Fluid and Electrolytes MASTERY ASSESSMENT

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1-Crohn disease 2-Cushing disease 3-End-stage renal disease 4-Gastroesophageal reflux disease

End-stage renal disease--One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? 1-Fluid retention 2-Urinary retention 3-Renal insufficiency 4-Abdominal distention

Fluid retention--With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).

A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released? 1-Hypokalemia 2-Hypoglycemia 3-Hyponatremia 4-Hypochloremia

Hyponatremia--Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

What is the priority nursing action in the care of a young child with severe diarrhea? 1-Measuring daily urine output 2-Maintaining fluid and electrolyte balance 3-Replacing the lost calories with high-fiber foods 4-Promoting perianal skin integrity by bathing often

Maintaining fluid and electrolyte balance--Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the patient. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother? 1-Importance of a well-balanced diet 2-Signs of dehydration in infants 3-The need for cleanliness of feeding utensils 4-Effect of antibiotics on viral gastroenteritis

Signs of dehydration in infants--It is most important for the mother to learn that immediate treatment is necessary for an infant with vomiting or diarrhea. Because infants have a greater proportion of body fluid to tissue than adults, they cannot maintain fluid balance in the event of a large loss of fluid through vomiting or diarrhea. An infant's diet consists almost totally of milk; teaching the mother about a well-balanced diet is irrelevant at this time. Although cleanliness is important, diarrhea may occur despite cleanliness. Antibiotics are not administered for viral gastroenteritis.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1-Decreased rate of glomerular filtration 2-Excessive blood loss through the burned tissues 3-Plasma proteins moving out of the intravascular compartment 4-Sodium retention occurring as a result of the aldosterone mechanism

The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

A nurse is caring for an infant with gastroenteritis and diarrhea. What should the nurse evaluate to determine the magnitude of the infant's fluid loss? 1-Tissue turgor 2-Hematocrit value 3-Moistness of mucous membranes 4-Weight compared with prior weight

Weight compared with prior weight--Loss of weight is the most accurate measurement of the magnitude of fluid loss; 1 L of fluid weighs 2.2 lb. Tissue turgor is subjective measure of dehydration and not as accurate as a comparison with the pre-illness weight. Although an increased hematocrit and dry mucous membranes each indicate dehydration, neither is an effective tool for assessing the amount of fluid loss.

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client? 1-Intravascular to interstitial as a result of glycosuria 2-Extracellular to interstitial as a result of hypoproteinemia 3-Intracellular to intravascular as a result of hyperosmolarity 4-Intercellular to intravascular as a result of increased hydrostatic pressure

Intracellular to intravascular as a result of hyperosmolarity--The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.

What is the cup-like structure that collects a client's urine and is located at the end of each papilla? 1-Calyx 2-Capsule 3-Renal cortex 4-Renal columns

calyx--The calyx is a cup-like structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? 1-Weight gain 2-Dehydration 3-Hyperactivity 4-Hyperglycemia

dehyrdration--The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? 1-Azotemia 2-Hypokalemia 3-Metabolic alkalosis 4-Respiratory alkalosis

Azotemia--The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO 2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.