Chapter 11 Assessment and Care of Patients with Fluid and Electrolyte Imbalances

• What are some potassium sparing diuretics?

spironolactone (Aldactone),l triamteren (Dyrenium) and amiloride (Midamor)

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? 1 Calcium level of 9.5 mg/dL 2 Magnesium level of 4.1 mEq/L 3 Potassium level of 6.0 mEq/L 4 Sodium level of 120 mEq/L

1 Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this client to an LPN/LVN. A magnesium level of 4.1 mEq/L, potassium level of 6.0 mEq/L, and a sodium level of 120 mEq/L are abnormalities in electrolytes that can cause serious complications and will require assessments and/or interventions by the RN.

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? 1 Client behavior that changes from anxious and restless to lethargic and confused 2 Deep furrows on the surface of the tongue 3 Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched 4 Urine output of 950 mL for the past 24 hours

1 Client behavior that changes from anxious and restless to lethargic and confused The client's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

Which situation can cause a client to experience "insensible water loss"? Select all that apply. 1 Diarrhea 2 Dry, hot weather 3 Fever 4 Increased respiratory rate 5 Nausea 6 Mechanical ventilation

1 Diarrhea 2 Dry, hot weather 3 Fever 4 Increased respiratory rate 6 Mechanical ventilation Insensible water loss occurs through the intestinal tract as diarrhea. It can be caused and/or influenced by dry, hot weather. Insensible water loss occurs through the skin, lungs (increased rate of respirations), and intestinal tract. It is increased in clients who are mechanically ventilated, and it is increased by the presence of fever. Nausea with no accompanying vomiting would not cause insensible water loss.

To safely administer potassium to a client with hypokalemia, which actions does the nurse perform? Select all that apply. 1 Establish and evaluate the patency of a large vein. 2 Obtain an IV controller device (pump). 3 Plan to assess the respiratory rate and oxygen saturation every hour. 4 Evaluate the heart rate and regularity. 5 Encourage the client to ambulate independently to relieve muscle cramps. 6 Prepare to administer potassium IV push to reduce the risk of infiltration.

1 Establish and evaluate the patency of a large vein. 2 Obtain an IV controller device (pump). 3 Plan to assess the respiratory rate and oxygen saturation every hour. 4 Evaluate the heart rate and regularity. To safely administer potassium, the nurse should ensure the client has good IV access, obtain a controller to tightly regulate the infusion rate at no greater than 10 mEq of potassium per hour, and evaluate the client's respiratory status (as respiratory insufficiency is the major cause of death). Pulse irregularities (rapid to slow and irregular) may occur with changes in serum potassium levels and should be evaluated. Clients with hypokalemia have skeletal muscle weakness, so fall precautions should be implemented, and the client should have assistance with ambulation. Potassium should never be given IV push, as it will result in cardiac arrest.

How is isotonic dehydration defined? 1 Fluids and electrolytes are lost from the body in equal amounts. 2 Fluids are lost from the body in greater quantities than electrolytes. 3 Electrolytes are lost from the body in greater quantities than fluids. 4 Fluids and electrolytes are lost from the body, but only water is used to replace losses.

1 Fluids and electrolytes are lost from the body in equal amounts. Isotonic dehydration is when fluids and electrolytes are lost in equal quantities. Hypertonic dehydration occurs when fluids are lost in greater quantities than electrolytes. Hypotonic dehydration occurs when electrolytes are lost in greater quantities than fluids, or when fluid and electrolyte losses are replaced by water only.

A client's electrocardiogram demonstrates a heart rate of 52 beats/min, prolonged PR interval with widened QRS complex, and the client is also hypotensive. The nurse reviews the morning labs for which conditions? 1 Hyperkalemia, hypercalcemia, hypermagnesemia 2 Hypokalemia, hypocalcemia, hypermagnesemia 3 Hypocalcemia, hyperkalemia, hypernatremia 4 Hypernatremia, hypercalcemia, hypophosphatemia

1 Hyperkalemia, hypercalcemia, hypermagnesemia Cardiovascular changes are consistent with elevated potassium, calcium, and magnesium. These signs and symptoms may progress to life-threatening cardiac emergency. Although hypocalcemia can interfere with cardiac contractility, hypokalemia and hypophosphatemia do not.

A client is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? 1 Hypernatremia 2 Hypomagnesemia 3 Hypercalcemia 4 Hyperphosphatemia

1 Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).

Which drug therapies might be used to manage symptoms of hypocalcemia? Select all that apply. 1 Magnesium sulfate 2 Calcium chloride 3 Potassium chloride (K-Dur) 4 Vitamin D (Calcitrol) 5 Zinc sulfate (Zinc 220) 6 Vitamin E (alpha tocopherol)

1 Magnesium sulfate 2 Calcium chloride 4 Vitamin D (Calcitrol) Magnesium sulfate may be used to manage neuromuscular symptoms of hypocalcemia. Calcium supplements are given to restore serum calcium levels. Vitamin D enhances the absorption of oral calcium. Potassium, zinc, and vitamin E are not indicated for the management of hypocalcemia.

A client has had a total urine output of 200 mL in the past 24 hours. Which priority action does the nurse take? 1 Notify the primary health care provider. 2 Encourage the client to drink more fluids. 3 Take no action because this is a normal urinary output. 4 Insert an indwelling urinary catheter.

1 Notify the primary health care provider. The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. With a urine output of 200 mL in 24 hours, a toxic buildup of nitrogen and lethal electrolyte imbalances can occur. The primary health care provider should be notified because additional tests or orders might be necessary. Encouraging the client to drink more fluids may be necessary once the underlying cause of the decreased urine output (oliguria) is determined. Inserting an indwelling urinary catheter may be indicated, but not before speaking with the provider.

Which intervention does the nurse include in caring for a client with generalized edema who is receiving a loop diuretic? 1 Turning the client every 2 hours. 2 Encouraging oral fluids. 3 Restricting dietary potassium. 4 Applying antiembolism stockings.

1 Turning the client every 2 hours. The client with generalized edema/fluid overload is at risk for developing skin breakdown, especially at pressure points over bony prominences. Changing position frequently reduces this risk. Fluids are more likely to be restricted with fluid overload, not encouraged. Loop diuretics cause potassium loss so dietary potassium is encouraged, not restricted. Antiembolism hose have no role in generalized edema from fluid overload.

The client with fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which changes indicate to the nurse that the diuretic resulted in overdiuresis? Select all that apply. 1 Weight loss of 9 pounds 2 Reports of lightheadedness when first standing from a lying position 3 Heart rate decrease from 80 to 72 beats/min 4 Heart rate increase from 70 to 96 beats/min 5 Respiratory rate decrease from 20 to 16 breaths/min 6 Morning blood glucose decrease from 142 mg/dL to 110 mg/dL 7 Reports of fatigue

1 Weight loss of 9 pounds 2 Reports of lightheadedness when first standing from a lying position 4 Heart rate increase from 70 to 96 beats/min 7 Reports of fatigue Diuretic drugs cause water loss and are often prescribed for edema. One liter of water weighs 2.2 pounds. Weight loss is expected when the client gets rid of excess water. If the prescribed diuretic is overly effective, too much water may be excreted by the kidneys and signs of dehydration from overdiuresis may occur. A weight loss of 9 pounds is approximately 4 liters of fluid. Lightheadedness when changing positions may suggest orthostatic hypotension. Other signs of too much fluid loss include an increase in heart rate and fatigue. The decrease in heart rate and respiratory rate would suggest the diuretic was effective.

When administering 20 mEq potassium chloride intravenously (IV), which is the priority intervention? 1 Monitor for pain or burning at the IV infusion site. 2 Administer at a rate of 10 mEq/hr. 3 Monitor respiratory rate and depth. 4 Place the client on a heart monitor during administration.

2 Administer at a rate of 10 mEq/hr. The maximum recommended infusion rate is 5-10 mEq/hr to avoid potentially lethal cardiac dysrhythmias. Monitoring for pain at the IV infusion site, assessing respiratory rate and depth, and placing the client on a heart monitor are all appropriate options, but because a rapid rate of administration could have lethal effects, it has the greatest priority.

What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Select all that apply. 1 Decreased deep tendon reflexes without paresthesia 2 Awakening at night with muscle spasms in the calf 3 Recent blunt trauma to the throat during a football game 4 Absent bowel sounds 5 Tingling around the mouth

2 Awakening at night with muscle spasms in the calf 3 Recent blunt trauma to the throat during a football game 5 Tingling around the mouth A history of anterior neck injury may be associated with hypocalcemia. Symptoms of hyporcalcemia include "charley horses" in the calf during rest or sleep, and tingling in the lips. Hypocalcemia does not affect bowel sounds. Decreased deep tendon reflexes without paresthesia is a neuromuscular change in hypercalcemia.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply. 1 Blood serum glucose 2 Blood pressure 3 Pulse rate and quality 4 Urinary output 5 Urine specific gravity levels

2 Blood pressure 3 Pulse rate and quality 4 Urinary output 5 Urine specific gravity levels The two most important areas to monitor during rehydration are pulse rate and quality and urine output; however, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is also important to monitor during rehydration. Blood glucose changes do not have a direct relation to a client's rehydration status.

Which electrolyte imbalance does the nurse anticipate in association with a serum magnesium reading of 1.1 mEq/L? 1 Potassium 5.7 mEq/L 2 Calcium 7.8 mg/dL 3 Sodium 149 mEq/L 4 Phosphorus 2.6 mg/dL

2 Calcium 7.8 mg/dL Hypocalcemia often occurs with hypomagnesemia. A calcium level of 7.8 mg/dL is low. A sodium level of 149 mEq/L is slightly elevated, but not related to the low magnesium level. A phosphorus level of 2.6 mg/dL is slightly low, but not related to hypomagnesemia.

Which nursing action does the nurse include in the care of an alert older adult who is mildly dehydrated? 1 Advising the client and family that strict bed rest is recommended due to fall risk. 2 Considering dietary restrictions and ability to swallow, and offering oral fluids every 2 hours. 3 Restricting oral fluids if the client is incontinent. 4 Assessing weight and vital signs every 4 hours.

2 Considering dietary restrictions and ability to swallow, and offering oral fluids every 2 hours. Oral fluid replacement is a priority when correcting mild to moderate dehydration in an alert client who can swallow. Because risk for falls is increased, the client should be offered assistance when ambulating. Bedrest is not recommended and may even contribute to other complications. Oral fluids should not be withheld due to incontinence. Initially, it is recommended to assess vital signs every 2 hours and weigh the client every 8 hours.

As adults age, which common physiologic change is likely to alter their hydration status? 1 Adrenal gland growth 2 Decreased muscle mass 3 Increased thirst mechanism 4 Poor skin turgor

2 Decreased muscle mass Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Adrenal growth is not a common age-related change. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status.

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? 1 Draws blood for laboratory tests 2 Elevates the head of the bed 3 Places the extremities in a dependent position 4 Puts the client in a side-lying position

2 Elevates the head of the bed Elevating the head of the bed will ease breathing for the client, so it should be done first. Although drawing blood for laboratory tests may be indicated, the nurse should perform interventions that will help with physiological changes caused by fluid overload first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.

Laboratory results report a client's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the client? 1 Level of consciousness 2 Heart rate 3 Bowel sounds 4 Feet for paresthesias

2 Heart rate Cardiovascular changes, specifically bradycardia; tall, peaked T waves; rhythm changes to complete heart block; asystole; and ventricular fibrillation are life-threatening consequences of elevated potassium. The provider or Rapid Response Team may need to be notified if changes in heart rate and rhythm are assessed. Paresthesias in the arms and feet and increased intestinal motility are lower-priority signs of elevated potassium. Level of consciousness would not be affected.

Which drain can be used after surgery as a closed wound drainage system? 1 T-tube 2 Hemovac 3 Penrose drain 4 Negative pressure wound device

2 Hemovac The health care provider uses a drain in the wound if greater than normal drainage is expected. A Hemovac drain is a closed wound drainage system. A T-tube is a specialty drain used for specific draining purposes, such as draining bile after a cholecystectomy. A Penrose drain is an open, gravity-type of drain system. A negative pressure wound device is used for chronic wounds or wounds that heal more slowly.

When assessing the laboratory results of a client who has hypomagnesemia, for which additional electrolyte imbalance should the nurse monitor? 1 Hyperkalemia 2 Hypocalcemia 3 Hypernatremia 4 Hypophosphatemia

2 Hypocalcemia Hypocalcemia often occurs with hypomagnesemia, so the nurse would monitor for signs and symptoms of low calcium levels. Hypomagnesemia may increase potassium secretion in certain circumstances, leading the health care provider to be aware that replacement of magnesium is crucial before attempting to replace potassium if the client is deficient in both. Hypernatremia and hypophosphatemia are not related to hypomagnesemia.

Which medication may affect the assessment of a client's fluid balance after a surgical intervention? 1 Penicillin twice a day 2 Digoxin once a day 3 Angiotensin-converting enzyme inhibitor twice a day 4 Aspirin once a day

3 Angiotensin-converting enzyme inhibitor twice a day Urine output is used as an indicator of perfusion adequacy after surgery or other procedures. Medications used to manage hypertension such angiotensin-converting enzyme (ACE) inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine. This may make it harder to use urine output as a primary measure of perfusion. Aspirin may prolong clotting. Penicillin and digoxin will not affect monitoring fluid balance postprocedure.

Which drug is used to reverse a benzodiazepine overdose in a postoperative client? 1 Midazolam (Versed) 2 Bupivacaine (Marcaine) 3 Flumazenil (Romazicon) 4 Lorazepam (Ativan)

3 Flumazenil (Romazicon) Clients receiving moderate sedation with a benzodiazepine may sometimes become overly sedated or have respiratory depression. Flumazenil (Romazicon) is the choice of drug for reversal of its sedating effects. Lorazepam and midazolam are also benzodiazepines and cannot reverse its sedative action. Bupivacaine is used in managing pain in postoperative clients.

Which electrolyte imbalance should be anticipated and monitored in a client with hyperphosphatemia? 1 Hypernatremia 2 Hypokalemia 3 Hypocalcemia 4 Hypermagnesemia

3 Hypocalcemia Phosphorus and calcium have an inverse or reciprocal relationship. When one is increased, the other is usually decreased. Therefore, a client with hyperphosphatemia should be monitored for hypocalcemia. Hyperphosphatemia does not cause hypernatremia, hypokalemia, or hypermagnesemia.

A client reports painful muscle spasms in the lower legs at rest, a tingling sensation in the hands and lips, and abdominal cramping and diarrhea. The nurse reviews the client's laboratory results for the presence of which disorder? 1 Hypophosphatemia 2 Hypermagnesemia 3 Hypocalcemia 4 Hypernatremia

3 Hypocalcemia The primary symptoms of hypocalcemia are neuromuscular changes, specifically painful muscle cramps, and paresthesias that may spread to the face, progressing to tetany. Abdominal cramping and diarrhea may also occur. Muscle spasms in lower legs at rest, tingling sensation in the hands and lips, and abdominal cramping and diarrhea are not primary characteristics of hypernatremia, hypermagnesemia, or hypophosphatemia.

A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working? 1 Decreased blood pressure (BP) 2 Increased heart rate 3 Increased urine output 4 Weight gain

3 Increased urine output When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the most important assessment to be monitored. Urinary output is most important. Lasix may cause a decrease in heart rate as it lowers the client's body fluid, but this effect would take some time to note. Weight loss, rather than weight gain, is often the effect of Lasix, but it does not occur immediately.

A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? 1 Administers 5 mEq intramuscularly (IM) 2 Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr 3 Infuses 10 mEq over a 1-hour period 4 Pushes 5 mEq through a central access line

3 Infuses 10 mEq over a 1-hour period A dose of KCl 10 mEq given over 1 hour is appropriate for this client. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines.

The nurse is assessing a client with hyponatremia. Which finding requires immediate action? 1 Diminished bowel sounds 2 Heightened acuity 3 Muscular weakness 4 Urine output of 35 mL/hr

3 Muscular weakness Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.

The health care provider writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first? 1 Administer sodium polystyrene sulfonate (Kayexalate) orally. 2 Ensure that a potassium-restricted diet is ordered. 3 Place the client on a cardiac monitor. 4 Teach the client about foods that are high in potassium.

3 Place the client on a cardiac monitor. Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

Which written order does the nurse clarify with the provider when caring for a client with a serum sodium level of 149 mEq/L? 1 Institute seizure precautions. 2 Weigh the client daily. 3 Place the client on nothing by mouth (NPO) status. 4 Monitor intake and output.

3 Place the client on nothing by mouth (NPO) status Ensuring adequate water intake is an important nutritional therapy in the treatment of hypernatremia; the nurse should ask for clarification of the NPO order. The other orders are appropriate in the management of clients with hypernatremia.

The nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern? 1 Glucose: 97 mg/dL 2 Magnesium: 2.1 mEq/L 3 Potassium: 5.9 mEq/L 4 Sodium: 143 mEq/L

3 Potassium: 5.9 mEq/L A potassium value of 5.9 mEq/L is high, and the client should be assessed further. A glucose value of 97 mg/dL, a magnesium value of 2.1 mEq/L, and a sodium value of 143 mEq/L are normal values.

An ECG is ordered for a client who was placed on IV fluids containing potassium. Which ECG finding is consistent with hyperkalemia? 1 Absent T waves 2 Elevated P waves 3 Prolonged PR intervals 4 Shortened QRS complexes

3 Prolonged PR intervals When hyperkalemia is present, an individual may show absent P waves, tall T waves, prolonged PR intervals, and widened QRS complexes.

When caring for a client with hyponatremia, which intervention does the nurse implement? 1 Intravenous administration of 0.45% normal saline 2 Administration of furosemide (Lasix) 3 Small-volume intravenous infusions of 3% normal saline 4 2-gram sodium diet

3 Small-volume intravenous infusions of 3% normal saline 3% saline is hypertonic and is given in small volumes to replenish serum sodium. 0.45% saline is hypotonic and will further dilute serum sodium levels. Furosemide (Lasix) causes sodium loss in the kidneys and would further contribute to hyponatremia. A 2-gram sodium diet restricts sodium intake; the goal of nutritional therapy with hyponatremia is to increase sodium intake.

After receiving change-of-shift report, which client does the RN assess first? 1. 26-year-old with nausea and vomiting who complains of dizziness when standing 2. 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst 3. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg 4. 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

3. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg The client with the history of receiving IV diuretics and having low blood pressure may be experiencing hypoperfusion caused by hypovolemia, and immediate assessment and interventions are needed. The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems that are not urgent at this time.

Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? 1. 32-year-old man consuming alcoholic beverages 2. 28-year-old woman with type 1 diabetes mellitus 3. 72-year-old woman appearing to be at least 20 pounds overweight 4. 68-year-old man who frequently wipes sweat from his forehead

3. 72-year-old woman appearing to be at least 20 pounds overweight The thirst mechanism is less sensitive in older adults, making them more at risk for dehydration. Women of any age have less total body water than men of similar sizes and ages, because men have more muscle mass than women and women have more body fat. (Muscle cells contain mostly water and fat cells have little water.) In addition, the 72-year-old woman is overweight, with an increased percentage of body fat compared to lean body mass, especially skeletal muscle. An obese person has less total water than a lean person of the same weight because fat cells contain almost no water. Although a 32-year-old man consuming alcohol, a 28-year-old with type 1 diabetes, and a 68-year-old who frequently sweats are at risk for dehydration, they are not as high-risk as the obese older adult.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN? 1. 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day 2. 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L 3. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L 4. 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

3. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal; this client is the most stable of the four clients described and can be assigned to the LPN/LVN. The data about the 44-year-old with CHF who has gained 3 pounds since the previous day indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, and that assessments and interventions by an RN are needed.

A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? 1 "Fast thinking! She really needs to rest after the night she had." 2 "Get the information now, or I'll report you for not doing your job." 3 "Never mind—I will do it myself." 4 "Weigh her now. We need her weight daily, at the same time."

4 "Weigh her now. We need her weight daily, at the same time." The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the client, assessing the client's fluid balance is more important. The responses of telling the nursing assistant to get the information now or she'll be reported or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the client. She should not be dismissed and belittled by the nurse.

The nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure (CHF). Which client statement indicates a correct understanding of CHF? 1 "I can gain 2 pounds of water a day without risk." 2 "I should call my provider if I gain more than 1 pound a week." 3 "Weighing myself daily can determine if my caloric intake is adequate." 4 "Weighing myself daily can reveal increased fluid retention."

4 "Weighing myself daily can reveal increased fluid retention." Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound of weight gained (after the first half-pound) equates to 500 mL of retained water. The client should be weighed at the same time every day (before breakfast) on the same scale. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems. The client should call the health care provider if more than 1 or 2 pounds are gained in a 24-hour period of if more than 3 pounds are gained in 1 week.

The nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs? 1 Alpha antagonists 2 Beta blockers 3 Corticosteroids 4 High-ceiling (loop) diuretics

4 High-ceiling (loop) diuretics High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion. Alpha antagonists, beta blockers, and corticosteroids are not potassium-depleting drugs.

The nurse is reviewing lab values for a client recently admitted to the medical-surgical unit. Which lab result is severely abnormal? 1 Potassium, 3.5 mEq/L 2 Sodium, 137 mEq/L 3 Chloride, 107 mEq/L 4 Magnesium, 6.2 mEq/L

4 Magnesium, 6.2 mEq/L A magnesium level of 6.2 mEq/L is greatly elevated. Clients with severe hypermagnesemia are in grave danger of cardiac arrest. The normal magnesium level is 1.3-2.1 mEq/L. The sodium and potassium results are within normal limits. The chloride level is just slightly elevated, with the normal range being between 98-106 mEq/L.

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? 1 Assessment of muscle tone and strength 2 Education about potassium-rich foods 3 Instruction on the proper use of drugs 4 Measurement of the client's urine output

4 Measurement of the client's urine output A home health aide may measure the client's intake and output, which then would be reported to the RN. Assessment, education, and instruction are higher-level nursing actions that should be done by the RN.

A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? 1 Auscultating bowel sounds 2 Checking deep tendon reflexes (DTRs) 3 Determining the level of consciousness (LOC) 4 Obtaining a pulse oximetry reading

4 Obtaining a pulse oximetry reading Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first. Bowel sounds, DTRs, and LOC may change in a client with hypokalemia, but these changes are not immediately life-threatening.

Which newly written prescription does the nurse administer first? 1 Intravenous (IV) normal saline to a client with a serum sodium of 132 mEq/L 2 Oral calcium supplements to a client with severe osteoporosis 3 Oral phosphorus supplements to a client with acute hypophosphatemia 4 Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L

4 Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the client with hypokalemia. The electrolyte disturbance (sodium level of 132 and low phosphorus level) and the need for calcium in this client are not immediately life-threatening.

An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this client related to the reason for admission? 1 What is your typical urinary elimination pattern and amount? 2 How is your appetite? 3 Have you noticed a change in the tightness of your shoes? 4 What is your typical daily fluid intake and what types of fluids do you drink?

4 What is your typical daily fluid intake and what types of fluids do you drink? Asking the client about the amount and types of fluids will provide additional information as to how the client deals with incontinence through fluid management and possible causes for the dehydration. Asking the client about appetite, urinary pattern, and tightness of shoes is not helpful in assessing the client's current health problem.

o max dilution recommended for IV administration of potassium:

• no greater than 1 meq of potassium to 10 mL of solution o 5-10 meq/hr infusion rate recommended for potassium o 20 meq/L amount/hr is to never to be exceeded; except in older adults

Laboratory results for a client with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action? 1 Assess the client's respiratory status. 2 Establish intravenous access. 3 Notify the provider of laboratory results. 4 Assess for orthostatic hypotension.

1 Assess the client's respiratory status. Hyponatremia may present with neuromuscular changes including muscle weakness of the legs, arms, and respiratory muscles. The nurse should assess the respiratory effectiveness of a client with hyponatremia as a priority. Obtaining assessment data is important when calling the provider in addition to reporting the laboratory result. Establishing IV access and assessing for orthostatic hypotension are important, but are lower-priority interventions.

o most common types of potassium supplements:

• potassium chloride, potassium gluconate, or potassium citrate

The nurse is teaching proper nutrition to a client who has been prescribed high-ceiling diuretic therapy. Which client response indicates a need for further teaching? 1 "I should eat more eggs and cereals to maintain a high potassium intake." 2 "Eating meat will help with my potassium needs." 3 "I should eat fish a few times a week." 4 "I should have fruits such as oranges, kiwi, and bananas every day."

1 "I should eat more eggs and cereals to maintain a high potassium intake." Breads, eggs, and cereal grains contain the least amount of natural potassium. Meats, fish, fruits, and some vegetables are highest in potassium. Diuretics that increase the kidney excretion of potassium can cause hypokalemia. The client should be encouraged to eat foods high in potassium when taking high-ceiling diuretic agents to help compensate for potassium loss.

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication? 1 Added to an IV, not to exceed 20 mEq/hr 2 Added to an IV, not to exceed 30 mEq/hr 3 Rapid IV push, a 25-mEq dose 4 Slow IV push, a 30-mEq dose

1 Added to an IV, not to exceed 20 mEq/hr The maximum recommended infusion rate of potassium is 5-10 mEq/hr. This rate is never to exceed 20 mEq/hr under any circumstances. Potassium should never be administered via IV push.

A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. The provider has ordered fall precautions. Which interventions does the nurse implement as part of fall precautions? Select all that apply. 1 Assess for orthostatic hypotension. 2 Orient the client frequently. 3 Loosely apply upper-extremity wrist restraints. 4 Maintain a calm, dim room to reduce confusion. 5 Place the bed in the lowest position with brakes locked. 6 Activate the bed alarm.

1 Assess for orthostatic hypotension. 2 Orient the client frequently. 5 Place the bed in the lowest position with brakes locked. 6 Activate the bed alarm. Multiple interventions are implemented to prevent falls, especially in older clients with dehydration. Assessing for orthostatic hypotension, orienting the client frequently, placing the bed in the lowest position with the brakes locked, and activating the bed alarm should all be implemented to reduce the client's risk of falling. In addition, frequent toileting and assistance to the bathroom may be indicated for this older client. Restraints are never appropriate. A dimly lit room may increase the risk of falls.

Which nursing action is recommended when providing care to a client with hypokalemia? 1 Question the continued administration of bumetanide (Bumex). 2 Obtain the prescribed vial of IV potassium chloride from the pharmacy and dilute before administration. 3 Establish a peripheral IV, preferably in the hand, for administering IV potassium chloride. 4 Administer prescribed oral potassium chloride (K-Dur) before a meal or snack.

1 Question the continued administration of bumetanide (Bumex). Bumetanide is a loop diuretic, which contributes to potassium loss and should be questioned. The Joint Commission has mandated that all concentrated electrolytes be mixed by a pharmacist and that vials of KCl should not be available in client care areas. A large vein with high blood flow should be accessed to avoid phlebitis; it is recommended that the hand be avoided. Oral potassium supplements should be given with or following a snack or meal to avoid nausea.

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer? 1. 0.45% saline 2. 5% dextrose in 0.45% saline 3. 5% dextrose in Ringer's lactate 4. 5% dextrose in water (D5W)

4. 5% dextrose in water (D5W) 5% dextrose in water (D5W) is an isotonic solution. 0.45% saline is a hypotonic solution, while 5% dextrose in 0.45% saline and 5% dextrose in Ringer's lactate are hypertonic solutions.

• digoxin and hypokalemia:

o for patients who are taking dig, hypokalmeia increases the sensitivity of the cardiac muscle to the drug and may result in dig toxicity, even when the dig level is within the therapeutic range

• How often should you monitor respiratory changes in a person with hypokalmeia? What should you assess?

at least hourly for severe hypokalemia; rate, depth, (watch for increasing rate and decreased depth), O2 sat and pulse oximetry; assess respiratory muscle effectiveness by checking the pts ability to cough; examine the face, oral mucosa, and nail beds for pallor or cyanosis

• Dysrhythmias can always lead to death, but dysrhythmias are particularly problems in what groups of people?

older adults taking dig

• If there is no kidney damage, what is the drug therapy of choice for hyperkalemia

increasing potassium secretion; potassium- excreting diuretics such as furosemide, are prescribed

• During hyperkalemia, there is a decreased difference between ICF and ECF potassium levels. Why is this significant?

increases cell excitability; as a result, most excitable tissues respond to less intense stimuli and may even discharge spontaneously

• What drugs increase the kidney's excretion of potassium?

loop diuretics (lasix and bumetanide [Bumex]), and thiazide diuretics

• drugs known to increase potassium loss through the kidneys:

o diuretics, corticosteroids, and beta-andrenergic agonists or antagonists

• indicators of hyperkalemia:

o heart rate is less than 60 bpm, P waves are absent, Twaves are tall, PR intervals are prolonged, QRS complexes are wide, deep tendon reflexes are hyperactive, bowel sounds are hyperactive, numbness or tingling is present in the hands and feet and around the mouth, pt is anxious, serum potassium is high

• indicators of potassium replacement therapy effectiveness:

o resper rate is greater than 12, O2 sats are at least 95% (or has returned to the pts normal baseline), pt can cough effectively, hand grasp strength increases, deep tendon reflexes are present, bowel sounds are present and active, pulse is easily palpated and regular, systolid bp when standing remains within 20 mm Hg of the systolic pressure obtained when sitting or lying, ST segment returns to isoelectric line, T waves increase in size and are positive, U waves decrease or disappear, pts cognition resembles his or her prehypokalemic state, serum potassium is normal

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Laboratory results include a potassium level of 7.0 mEq/L. Which medication does the nurse anticipate administering? 1 Insulin (regular insulin) and dextrose (D20W) 2 Loperamide (Imodium) 3 Sodium polystyrene sulfonate (Kayexalate) 4 Supplemental potassium

1 Insulin (regular insulin) and dextrose (D20W) If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose may be prescribed to promote movement of potassium from the blood into the intracellular fluid (ICF). Imodium is used in the treatment of diarrhea. Kayexalate is used for hyperkalemia, but not when the potassium level is this high (7.0). Additional potassium would make the client's condition more critical.

Which component of a client history would most likely be associated with hyperphosphatemia? 1 Chronic bronchitis 2 Kidney failure 3 Hyperparathyroidism 4 Colon cancer

2 Kidney failure Hyperphosphatemia in acute or chronic kidney disease results from decreased loss of phosphorus due to the poor function of the kidneys. Chronic bronchitis does not affect phosphorus levels. Hypoparathyroidism (not hyperparathyroidism) may contribute to hyperphosphatemia. Certain cancer treatments, not the cancer itself, may cause hyperphosphatemia.

Which order does the nurse clarify with the provider based on the following available client data? 1 Measure intake and output for 48 hours. 2 No activity restrictions; ambulate ad lib. 3 Encourage oral rehydration/intake. 4 Report urine output less than 0.5 mL/kg/hr.

2 No activity restrictions; ambulate ad lib. The client data suggest dehydration. Safety is a priority concern in the care of this client. The nurse should clarify the activity order as fall precautions and activity limitations may be indicated for safety. The other orders are appropriate in the care of a client with dehydration.

The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a client who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply. 1 Temperature 2 Pulse rate and quality 3 Neck vein distention 4 Urinary output 5 Bowel sounds

2 Pulse rate and quality 4 Urinary output Pulse rate and quality as well as urinary output best reflect improving volume status with rehydration therapy. Temperature, neck vein distention, and bowel sounds are not indicators of an improving volume state.

o hypokalemia respiratory status at least every

2 hours because respiratory insufficiency is a major cause of death

The nurse is performing discharge dietary teaching for a client with hyperkalemia. Which statement does the nurse include in the teaching? 1 "You may eat avocados, broccoli, and cantaloupe." 2 "You may use salt substitutes." 3 "You may eat apples, strawberries, and peaches." 4 "You don't need to restrict dairy products."

3 "You may eat apples, strawberries, and peaches." The client with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches. The client should avoid foods high in potassium, which include avocados, broccoli, cantaloupe, and dairy products. Salt substitutes contain potassium.

On the second day of caring for a client with generalized edema, which change best reflects that the administered diuretic is effective? 1 Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr 2 Respiratory rate decrease from 24 to 20 3 Weight loss of 6 pounds 4 Blood pressure decrease from 138/88 to 126/78 mm Hg

3 Weight loss of 6 pounds Weight loss and increased urinary output are primary indicators of the effectiveness of a diuretic. In clients with edema, each pound of weight gained after the first pound equates to 500 mL of retained water, so if water loss occurs with diuretic therapy, weight loss will result. The changes in vital signs may reflect volume loss, but are not the best indicators of the effectiveness of a diuretic.