which goal takes the highest priority?

The client will establish adequate daily nutritional intake.

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag. There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output?

The client's intake was 300 ml greater than output.

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

blood pressure.

A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for:

cardiac arrhythmia.

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

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

excess fluid volume

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

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

hyperkalemia

he nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize?

impaired skin integrity

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of

increasing fluid intake to prevent dehydration.

A nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's laboratory report. Which finding indicates the need for intervention?

ketones in urine

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

lactated Ringer's solution

Immediately after surgery to create an ileostomy, which goal has the highest priority?

maintaining fluid and electrolyte balance

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

muscle weakness in the legs

After being sick for three days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). Which diagnostic test will the nurse prioritize in monitoring?

serum potassium level

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

sodium and potassium abnormalities.

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

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

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?

urine output

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use?

use of an intravenous infusion pump