Fluid and Electrolyte Practice

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature

- Increased heart rate - Increased blood pressure - Increased respiratory rate

Circulatory overload causes:

- dyspnea - cough - rales - tachycardia - JVD

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

- poor skin turgor - hypotension - flat neck veins

A nurse is completing the 8-hr I&O for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record?

1140 mL

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? a. A client who has a urine specific gravity of 1.010. b. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. c. A client who has a hematocrit of 45%A client who has a temperature of 39° C (102° F) d. A client who has a temperature of 39 C (102 F)

A client who has a temperature of 39 C (102 F) weight gain is the answer....

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? a. Collect a urine specimen for culture and sensitivity. b. Continue routine care because the results are within the expected reference range. c. Decrease the IV fluid infusion rate and limit oral fluid intake. d. Evaluate urine for amount and for specific gravity.

Evaluate urine for amount and for specific gravity.

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? a. pitting edema b. fatigue c. dyspnea d. oliguria

Fatigue

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? a. Decreased urine specific gravity b. Decreased Hgb c. Increased BUN d. Increased urine ketones

Increased BUN

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 mm Hg

Skin tenting present

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? a. Sodium 165 mEq/L b. Potassium 5.2 mEq/L c. Urine specific gravity 1.020 d. Hct 62%

Urine specific gravity 1.020 (within normal range of 1.005-1.030)

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? a. flushing b. bradycardia c. dyspnea d. vomiting

dyspnea

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

eat foods that contain plenty of potassium (furosemide can cause potassium loss)

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? a. irritability b. slow, bounding pulse c. decreased temp d. tetany

irritability

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? a. lethargy b. hyperactive deep tendon reflexes c. prolonged ST segment d. hyperactive bowel sounds

lethargy

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? a. dry, sticky mucous membranes. b. negative Chvostek's sign c. muscle tremors d. polyuria

muscle tremors

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?

nausea and vomiting

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following findings should the nurse expect? a. tingling of the extremities b. hypoactive deep tendon reflexes c. shortened QT intervals d. constipation

tingling of the extremities

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a. decreased heart rate b. dyspnea c. increased blood pressure d. weak pulse

weak pulse

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4oz of orange juice, 3oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3oz of water. The nurse should record how many mL of intake on the client's record?

1170

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

1720

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance? a. 0.5 mL/kg/hr b. 2 mL/kg/hr c. 7.5 mL/kg/hr d. 15 mL/kg/hr

2 mL/kg/hr

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? a. 25 b. 13 c. 10 d. 18

25

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260

1 0z = __ mL

30

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? a. 3.1 b. 10 c. 16.5 d. 35

35

A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? A. 720 mL B. 550 mL C. 380 mL D. 600 mL

380 mL

Oliguria is defined as less than ______ mL of total output in 24 hr or less than 30 mL per hr

400

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the clients record?

740

A nurse is calculating a client's fluid output for a 12hr period. It includes Jackson-Pratt (JP) drainage 35mL, NG suction 120mL, and incontinence pads weighing 240g, 310g, and 270g. The dry weight of the incontinence pads is 90g. The nurse should record how many mL of output on the client's record?

890 mL

A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification?

Adding pecans will be a change I can readily make. (pistachios are high in potassium)

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium? a. Bananas b. Cooked carrots c. Cheddar cheese d. 2% milk

Bananas

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? Select all that apply. a. Broth b. Grape juice c. Nonfat milk d. Custard e. Lemon gelatin

Broth Grape juice Lemon gelatin

A nurse in a providers office is reviewing the laboratory results of a client who takes furosemide for hypertension. the nurse notes that the clients potassium level is 3.3 mEq/L. the nurse should monitor the client for which of the following complications? a. Cardiac dysrhythmias b. Hypoglycemia c. Seizures d. Neurogenic shock

Cardiac dysrhythmias

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? a. Chvostek's sign b. Babinski's sign c. Brudzinski's sign d. Kernig's sign

Chvostek's sign

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being a risk for fluid volume deficit? a. the client who has been NPO since midnight for endoscopy b. client who has gastroenteritis and is febrile c. the client who has end stage renal failure and is scheduled for dialysis today d. the client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600

Client who has gastroenteritis and is febrile

A nurse is preparing to administer potassium chloride (KCl) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take? 1. Give the ordered KCl as prescribed. 2. Omit the KCL dose and document it was not given. 3. Hold the prescribed dose and notify the provider of the serum potassium level. 4. Call the lab to verify the client's results.

Give the ordered KCl as prescribed.

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? a. Broth b. Water c. Diluted apple juice d. Oral rehydration solution

Oral Rehydration Solution

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? a. The client who has a tracheostomy tube attached to humidified oxygen b. The client who has an indwelling urinary catheter to gravity drainage c. The client who has a chest tube to water seal d. The client who has a nasogastric (NG) tube to suction

The client who has a nasogastric (NG) tube to suction

A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? a. Heart rate 130/min b. Respiratory rate 24/min c. Urine specific gravity 1.015 d. Capillary refill greater than 3 seconds

Urine specific gravity 1.015

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? a. Urine specific gravity 1.035 b. Hematocrit 44% c. BUN 19 mg/dL d. Sodium 155 mEq/L

Urine specific gravity 1.035

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?A. Hyperactive bowel sounds B. Extreme thirst C. Weak, irregular pulse D. Hyperactive reflexes

Weak, irregular pulse

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

administering sodium polystyrene

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? a. body weight b. skin integrity c. blood pressure d. respiratory rate

body weight

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess?

bounding pulse pitting edema crackles upon auscultation

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq/L PO daily. the nurse reviews the clients most recent laboratory results and finds the clients potassium level is 5.2 mEq/L/ which of the following actions should the nurse take?

call the prescribing physician and inform her of the clients serum potassium level results.

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? a. client is currently prescribed spironolactone b. client has a history of alcohol abuse disorder c. client reports drinking 3.5-4 L of water each day d. client has an NG tube to gastric suction

client has an NG tube to gastric suction

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? a. Plain Yogurt b. Carrot Juice c. Lemon Sherbet d. Cranberry Juice

cranberry juice

a nurse is a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? a. furrows on the tongue b. elevated blood pressure c. protruding eyeballs d. hypothermia

furrows on the tongue

A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide? a. bicarbonate b. carbon dioxide c. potassium d. phosphate

potassium