Fluid and Electrolytes(Exam 2)

Electrolyte imbalance An elevated hematocrit level

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. A. Electrolyte imbalance B. A low urine specific gravity C. An elevated hematocrit level D. Low protein level in the urine E. Absence of ketones in urine

Metabolic alkalosis

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?

Complete a head-to-toe assessment.

The nurse receives report that a client's pH level is 7.4. Which nursing action would bemost appropriate?

Compensated respiratory alkalosis

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid- base imbalance do both nurses agree is the client's current state?

Drink at least eight glasses of fluid each day. Respond to thirst. Drink water as an inexpensive way to meet fluid needs.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. A. Drink carbonated beverages to help balance fluid volume. B. Drink at least eight glasses of fluid each day. C. Respond to thirst. D. Drink caffeinated beverages to retain fluid. E. Drink water as an inexpensive way to meet fluid needs.

kidney stones and blood clots

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

insensible fluid loss

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern as a result of the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, what is the nurse most concerned about?

Neurologic system

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

The lungs are not able to blow off carbon dioxide.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH?

A hot dog with catsup

The nurse is caring for a client prescribed a low-sodium diet. Which food, identified as a client favorite, will the nurse discourage?

hypocalcemia

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

A drop in systolic blood pressure (15 mm Hg) upon rising

The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

elevated blood pressure

The nurse is caring for a client with heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

dark, concentrated urine

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

Lungs and kidney

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Seek a physician's order to dilute the infusion.

The nurse is caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should the nurse do?

Beverages with alcohol or caffeine

The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Potassium: 5.8 mEq/L

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Offer a prescribed antiemetic medication.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Intracellular fluid

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location that contains the most body water?

A 52-year-old with diarrhea

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

In dehydration, only extracellular is depleted.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

active transport

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

Decreased abdominal girth

The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?

Bases bind with hydrogen.

The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a group of students. Which action by bases keeps the blood pH nearly neutral?

No, sodium intake should be restricted.

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

Hypertonic solution

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

Metabolic acidosis

The client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Bicarbonate

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of themost important indications of an acid-base imbalance that is shown in an ABG?

weight

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

2500 mL

The nursing instructor is discussing with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?

Active transport

What is one process by which dissolved chemicals move from one area of the body to another?

Elevated hematocrit level

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Initiate an IV of albumin.

Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?

hypomagnesemia

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?