Fluid and Electrolytes Q's

A client will receive a unit of whole blood. Which intravenous solution does the nurse obtain for infusion with the blood? A. D5W B. D5W1/2NS C. 0.9% NS D. 0.45% NS

C. 0.9% NS Blood should always be run alongside 0.9% NS to prevent agglutination or hemolysis of the blood. Using a dextrose solution, which applies for the D5W and D5W1/2NS, will cause agglutination (clumping of the blood), which can lead to clots in systemic circulation. 0.45% NS is hypotonic to blood, which is bad bc you can have some problems arise if the concentration of IV fluids you're giving differs from your patient's blood itself. 0.9% NS is isotonic to blood.

The nurse provides care for an adult client during the resuscitation phase of a severe burn injury. Which assessment finding indicates to the nurse that the amount of intravenous fluid replacement needs to be increased? A. Urine output 15 mL/hr B. Engorged neck veins C. Electrolytes within normal limits D. Decreased core body temperature

A. Urine output 15 mL/hr Engorged neck veins is a sign of fluid overload. Electrolytes are important to monitor, but it's not the primary purpose of fluid replacement. Body temperature isn't really an indicator for needing IV fluids, more so decreased body temperature for a patient with severe burn injury tells you that they are at risk of hypothermia. Aggressive fluid resuscitation must occur during the first 48 hours following a severe burn injury to maintain circulating blood volume to vital organs. The rate of urinary output (UOP) is the most reliable indicator of adequate fluid therapy during this crucial period. Typical urine output is 25 mL/hr for children, 30-50 mL/hr for adults. In general, a urine output of less than 1 mL/kg/hr is a sign of danger.

*************A client sustains burns to the anterior portions of both upper extremities, the trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of body surface area burned. Which is the correct percentage? A. 1.23% B. 2.36% C. 3.45% D. 4.54%

B. 2.36% The calculation would be: 4.5% for each arm, 18% for the trunk, 9% for the front of one leg. The latter two percentages are too high, the first is too low.

A client with a central venous access device receives parenteral nutrition (PN). The nurse notes the PN is infusing at a very sluggish rate. Which is the best action for the nurse to take? A. Ask the client to turn on the left side and perform the Valsalva maneuver B. Stop the infusion and flush the intravenous catheter C. Remove central venous catheter and insert a new central line D. Lower the head of the bed and administer oxygen via mask

B. Stop the infusion and flush the intravenous catheter If there are symptoms of an air embolism, such as tachypnea or cyanosis, the client should turn on the left side and perform a Valsalva manuever. The nurse should not discontinue a central venous catheter without the health care provider's prescription. If there are signs and symptoms of air embolism, the head of the client's bed should be lowered and oxygen should administered. The PN infusion should be stopped temporarily and the central line should be flushed to try and unclog the catheter.

The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics as likely the cause of which electrolyte imbalance? A. Hypernatremia B. Hyperkalemia C. Hyponatremia D. Hypokalemia

D. Hypokalemia Hypernatremia is caused by hypertonic tube feedings without water supplements, diarrhea, hyperventilation, diabetes insipidus, inadequate water ingestion, and OTC medications such as aspirin. Hyperkalemia is caused by acute kidney injury or chronic kidney disease, use of potassium supplements, or burns. Hyponatremia is caused by vomiting, diuretics, excessive administration of IV dextrose and water, excessive water intake, or a prolonged low-sodium diet. Nasogastric drainage, vomiting, diarrhea, and the use of diuretics all involve the loss of extracellular fluid, which contains potassium.

A client is receiving 40 drops per minute of dextrose 5% in water. The IV set delivers 10 drops per milliliter. If the nurse starts the IV infusion at 1200 with 1000 mL, how many mL will remain at 1530?

160 mL Military time is being used here (1200 is noon, 1530 is 3:30 pm). There are 60 minutes in an hour. The span of time lapsed here is 3.5 hours. 60x3.5=210 min Each mL gives 10 drops. If there are 40 drops dispensed per minute, that means 4 mL are used per minute. 210x4=840 mL To figure out how many mL are used across 210 min, you need to multiply 210 by 4 (value of mL used in one min) 1000-840=160 mL The infusion started with 1000 mL. Subtract 840, which is how much will be used in the time period from the question, to get the difference of how much will be left.

A client asks the nurse, "What does it mean if someone is a universal blood donor?" Which is the best explanation the nurse can give the client? A. A universal blood donor has type O blood, which is compatible with all blood types. This means the person can give blood to anyone. B. A universal blood donor has special factors in the blood that convert the recipient's blood type. This means the person can give blood to anyone. C. A universal blood donor has type AB blood, which means the person can receive a transfusion from anyone. D. A universal blood donor is one who is Rh positive. This means the person can give blood to anyone.

A. A universal blood donor has type O blood, which is compatible with all blood types. This means the person can give blood to anyone. This is about knowing the ABO blood classification system and compatibility. It's based on antigenic components of the RBC, identified by presence or absence of two different antigens (A or B) on the surface of the erythrocyte. The four types are A, B, AB, and O (and + and - for each). O can donate to any of the other types, but can only receive O blood. A can donate to A and AB, receives from O and A. B donates to B and AB, receives from B and O. AB is the universal recipient and can blood of any type, but donates only to AB. Considering the Rh factor is also important in effectively determining compatibility. There's no such thing as a blood type w special factors that convert the recipient's blood, thus making them compatible. AB is the universal recipient, not universal donor. Being Rh positive means you can't donate to anyone bc you can't donate to people who are Rh negative (Rh negative can donate to Rh positive tho).

An adult client has a history of diabetes insipidus. The nurse identifies which imbalance is most likely to develop if this medical problem occurs? A. Hypernatremia B. Hyponatremia C. Hyperkalemia D. Hypokalemia

A. Hypernatremia Hyponatremia causes nausea, muscle cramps, increased intracranial pressure, and confusion. The nurse should offer sodium rich foods, restrict fluids, and record intake and output. Symptoms of hyperkalemia include dysrhythmias, cardiac arrest, muscle weakness, paralysis, nausea, diarrhea. The nurse will administer prescribed sodium polystyrene. Symptoms of hypokalemia include muscle weakness, paresthesias, dysrhythmias, and increased sensitivity to digitalis. If IV potassium is prescribed, it can irritate veins and cause phlebitis. The nurse will assess the IV site as per agency policy. Diabetes insipidus is a disorder of water metabolism caused by deficiency of antidiuretic hormone (ADH). Large amounts of water are lost from the body causing a buildup of sodium in the body, leading to hypernatremia. Symptoms of this include excessive urine output, chronic and severe dehydration, excessive thirst, weakness. The nurse will record intake and output, monitor urine specific gravity, condition of skin, vitals, and administer prescribed desmopressin.

Which results does the nurse expect after a client receives a transfusion of whole blood? A. Increased hemoglobin and hematocrit levels in 12-24 hours B. Increased platelet level in approximately 24 hours C. Increased circulating blood volume with unchanged hematocrit D. Reduced edema since water will move from the extravascular to the intravascular space

A. Increased hemoglobin and hematocrit levels in 12-24 hours Platelets are a blood product used to increase the platelet count in the client's blood. Whole blood contains the blood's cellular and liquid portion; both volume and hematocrit will change. Hyperosmolar solution, such as albumin, acts by moving water from the extravascular to the intravascular space. Whole blood is not a hyperosmolar solution. Whole blood increased your hemoglobin and hematocrit. Transfusions like this might be given due to acute, rapid bleeding in a patient.

Which intravenous solution does the nurse use before and after administration of a blood transfusion? A. Isotonic saline B. Dextrose 5% in water (D5W) C. Lactated Ringer solution D. Any solution may be used

A. Isotonic saline Glucose solution causes hemolysis and aggregation of RBCs. Lactated Ringer solution causes agglutination of RBCs. Because of this, not any solution would be appropriate to use on a patient in this condition. Isotonic (0.9% NS) saline solution doesn't cause aggregation or hemolysis of RBCs and is the preferred solution to use when administering a blood transfusion.

Which signs and/or symptoms does the nurse recognize as signs of intravenous fluid infiltration? A. The site is pale, cool to the touch, and edematous B. The client experiences dyspnea, rapid weak pulse, and decreased urine output C. Purulent drainage is noted around the infusion site D. There is a red streak along the client's vein, and the client reports burning pain and tenderness

A. The site is pale, cool to the touch, and edematous Dyspnea, a rapid weak pulse, and reduced urine indicate a systemic fluid imbalance, not localized infiltration. Purulent drainage at the IV site indicates localized infection. The IV should be discontinued at once and the health care provider notified. The nurse should assess the client for other signs of infection. The presence of burning pain and tenderness and the appearance of a red streak down the course of a vein indicate phlebitis. Chemical injury or mechanical trauma to the vein causes phlebitis. Once the catheter is dislodged from the vein, the subcutaneous tissue fills with the infusion solution. As circulation within the tissue is impaired by the increasing pressure of the infiltrated solution, the site becomes pale and cool to the touch. The nurse should monitor the infusion site at least every two hours, and every one hour if medication is present in the IV solution. If infiltration occurs, the IV should immediately be discontinued and restarted in the other extremity.

The nurse begins to administer a blood transfusion to a client. After ten minutes the client begins to experience chills, fever, tachycardia, and hypotension. The nurse immediately stops the blood transfusion, begins a normal saline flush, and calls to tell the health care provider that the client is experiencing which type of transfusion reaction? A. an acute hemolytic reaction B. a febrile, nonhemolytic reaction C. a mild allergic reaction D. a circulatory overload reaction

A. an acute hemolytic reaction Gotta know what kinds of blood transfusion reactions there are in order to get this right. The sx described in the question are indicative of an acute hemolytic rxn where antibodies in the plasma attach to antigens on the transfused RBCs, causing RBC destruction. These rxns typically develop within the first 15 min of starting the transfusion. Other sx you might see include low back pain, flushing, dyspnea, vascular collapse, hemoglobinuria, bleeding, shock, cardiac arrest, DIC, and death. Latent hemolytic rxns can cause acute jaundice, dark urine, and fatigue too. The sx presentation of the question doesn't match any of the rest of the types of transfusion rxns here. A febrile, nonhemolytic rxn preseents as chills, rigors, and fever. May also be accompanied by HA, flushing, anxiety, v, and muscle pain. This type of rxn occurs when the client develops sensitization to donor WBCs (most common), plts, or plasma proteins. A mild allergic rxn presents as flushing, itching, pruritus, and urticaria (hives). This type of rxn is caused when the client's body has a sensitivity to foreign plasma proteins, and is most common in people w a hx of allergies. A circulatory overload rxn has sx of cough, dyspnea, pulmonary congestion, adventitious breath sounds, HA, HTN, tachycardia, and distended neck veins. This type of rxn happens when the fluid is administered faster than the circulatory system can accommodate. Clients w cardiac and renal dz are most at risk.

The nurse provides care for a client after a total abdominal hysterectomy. The nurse notes the client's vital signs are apical pulse 102 and thready, respirations 28 per minute, and supine blood pressure 88/50. The client is weak and restless with skin that is pale, moist, and cool to the touch. Which intervention should the nurse take to care for the client? A. Place the client in high Fowler's position and notify the health care provider at once B. Administer oxygen at two to three liters per minute C. Decrease the rate of flow of the intravenous fluids D. Ambulate the client in the hallway

B. Administer oxygen at two to three liters per minute You shouldn't elevate the patient's upper body like with High Fowler's; you should instead elevate the patient's legs to make sure that there's adequate perfusion of vital organs. But it is right for the nurse to notify the health care provider since the patient's symptoms are consistent with hypovolemia and possible hemorrhage. Increasing the intravenous flow rate will help correct the hypovolemia. Fluid volume and possibly blood will need to be replaced to prevent the client from deteriorating into shock. The client isn't stable, so you shouldn't be walking around with them right now. They should stay in bed and be carefully monitored. These findings indicate hypovolemia and possible hemorrhage. Oxygen therapy prevents hypodermis, which is secondary to hypovolemia. Again, notify the provider immediately.

The nurse provides care for a client diagnosed with partial thickness and full thickness burns over 40% of the body. Which nursing action is essential for the nurse to perform before changing the dressings? A. Administer hyperimmune tetanus B. Administer prescribed analgesics C. Obtain and record the client's vital signs D. Obtain the client's weight

B. Administer prescribed analgesics Hyperimmune tetanus is for preventing tetanus infections, which is irrelevant given the information given here. You don't have to get vitals before changing dressings, but you might need to get RR and HR as part of pre-assessment for med admin depending on what's being administered, and you should always be mindful of increased RR and HR during the dressing change since they can be signs of pain and anxiety during the procedure. Weighing the patient is irrelevant to wound care. Second degree burns are extremely painful. The nurse should give analgesics 30 minutes before dressing changes to ensure the client has optimal pain relief and experiences minimal discomfort.

A school-age client with burns on the legs continually picks off the new scabs. The exposed wounds will not heal because of this behavior. The client explains, "The picking helps with the itches." Which is the most appropriate nursing intervention to foster the child's behavioral change? A. Tell the client the wounds may become infected by picking off the protective scabs. B. Medicate the client with sedatives to promote sleep and reduce discomfort. C. Allow the client to watch a favorite movie if the client will not touch the wounds. D. Restrain the client's hands when the client is unaccompanied.

C. Allow the client to watch a favorite movie if the client will not touch the wounds. Education won't change behavior caused by the client's wish to relieve the physical sensations of itching. Sedatives are a form of chemical restraint, which is too extreme to use in this situation. Always treat with the least restrictive, but still effective methods possible. Physical restraint should be reserved for situations in which the client is in immediate danger. Behavioral modification techniques, like rewarding desired behavior, are most effective in changing children's behavior.

A client is to receive 1000 mL D5W with 40 mEq KCl intravenously to infuse over 10 hours. The nurse begins the IV in the left forearm. Two hours later, the client reports pain at the intravenous site. The nurse assesses the arm and notes that it is cool and hard near the intravenous site. Which initial nursing measure does the nurse take? A. Decreases the flow rate so the medication is less irritating B. Discontinues the intravenous infusion and plans to restart it in another site C. Explains to the client that this is expected with infusions of KCl D. Elevates the affected arm on a pillow and applies a warm compress to decrease discomfort

B. Discontinues the intravenous infusion and plans to restart it in another site Infusions of KCl can cause burning and discomfort. In some situations the infusion rate needs to be altered to decrease discomfort. The description of the site indicates the IV has infiltrated. Decreasing the flow rate will not relieve the infiltrated intravenous (IV). Although an infusion of potassium may be uncomfortable, the IV site should not be swollen, firm, or cool. The nurse should perform this action after the IV is discontinued to decreased discomfort at the site, decrease edema, and improve circulation to inflamed tissues. Any infiltrated IV should be discontinued immediately, the extremity elevated, and warm moist compresses applied. Infiltration occurs when the IV needle or catheter is dislodged from the vein and is in the subcutaneous tissue. If infiltration occurs, the IV site appears cool, clammy, swollen, and may be painful.

A central venous pressure line is inserted in a client. Following the catheter insertion, the client reports dyspnea, shortness of breath, and chest pain. The nurse understands the most probable cause of these symptoms is which condition? A. Fluid overload B. Pneumothorax C. Hypokalemia D. Pneumonia

B. Pneumothorax Symptoms of fluid overload are bounding pulse, increased RR, dyspnea, rales, hypertension, and increased venous pressure. Fluid overload a less probable cause here. Symptoms of hypokalemia are muscle weakness, paresthesias, dysrhythmias, and increased sensitivity to digitalis. Hypokalemia isn't a complication that's faced from central venous line insertion. Pneumonia is an inflammatory process caused by bacteria, fungus, virus, parasite, or chemical. Symptoms of this include fever, leukocytes, productive cough, dyspnea, and pleuritic pain. Pneumonia isn't a complication of central venous line insertion. A pneumothorax, which is a lung collapse, is a potential complication during insertion of any central venous pressure line, especially a subclavian line because of the proximity of the central veins and the lung cavity. A pneumothorax can occur due to perforations of the pleura by the catheter. Symptoms include pain and respiratory distress.

The nurse is assigned to transfuse one unit of packed red blood cells to a client. Prior to beginning the transfusion, the nurse has to leave the unit to attend an important administrative meeting. Which staff person is most appropriate for the nurse to delegate this assignment? A. Licensed practical nurse B. Registered nurse C. Unlicensed assistive personnel (UAP) D. Medical assistant

B. Registered nurse LPNs and LVNs can't do blood transfusions in a lot of states. They can perform daily care duties, med admin (except for IV meds), and some invasive tasks like catheterization and dressing changes. So this is state dependent and might or might not be within their scope of practice, and it wouldn't be as appropriate to delegate this here. UAPs definitively can't do blood transfusions. They can do noninvasive duties like daily care, skin care, and ambulation assistance. Medical assistants cannot perform blood transfusion procedures either. They can do daily care and administer injections, but can't provide IV meds or do invasive tasks either. RNs can do this task for sure.

A client diagnosed with gastroenteritis and dehydration is receiving fluid volume replacement with NS infusing at 100 mL/hour. Four hours after the infusion is started, the nurse assesses the client and notes the blood pressure is 84/50, the heart rate is 110 bpm and the urine output is 15 mL/hour and dark yellow. Which action does the nurse take initially? A. increase the IV fluids to 150 mL/hour B. assess the client's IV access C. place the client in Trendelenburg position D. notify the health care provider

B. assess the client's IV access When you see these VS, you should interpret them as the patient being dehydrated and not responding to volume resuscitation properly. Follow ADPIE - assess first after you see these vitals, investigate the problem yourself to see if you can figure out what's going on before talking to the provider or taking other actions. Assess the IV - is it infusing as rx? Has the patient received the rx/desired amt of fluid in the past hours that they've had it? Changing the rate of an infusion is something that a nurse can't do w/o provider permission. Trendelenburg has been effective for helping extreme HoTN and shock - the patient's BP is such that this isn't warranted rn. The reason why you should assess the IV site first and make sure the patient has received all of the rx fluids is bc if they haven't been getting the fluids, you gotta make the appropriate corresponding correction to their infusion so that it IS working properly. If the patient HAD been getting all the rx fluids and was still showing those VS, then you'd have to talk to the provider bc another underlying problem could be at play. Another thing that might happen in that situation is that the infusion rate might need to be increased.

A client receives magnesium sulfate IV for treatment of preeclampsia. The nurse knows it is most important to have which interventions at the bedside? A. oxygen and padded tongue blade B. reflex hammer and calcium gluconate C. protamine sulfate and vitamin K D. particulate respirator and suction equipment

B. reflex hammer and calcium gluconate Mg has a CNS depressant effect. Sx of hypermagnesemia can occur when a patient receives Mg replacement. These include bradycardia, HoTN, weak muscle contractility, lethargy, diminished or absent DTRs. A reflex hammer is needed for monitoring DTRs. IV calcium gluconate can block the cardiac effects of hypermagnesemia. The other options wouldn't be needed for emergent tx given the IV calcium gluconate or the preeclampsia. Oxygen could be required for ventilatory support in severe respiratory distress. Motor seizures are more likely to occur w HYPOmagnesemia, not HYPERmagnesemia. Preeclampsia can become eclampsia and cause motor seizures. Tongue blades aren't used during motor seizures. Protamine sulfate is the antidote for heparin, and vitamin K the antidote for warfarin. Heparin and warfarin are both anticoags, and you wouldn't normally use these for patients w hypermagnesemia bc it's generally not a problem w this condition. A particulate respirator is a facial piece of PPE used by all HCP who enter a TB iso room. It's not needed w preeclampsia or hypermagnesemia. Suction equipment could be required for ventilatory support for a client in severe respiratory distress.

A client reports dyspnea the third day after a major burn episode. The client has crackles in both lower lung fields, the urine output is 125 mL/hr, and the CVP is 14 mm Hg (19 cm of water). Which statement is the correct interpretation of this data? A. the client is developing shock B. the client is in the acute phase of burn injury C. the client is exhibiting a normal response to the burn injury D. the client is developing hypostatic pneumonia

B. the client is in the acute phase of burn injury To get this right, you would've had to know about the phases of burn injury recovery. About 48 hrs after a burn/thermal injury, the capillary permeability stabilizes and the interstitial fluid shifts back in the vascular compartment from the surrounding tissue space. This makes the person HYPERvolemic (high bv). S/sx include a slightly increased bounding pulse, increased respiratory rate w SOB, lung crackles upon auscultation, JVD, decreased Hct, decreased BUN. This phase is called the acute phase of burn management. Shock is a characteristic, expected finding in burn patients 24-48 hrs after a burn/thermal injury. Massive third spacing of fluid and loss of intravascular volume result in decreased CVP and urine output. Normal CVP is 2-8 mm Hg (3-11 cm of water). In this emergent phase of burn management, the client receives fluid volume replacement based on extent of burn injury and body weight. Normal findings for a given condition or in general mean that no intervention is needed in that situation, which isn't the case. This person needs interventions that'll prevent fluid volume overload and cardiac and pulmonary decompensation. It's a tricky option based on the wording. Saying that the patient is in the acute phase of their burn injury is more accurate/reflective of the scenario set up by the question. Although crackles and other adventitious lung sounds ARE evidence of hypostatic pneumonia, this combo of sx doesn't support that condition, making it the wrong answer. Remember to think about the patient's whole clinical picture.

A client has a nasogastric tube connected to intermittent suction. Which blood test results are of most concern to the nurse? A. Blood urea nitrogen 16 mg/dL (5.71 mmol/L) B. White blood cells 8,500/mm^3 (8.5 x 10^9/L) C. Potassium 2.9 mEq/L (2.9 mmol/L) D. Glucose 90 mg/dL (5.0 mmol/L)

C. Potassium 2.9 mEq/L (2.9 mmol/L) This question is about knowing your normal vs abnormal values. Normal range for K+ is 3.5-5.5 mEq/L. It can be hypothesized that the low potassium is d/t the removal of gastric secretions by the NGT. They should get IV potassium. Besides gastric suction, other causes of low potassium include vomiting, diarrhea, diuretics, steroids, and inadequate dietary intake. All of the other values provided are WNL.

The nurse provides care for a client diagnosed with congestive heart failure who is receiving intravenous fluids. The client states, "I keep coughing and coughing. Maybe I am getting a cold." What action should the nurse take first? A. stop the IV fluids B. place the client in high Fowler's position C. auscultate the client's lungs D. provide a humidifier in the client's room

C. auscultate the client's lungs ADPIE!!!! Always assess first before taking any actions, which is what the rest of the options listed here are. Know that HF predisposes a person to developing fluid volume overload, signs of which are coughing, dyspnea, and edema. The nurse should auscultate the lungs, review the patient's weight and I & O, and assess other VS. Again, stopping IV fluids, putting the patient in high Fowler's, and putting a humidifier in the room are all nursing interventions that you can't do unless you have an initial assessment guiding your patient care. Given that we're talking about fluid overload, it's likely that fluid infusions would be at least slowed if not stopped. Putting them in high Fowler's is something you actually would do too if you noted fluid overload bc the position facilitates breathing. Humidifiers help prevent a person's airways from getting dried out, and would be used for certain conditions like croup. Not really used for HF patients.

The nurse assesses an older adult client diagnosed with urosepsis and dehydration who is receiving intravenous fluids. Which assessment finding does the nurse address first? A. the client's scheduled IV antibiotic is due in 10 minutes B. the client reports a "bad headache" C. the client has crackles in the lung bases D. the client has a temperature of 100 F (37.8 C)

C. the client has crackles in the lung bases The question is asking you to prioritize what you'd take on first if you saw these four findings together, not asking WHETHER it's possible to see these findings together - don't get tripped up over that. Older adults are predisposed to getting fluid overload when they're on IV fluids. The nurse should assess lung sounds, I&O, UO, and VS trends. Ideally, you wanna strictly adhere to antibiotic scheds, but if you've got an acute and emergent situation developing w your patient, ofc you'd address that first. You've got a window of acceptable time for the patient to get the medication to be considered on time - they might not be alive to get the med if you don't address the acute issues. Here, lung crackles would take priority over giving the antibx for the time being. HAs are sx that definitely should be addressed - these can be sx of stroke or aneurysm, at the very least they'll be addressed as part of sx and pain management in your nursing care. A 100 F temp is something to be addressed for sure but is something you anticipate given the sepsis. You're likely gonna at least monitor if not tx the fever but the priority will still be the lung crackles, cuz that can turn into respiratory distress. One thing to note is that fevers can also be caused by lung congestion!!

The nurse provides care for a client diagnosed with diarrhea and dehydration. Which assessment would the nurse expect to see? A. the client has dark circles around the eyes B. the client's skin is hot and red C. the client has voided 100 mL of dark urine in 8 hours D. the client has a bounding pulse and high blood pressure

C. the client has voided 100 mL of dark urine in 8 hours Remember that 30 mL/hr is the lower range of normal for UO - if it's been 8 hrs, this person should've at least had 240 mLs if they were gonna be considered normal in that regard. But, instead, it's been 8 hours and they've only voided less than half that. A decrease in UO stems from decreased ECF volume available to the kidneys. Decreased kidney perfusion and the body's attempt to retain water results in the client voiding small amts of a more concentrated urine. SUNKEN EYES and poor skin turgor are signs of dehydration, not dark circles. Dark circles are caused by other underlying problems like allergies, malnutrition, weight loss, bruising, and lack of sleep. Someone who's dehydrated also wouldn't have hot and flushed (red) skin - you'd expect them to have cool and pale skin bc of the lower ECF volume. Fever could make your skin hot and other conditions can cause your body to generate abnormal levels of heat, but dehydration isn't one of them. Bounding pulse and high BP also aren't what you see in dehydrated people - you'd find tachycardia (so HR is fast) and HoTN (low BP). With worsening dehydration, an inadequate circulation blood volume causes the pulse to increase in rate and become thready, not stronger, as it would be if someone's pulse were bounding. BP typically falls at that stage of dehydration.

A client is diagnosed with dehydration and weakness. The client is five feet ten inches tall and weighs 100 pounds. As the nurse starts the intravenous fluids, the client says, "How many calories are in that bag? I can't gain any weight." The client's laboratory values are potassium 2.5 mEq/L (2.5 mmol/L), sodium 129 mEq/L (129 mmol/L), and chloride 92 mEq/L (92 mmol/L). ABGs show uncompensated metabolic acidosis. Which goal is the priority for the client's care? A. Encouraging the client to eat a high calorie, high carbohydrate diet B. Promoting an improved perception of body image C. Encouraging the client to keep a food journal D. Correcting fluid and electrolyte disturbances

D. Correcting fluid and electrolyte disturbances Improving nutrition by eating frequent, small, calorie rich and nutrient dense meals and snacks addresses a goal for reintroducing normal eating patterns for a client with a severe eating disorder. This may require weeks or months of therapy to achieve and is not the immediate concern for this client. Body image is a longer term goal to assist the client to recognize the positive changes in body image. This doesn't address their immediate needs. Keeping a food journal is for understanding someone's feelings associated with food, but this is not the most concerning issue for this client. This patient has immediate physical needs that place the client at immediate risk. The potassium level must be corrected to prevent life-threatening dysrhythmias. The client's dehydration and acidosis must be addressed and treatment carefully monitored.

The nurse notices flattened T waves on the electrocardiograma (ECG) of a client diagnosed with acute kidney injury. Based on this finding, the nurse checks the laboratory values for which electrolyte imbalance? A. Hypocalcemia B. Hyponatremia C. Hypomagnesmia D. Hypokalemia

D. Hypokalemia Hypocalcemia is indicated by numbness, tingling, and muscle weakness. It might look like tetany, since the hand/feet spasms and laryngospasm symptoms overlap between the two. Hyponatremia is most often associated with water intoxication. The client would exhibit confusion and lethargy which can progress to seizures and coma. Hypomagnesemia is associated with diarrhea, diuretics, alcoholism, or hypoparathyroidism. The client may exhibit tremors, seizures, and muscle spasms. Atrial fibrillation and a prolonged QT interval are associated with this, but what this question is describing is a flattened T wave, not a prolonged QT. Hypokalemia is associated with T wave changes and the presence of a U wave. Potassium is involved in cardiac rhythm and nerve transmission. Normal potassium level is 3.5-5 mEq/L. Other symptoms of hypokalemia include weakness, muscle cramping, thirst, and heart palpitations.

A client is diagnosed with hypoparathyroidism. Which action does the nurse take to ensure the safety of the client? A. Encourages exercise to strengthen muscles B. Ensures the client avoids vitamin D in the diet C. Maintains the client in supine position D. Institutes seizure precautions

D. Institutes seizure precautions Exercises are pretty much irrelevant for the patient's condition here. Hypoparathyroidism puts people at risk of hypocalcemia and vitamin D deficiency, so it would be good for them to have more calcium and vitamin D in their diet. There isn't a reason to maintain the client in a supine position. There would be no restriction on activity as far as positioning in bed. The client might need help with ambulating and requiring assistance with activities. Clients with hypoparathyroidism are at risk for motor seizures, respiratory distress, and tetany as a result of hypocalcemia. The use of seizure precautions is appropriate. The nurse should also monitor the client for tingling and numbness of the fingers and lips, as this can be a precursor to the development of tetany.

A toddler client has nausea, vomiting, and diarrhea. Which implementation is best for the nurse to use to maintain an adequate fluid intake? A. Keep the client NPO and give hypotonic solutions intravenously B. Force fluids and give hypertonic solutions intravenously C. Provide gelatin and ice pops to increase fluid intake D. Offer oral rehydration solutions (ORS) to rehydrate

D. Offer oral rehydration solutions (ORS) to rehydrate NPO is the opposite of what you should do for this patient. You need to offer them oral rehydration solutions and monitor further for signs of dehydration. A regular diet should only be reinstated once the child is rehydrated, so keep them on a modified diet till they get back to where they need to be. Parenteral fluids are only necessary if the toddler is severely dehydrated or in shock. It's no longer recommended to give clear fluids like fruit juices, carbonated soft drinks, or gelatin because these are high in carbohydrates, low in electrolytes, and have a high osmolality. Consequently, giving gelatin and ice pops wouldn't be the best move here. Oral rehydration solutions contain sodium, potassium, chloride, citrate, and glucose. The amount given is determined by the degree of dehydration and child's weight. If the child is vomiting, give a small amount of oral rehydration solution at frequent intervals.

The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and respirations are deep and labored with a respiratory rate of 32 breaths per minute. The arterial blood gas values are PaCO2 30 mm Hg (3.99 kPa), pH 7.30, and HCO3 20 mEq/liter (20 mol/L). Which action does the nurse take? A. Starts an infusion of 5% dextrose and water as per standing orders and contacts the health care provider. B. Places a paper bag over the client's nose and mouth to re-breathe expired air. C. Gives morphine intravenously to relieve the client's pain. D. Places the client in Fowler's position and encourages measures to support hyperventilation.

D. Places the client in Fowler's position and encourages measures to support hyperventilation. Sodium bicarbonate is the appropriate intravenous solution to correct metabolic acidosis. Rebreathing expired air is a technique used to reverse hyperventilation in clients experiencing respiratory alkalosis. Narcotic analgesics and other medications that depress respirations should be avoided. Hyperventilation should be encouraged to compensate for the metabolic acidosis. Fowler's position allows full chest expansion and hyperventilation in the respiratory compensatory mechanism for the client's metabolic acidosis.

In which position does the nurse place a client to ensure accurate central venous pressure (CVP) measurements? A. Left lateral Sims position with the zero (0) point of the transducer stopcock level with the phlebostatic axis B. Right side-lying position with the zero (0) point of the transducer stopcock level with the phlebostatic axis C. Trendelenburg position with the zero (0) point of the transducer stopcock 5 degrees below the phlebostatic axis D. Supine with the head of the bed elevated no more than 20 degrees, and transducer stopcock level with the phlebostatic axis

D. Supine with the head of the bed elevated no more than 20 degrees, and transducer stopcock level with the phlebostatic axis The zero (0) transducer must be correctly placed at the phlebostatic axis to avoid obtaining inaccurately low CVP readings. This cannot be done when the client is in a side-lying position. The zero (0) transducer can't be correctly placed when the client is in a right side-lying position. The CVP readings might be falsely elevated when the client is in this position. The Trendelenburg position will cause increased pressures in the right atrium and inaccurately elevate the CVP readings. The phlebostatic axis is a point located by drawing an imaginary line from the fourth intercostal space at the sternum and finding its intersection with an imaginary line drawn down the center of the chest below the axillary. The measurement of the pressures of blood in the right atrium is most accurate when the client is placed in a supine position with the transducer level with the phlebostatic axis.

The nurse performs the morning assessment of a client, and determines that the intravenous site in the client's right arm is infiltrated. Which intervention does the nurse take first? A. slows the rate and contacts the health care provider B. removes the dressing covering the site, and gently pulls the needle or catheter back until the infusion begins to drip again C. flushes the tubing with 3 mL of normal saline D. discontinues the infusion and elevates the affected extremity

D. discontinues the infusion and elevates the affected extremity Infiltration is the abnormal accumulation of fluids in the subcutaneous tissue. Once the needle or catheter becomes dislodged from the patient's vein, the IV infusion must be dc'ed, or fluid will begin to collect in the subq tissue and cause pain, swelling, and coolness. Elevation of the extremity alleviates these sx. Note that stopping the infusion and initiating a new IV site doesn't require provider permission/order, you can do it yourself. It doesn't matter if you slow the rate if the fluid being given to the patient is getting into their tissue as opposed to the circulation. Pulling or moving the needle/catheter as an attempt to maneuver it and "save" the IV site is likely to cause additional trauma to the already swollen subq tissue. Never try to save the site, always dc it and start a new one. Never flush the site or give more fluid thru it bc adding more fluid to an already edematous site may force an occlusion in the needle/catheter to become mobile in the vessel (CLOT). The fluid may flush easily into the infiltrated tissue and doesn't indicate that the IV cannula is in the vessel.