276 Arnold Fluid & Electrolyte Balance

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?

decreased ability to detect thirst Explanation: The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased, and dissolved particles in the extracellular fluid compartment become more concentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and aldosterone as a normal part of aging.

A client has been taking furosemide for 2 days. The nurse should review the laboratory record for changes in which blood level?

a decreased potassium Explanation: Furosemide is a loop diuretic and inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle. Furosemide promotes sodium diuresis, resulting in a loss of potassium and serious electrolyte imbalances. Furosemide does not affect the BUN level.

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? hypernatremia hypercalcemia hyperkalemia hypermagnesemia

hyperkalemia Explanation: Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination does not help reverse the effects of hypercalcemia, hypernatremia, or hypermagnesemia.

Which client is most likely to exhibit dehydration? a 75-year-old woman who has been placed on NPO status 8 hours before surgery a 60-year-old man with pneumonia and a temperature of 101°F (38.3°C) an 8-month-old infant with persistent diarrhea for 24 hours a 21-year-old man with profuse diaphoresis after a game of football

an 8-month-old infant with persistent diarrhea for 24 hours Explanation: Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and replacement fluids given.Healthy young adults have a higher tolerance for fluid loss and can quickly regain their fluid balance when fluids are lost through normal activity.The 75-year-old woman who was placed on NPO status before surgery is not likely to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions present that would precipitate fluid loss.The 60-year-old client with pneumonia and a fever should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is actively losing fluids through diarrhea.

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client? acute pain deficient fluid volume ineffective tissue perfusion deficient knowledge

deficient fluid volume Explanation: Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. In addition the client has been vomiting for 24 hours and has a low blood pressure. Therefore, deficient fluid volume is the priority diagnosis. deficient knowledge and ineffective tissue perfusion are applicable but not the primary nursing diagnoses. Pain is an issue with this client; however, treating the client's hypovolemia is the priority.

A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence and has decreased the fluid intake because of the incontinence. What is the nurse's best response to the client? "Drink eight glasses of water a day and urinate every 2 hours." "Limiting your fluids will cause kidney stones." "If your incontinence continues, we will reinsert your catheter." "Yes, limiting your fluids can decrease your incontinence."

"Drink eight glasses of water a day and urinate every 2 hours." Explanation: Clients who have undergone TURP need to be instructed to maintain an adequate fluid intake despite urinary dribbling or incontinence. The client should be advised to drink at least eight glasses of water a day to dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours can help decrease incidents of incontinence. Teaching the client Kegel exercises is also beneficial for strengthening sphincter tone. The nurse should not encourage the client to decrease fluids. It is not necessarily true that a decreased intake will cause renal calculi. Threatening the client with a catheter is not beneficial, and it is not the treatment of choice for a client who is experiencing incontinence from TURP.

A client is receiving parenteral nutrition through a central venous catheter. As the nurse is changing the dressing at the catheter site, the client asks why this type of catheter is being used instead of a regular peripheral I.V. Which is the best response by the nurse to explain the use of the central venous catheter? "The solution is hypotonic and can be given only through a central venous catheter." "The nutrients that are being administered are too concentrated for a peripheral I.V." "Central venous catheters are inserted when peripheral veins can no longer be used." "The central venous catheter allows nutrients to be administered at a much greater pace."

"The nutrients that are being administered are too concentrated for a peripheral I.V." Explanation: Parenteral nutrition solutions have five to six times the concentration of nutrients of blood. They would be very irritating to the vascular intima if delivered via a peripheral vein. When administered via a central venous catheter, concentrated solutions are rapidly diluted to isotonic levels. The other answers are incorrect because the principal reason for the central venous catheter is to provide concentrated nutrition; fluids and electrolytes can be restored via regular I.Vs. Parenteral nutrition is not hypotonic, but hypertonic, and therefore cannot be administered peripherally. Central venous catheters are not accessed if peripheral veins have been overused; a cut down and deeper peripheral veins are then used.

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do? Use the mineral oil regularly on a weekly basis to prevent constipation. Avoid mineral oil because it can lead to vitamin C deficiency in pregnant clients. Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Take the mineral oil with fruit juice to increase the action of the mineral oil.

Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Explanation: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation.

A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider? If symptoms persist for more than 72 hours, contact the physician. Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes. Sugar is a good source of nutrition when rehydrating a child. A child who has three wet diapers each day isn't considered dehydrated.

Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes. Explanation: Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child's tolerance level. Simple sugars aren't a good source of hydration because of their osmotic effects. The nurse shouldn't wait 72 hours before taking action if a child is vomiting or has diarrhea. Toddlers can become dehydrated in a short time. A physician should see a child whose vomiting or diarrhea persists for 24 to 36 hours. Wet diapers are a good source of determining hydration; however, three wet diapers each day isn't a normal finding for toddlers. A hydrated toddler should have six to eight wet diapers per day.

While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first? Continue to monitor the bag of IV solution. Ask another nurse to look at the solution. Notify the health care provider (HCP). Hang a new bag of D5W, and complete an incident report.

Hang a new bag of D5W, and complete an incident report. Explanation: Maintenance of IV sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, solution, and tubing; these measures help prevent complications. The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify this action with another nurse. Paging the HCP is not necessary; maintaining the IV and using the correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital policy should be followed if there is a question as to whether there could have been an unknown substance in the bag that caused it to change color.

The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure? clubbing of the fingernails on both hands dyspnea on exertion bilateral edema of the feet and ankles bilateral crackles that clear with coughing

bilateral edema of the feet and ankles Explanation: A client with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), may experience symptoms that are similar to those of left-sided heart failure, such as dyspnea on exertion. However, without other risk factors, the client with COPD is at risk for right-sided, not left-sided, heart failure. Bilateral edema of the feet and ankles would not occur with chronic bronchitis but is evidence of right-sided heart failure due to the resistance to venous return to the right side of the heart. Bilateral crackles that clear with coughing would occur with chronic bronchitis. Note that pulmonary edema is not expected with right-sided heart failure. Nail clubbing develops in chronic bronchitis because of chronic oxygen deprivation and is not evidence of heart failure.

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? metabolic acidosis respiratory acidosis respiratory alkalosis metabolic alkalosis

metabolic alkalosis Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an intravenous line with dextrose in 5% water infusing at 40 ml/hour and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters would the nurse calculate as urine? Record your answer as a whole number.

1180 Explanation: During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml X 8 hour = 1,600 ml/8 hour). The nurse would subtract this amount from the total volume in the drainage bag to determine the urine output (2,780 ml - 1,600 ml = 1,180 ml).

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 Explanation: First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg.Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms:0.2g/kg X 60 kg = 12 g.

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. This client is exhibiting signs of digoxin toxicity. Hypokalemia can increase the risk of digoxin toxicity; the potassium value is low, so potassium should be replaced. The sodium, magnesium, and calcium levels are all within normal limits and do not require intervention.

A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for? edema muscle cramping confusion tremors

muscle cramping Explanation: Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.

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? Eliminate dairy products from the diet. Strain all urine for one week. Increase daily fluid intake to at least 2 to 3 L. Follow measures to alkalinize the urine.

Increase daily fluid intake to at least 2 to 3 L. Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

The nurse is caring for a client admitted with severe blood pressure 80/40 hypotension and positive blood cultures for Escherichia coli. What are the priority interventions for this client? Select all that apply. Limit visitors and reduce noise level in room. Administer ceftriaxone. Place client in negative-pressure room. Teach client about the need to increase fluids. Maintain intravenous fluids and vasopressors.

Maintain intravenous fluids and vasopressors. Administer ceftriaxone. Explanation: This client requires antibiotics, fluids, and vasopressors. With severe hypotension, this is not the ideal teaching time for the client. Visitors do not need to be restricted. A negative-pressure room is not indicated for this client.

A nurse is administering 50 mEq potassium chloride (KCl) in 250 mL 0.9 normal saline (NS) intravenously piggyback (I.V.PB) to a client with hypokalemia. Which action should the nurse take?

Provide continuous cardiac monitoring during the infusion. Explanation: I.V. potassium chloride (KCl) is administered at a maximal rate of 10 mEq/hour. The pump would be set for 50 mL/hour to infuse the I.V.PB over 5 hours. Rapid I.V. infusion of KCl can cause cardiac arrest. Cardiac monitoring should be provided while client is receiving potassium because of the risk for dysrhythmias.

A school-age child is admitted to the hospital in vasoocclusive sickle cell crisis. Place the interventions in the order of priority (from first to last) that the nurse should implement them. All options must be used.

Start an intravenous infusion. Start oxygen via nasal cannula. Administer morphine for the pain. Draw blood for electrolyte levels and pH balance. Explanation: The nurse should first start an intravenous infusion because dehydration increases sickling of cells; maintaining fluid balance is the top priority. The nurse should next start oxygen and then administer morphine for pain. Last, the nurse should obtain a blood sample for laboratory studies.

Which statement describes the rationale for administering vitamin K to every neonate? The neonate lacks intestinal flora to make the vitamin. Neonates don't receive the clotting factor in utero. It boosts the minimal level of vitamin K found in the neonate. The drug prevents the development of phenylketonuria (PKU).

The neonate lacks intestinal flora to make the vitamin. Explanation: Neonates are at risk for bleeding disorders during the first week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is greater than 35 mL/h. Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?

Weigh the child before breakfast. Explanation: The best indicator of fluid balance is weight. Therefore, daily weight measurements help determine fluid losses and gains. Although limiting visitors to 2 to 3 hours per day or maintaining strict bed rest would help to ensure that the child gets adequate rest, this is unrelated to the child's fluid balance. In nephrotic syndrome, urine is tested for protein, not specific gravity.

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem? abnormally high salt loss through perspiration little skin pigment to prevent sunburn poor ability to concentrate urine poorly functioning temperature control center

abnormally high salt loss through perspiration Explanation: One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Extra salt is almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate? assessing the client for the presence of any metal implants administering fluids to the client placing the client on bed rest having the client take nothing by mouth until the gag reflex has returned

administering fluids to the client Explanation: A client that receives an MRI with contrast will need to have fluids offered to facilitate kidney excretion of the contrast medium. There is no need to numb the client's throat for this procedure so the client's gag reflex should not be affected. There is no need to restrict the client's activity. The nurse should assess for the presence of metal implants prior to the MRI, not after.

A client with an I.V. of normal saline at 150 mL/hour reports dyspnea and restlessness. What is the priority nursing action?

assess lung sounds Explanation: Further assessment is required to determine if this client is experiencing fluid overload. The priority assessment would be the lungs. The I.V. should not be decreased, as it has not been determined if it is the cause of the dyspnea. Although client weight is a good indicator of fluid balance over time, it must be compared day to day and will not be useful in an acute problem. The electrolytes may indicate fluid balance over time; however, it is not useful in an acute situation.

A client who is 12 hours post total thyroidectomy reports tingling around the mouth. Which assessment is the priority? potassium level calcium level blood pressure sodium level

calcium level Explanation: Tingling around the mouth after a thyroidectomy may indicate decreased calcium levels and should be assessed. A thyroidectomy does not affect sodium or potassium levels. Assessing vital signs is important, but is not the priority.

When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 mL/day, which fluid should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst? lemonade ice chips diet cola tap water

ice chips Explanation: The most appropriate and effective choice would be ice chips because they help moisten the mouth and lips while keeping fluid intake low. However, ice chips must still be counted as intake with the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fluid intake low.

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply. polydipsia aphasia polyuria muscle twitching and spasms numbness tingling

muscle twitching and spasms numbness tingling When the parathyroid gland is removed, the body may not produce enough parathyroid hormone to regulate calcium and phosphorous levels. The symptoms of hypocalcemia include peripheral numbness, tingling, and muscle spasms. Aphasia is not a symptom of calcium depletion. Polyuria and polydipsia are symptoms of diabetes mellitus.

When admitting an older adult client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?

poor skin turgor Explanation: In a client with persistent nausea and vomiting, the nurse should anticipate that the client may be dehydrated and exhibit signs of a fluid deficit, such as poor skin turgor. Other typical findings include lethargy, dry mucous membranes, tachycardia, weight loss, and decreased urine output. Blood pressure is usually within normal limits in the case of a mild to moderate fluid deficit because of the compensatory mechanisms of sympathetic nervous system stimulation of the heart (causing tachycardia) and peripheral vasoconstriction.

After a total laryngectomy, the client has a feeding tube. What is the purpose of the feeding tube? The feeding tube:

provides nutrition. Explanation: The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client as the surgical site is healing. The feeding tube does help prevent aspiration by preventing ingested fluid from leaking through the wound into the trachea before healing occurs; however, the primary rationale is to meet the client's nutritional and fluid needs. A tracheoesophageal fistula is a rare complication of total laryngectomy and may occur if radiation therapy has compromised wound healing. A feeding tube does not help maintain an open airway.

A client's intravenous catheter has become occluded. The nurse knows that the reason for the occlusion is:

thrombosis at the site. Explanation: The catheter occlusion may have been caused by inadequate flushing. It is usually a lipid build use, not particulate matter. The other choices are incorrect because they are not common causes. The I.V. rate is appropriate, infection is not the most common cause of catheter occlusion if the catheter is changed per hospital protocol, and dressing and tape should not occlude flow.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated? diabetic ketoacidosis SIADH secretion diabetes insipidus diabetes mellitus

diabetes insipidus Explanation: Diabetes insipidus is characterized by a great thirst (polydipsia) and large amounts of dilute, watery urine with a specific gravity of 1.001 to 1.005. Diabetes mellitus presents with polydipsia, polyuria, and polyphagia, but the client also has hyperglycemia. Diabetic ketoacidosis presents with weight loss, polyuria, and polydipsia, and the client has severe acidosis. A client with SIADH cannot excrete dilute urine; the client retains fluid and develops a sodium deficiency.

The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider? hypocalcemia hyponatremia hypokalemia hypomagnesemia

hypokalemia Explanation: Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will: select a diabetic diet correctly. state dietary restrictions. maintain normal fluid and electrolyte balance. exhibit serum glucose level within normal range.

maintain normal fluid and electrolyte balance. Explanation: Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus.

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance? Increase intake of milk and milk products. Decrease foods high in potassium. Restrict fluid intake to 1,000 mL/day. Increase foods high in sodium.

Decrease foods high in potassium. Explanation: Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.

When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?

Evaluate laboratory results for electrolytes. Explanation: IV solutions are prescribed based upon the fluid and electrolyte status of the client, so laboratory results should be monitored first. Safety recommendations are for standard premixed solutions. If solutions are not premixed, additives are completed by the pharmacy, not at the bedside. Potassium chloride is never given by IV push because this could be fatal. Administration guidelines require no more than 10 mEq (10 mmol/L) of potassium chloride be infused per hour on a general medical-surgical unit. An infusion device or pump is required for safe administration.

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? Fluid intake should be half the urine output. Fluid intake should be double the urine output. Fluid intake should be inversely proportional to the urine output. Fluid intake should be about equal to the urine output.

Fluid intake should be about equal to the urine output. Explanation: Normally, fluid intake is about equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.

Which adverse effect occurs when there is too rapid an infusion of TPN solution?

circulatory overload Explanation: Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

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? irregular pulse constipation dysuria hyperkalemia

hyperkalemia Explanation: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?

hypokalemia Explanation: Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting.

A child with diabetic ketoacidosis is being treated for a blood glucose level of 738 mg/dl (41.0 mmol/L). The nurse should anticipate an order for: 5% dextrose in water with PZI insulin. normal saline with regular insulin. 5% dextrose in water with NPH insulin. normal saline with ultralente insulin.

normal saline with regular insulin. Explanation: Short-acting regular insulin is the only insulin used for insulin infusions. Initially, normal saline is used until blood glucose levels are reduced, then a dextrose solution may be used to prevent hypoglycemia. Ultralente, NPH, and PZI insulins have a longer duration of action and shouldn't be used for continuous infusions.

The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider? blood urea nitrogen (BUN) 40 mg/dL (urea 14.3 mmol/L) creatinine 2.5 mg/dL (221 umol/L) sodium 130 mEq/L (130 mmol/L) potassium level of 6.5 mEq/L (6.5 mmol/L)

potassium level of 6.5 mEq/L (6.5 mmol/L) Explanation: A potassium level of 6.5 mEq/L requires immediate follow-up because it's considered critically high, making the child prone to cardiac arrhythmias. The creatinine, sodium, and BUN are all abnormal but to be expected in a client with acute renal failure. They do not require immediate follow-up, but the nurse's action will largely depend on the client's previous results and the degree of change.

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. Explanation: The nurse should conclude that the client's intake was 300 ml greater than output. To reach this conclusion, the nurse should add the nasogastric drainage (300 ml) and the urinary output (200 ml) to get an output of 500 ml. The nurse should add the amount of IV fluid that infused during the shift (300 ml) to the amount of liquid consumed (500 ml) to get 800 ml for the client's intake. The nurse should then compare the output (500 ml) to the intake (800 ml) and determine that the intake was 300 ml greater than the output (800 ml - 500 ml = 300 ml).

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary. Explanation: This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment? isotonic hypotonic hypertonic electrotonic

hypertonic Explanation: The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale had been prescribed a loop diuretic to treat peripheral edema. The nurse should monitor the client closely for what side effect of loop diuretic therapy that could worsen the client's hypercapnia? hyponatremia hypokalemia hyperuricemia orthostatic hypotension

hypokalemia Explanation: All the options offered are potential side effects of loop diuretics, but only hypokalemia would directly pose the risk for increasing hypercapnia. When potassium levels are low, hydrogen ions shift into the intracellular space to liberate potassium into the extracellular space, and this contributes to metabolic alkalosis. To compensate for metabolic alkalosis, hypoventilation occurs in an attempt to retain carbon dioxide (the respiratory acid) and decrease the client's pH. Therefore, hypokalemia can worsen hypercapnia. Diuretics must be used with caution in clients with COPD. However, diuretics may be prescribed to treat peripheral edema that results from right ventricular dysfunction and the resulting systemic venous congestion.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? providing pain-relief measures encouraging coughing and deep breathing promoting carbohydrate intake limiting fluid intake

limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? metabolic alkalosis and hypokalemia metabolic alkalosis and hyperkalemia metabolic acidosis and hyperkalemia metabolic acidosis and hypokalemia

metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? The client is pain free. The client walks in the hallway unassisted. The client voids 500 mL of urine. The client tolerates eating a hamburger.

The client voids 500 mL of urine. Explanation: Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. How much fluid should the nurse tell the client to drink? at least 3,000 mL of fluids daily at least 1,000 mL more than usual twice as much fluid as usual as much water or juice as possible

at least 3,000 mL of fluids daily Explanation: Instructions should be as specific as possible, and the nurse should avoid general statements such as "as much as possible." A specific goal is most useful. A mix of fluids will increase the likelihood of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 L more than she usually drinks if her intake was inadequate to begin with.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? blood pH of 7.25 serum sodium level of 135 mEq/L serum potassium level of 3.5 mEq/L loss of 2.2 lb (1 kg) in 24 hours

loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

2/10/2017 0800 A client was admitted for intracranial hemorrhage four days ago. Morning laboratory results demonstrate a low serum sodium of 121 mEq/L, a low serum osmolality of 256 mOsm/kg, a high urine osmolality of 588 mOsm/kg, and a high urine sodium of 89 mmol/L. Vital signs are stable. Urine output is high, averaging greater than 100 cc/hr. Which nursing interventions should the nurse include when planning care for a client with cerebral salt wasting (CSW) syndrome? synthetic vasopressin replacement sodium restriction sodium and fluid replacement fluid restriction

sodium and fluid replacement Explanation: Cerebral salt wasting syndrome is a volume-depleted and sodium-wasting state, requiring fluid replacement with isotonic solutions to prevent further deterioration. Its presentation is similarly to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is treated with free water restriction. Synthetic vasopressin replacement is used to treat central diabetes insipidus.

The nurse is placing an intravenous (IV) catheter in a client who has a risk of impaired skin integrity due to dehydration. Place the steps in order for this procedure. All options must be used.

Palpate and select an appropriate vein. Cleanse client's skin with an antiseptic. Hold skin taut 1-2 inches below the site. Insert catheter and observe for blood return. Stabilize catheter and flush with saline. Explanation: The client with fluid volume deficit due to dehydration would likely require an IV infusion of fluids as a treatment for this. Having an improved skin turgor with decreased dehydration will reduce the client's risk for impaired skin integrity. The client would have the catheter inserted and then flushed with saline once the appropriate vein was selected, the skin cleansed, and then the skin held taut below the site to stabilize the vein for IV insertion. Avoid touching the cleansed area to maintain this antisepsis.

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 restore sodium stores that were lost from the burns to improve skin integrity and maintain a barrier to prevent signs of hypovolemic shock and restore circulation to maintain appropriate glucose levels in the blood

to prevent signs of hypovolemic shock and restore circulation Explanation: Lactated Ringer's is infused to restore circulating fluid volume and prevent signs of hypovolemic shock. Intravenous administration of dextrose to restore glucose is not the priority at this time. The client has severe burns, so improving skin integrity is not an issue at this time.

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 weighing each diaper serum sodium levels urine specific gravity

daily weight Explanation: The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

A client with heart failure is given a prescription for torsemide. Two days after the drug therapy is started, which sign indicates the drug is having the intended outcome? The client:

weighs 7 lb (3 kg) less than the client did 2 days ago. Explanation: The primary reason to give a diuretic to a client with heart failure is to promote sodium and water excretion through the kidneys. As a result, the excessive body water that tends to accumulate in a client with heart failure is eliminated, which causes the client to lose weight. Monitoring the client's weight daily helps evaluate the effectiveness of diuretic therapy. Clients should be advised to weigh themselves daily. An increased appetite or decreased thirst does not establish the effectiveness of the diuretic therapy, nor does having clearer urine after starting torsemide.

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? a. Children with iron-deficiency anemia are equally as susceptible to infection as are other children. b. Children with iron-deficiency anemia are less susceptible to infection than are other children. c. Little is known about iron-deficiency anemia and its relationship to infection in children. d. Children with iron-deficiency anemia are more susceptible to infection than are other children.

Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

The nurse is caring for a client with chronic renal failure. The nurse should monitor the client for which adverse effects of hypermagnesemia?

lethargy Explanation: Early signs and symptoms of hypermagnesemia include drowsiness, lethargy, nausea, and vomiting. Flushed skin is a sign of hypernatremia. Severe thirst is associated with hyperglycemia. Tremors are associated with hypomagnesemia.

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. Prepare to give the child a transfusion of packed red blood cells. Prepare to give the child a transfusion of platelets. Encourage mouth care with a soft toothbrush.

Encourage meticulous handwashing by the client and visitors. Explanation: A WBC of 2000 mm3 (2 X 109/L) is low and increases the child's risk for infection. Meticulous handwashing is a standard/routine precaution and the first line of defense in combating infection. A platelet count of 150,000 ?L (150 X 109/L) is within normal range, so there is no need to transfuse the child with platelets. Mouth care will help decrease the risk of infection. However, handwashing is the priority because it will have the greatest effects on diminishing the risk of infection. A Hgb of 12.5 g/dL (125 g/L) and a HCT of 36.8% (0.37) are within normal range so there is no need to transfuse packed red blood cells.

nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? high serum sodium level increase in blood volume low serum potassium level increase in blood pressure

low serum potassium level Explanation: Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.