Fluid & Electrolyte

A Client is admitted for dehydration, and an IV infusion of NS at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" What is the nurse's priority action? A) Elevate the head of the bed and obtain vital signs B) Discontinue the IV site and contact the primary HCP C) Assess for allergies and change the IV to an intermittent infusion device D) Contact the primary HCP to obtain a rx for a sedative

A) Elevate the head of the bed and obtain vital signs Elevating the head of the bed facilitates breathing by decreasing pressure against diaphragm. Checking vital signs after this is first step in assessing the cause of the distress. Discontinuing IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the HCP at this time; no info to support assessing for allergies and changing the IV to an intermittent infusion device; assessment for allergies should be done on admission

After reviewing the reports of a client, the nurse suspects hypofunctioning of the adrenal gland. Which findings are consistent with hypofunctioning of the adrenal gland? A) Increased serum calcium B) Decreased serum cortisol C) Decreased serum sodium D) Decreased serum potassium E) Increased serum glucose

A) Increase serum calcium B) Decreased serum cortisol C) Decreased serum sodium decreased serum potassium and decreased serum bicarbonate levels are associated with hyperfunctioning of the adrenal gland. Normal to increased serum glucose is associated with hyperfunctioning of the adrenal gland.

A low-dose IV dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nures to administer this medication to the client? A) Peripherally inserted central catheter (PICC) line B) #20 angiocatheter in either antecubital area C) Large-gauge butterfly needle in hand D) Femoral line

A) Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, if it infiltrates into skin it can cause tissue necrosis. Must be infused through PICC line Angiocatheter and butterfly needle are not central lines. Femoral line is a central line but is used only in extreme emergencies because of risk of insertion site infection

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? A) Edema results in separation of skin from pigmented and vascular tissue B) Pitting edema leaves an indentation on the site of application of pressure C) Trauma or impaired venous return should be suspected in clients with edema D) If the pressure on an edematous site leaves indentation of 2mm, a score of 2+ is given

D) If the pressure on an edematous site leaves indentation of 2mm, a score of 2+ is given A 1+ score is given if the depth of indentation is 2 mm. A 2+ is score given if depth of edema indentation is 4 mm Accumulation of edematous fluid will result in separation of skin and underlying vasculature. Edema is classified as pitting if application of pressure on edematous site will leave an indentation for some time. Edema results from direct trauma to the tissue or by impaired venous return.

A nurse is caring for a post-op client who has a NG tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? A) Tingling of the fingertips and toes B) Dry and sticky mucous membranes C) Abdominal cramping and irritability D) Muscle weakness and cardiac dysrhythmias

D) Muscle weakness and cardiac dysrhythmias related to potassium depletion in skeletal and cardiac muscles; sodium-potassium pump facilitates conduction of nerve impulses and muscle activity tingling of fingertips and toes is related to hypocalcemia or hyperkalemia. Dry and sticky mucous membranes are related to hypernatremia. abdominal cramping and irritability are related to hyperkalemia

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? A) Alkalosis B) Renal failure C) Hypervolemia D) Pulmonary edema

D) Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of high osmotic pressure exerted by the salt content of the aspirated ocean water; results in pulmonary edema. hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (select all that apply) A) Anorexia B) Vomiting C) Constipation D) Muscle weakness E) Irregular heart rate

B) Vomiting D) Muscle weakness E) Irregular heart beat Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in sodium- potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia.

Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? A) Providing oxygen B) Encouraging carbohydrates C) Administering fluid replacement D) Teaching facts about dietary principles

C) Administering fluid replacement As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level. Dietary instruction is inappropriate during the crisis.

During percussion of the client's bladder, the primary healthcare provider hears sounds as high up as the umbilicus. While caring for this client, the nurse provides privacy, assistance, and voiding stimulants as needed. What other action should the nurse perform while caring for this client? A) Administer potentially nephrotoxic agents B) Evaluate the client's hx for steroid therapy C) Evaluated the client's hx for anticholingeric therapy D) Administer NSAIDs

C) Evaluated the client's hx for anticholingeric therapy Anticholingeric drugs promote urine retention. Nurse should provide privacy, assistance, and voiding stimulants, such as warm water over perineum as needed. The nurse should carefully administer potentially nephrotoxic agents if the client had decreased glomerular filtration rate (GFR). Nurse should evaluate the client's hx for steroid therapy if there is an increase in BUN levels. Nurse should not administer NSAIDs for urinary retention.

An older adult client states, " I walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the clinic nurse teach the client? A) Drink fruit juices if you start to feel dehydrated B) Thirst is a good guide to use to determine fluid intake C) Fluids should be increased if the urine is getting darker D) Water should be consumed when the skin becomes dry

C) Fluids should be increased if the urine is getting darker When urine is dark, the amount of fluid to be excreted is decreased, and the body is attempting to conserve fluid. Fruit juices should be avoided during rehydration because of their high sugar content. By the time people become thirsty, they are already dehydrated. Dry skin in older adults may be related to aging rather than to dehydration and is not a good indicator for dehydration in older adults