Fluid & Electrolytes

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics **The normal serum sodium level is 136 to 145 mEq/L. A serum sodium level of 130 mEq/L indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. **The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? 1. An oral temperature of 98.8° F (37.1° C) 2. A urine specific gravity of 1.043 3. A urine output that is pale yellow 4. A blood pressure of 120/80 mm Hg

2. A urine specific gravity of 1.043 **The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.003 to 1.030. **A temperature of 98.8° F (37.1° C) is only 0.2 of a point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1. Weighs athletes before, during, and after football practice 2. Asks the athletes to take a salt tablet before football practice 3. Schedules fluid breaks every 30 minutes throughout practice 4. Tells the athletes to drink 16 oz of fluid per pound lost during practice

2. Asks the athletes to take a salt tablet before football practice **Salt tablets would not be taken because they can contribute to dehydration. **Frequent fluid breaks need to be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz of fluid needs to be consumed for every pound lost.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? 1. Client with a major burn 2. Client with an ischemic stroke 3. Client with Laënnec's cirrhosis 4. Client with chronic kidney disease

2. Client with an ischemic stroke **Fluid that shifts into the interstitial spaces and remains there is referred to as third space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavity and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition.

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. 1. 10% dextrose in water 2. 0.45% sodium chloride 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 5. 5% dextrose in 0.225% saline 6. 5% dextrose in lactated Ringer's solution

1. 10% dextrose in water 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 6. 5% dextrose in lactated Ringer's solution **Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1. Blood transfusions 2. Metabolic alkalosis 3. Bleeding or hemorrhage 4. Decreased sodium excretion 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium

1. Blood transfusions 3. Bleeding or hemorrhage 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium **With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. 1. Bounding pulse 2. Difficulty breathing 3. Increased urine output 4. Presence of dependent edema 5. Neck vein distention in the upright position

1. Bounding pulse 2. Difficulty breathing 4. Presence of dependent edema 5. Neck vein distention in the upright position **Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1. Daily weight 2. Urinary output 3. IV fluid intake 4. NG tube intake

1. Daily weight **Daily weight is the best indicator of fluid balance. **Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, pastelike coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1. Dehydration 2. Hypokalemia 3. Fluid overload 4. Hypernatremia

1. Dehydration **When a patient is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the patient stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1. Dehydration 2. Hypertension 3. Physiological stress 4. Decreased blood volume 5. Decreased plasma osmolarity

1. Dehydration 3. Physiological stress 4. Decreased blood volume **ADH is produced in the brain and stored in the posterior pituitary gland. ts release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions would be included in the plan of care? Select all that apply. 1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 3. Encourage low-fiber foods to prevent diarrhea. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate.

1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate. **Patients with hypokalemia will need instruction on potassium rich foods, and all patients need to maintain adequate hydration, safety is a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care would the nurse include? Select all that apply. 1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 4. Monitor for numbness and tingling around the mouth. 5. Prevent complications during potassium administration.

1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 5. Prevent complications during potassium administration. **The priorities for nursing care of a client with hypokalemia are to ensure adequate oxygenation, to assure client safety in fall prevention and potassium administration, and to monitor for complications related to diuretic therapy and client response to therapy.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG)

1. Hypotension **Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1. Monitor the client for dysrhythmias. 2. Encourage increased intake of phosphate antacids. 3. Discontinue any magnesium-containing medications. 4. Encourage intake of foods such as ground beef, eggs, or chicken breast.

1. Monitor the client for dysrhythmias. **a normal magnesium level is 1.3-2.1. Cardiac monitoring is indicated because this patient is at risk for ventricular dysrhythmias. **Phosphate use needs to be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue the magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1. Prolonged bed rest 2. Renal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest **A normal calcium level is 9.0-10.5. A patient with a calcium level of 6.0 is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long term effect of prolonged bed rest is hypocalcemia. **End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142, chloride 103 mEq/L, potassium 5.2 mEq/L, and bicarbonate 23 mEq/L What action would the nurse plan to take? 1. Take no action. 2. Order a stat hemodialysis treatment. 3. Recheck the labs because these values are all abnormal. 4. Page the primary health care provider (PHCP) with the results.

1. Take no action. **No action is needed because all of the blood levels are normal for a hemodialysis patient before a treatment. The normal ranges of serum electrolyte levels are sodium: 135-145 chloride: 98-106 bicarbonate: 21-28 potassium: 3.5-5.0 Although the potassium level is elevated, the normal range for potassium for a patient with chronic kidney disease receiving hemodialysis is 4-6.5.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings would be anticipated in this client? Select all that apply. 1. Tetany 2. Constipation 3. Renal calculi 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

1. Tetany 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign **The normal calcium level is 9-10.5; thus, the patient results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and the presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the patient will experience hypotension. A low calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics **A normal sodium level is 136-145. A sodium level of 130 indicates hyponatremia. Hyponatremia can occur in the patient taking diuretics. **The patient taking corticosteroids and the patient with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

Which clients are most likely to be at risk for the development of third spacing? Select all that apply. 1. The client with cirrhosis 2. The client with liver failure 3. The client with diabetes mellitus 4. The client with a minor burn injury 5. The client with chronic kidney disease

1. The client with cirrhosis 2. The client with liver failure 5. The client with chronic kidney disease **Fluid that shifts into the interstitial spaces and remains there is referred to as third space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, severe burn injuries, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1. Twitching **A patient with lactose intolerance is at risk for developing hypocalcemia because food products that contain calcium also contain lactose. The normal calcium level is 9-10.5. A level lower than 9 indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping and diarrhea.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1. U waves 3. Inverted T waves 4. Depressed ST segment **The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves.

The nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

1. Weight loss and poor skin turgor **A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Assessment findings in a patient with fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. **Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? 1. Confusion 2. Muscle weakness 3. Mental status changes 4. Depressed deep tendon reflexes

2. Muscle weakness **Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. **Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. **Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (557 mcmol/L)

2. Requires nasogastric suction **The normal potassium level is 3.5-5.0. A potassium deficit is known as hypokalemia. Potassium rich gastrointestinal fluids are lost through gastrointestinal suction, placing the patient at risk for hypokalemia. **The patient with tissue damage or Addison's disease and the patient with hyperuricemia are at risk for hyperkalemia.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (559 mmol/L)

2. Requires nasogastric suction **The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output.

2. Resume full activity level. **Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution would the nurse use to irrigate the NG tube? 1. Tap water 2. Sterile water 3. 0.9% sodium chloride 4. 0.45% sodium chloride

3. 0.9% sodium chloride **Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. **Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client would the nurse monitor closely for signs of hyperkalemia? 1. A client with ulcerative colitis 2. A client with Cushing's syndrome 3. A client admitted 6 hours ago with a 40% burn injury 4. A client who has a history of long-term laxative abuse

3. A client admitted 6 hours ago with a 40% burn injury **Hyperkalemia is likely to occur in patients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other patients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. **Patients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations **A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations **A fluid volume excess is also known as overhydration or fluid overload and occurs when the fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness and decreased hematocrit. **Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. **Weakness can be present in either fluid volume excess or deficit.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse would determine that the client's status is returning to normal if which is no longer exhibited? 1. Tetany 2. Tremors 3. Areflexia 4. Muscular excitability

3. Areflexia **Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss on consciousness. **Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding would the nurse expect to note? 1. Bradycardia 2. Elevated blood pressure 3. Changes in mental status 4. Bilateral crackles in the lungs

3. Changes in mental status **A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. **The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What would the nurse do next? 1. Document this assessment finding. 2. Call another nurse to verify this finding. 3. Check skin turgor over the client's sternum. 4. Call the primary health care provider (PHCP) to obtain a prescription for fluid replacement.

3. Check skin turgor over the client's sternum. **In an older adult, skin turgor needs to be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a patient gets older, the skin loses elasticity and can tent over the hands and arms, even when the patient is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is caring for a group of clients on the clinical nursing unit. Which client would the nurse plan to monitor for signs of fluid volume deficit? 1. Client in heart failure 2. Client in acute kidney injury 3. Client with an ileostomy 4. Client with controlled hypertension

3. Client with an ileostomy **The patient with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, and draining fistulas. **Patients that have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action would the nurse take first? 1. Hang the solution. 2. Check the client's daily laboratory results. 3. Contact the primary health care provider (PHCP). 4. Ask the client whether any liver study tests have ever been done.

3. Contact the primary health care provider (PHCP). **The nurse must contact the HCP before administering the solution. Fluid and electrolyte replacement solutions such as lactated Ringers are contraindicated for patients with kidney and liver disease or lactic acidosis.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds **The normal sodium level is 136-145. Hyponatremia is evidenced by a level lower than 136. Hyperactive bowel sounds indicate hyponatremia. **The remaining options are signs of hypernatremia.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to make a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

3. Integumentary output **Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. **Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

3. Integumentary output **Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is calculating a client's fluid intake for a 24-hour period. The client suffers from chronic kidney disease, is on hemodialysis, and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and dinner. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank. __________mL

30 mL **The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and 4 oz at dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So if the client took in 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid on this day.

The nurse is reviewing the assessment findings for a client who has been taking spironolactone for treatment of hypertension. Which, if noted in the client's record, would indicate that the client is experiencing an adverse effect related to the medication? 1. Client complaint of dry skin 2. Client complaint of constipation 3. A potassium level of 3.5 mEq/L (3.5 mmol/L) 4. A potassium level of 5.8 mEq/L (5.8 mmol/L)

4. A potassium level of 5.8 mEq/L (5.8 mmol/L) **Spironolactone is a potassium sparing diuretic. Slide effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding would the nurse most likely expect to note in the client based on this magnesium level? 1. Tetany 2. Twitches 3. Positive Trousseau's sign 4. Loss of deep tendon reflexes

4. Loss of deep tendon reflexes **The normal serum magnesium level is 1.3-2.1 mEq/L. A patient with a magnesium level of 3.5 is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. **Tetany, twitches, and a positive Trousseau's sign are seen in patients with hypomagnesemia.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

4. Prolonged QT interval 5. Prolonged ST segment **The normal serum calcium level is 9 to 10.5 mg/dL . A serum calcium level lower than 9 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse would select which solution to use for the nasogastric tube irrigation? 1. Tap water 2. Sterile water 3. Distilled water 4. Sodium chloride

4. Sodium chloride **A potassium level of 4.5 is within normal range. A sodium level of 132 is low, indicating hyponatremia. In patients with hyponatremia, sodium chloride (normal saline) rather than water would be used for gastrointestinal irrigations because it is an isotonic solution.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn **The normal potassium level is 3.5-5. A potassium level higher than 5 indicates hyperkalemia. Patients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as trauma, burns, sepsis, or metabolic respiratory acidosis, are at risk for hyperkalemia. **The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn **normal potassium level is 3.5-5.0. anything greater than 5.0 indicates hyperkalemia. cell destruction is a cause of hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. **The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease that developed as a complication of diabetes mellitus

4. The client with kidney disease that developed as a complication of diabetes mellitus **A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Kidney disease is a complication of diabetes mellitus and as a result of the kidney disease, the elimination of fluid is affected and the patient retains fluid. **The patient taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032

4. Urine specific gravity of 1.032 **The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. **Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.