ATI Fluid & Electrolytes
A nurse is assessing a client who is receiving TPN therapy via an infusion pump. WOTF actions should the nurse take? Obtain the client's BG q12hrs Change the IV tubing q24hrs Change the IV site dressing q4days Weight the client every other day
Change the IV tubing q24hrs.
A nurse is caring for four clients. After administering morning meds, she realizes the nifedipine prescribed for one client was inadvertently administered to another client. WOTF actions should the nurse take first? Notify the client's provider. Check their VS. Fill out an occurrence form. Administer the meds to the correct client.
Check their VS. R: The nurse should know nifedipine is to lower BP, therefore the nurse should check the pt to make sure they are not hypotensive.
A nurse is providing teaching to a client who has renal failure and an elevated phosphorus level. The provider instructed the client to take aluminum hydroxide 300mg PO tid. For WOTF adverse effects should the nurse inform the client? Constipation Metallic taste HA Muscle spasms
Constipation. R: constipation is a common side effect of aluminum-based antacids. The nurse should instruct the pt to inc fiber intake and that stool softeners/laxatives may be needed.
A nurse is caring for a 3yo child who has had 160mL of urine output over the past 8hr period. The child weighs 33lbs. WOTF actions should the nurse take? Notify the provider. Continue to monitor the client. Provide oral rehydration fluids. Perform a bladder scan at the bedside.
Cont to monitor the client. R: The urine output is WDL. A child's urine output should be >1mL/kg/hr.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. WOTF provides a reliable measure of fluid retention? Daily weight Sodium level Tissue turgor I&O
Daily weight
A nurse is assessing a client who has diabetes insipidus. WOTF findings should the nurse expect? Dehydration Polyphagia Hyperglycemia Bradycardia
Dehydration. R: DI can cause excess excretion of dilute urine, resulting in dehydration.
A nurse is reviewing the lab results of a client who is dehydrated. WOTF BUN lab values should the nurse report to the provider? 25 mg/dL 13 mg/dL 10 mg/dL 18 mg/dL
25mg/dL. R: Expected range is 10-20mg/dL.
A nurse is admitting a 6mo infant who has dehydration. WOTF amts of urinary output should indicate to the nurse that the tx has corrected the fluid imbalance? 0.5 mL/kg/hr 2 mL/kg/hr 7.5 mL/kg/hr 15 mL/kg/hr
2mL/kg/hr. R: The expected urinary output for infants up to 1yo is 2 mL/kg/hr.
A nurse is assessing four clients for fluid balance. The nurse should identify that WOTF clients is exhibiting manifestations of dehydration? A client who has a urine sp gr of 1.010. A client who has a weight gain of 2.2kg (2lbs) in 24hrs. A client who has a hematocrit of 45%. A client who has a temp of 39C/102F.
A client who has a temp of 39C/102F. R: A fever is a manifestation of dehydration.
A nurse is caring for a group of clients. The nurse should recognize that WOTF clients is at risk for Vit B6 deficiency? A client taking gabapentin as part of tx phenytoin for a seizure disorder. A client who has asthma. A client who has chronic alcohol use disorder. A client who takes heparin to prevent DVT.
A client who has chronic alcohol use disorder. R: Alcohol consumption destroys and inc elimination of B6.
A nurse is reviewing a client's lab values and discovers the client has a serum potassium of 6.2mEq/L. WOTF interventions should the nurse anticipate? Initiating an IV potassium infusion. Encouraging the client to eat bananas. Administering sodium polystyrene sulfonate. Administering a potassium-sparing diuretic.
Administering sodium polystyrene sulfonate. R: This absorbs excess potassium and excretes it through the stool. Other tx includes hemodialysis, IV glucose, and insulin.
A nurse is caring for a group of adolescents. WOTF findings should be reported to the provider immediately? A pt who is 1 day postop and has a temp of 37.5C/99.5F. A pt who has a burn injury to an estimated 5% of his leg and is crying. A pt's BP changes from 112/60mmHg to 90/54mmHg when standing. A pt who has an ankle fracture reports a pain level increase from 3 to 5 after amb.
BP change. R: A drop in systolic BP of >20mmHg or drop of diastolic of >10mmHg is orthostatic hypotension, which can be d/t hypovolemia.
A nurse in an ED is caring for an infant who has a 2-day hx of vomiting and an elevated temp. WOTF should the nurse recognize as the most reliable indicator of fluid loss? Body weight Skin integrity BP RR
Body weight.
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that WOTF findings indicate fluid volume excess? Bounding pulse Pitting edema Swelling at the IV site Urine sp gr >1.030 Crackles on auscultation
Bounding pulse, pitting edema, crackles on auscultation.
A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. WOTF items should the nurse offer the client? Broth Grape juice Nonfat milk Custard Lemon gelatin
Broth, grape juice, and lemon gelatin.
A nurse in a provider's office is reviewing the lab results of a client who takes furosemide for HTN. The nurse notes the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for WOTF complications? Cardiac dysrhytmias Hypoglycemia Seizures Neurogenic shock
Cardiac dysrhythmias. R: This is below the expected range, which can cause flattened T-waves, prominent U-waves, and S-T depression.
A nurse is caring for a client who has a postop ileus and an NGT that has drained 2500mL in the past 6hrs. WOTF electrolyte imbalances should the nurse monitor for? Inc sodium Dec potassium Inc magnesium Dec calcium
Dec potassium level. R: Hypokalemia occurs at <3.5mEq/L d/t diuretic use, diarrhea, vomiting, and prolonged NGT suctioning.
A nurse is reviewing the lab results of a client who has liver failure with ascites and is receiving spironolactone. WOTF findings should the nurse expect? Dec sodium level Dec phosphate level Dec potassium level Dec chloride level
Dec sodium levels. R: Spironolactone is a potassium-sparing diuretic that inhibits the action of aldosterone, resulting in an inc excretion of sodium.
A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. WOTF instructions should the nurse include? Take aspirin is HA develops Eat foods that contain plenty of potassium Expect some swelling in the hands and feet Take the med at bedtime.
Eat foods that contain plenty of potassium. R: Furosemide, a high-ceiling loop diuretic, can cause potassium loss. Encourage nuts, dried fruits, bananas, and citrus fruits.
A home health nurse is making a visit to a client who takes a daily diuretic for HF. WOTF manifestations should the nurse identify as indicating the client is hypokalemic? Pitting edema Fatigue Dyspnea Oliguria
Fatigue. R: muscle weakness accompanies hypokalemia.
A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. WOTF scheduled meds should the nurse plan to administer? Lisinopril Digoxin Furosemide Potassium iodine
Furosemide. R: This results in loss of potassium from the nephron as part of its diuretic effect. This med can be given when a pt has an inc potassium level to lower it.
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. WOTF findings should the nurse expect? Hypothermia Protruding eyeballs Elevated BP Furrows in the tongue
Furrows in the tongue.
A nurse is preparing to administer KCl to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2mEq/L. WOTF actions should the nurse take? Give the ordered KCl as prescribed. Omit the KCl dose and document that it was not given. Hold the dose and notify the provider of the potassium level. Call the lab to verify the results.
Give the ordered KCl as prescribed. R: The pt is hypokalemic, therefore the nurse should give as prescribed.
A nurse is caring for a client who has a prescription for a clear liquid diet. WOTF foods should the nurse allow the client to have? Grape juice Lemon sherbet Milkshake Vanilla ice cream
Grape juice. R: CLD includes apple/grape juices, broth, black coffee, and plain gelatin.
A nurse is reviewing the lab test results from a client who has prerenal acute kidney injury (AKI). WOTF electrolyte imbalances should the nurse expect? Hyperkalemia Hypernatremia Hypercalcemia Hypophosphatemia
Hyperkalemia. R: AKI is a loss of renal function that results in failure to maintain homeostasis, and thus acid-base balance. The nurse should expect hyperkalemia d/t the kidneys inability to filter and excrete potassium.
A nurse is caring for a client who has HF and is receiving IV furosemide. The nurse should monitor the client for WOTF electrolyte imbalances? Hypernatremia Hyperuricemia Hypercalcemia Hyperchloremia
Hyperuricemia. R: The nurse should instruct the pt to notify them of any tenderness or swelling of the joints.
A nurse is caring for a client who has HF and a new prescription for furosemide. For WOTF adverse effects should the nurse monitor? Hypervolemia HTN Hypokalemia Hypoglycemia
Hypokalemia.
A nurse is assessing a client who has fluid volume deficit. The nurse should expect WOTF findings? Dec urine sp gr Dec Hgb Inc BUN Inc urine ketones
Inc BUN. R: Inc BUN is expected in FVD d/t hemoconcentration of substances in the blood from excess water loss.
A nurse is assessing a client who has fluid overload. WOTF findings should the nurse expect? Inc HR Inc BP Inc RR Inc HCT Inc temp
Inc HR, Inc RR, Inc BP. R: Inc cardiac contractility, bounding pulse, and inc RR/crackles heard in lungs with excess fluid.
A nurse in an ED is assessing an infant who is dehydrated. WOTF findings should the nurse expect? Irritability Slow, bounding pulse Dec temp Tetany
Irritability. R: The pt would exhibit tachycardia and inc temp. Tetany is a manifestation of hypoglycemia.
A nurse is reviewing the lab results of a client who takes furosemide. WOTF results should the nurse identify as the priority finding? K 2.9 mEq/L Phosphorus 4.5 mEq/L Na 145 mEq/L Ca 8.2 mg/dL
K 2.9mEq/L. R: This pt is hypokalemic, as the expected range is 3.5-5mEq/L. This can be life-threatening.
A nurse is assessing a client who has a sodium level of 116 mEq/L. WOTF findings should the nurse expect? N&V Extreme thirst Flushed skin Fever
N&V. R: This indicates hyponatremia. N&V is expected.
A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. WOTF findings should the nurse recognize as a potential causative factor? Client is currently prescribed spironolactone. Client has a hx of alcohol abuse. Client reports drinking 3.5-4L water/day. Client has an NGT to gastric suction.
NGT to gastric suction. R: A pt w/an NGT has an inc risk for developing hypokalemia d/t GI loss of potassium.
A nurse is assessing a client who has a urine output of 250mL in a 24hr period. WOTF terms should the nurse place in the client's EHR? Enuresis Anuria Nocturia Oliguria
Oliguria. R: Oliguria: 100-400mL in 24hr. Anuria: <100mL.
A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing WOTF types of fluids? Broth Water Diluted apple juice Oral rehydration solution
Oral rehydration solution. R: this is the fluid of choice for infants and children who have dehydration d/t diarrhea.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. WOTF findings should the nurse expect? Poor skin tugor Bradycardia Hypotension Pale yellow urine Flat neck veins
Poor skin turgor, hypotension, and flat neck veins.
A nurse is reviewing the serum lab findings for a client who has HTN and is prescribed hydrochlorothiazide. WOTF findings should the nurse report to the provider? Sodium 136 mEq/L Potassium 2.3 mEq/L Chloride 99 mEq/L Calcium 10 mg/dL
Potassium 2.3 mEq/L. R: A potassium below 3 mEq/L is hypokalemia.
A nurse is caring for a client who has HF and a new prescription for furosemide. WOTF lab values should the nurse review before administering furosemide? Bicarbonate CO2 Potassium Phosphate
Potassium. R: Furosemide is a loop diuretic and promotes excretion of potassium.
A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit WOTF nutrients? Protein Calcium Calories Phosphorus Sodium
Protein, phosphorus, and sodium.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. WOTF is the priority nursing assessment for this client? Temp Fetal heart rate Bowel sounds RR
RR. R: Magnesium sulfate is typically administered to a pt in preterm labor to achieve the tocolytic (uterine relaxation) effect. This depresses the CNS and causes respiratory depression.
A nurse is caring for a client who has SIADH and a sodium level of 123 mEq/L. WOTF prescriptions should the nurse anticipate? Maintain an IV of 0.45% NaCl. Restrict fluid intake to 1000mL/day. Provide a diet containing 2g of Na/day. Provide a diet containing 2g of Na/day. Administer desmopressin acetate 0.2mg orally.
Restrict fluid to 1000mL/day. R: SIADH results in excess fluid volume, which dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood.
A nurse is reviewing a client's lab results. WOTF lab values should the nurse report to the provider? Sodium 126 mEq/L Potassium 3.6 mEq/L Magnesium 1.9 mEq/L Chloride 99 mEq/L
Sodium 126 mEq/L. R: sodium levels should be 136-145 mEq/L.
A nurse is reviewing the lab test results of a client who is scheduled for a carotid endarterectomy in 3 days. WOTF results should the nurse report to the provider? Sodium 151 mEq/L Chloride 105 mEq/L Potassium 3.8 mEq/L Calcium 9.6 mEq/L
Sodium 151mEq/L. R: This is hypernatremia. The normal range is 136-145mEq/L.
A nurse is assessing a client who has diabetes insipidus. WOTF findings is a manifestation of this diagnosis? HTN Bounding peripheral pulses Tachycardia Hyperglycemia
Tachycardia. R: This is d/t dehydration from fluid loss.
A nurse is caring for four hospitalized clients. WOTF clients should the nurse identify as being at risk for FVD? The client who has been NPO since midnight for endoscopy. The client who has left-sided HF and has a brain natriuretic peptide (BNP) level of 600pg/mL. The client who has EDRF and is scheduled for dialysis today. The client who has gastroenteritis and is febrile.
The client who has gastroenteritis and is febrile. R: Both are risk factors for FVD (dehydration).
A nurse is caring for a client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. WOTF data is priority for the nurse to asses? The coping ability of the client. The client's bowel sounds 24-48. The surgical dressing. The patency of the NG tube.
The surgical dressing. R: Hemorrhage is a major complication postop, so the nurse should assess for early indications of bleeding - visible blood stains on the dressing, rapid, thready pulse, tachycardia, and dec urine output.
A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. WOTF findings should the nurse expect? Tingling of the extremities Hypoactive DTR Shortened QT intervals Constipation
Tingling of the extremities. R: 7.6 mEq/L indicates hypocalcemia. A thyroidectomy inc risk of parathyroid injury which can lead to hypocalcemia. Expect tingling/numbness of the extremities and around the mouth, muscle tremors, cramps, and cardiac dysrhythmias.
A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. WOTF foods should the nurse instruct the client to avoid? Green beans Tomatoes Bananas Asparagus Raisins
Tomatoes, bananas, raisins.
A nurse administers desmopressin to a client who has a diagnosis of DI. The nurse recognizes that WOTF lab findings indicate a therapeutic effect of the medication? Serum Na 146mEq/L BG 80mg/dL Urine sp gr 1.015 BUN 15mg/dL
Urine 1.015. R: This is WDL 1.010-1.025.
A nurse is caring for a client who has impaired renal function. For WOTF findings should the nurse notify the provider? Urine output of 175mL in the past 8hrs. Urine output of 2200mL in the past 24hrs. First-voided urine in the morning has a strong odor. Urine is cloudy after sitting in the urinal for 6hr.
Urine output of 175ml/8hrs. R: The nurse should notify the provider if the pt's urinary output is <30ml/hr. This indicates a fluid imbalance, dec circulatory fluid volume, and possibly inadequate renal perfusion.
A nurse is caring for a client who has a prescription for potassium chloride 20 mEq PO daily. The nurse reviews the client's most recent lab results and finds the client's potassium level is 5.2mEq/L. WOTF actions should the nurse take? Give the ordered KCL as prescribed. Omit the KCL dose and document it was not given. Call the doc and inform her of the results. Call the lab to verify the client's results.
Call the doc and inform her of the results. R: As the pt is hyperkalemic, the nurse should hold the med and notify the doc.
A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. WOTF interventions should the nurse include in the plan of care? Monitor the client's I&O q6hrs. Offer the client 240mL/8oz of oral fluids q4hrs. Check the client's IV infusion q8hrs. Administer furosemide to the client.
Check the client's IV infusion q8hrs.
A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. WOTF interventions should the nurse include in the plan of care? Measure BG q4hrs. Administer a diuretic. Initiate fluid restrictions. Check urine spec gravity.
Check urine specific gravity. R: The nurse should check this to monitor urine concentration. The nurse should expect >1.005.
A nurse is caring for a client who is postop following abd surgery. The surgeon initially prescribes a clear liquid diet. WOTF items should the nurse include on the client's lunch tray? Lemon sherbet Plain yogurt Cranberry juice Carrot juice
Cranberry juice.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. WOTF instructions should the nurse include in the teaching? Drink 3L of fluid every day. Take 3000mg of Vit C daily. Restrict calcium intake to 1 serving/day. Eat 12oz of animal protein/day.
Drink 3L of fluid every day. R: Drinking 3-4L of fluid/day dilutes the urine and reduces the risk of stone formation.
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. WOTF assessments is an indication that the client might be experiencing circulatory overload? Flushing Dyspnea Bradycardia Vomiting
Dyspnea. R: CO cause dyspnea, cough, rales, tachycardia, and JVD.
A nurse is caring for a client who is receiving IV fluids to correct dehydration. WOTF laboratory values should indicate to the nurse that the client is effectively responding to treatment? Sodium 165 mEq/L Potassium 5.2 mEq/L Urine sp gr 1.020 Hct 62%
Urine sp gr 1.020. R: In cases of FVD or dehydration, the Hct is elevated d/t hemoconcentration, which is an indication of dehydration. For men the range is 42-56% and women 37-47%.
A nurse is assisting with the care of a newborn immediately following birth. WOTF meds should the nurse anticipate administering? Vit K injection Hep B immunization Antibiotic ointment to both eyes Lidocaine gel to the umbilical stump Hib immunization
Vit K injection, Hep B immunization, antibiotic ointment to both eyes.
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? Dec HR Dyspnea Inc BP Weak pulse
Weak pulse. R: A dec volume of circulating blood and less pressure w/in the vessels results in weak peripheral pulses (thready).
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. WOTF findings should the nurse expect? Hyperactive reflexes Extreme thirst Weak, irregular pulse Hyperactive bowel sounds
Weak, irregular pulse. R: Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.
A nurse is teaching a client who has a new prescription for NPH insulin. WOTF instructions should the nurse include? "Discard the medication if it is cloudy." "Briskly shake the medication before filling the syringe." "Take this med 15 mins before meals" "Eat a snack 8 hrs after taking this med."
"Eat a snack 8hrs after taking this med." R: NPH peaks 6-14hrs after dosing, during which the pt is at most risk for hypoglycemia.
A nurse is teaching a client who has acute kidney disease about fluid restrictions. WOTF statements by the client should the nurse identify as understanding of the teaching? "I should consume most of the fluid during the evening." "I will make a list of my favorite beverages." "I will put beverages in large containers to give the appearance of drinking a lot." "I will not add ice cream to the amount of fluid intake."
"I will make a list of my favorite beverages." R: The nurse should work with the pt to develop a schedule for fluid restrictions and should attempt to include the pt's favorites to promote satisfaction.
A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. WOTF instructions should the nurse include? "Inc intake of dietary phosphorus". "Eliminate foods high in protein from your diet". "Reduce intake of foods high in potassium". "Inc intake of sodium-containing food".
"Reduce intake of foods high in potassium". R: Potassium clearance is impaired in a pt w/end stage kidney disease.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy d/t NPO status. WOTF solutions should the nurse prepare to infuse? Lactated Ringer's Dextrose 5% in 0.9% NaCl 0.45% NaCl Dextrose 10% in water
0.45% NaCl. R: A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% NaCl or 0.225% NaCl.
A nurse is caring for a client who is receiving TPN. The nurse notices the solution bag is almost empty and there is not another bag of TPN to administer. WOTF IV solutions should the nurse administer until the next bag of TPN is available? 10% Dextrose in water 0.45% NaCl Lactated Ringer's solution 5% Dextrose in Lactated Ringer's solution
10% Dextrose in water. R: TPN has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if another bag of TPN is unavailable.
A nurse is admitting a client who is dehydrated. WOTF BUN levels should the nurse expect the client to have upon admission? 3.1 mg/dL 10 mg/dL 16.5 mg/dL 35 mg/dL
35mg/dL. R: Pts w/dehydration can have dec bl flow, which leads to dec renal excretion of BUN. Other causes: GI bleeding, HF, burns, shock, and MI. Dehydration inc BUN.
A nurse is monitoring the urinary output of an adult client who had a colon resection. WOTF 24hr output totals indicates oliguria? 720mL 550mL 380mL 600mL
380mL. R: Oliguria is <400mL or <30mL/hr.
A nurse is reviewing the lab results of a client who has fluid volume deficit. The nurse would expect WOTF findings? Urine specific gravity 1.035. HCT 44%. BUN 19 mg/dL. Na 155 mEq/L.
A client experiencing fluid volume deficit would have a urine specific gravity >1.030.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. WOTF abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U-waves Elevated ST segment Wide QRS Inverted P wave
Abnormally prominent U-wave. R: U-waves are rare, but associated w/hypokalemia, HTN, and heart disease. A pt w/hypokalemia may have a flattened T-wave, prolonged PR interval, prominent U-wave, or ST depression.
A nurse is preparing to measure an infant's vital signs. The nurse should use WOTF sites to assess a heart rate? Carotid artery Apex of the heart Brachial artery Radial artery
Apex of the heart.
A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium? Bananas Cooked carrots Cheddar cheese 2% milk
Bananas. Rationale: 1c bananas = 806mg potassium. Recommend orange juice and spinach as well.
A nurse in the ED is caring for a client who collapsed after playing football on a hot day. After reviewing the admission lab findings, the nurse recognizes these findings are consistent with WOTF? Renal failure. Low-protein diet. Dehydration. SIADH.
Dehydration. R: Hypernatremic (hypertonic) dehydration occurs w/excess fluid loss d/t perspiration, respiration, and inadequate fluid intake. The sodium is elevated, while glucose, potassium, BUN, chloride, and creatinine are WDL.
A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve WOTF conditions? Electrolyte imbalance Diarrhea Constipation Delayed gastric emptying
Diarrhea.
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His BUN is 32mg/dL, creatinine 1.1mg/dL, and hematocrit 50%. WOTF nursing interventions is appropriate? Collect a urine specimen for C&S. Cont routine care because the results are WDL. Dec the IV fluid infusion rate and limit oral fluid intake. Evaluate urine for amt and for specific gravity.
Evaluate urine for amt and for specific gravity. R: These results indicate the pt is dehydrated. The higher the specific gravity, the more dehydrated the pt is.
A nurse is caring for a client who has ESKD and reports having SOB and swelling in his LE. Upon assessment, the nurse notes the client has crackles in his lungs and an inc BP. The nurse should suspect wotf based on the client's manifestations? Hypovolemia Hypervolemia Hyperkalemia Hyponatremia
Hypervolemia. R: A client w/ESKD experiences excess fluid volume. The inc in fluid cause HTN and anemia and ultimately causes HF. Dyspnea, crackles, and edema indicates HF.
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For WOTF electrolyte imbalances should the nurse monitor? Hypermagnesemia Hypokalemia Hyperkalemia Hypomagnesemia
Hypokalemia. R: Corticosteroid use can lead to hypokalemia, which includes muscle weakness and cardiac arrythmias.
The nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. WOTF findings should the nurse expect during the initial assessment? Lethargy Hyperactive DTR Prolonged ST segment Hyperactive bowel sounds
Lethargy. R: 12.3 mg/dL is hypercalcemia. The nurse should monitor for lethargy, generalized weakness, and confusion.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35mL of urine/hr. The nurse should place the client on WOTF diets? Low-sodium, fluid-restricted Regular diet, no added salt Low-carb, low-protein Low-protein, low-potassium
Low-sodium, fluid-restricted.
A nurse is collecting the medical history from a client who has manifestations of SIADH. The nurse should ask the client if he has a hx of WOTF conditions that can cause SIADH? OA Lung cancer Liver cirrhosis Dyspepsia
Lung cancer. R: Some of the tx options for small cell lung cancer can cause secretion of ADH. This results in the body retaining water and can cause SIADH s/s.
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. WOTF findings should the nurse expect? Dry, sticky mucous mb Polyuria Negative Chvostek's sign Muscle tremors
Muscle tremors. R: This is hypocalcemia, which can include muscle tremors and cramps -> tetany, convulsions.
A nurse is caring for four clients who have drainage tubes. WOTF clients should the nurse recognize as being at risk for hypokalemia? Tracheostomy tube attached to humidified O2. Indwelling urinary catheter to gravity drainage. Chest tube to water seal. NGT to suction.
NGT to suction. R: When attached to suction, an NGT will remove gastric contents (which are high in electrolytes - especially potassium), which puts pt at risk for hypokalemia.
A nurse is caring for a client who has HTN and has a potassium level of 6.8mEq/L. WOTF actions should the nurse take? Suggest the client use a salt substitute. Obtain a 12-lead ECG. Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level.
Obtain a 12-lead ECG. R: This pt is hyperkalemic and at risk for dysrhythmias as well as cardiac arrest.
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this med is effective, the nurse should expect WOTF changes on the client's WCG? Reduction of T-wave amplitude. Shortening of P-wave duration. Widening of the QRS complex. Restoration of QRS complex amplitude.
Reduction of T-wave amplitude. R: Polystyrene sulfonate should bring the potassium level back to the expected range of 3.5-5.0 mEq/L. Hyperkalemia cause peaked T-waves and sometimes a widened QRS, so resolution of the imbalance should restore this.
A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes WOTF as a manifestation of hypokalemia? Shallow respirations Hypertensive crisis Diarrhea Hyperreflexia
Shallow respirations. R: hypokalemia causes weakness in the accessory muscles of breathing.
A nurse is caring for a client who requires TPN. WOTF actions should the nurse take when finding that the TPN solution is infusing too rapidly? Turn the client on his left side Sit the client upright Prepare to add insulin to the TPN infusion Stop the TPN infusion
Sit the client upright. R: Fluid overload can cause dyspnea. The nurse should slow the infusion rate and sit the client upright to help prevent or treat dyspnea. Administer O2 if necessary.
A nurse is performing an admission assessment on a client. WOTF findings should the nurse identify as an indication that the client is dehydrated? Low body temp JVD Skin tenting present BP 178/90mmHg
Skin tenting present. R: Indication of poor skin tugor.
A nurse is caring for a 3yo child who was admitted with acute diarrhea and dehydration. WOTF findings indicates that oral rehydration therapy has been effective? HR 130/min RR 24/min Urine sp gr 1.015 Cap refill >3secs
USG 1.015. R: 1.010-1.025 is WDL.
