Adult Health-Test #3-Fluid and Electrolytes

A potential complication of a prostatectomy is?

hemorrhage

0.45% saline is what type of IV fluid?

hypotonic solution

medicine that may cause bloating & increased abdominal girth

metamucil

assessment finding of hypovolemia

orthostatic hypotension

Which assessment do you interpret as a transfusion reaction

Chills, tachycardia, and flushing -A transfusion reaction occurs when the immune system reacts against the blood that is being transfused. Chills, tachycardia, and flushing are common manifestations.

Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

Correct handwashing technique -Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures. including indwelling catheters. Masks. gowns. and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.

The nurse is evaluating the medication list of a newly-admitted client with hypokalemia. The client has been experiencing dysrhythmias and is on a cardiac monitor. Which medication from the list would alert the nurse to pursue a discussion with the physician? a. an oral antidiabetic agent b. a cardiac rhythm drug c. an over the counter antacid d. a loop diuretic

D: a Loop diuretic -Excess potassium loss through the kidneys is often secondary to drugs such as potassium-wasting diuretics. Hypokalemia may lead to cardiac dysrhythmias. Potassium-wasting diuretic therapy may require supplemental oral potassium.

Teaching a pt. who is taking finasteride (Prosper), an 5-alpha reductase inhibitor (5-ARI). What medication side effects does the nurse include in teaching?

ED Dizziness Decreased libido

A nurse is monitoring a patient who is receiving fluids intravenously. Which clinical manifestation at the insertion site indicates that the IV has been infiltrated? a. Edema b. Redness c. Firmness d. Inflammation

Edema

The nurse is caring for a patient who is 24 hours post-TURP and is having painful bladder spasms. Which intervention should the nurse plan to implement?

Give the prn prescribed belladonna and opium suppository

A medication or urinary urgency/frequency:

oxybutynin

Which of the following hospitalized clients would the nurse be most concerned is at risk for developing an imbalance related to water loss? Select all that apply. a. A 50-year old undernourished female b. A 75-year old female of average body weight c. A 60-year old male of average body weight d. A 45-year old obese male

-A 45-year old obese male & A 75-year old female of average body weight A 45-year old obese male On average, females have a lower proportion of water to total body weight composition. The obese client has a lower proportion of water to total body weight. After age 65, total body water may decrease 45-50% of the total body weight.

Which of the following is most likely to result in respiratory alkalosis? A. Steroid use B. Hyperventilation C. Chronic alcoholism D. Fad dieting

Hyperventilation -Is marked by a decreased PaCO2 and an increased pH; anxiety with hyperventilation is a cause

Urinary retention:

Inability to empty the bladder (acute and chronic) Can be acute, chronic, less common than urinary incontinence Age, male gender, surgical pts, stroke, DM, prostatitis, etc. Clinical manifestations Treatment

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips?

One-half of the volume -When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

UAP hygiene instructions for an older patient who is uncircumcised. What does the nurse instruct the UAP do?

Replace the foreskin over the penis after bathing

Mrs. Green's arterial blood gas results are as follows: pH, 7.32; PaCO2, 52 mm Hg; PaO2, 78 mm HG; HCO3, 24 mEq/L. Mrs. Green has:

Respiratory acidosis -A combination of increased PaCO2, excess carbonic acid, and an increased hydrogen ion concentration

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. You interpret these laboratory values to indicate:

Respiratory acidosis. -The pH is abnormally low, which indicates acidosis. The PaCO2 is high, which indicates respiratory acidosis. The HCO3- is in the normal range, which indicates an acute respiratory acidosis that has not had time for renal compensation. The low PaO2 and severe dyspnea and wheezing are consistent with this interpretation.

A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?

Serum Potassium - Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.

Mr. Frank is an 82-year-old patient who has had a 3-day history of vomiting and diarrhea. Which symptom would you expect to find on a physical examination?

Tachycardia -Any condition that results in the loss of GI fluids predisposes the patient to the development of dehydration and a variety of electrolyte disturbances.

Chronic use of laxative can lead to this: (elimination)

constipation

Signs and symptoms of Chronic prostatitis:

-Acute bacterial prostatitis is often caused by common strains of bacteria. The infection can start when bacteria in urine leak into your prostate. Antibiotics are used to treat the infection. -Prostatitis is swelling and inflammation of the prostate gland, a walnut-sized gland situated directly below the bladder in men. The prostate gland produces fluid (semen) that nourishes and transports sperm. -Prostatitis often causes painful or difficult urination. Other symptoms include pain in the groin, pelvic area or genitals and sometimes flu-like symptoms. -Prostatitis affects men of all ages but tends to be more common in men 50 or younger.

A patient with systemic lupus erythematosus (SLE) arrives at the emergency department with a two-day history of intermittent fever, fatigue, and pain. Which subjective symptoms does the nurse know must be assessed immediately? Select all that apply

-Pain ratings -Fever patterns -Joint inflammation

Which disorders may cause peripheral neuropathy? Select all that apply.

-Rheumatoid arthritis -Systemic lupus erythematosus (SLE)

Your patient is a 20-year-old woman admitted to the hospital following an automobile accident. She had internal injuries, hemorrhaging and was hypotensive throughout surgery for removal of a ruptured spleen. Four hours after surgery and a blood transfusion; her urine output is decreasing, her renal function tests are abnormal, and her serum potassium levels are elevated.

1. What is the relationship between this patient's decreased urine output and her increased potassium level? Potassium is excreted through urine, thus decreased urine output causes increased potassium. 2. What are the treatment options when a patient has impaired renal function? Dialysis 3. What is the most serious result of increased serum potassium? Cardiac arrest (as a result of decreased heart rate) or death.

Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record?

1000 mL -Add one half the volume of ice chips to other intake to calculate total intake.

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? A. 56-year-old with acute kidney renal failure B. 40-year-old with appendicitis C. 28-year-old who has acute pancreatitis D. 65-year-old with hypertension and asthma

28-year-old who has acute pancreatitis -People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids.

Which patient below would have a potassium level of 5.5?

A patient with Addison's disease -A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.

The nurse is preparing to administer the discharge teaching instructions to a client with heart failure. Which measure will be included that the client will need to monitor on their own related to their recent hospitalization? a. daily weight b. weekly electrolyte level c. daily fasting blood sugar d. daily urine dipstick for protein

A: Daily weights are one of the most important determinations of fluid balance. -Weighing at home at the same time with the same amount of clothing on will track overall fluid changes as they occur. Acute weight gain or loss represents fluid gain or loss. The other measures would not be the responsibility of the client. Blood sugar measurement does not directly apply in this situation.

Which of the following defining characteristics is consistent with fluid volume deficit?

Dry mucous membranes, thready pulse, tachycardia

Mary Jean. a first year nursing student. was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

Encouraging slow. deep breaths -The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow. deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis. and administering sodium chloride is appropriate for metabolic alkalosis.

Pt just started taking an alpha blocker medication to treat BPH. What instruction related to the medication side effects, will the nurse give to the UAP who will assist the patient with activities of daily living (ADLs)?

Have him sit up slowly and pause before standing

Older patient has enlarged prostate with chronic urinary retention but declines to seek treatment because "it's been that way for a long time". The nurse would encourage a follow-up appointment to precent which complicate not this chronic condition?

Hydronephrosis

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?

Hypocalcemia -Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia.

In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority?

Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions -As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.

Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing?

Provide frequent oral care to keep her mucous membranes moist

When caring for a patient with systemic lupus erythematosus, the nurse recognizes which major and serious complication of the disorder?

Renal failure

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance?

Respiratory alkalosis -Hyperventilation causes excessive excretion of carbonic acid, putting the patient at risk for developing respiratory alkalosis. Interventions to decrease the pain and hypoxia that are causing his hyperventilation will decrease his risk of respiratory alkalosis.

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? A. Notify the health care provider B. Insert an indwelling catheter C. Alert the blood bank D. Stop the transfusion

Stop the transfusion

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. Which of the following is an expected finding?

Tachycardia is an expected finding of hypovolemia.

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?

The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium.

You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true?

This is known as Trousseau's Sign and is present in patients with hypocalemia -The correct answer is "this is known as Trousseau's Sign and is present in patients with hypocalemia". Patient's with hypokalemia may present with a positive Trousseau's and Chvostek sign.

A patient with systemic lupus erythematosus (SLE) has persistent proteinuria, for which the healthcare provider prescribed both oral steroids and a cytotoxic agent. When the patient asks why two medications are necessary, what is the nurse's best response?

"Oral steroids are used in the initial treatment period while the cytotoxic agent takes effect."

Survival in patients with systemic lupus erythematosus (SLE) is dependent on which factors? Select all that apply.

-Age -Sex -Race -Comorbid conditions

Your patient is a 53-year-old woman admitted to the hospital trauma center from a local nursing home where she fell and broke her hip. On admission she complained of severe pain in the pelvic region and had a shortened left extremity and decreased abduction. She also complained of nausea and vomiting which has worsened over the last few days. She has been taking large doses of supplemental vitamin D and calcium for osteoporosis and has had limited ambulation for the past two years. Lab tests: sodium = 133 mEq/L; potassium = 3.5 mEq/L; calcium = 18 mg/dL

1. What are the contributing factors that caused the increased serum calcium? Large doses of vitamin D and calcium, limited mobility 2. What factors contributed to the patient's fractured hip? Osteoporosis 3. What is the medical and nursing care is indicated for the patient with hypercalcemia? Diet restriction, lasix, 0.9% NS, Calcitonin

Your patient is a 40-year-old woman admitted to the hospital with complaints of progressive muscle weakness. She has been taking a diuretic for several weeks and recently developed vomiting and diarrhea. She has postural hypotension (BP 110/70 supine and 90/60 standing) and reduced skin turgor. Lab data: serum K+ = 2 mEq/L; serum Na+= 138 mEq/L; HCO3− = 40 mEq/L.

1. What is the most likely cause of the patient's hypokalemia? Diuretic use 2. Which of her symptoms suggests hypokalemia? Mainly muscle weakness 3. What nursing interventions are indicated? Replace potassium, treat the cause: stop diuretics

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate do you program into the infusion pump?

125 mL/hr -To infuse 500 mL in 4 hours, set the rate at 125 mL/hr (500 ÷ by 4 = 125).

Nurse John Joseph is totaling the intake and output for Elena Reyes. a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice. 850 ml of water. 2 cups of beef broth. and 900 ml of half-normal saline solution and outputs 1.500 ml of urine during the shift. How many milliliters should the nurse document as the client's intake.

2470 -The fluid intake includes 8 oz (240 ml) of apple juice. 850 ml of water. 2 cups (480 ml) of beef broth. and 900 ml of I.V. fluid for a total of 2.470 ml intake for the shift.

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action?

Decrease the IV flow rate -When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of extracellular fluid volume excess. For patient safety the IV flow rate must be decreased immediately.

What is the correct order for discontinuing intravenous (IV) access? 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.

6, 4, 2, 1, 5, 3, 7 A health care provider's order is necessary before discontinuing IV access, unless there is a complication such as infiltration or phlebitis. Identifying the patient and explaining the procedure are performed before hand hygiene and glove application to maintain clean gloves. Removing the site dressing before stopping the infusion and then withdrawing the catheter keeps the vascular access device patent without forming a clot that could embolize during catheter withdrawal.

The client most at risk for metabolic alkalosis is:

A 30-year-old postsurgical client undergoing nasogastric suction Rationale: Removal of gastric acids may result in met- abolic alkalosis. The client unable to access water is at risk for fluid volume deficit and hypernatremia. The infant is at risk for fluid volume excess. The client experiencing a stroke is not at risk for a specific fluid, electrolyte, or acid-base imbalance.

Which patient is at most risk for hypomagnesemia?

A 55 year old chronic alcoholic -The correct answer is a 55 year old who is a chronic alcoholic. Patients who suffer from alcoholism have an increased secretion of magnesium and usually do not eat a proper diet, therefore, they are at risk for lower magnesium levels.

You assess four patients. Which patient has greatest risk for hypomagnesemia?

A 72-year-old with chronic alcoholism -Patients who have chronic alcoholism are at high risk for hypomagnesemia because of decreased magnesium intake and absorption and increased magnesium excretion.

Which patient below would have a potassium level of 5.5?

A patient with Addison's disease -A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl?

Auscultate dependent portions of the lungs -Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults.

Medication is given for bladder spasms?

B & O (belladonna alkaloids & powdered opium)

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?

Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output -The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells.

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressure, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?

Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output -The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells.

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?

Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output. The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal etc. It is a complicated physiological process because the Dextrose has unique capabilities when it is metabolized....although the solution is labeled as hypertonic it becomes a hypotonic solution when the Dextrose is metabolized by the cells.

A patient with tented skin turgor. dry mucous membranes. and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included the care plan of Mark for his patient?

Administering I.V. and oral fluids -The client's assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.

Which patient is at most risk for fluid volume deficit? A. A patient who has been vomiting and having diarrhea for 2 days. B. A patient with continuous nasogastric suction. C. A patient with an abdominal wound vac at intermittent suction. D. All of the above are correct.

All of the above are correct.

Which patient is at more risk for an electrolyte imbalance?

An 8 month old with a fever of 102.3 'F and diarrhea -The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.

Which of these patients do you expect will need teaching regarding dietary sodium restriction? A. An 88-year-old with a fractured femur scheduled for surgery B. A 65-year-old recently diagnosed with heart failure C. A 50-year-old recently diagnosed with asthma and diabetes D. A 20-year-old with vomiting and diarrhea from gastroenteritis

An 88-year-old with a fractured femur scheduled for surgery

Which question by a client hospitalized for a fluid volume deficit would require the nurse to investigate in more detail the probable cause of the dehydration? a. "Do I have to drink everything that is sent on my meal trays? I do not drink coffee or tea." b. "I have not had a bowel movement for 2 days. Can I get a laxative?" c. "I have tried to limit my sodium intake at home, but I am not very successful. Will I have to continue with this?" c. "I try to use the bathroom many times a day so that I will not have to get up through the night. Do you think this caused me to lose too much water?"

B: "I have not had a bowel movement for 2 days. Can I get a laxative?" -Chronic abuse of laxatives and/or enemas may lead to fluid loss in a client. Elderly clients are most at risk for this as their overall fluid composition to total body weight has decreased. The frequent or dependent use of laxatives or enemas may not be readily reported on admission.

A client is admitted to the hospital for dehydration related to a gastrointestinal viral illness. The client is also on an alcohol withdrawal protocol. He complains of his lips and mouth feeling numb and tingling. When the nurse observes the lab results from the morning, which result would provide an insight into this client's complaint? a. low sodium level b. low calcium level c. high magnesium level d. high potassium level.

B: Low calcium level. -Clients with a history of alcoholism are prone to hypocalcemia. The numbness and tingling of the lips and mouth (circumoral) are symptomatic of this and when coupled with muscle spasms are referred to as "tetany."

While assisting a new client from a wheelchair to a bed in the emergency room, the client complains of being dizzy. Which intervention by the nurse would be the best in this situation? a. assess peripheral pulses b. take an apical pulse c. assess for diuretic use d. assess blood pressure

D: Assess blood pressure. -Postural or orthostatic hypotension is a sign of hypovolemia. A drop of more than 15 mmHg in systolic blood pressure when changing positions (lying to sitting, sitting to standing) often indicates fluid depletion. Assessing for diuretic use may yield information that contributes to the problem, but directly assessing the blood pressure is an immediate response to an exhibited symptom.

A patient reports to a rheumatology clinic with a swan neck deformity of the fingers of the left hand and is referred for laboratory testing for systemic lupus erythematosus (SLE). The patient calls back several days later saying, "The healthcare provider must be wrong. This has to be arthritis like my mother has." What is the nurse's best response?

Explain that arthritis is not the only medical condition that can cause joint deformities

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?

Fluid that has sodium (salt) in it -Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?

Fullness of neck veins when supine -ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV neck veins are full when the individual is supine. With ECV deficit they are flat.

After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A. Magnesium level of 2.3 B. Phoshorus level of 2.0 C. Potassium level of 5.6 D. Potassium level of 2.2

Hypokalemia (normal potassium levels are 3.5 to 5.0) will present with these type of EKG findings

Which patient do you plan to teach regarding water restriction? A. A 23-year-old with extracellular fluid volume (ECV) deficit B. A 34-year-old with hyponatremia C. A 47-year-old with hypercalcemia D. A 69-year-old with metabolic acidosis

Hyponatremia involves excessive water for the amount of sodium in the blood; the body fluids are too dilute. Therefore water restriction is the most common therapy for hyponatremia.

The body fluids constituting the interstitial fluid and blood plasma are:

Hypotonic -Extracellular fluid is all the fluid outside of the cell and has three compartments.

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

In a client with hypocalcemia. a positive Trousseau's sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek's sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth. and muscle spasms in the extremities and face.

Which patient is at most risk for fluid volume deficient?

Increased blood pressure and crackles throughout the lungs -The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia.

A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment?

Increased blood pressure and crackles throughout the lungs -The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia.

Urinary incontinence:

Involuntary urination not a disease Acute, chronic, reversible or irreversible Age, women, smoking, DM, meds, etc Clinical manifestations Treatment

Bright-red blood with numerous clots in the urinary drainage bag for a pt. who had a TURP. After notifying the surgeon, what does the nurse do next?

Irrigate the catheter with normal saline per protocol

Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client's need to maintain skin integrity?

Keeping the linens dry and wrinkle free -Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues. helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.

Which medication would be appropriate to give to a patient with urinary calculi or ureteral stones?

Medications-thiazide diuretics help with Ca stones and Allopurinol helps with uric acid and gout

A practitioner progresses a patient's diet from clear liquid to full liquid. Which can the nurse include on the full liquid diet that is not included on the clear liquid diet?

Milk

In report from a transferring facility you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority?

Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions -As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?

Oliguria -Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia.

Khaleesi is admitted in the hospital due to having lower than normal potassium level in her blood stream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

Orange juice and bananas -The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium. along with raisins. apricots. avocados. beans. and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia

After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?

Potassium level of 2.2 -Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings.

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

Rationale: The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first?

Stop the infusion and discontinue the intravenous infusion -Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped, and the VAD removed as the highest priority

The nurse is educating a patient with systemic lupus erythematosus (SLE) about precipitating factors of the disease. Which precipitating factors should the nurse be sure to include when discussing them?

Sun exposure, hydralazine, and oral contraceptives

Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess?

Tented skin turgor and thirst -Hypernatremia refers to elevated serum sodium levels. usually above 145 mEq/L. Typically. the client exhibits tented skin turgor and thirst in conjunction with dry. sticky mucous membranes. lethargy. and restlessness. Muscle weakness and paresthesia are associated with hypokalemia

Which patient is at more risk for an electrolyte imbalance? A. A 5 year old with RSV B. An 8 month old with a fever of 102.3 'F and diarrhea C. A 55 year old diabetic with nausea and vomiting D. A healthy 87 year old with intermittent episodes of gout

The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer. Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect?

Third spacing -You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values.

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect?

Third spacing -You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values.

Maya. who is admitted in a hospital. is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?

Turn the client to the right side for 2 hours -When intervening with a client complaining of pain. the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with. not instead of. administration of pain medication. The nurse should medicate the client and not discourage medication.

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium?

Urine output -Increased potassium intake when potassium output is decreased is a major risk for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal.

A woman with advanced systemic lupus erythematosus (SLE) who suffers from profound kidney and lung dysfunction would like to become pregnant. Based on the nurse's knowledge of SLE, what can the nurse tell the patient?

Women with profound effects from SLE should not become pregnant."

Chvostek sign:

a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify early changes in the patient's postoperative fluid volume? (Select all that apply) a. Intake and output b. Skin turgor c. Lung sounds d. Respiratory rate e. Level of consciousness

a, b, c, d, e

Diagnostic test for fetal incontinence

anorectalmanometry

A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. What conclusion does the data support?

c. Hypernatremia

confusion, restlessness & agitation may result from what?

hypernatremia

clinical manifestation with hypocalcemia

trousseaus sign