PCC: ATI/PrepU: Fluid and Electrolyte
A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria. B. Specific gravity is decreased in clients who have hypovolemia. C. BUN is decreased in clients who have dehydration. D. Creatinine levels are increased in clients who have acute kidney injury.
D: creatinine levels are increased in clients who have acute kidney injury. Rationale: Increased creatinine levels are associated with renal failure. - Hypokalemia is associated with polyuria. - Specific gravity: is increased in clients who have hypovolemia. - BUN: is increased in clients who have dehydration.
Hypertonic (Hint: grumpy and shrunken)
High solute outside the cell Higher water inside the cell Fluid moves out of the cell Cell shrinks A hypertonic fluid will pull a less concentrated solution into itself. Draw fluid out of the cells and into the blood. Example: 3% NS, 5% NS
Hypotonic (Hint: fluffy and uncomfortable)
Higher solute inside the cell Higher water outside the cell Fluid moves into the cell Cell swells A hypotonic fluid will shift and flow into a more concentrated solution. Draw fluid from vessels and move fluid into the cells Example: D5W, 0.45% NS
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias? Serum potassium level Serum calcium level Serum sodium level Serum chloride level
Serum potassium level Explanation: The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser effect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.
A nurse is caring for a client with end-stage renal disease ESRD. Which of the following are expected findings? (SATA) o Slurred speech o Bone pain o Bradypnea o Pruritis o Hypotension
Slurred speech: Slurred speech is an expected finding of ESKD. Bone pain: Bone pain is an expected finding of ESKD. Pruritus: Pruritus is an expected finding of ESKD. - Bradypnea is incorrect. Tachypnea, rather than bradypnea, is an expected finding of ESKD. - Hypotension is incorrect. Hypertension, rather than hypotension, is an expected finding of EKRD.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. BUN: 28 mg/dL B. K+: 5.0 mEq/L C. Na+: 145 mEq/L D. Ca: 9 mg/dL
A. BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.
Hypermagnesemia "DARK" plus "Calm & Quiet" (Serum magnesium level higher than 2.5mEq/L)
Caused by: D-DKA A-Antacids containing Mag/mag supplements R-Renal failure (kidneys can't excrete Mg+) K-K+ (hyperkalemia) Symptoms: "Calm & Quiet" Cardiac-Heart block, bradycardia, hypotension Decreased DTR Depressed shallow respirations Hypoactive bowel sounds
Hyponatremia "AIDS" and "SALT LOSS" (Serum sodium below 135 mEq/L)
Causes: A-Adrenal Insufficiency I-Intoxication of water D-Diuretics S-SIADH Symptoms: Depressed and Deflated S-Stupor/coma A-Anorexia (N/V) L-Lethargy T-Tendon reflexes decreased L-Limp muscles (weakness) O-Orthostatic hypotension S-Seizures/headache S-Stomach cramping Cardiac-Tachycardia & weak, thready pulses
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? A. If the woman has a full bladder, labor may be uncomfortable for her. B. If the woman's bladder is distended, it may rupture. C. A full bladder or rectum can impede fetal descent. D. A full rectum can cause diarrhea.
D. A full bladder or rectum can impede fetal descent. Explanation: Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition, she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? A. neuromuscular function B. bowel sounds C. respiratory rate D. electrocardiogram (ECG) results
D: electrocardiogram (ECG) results Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation.
Isotonic (Hint: Happy and normal)
Equal solute Equal water No fluid movement Normal Isotonic fluid stays inside the bloodstream or the intravascular compartment Example: 0.9% NS, LR
The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child? impaired mucous membranes fluid volume deficit alteration in nutrition risk for infection
fluid volume deficit Explanation: Initial treatment should focus on the child's fluid and electrolyte balance and rehydrating the child. Subsequent measures to identify the possible microorganisms responsible and resting the gastrointestinal tract should also be addressed.
Mg+ M-Magnesium M-Mellows the M-Muscles (relaxes)
(1.8-2.6)
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? A. Urine output of 175ml in the past 8 hours. B. Urine output of 2,200 ml in the past 24 hours. C. First voided urine in the morning has a strong order. D. Urine is cloudy after sitting in the urinal for 6hrs.
A: Urine output of 175ml in the past 8 hours. The nurse should notify the provider if the client's urinary output is less than 30 mL/hr. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion. (30ml*8hours= 240)
A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? A. Vitamin C B. Zinc Sulfate C. Water D. Protein
D. Protein Explanation: Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.
Na+ S-Sodium S-Swells the body to maintain: -blood pressure -blood volume -pH balance
(135-145)
Ca+ (calcium) The 3 B's strong B-Bone B-Blood B-Beats (Heart)
(8.8-10.4)
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number.
12 Explanation: First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg. Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms: 0.2g/kg X 60 kg = 12 g.
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take? A. Give the ordered KCL as prescribed. B. Omit the KCL dose and document that it was not given. C. Hold the prescribed does and notify the provider of the serum potassium level. D. Call the lab to verify the clients' results.
A: Give the ordered KCL as prescribed. Rationale: The client's serum potassium level is below the recommended reference range. The nurse should administer the KCL as prescribed. - Omit the KCL dose: The nurse should not omit the ordered medication. - Hold prescribed dose: The client's serum potassium level is below the recommended reference range. The nurse should not hold the medication. There is no indication that the provider should be notified, as a prescription for the low level of potassium has been given. - Call the lab: The nurse has already received the lab values from the lab, so notifying the laboratory is not indicated.
A nurse is providing teaching to a group of adult athletes about prevention the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching? A. Impaired motor control. B. Drop in body temperature during exercise. C. Increased appetite. D. Decreased resting heart rate.
A: Impaired motor control Rationale: Impaired motor control is a clinical manifestation of dehydration. - Drop in temp during exercise: The body temperature will increase with exercise in a body experiencing dehydration. - Increased appetite: A body experiencing dehydration will have a loss of appetite. - Decreased resting heart rate: The resting heart rate will increase in a body experiencing dehydration.
A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following finding should the nurse expect? A. Bulging anterior fontanel. B. Bradypnea. C. 13% weight loss. D. Capillary refill 3 seconds.
C: 13% weight loss. A weight loss greater than 10% is a manifestation of severe dehydration in an infant. - Anterior fontanel: A sunken anterior fontanel is a manifestation of severe dehydration in an infant. - Hyperpnea is a manifestation of severe dehydration in an infant. - Cap refill: greater than 4 seconds is a manifestation of severe dehydration in an infant.
Hypomagnesemia "AGED" & buck wild.... (Serum level below 1.8 mEq/L)
Causes: A-Alcoholism G-GI loss (N/V/D) E-Excretion impaired D-DKA Symptoms: Cardiac-V-Fib Increased DTR/Clonus Paresthesia Nystagmus Diarrhea
Hypocalcemia "ACID" "CATS" "TT/CC" (Serum level below 8.5mh/dL)
Causes: A-Antibiotics C-Corticosteroids I-Insulin D-Diuretics Symptoms: C-Convulsions A-Arrhythmias T-Tetany S-Stridor and spasms T-Trousseau's T-Twerking arm with BP cuff on C-Chvostek's C-Cheek smile when touched Bleeding and fracture risk
Hypernatremia "DIVA" is "BIG & BLOATED" (Serum sodium higher than 145mEq/L)
Causes: D-Dehydration I-IV hypertonic solution excess V-Vitamins "sodium" supplement A-Amount of sodium excess Symptoms: Big and Bloated F-Fever (low grade) R-Restless, irritable, anxious, confused I-Increased BP and fluid retention E-Edema D-Decreased UO and dry mouth S-Swollen, dry tongue A-Agitation L-Low-grade fever T-Thirst
Hypercalcemia "HAM BACK ME" (Serum Calcium level higher than 10.5mg/dL)
Causes: H-Hyperparathyroidism A-Antacids (calcium supplements) M-Malignancies (cancer cells release excess calcium) Symptoms: B-Bone pain A-Arrhythmias C-Cardiac arrest K-Kidney stones M-Muscle Weakness E-Excessive urination Swollen and slow-moans, groans, and stones (constipation, bone pain, renal calculi, decreased DTR)
A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? A. A client who has a urine specific gravity of 1.010. B. A client who has a weight gain of 2.2kg (2lb) in 24 hours. C. A client who has a hematocrit of 45% D. A client who has a temperature of 39c (102F)
D: A client who has a temperature of 39c (102F) Rationale: This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration. - Urine specific gravity 1.010: This urine specific gravity is within the expected reference range of 1.010 to 1.025. Concentrated urine and a specific gravity of greater than 1.030 are manifestations of dehydration. - Weight gain: Weight gain is a manifestation of fluid volume excess. - Hematocrit: Expected reference range is 37% to 64%. An elevated hematocrit is a manifestation of hemoconcentration and dehydration.
The nurse is planning care for a group of clients. Which clients should the nurse prioritize as "at risk" for hypercalcemia and advocate for monitoring calcium levels? Select all that apply. A client with prolonged immobility A client with hypophosphatemia A client with hypoparathyroidism A client who has breast cancer with bone metastasis A client with heart failure who is taking a loop diuretic
A client with prolonged immobility A client with hypophosphatemia A client who has breast cancer with bone metastasis Explanation: The major causes of hypercalcemia are hyperparathyroidism; increased mobilization of calcium from bone (as in cancer with metastatic bone lesions); immobilization; and vitamin D intoxication. A low phosphate level will result in higher serum calcium due to the inverse relationship between these two electrolytes. A client taking a loop diuretic is more prone to hypocalcemia as this medication promotes the loss of calcium in urine.
Accidental removal of one or both parathyroid glands can occur during a thyroidectomy. Which of the following is used to treat tetany? Calcium gluconate Synthroid Propylthiouracil (PTU) Tapazole
Calcium gluconate Explanation: Sometimes in thyroid surgery, the parathyroid glands are removed, producing a disturbance in calcium metabolism. Tetany is usually treated with IV calcium gluconate. Synthroid is used in the treatment of hypothyroidism. PTU and Tapazole are used in the treatment of hyperthyroidism.
The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching? A. "I will remind her that she will need an IV if she does not drink." B. "Anything that melts at body temperature is counted as a fluid." C. "Ice chips count as fluid intake. One cup of ice equals a half-cup of water." D. "I should offer her small amounts of fluid frequently."
A. "I will remind her that she will need an IV if she does not drink." Explanation: The child is likely to view an IV both as frightening and as punishment. Intravenous fluids should be seen as therapy. Threats such as this should not be used to achieve compliance with eating or drinking. The other statements show understanding.
A client with acquired immune deficiency syndrome (AIDS) reports diarrhea after every meal. What is the nurse's best response? A. Avoid residue, lactose, fat, and caffeine. B. Encourage large, high-fat meals. C. Reduce food intake. D. Increase the intake of iron and zinc.
A. Avoid residue, lactose, fat, and caffeine. Explanation: Diarrhea may subside when the client avoids residue, lactose, fat, and caffeine. Although eating may seem to cause diarrhea, the client must understand that limiting the intake of food to control diarrhea only exacerbates wasting. The client will tolerate a low-fat, high-carbohydrate, soft or liquid diet better than large, high-fat meals. The client should be advised to avoid large doses of iron and zinc because they can impair the functioning of the immune system.
An older adult client is admitted with polyuria, severe constipation, significant postural hypotension, and showing signs of alkalosis. While awaiting the lab results, what action by the nurse would be most appropriate? A. Facilitate a STAT ECG. B. Keep the client NPO. C. Administer a cleansing enema. D. Infuse Lactated Ringer's as ordered.
A. Facilitate a STAT ECG. Explanation: The client exhibits the manifestations of hypokalemia, which can have serious cardiac consequences; an ECG is a priority. The client may or may not be kept NPO. An enema does not address the client's most serious health risks. Lactated Ringer's is not the treatment of choice for hypokalemia.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS? A. Liquids B. Gluten C. Sucrose D. Iron and zinc
A. Liquids The nurse should encourage clients with AIDS to consume liquids in order to help replace fluid and electrolyte losses. Gluten and sucrose may increase the complication of malabsorption. Large doses of iron and zinc should be avoided because they can impair immune function.
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect? A. Hyperkalemia B. Hypernatremia C. Hypercalcemia D. Hypophosphatemia
A: Hyperkalemia Rationale: AKI is a loss of renal function that results in a failure to maintain homeostasis. Fluid and electrolyte balance, as well as acid-base balance, are disrupted. The nurse should expect the client to have hyperkalemia due to protein breakdown and the subsequent release of intracellular potassium into the circulation. The kidneys' inability to filter and excrete potassium results in hyperkalemia. - Hypernatremia: A client who has AKI develops hyponatremia due to a reduction in the glomerular filtration rate and decreased ability to excrete water. - Hypercalcemia: The nurse should expect a client who has AKI to have hypocalcemia due to a decreased ability to absorb calcium from the intestines. - Hypophosphatemia: The nurse should expect a client who has AKI to have hyperphosphatemia due to the inability of the kidneys to filter waste products from the blood.
A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (kcl) 20 mEq extended-release PO daily. Which of the following instructions should the nurse provide about the new prescription? A. Take the extended-release tablets on an empty stomach. B. Add an antacid if the medication causes indigestion. C. Take the extended-release tablets whole. D. Expect urinary output to decrease while on this medication.
A: Take the extended-release tablets whole. Rationale: Extended-release tablets should be taken whole and should not be broken, crush, or chewed. - Antacids: Advise the client to avoid OTC medications, including antacids, without the approval of the provider. Calcium containing antacids can increase the effect of the potassium supplement. - Empty stomach: The nurse should instruct the client that the medication should be taken with or after meals. - Decreased urinary output while taking potassium chloride: The client to notify the provider immediately for any decrease in urinary output.
The nurse reports a client's elevated serum calcium level, and the client asks what controls calcium levels in the body. What is the nurse's best response? A. renin B. parathyroid hormone (PTH) C. thyroid-stimulating hormone (TSH) D. erythropoietin
B. Parathyroid hormone (PTH) PTH is the most important regulator of serum calcium levels in the body. Renin controls blood pressure, erythropoietin stimulates production of red blood cells TSH stimulates thyroid hormone secretion.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A. Elevating the head of the bed B. Reinforcing dressings or applying pressure if bleeding is frank C. Rubbing the back D. Encouraging the client to breathe deeply
B. Reinforcing dressings or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.
The nurse is caring for a client who has produced an average of 20 mL/hour for the previous day. The nurse recognizes this compares in which way to the normal urine output? A. This represents normal urinary output for 24 hours. B. The kidneys should produce about 1.5 L of urine each day. C. The kidneys should produce a minimum of 10 mL/hr over one day. D. The normal kidney produces an average 3000 mL of urine daily.
B. The kidneys should produce about 1.5 L of urine each day. Explanation: The kidneys normally produce approximately 1.5 L or 1500 ml of urine each day.
Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? A. An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction B. A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery C. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use D. A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL)
C. A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Hypomagnesemia is particularly troublesome during treatment of alcohol withdrawal. Therefore, the serum magnesium level should be routinely measured in patients undergoing withdrawal from alcohol. TPN, heart disease, and lymphoma are not identified as central risk factors for the development of hypomagnesemia.
A university student is admitted to the emergency department after a long night of binge drinking. The next morning, which component of the homeostatic action of ADH is directly affected by the excess alcohol? A. Stored ADH is released into circulation. B. ADH is transported along a neural pathway to the kidneys for further breakdown. C. Vasopressin 2 (V2) receptors are located in tubular cells of the cortical collecting duct. D. ADH is synthesized by cells in the supraoptic pathway and then transported to the adrenal gland.
C. Vasopressin 2 (V2) receptors are located in tubular cells of the cortical collecting duct. Explanation: ADH is produced in the hypothalamus, sequestered in the pituitary, and released in response to increased serum osmolality. The V2 receptors, which are located on the tubular cells of the cortical collecting duct, control the water reabsorption by the kidney and facilitate the maintenance of osmolality of body fluids.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's spouse reports that the client acted confused and was extremely weak upon waking that morning. The client's blood pressure is 90/58 mm Hg, pulse is 116 beats/minute, and temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion? A. Hypotonic Saline B. Insulin C. Potassium D. Hydrocortisone
D. Hydrocortisone Explanation: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. The client needs normal — not hypotonic — saline solution. Potassium isn't indicated because these clients are usually hyperkalemic. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia.
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? A. Hypothermia. B. Protruding eyeballs. C. Elevated blood pressure. D. Furrows of the tongue.
D: Furrows of the tongue. Rationale: In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows. - Hypothermia: Older adult clients who have dehydration are more likely to have an elevated body temperature. - Protruding eyeballs: In older adult clients, sunken eyeballs are an indication of dehydration. - Elevated blood pressure: In older adult clients, orthostatic hypotension is an indication of dehydration.
Hyperkalemia Symptoms "MURDER"
Symptoms: Muscle weakness Urine, oliguria, anuria Respiratory distress Decreased cardiac contractility EKG changes (peaked T at 6, prolonged PR at 7, absent P and wide QRS at 8-9) Reflexes, hyperreflexia, or areflexia (flaccid)
Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate
Potassium Explanation: Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Replace lost fluids and electrolytes. Prevent renal shutdown. Monitor cardiac status.
Replace lost fluids and electrolytes. Explanation: After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention? A. lung congestion B. nausea C. temperature D. blood pressure
A. lung congestion Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms.
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. Sodium 165 mEq/L. B. Potassium 5.2 mEq/L. C. Urine specific gravity 1.020. D. Hct 62%
C: Urine specific gravity 1.020. Rationale: In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, indicating effective treatment. - Sodium: A sodium level of 165 mEq/L is increased and represents hypernatremia, which is an indication of dehydration. The expected reference range of sodium is 135 to 145 mEq/L. - Potassium: A potassium level of 5.2 mEq/L is increased and represents hyperkalemia, which is an indication of dehydration. The expected reference range of potassium is 3.5 to 5.0 mEq/L. - Hct: In cases of fluid volume deficit or dehydration, the Hct is elevated due to hemoconcentration, which is an indication of dehydration. The expected reference range of Hct varies with gender: for males: 42 to 56% for women: 37 to 47%.
Hypokalemia "GOT SHOT" while "ASIC WALT" (Serum potassium level below 3.5 mEq/L)
Causes: G-GI loss (vomiting) O-Osmotic diuresis T-Thiazides & loop diuretics S-Severe acid imbalance H-Hyperaldosteronism O-Other medications (corticosteroids) T-Transcellular shift Symptoms: Low & slow-heart, GI, muscle A-Alkalosis S-Shallow respirations I-Irritability C-Confusion and drowsiness W-Weakness and fatigue A-Arrhythmias L-Lethargy T-Thready pulse, U-shaped waves HR decreased/UO increased
Hyperkalemia "MACHINE" (Serum potassium level higher than 5.0mEq/L)
Causes: M-Medications, ACE, spironolactone, NSAIDS A-Acidosis (metabolic or respiratory) C-Cell destruction (burn, trauma, injury) H-Hypoaldosteronism I-Intake excess of K+ N-Nephrons/renal failure E-Excretion impaired
A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next? Notify the health care provider. Check the client's potassium level. Calculate the client's intake and output. Administer potassium.
Check the client's potassium level. Explanation: The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the health care provider. Because the client is taking furosemide, a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the health care provider with a more complete database. The health care provider will need to be notified after the nurse checks the latest potassium level. The intake and output will not change the heart rhythm. Administering potassium requires a health care provider's order.
A nurse is admitting a 6-month-old infant who has dehydration. Which one of the following amounts of urinary output should indicate to the nurse that treatment has corrected the fluid imbalance? A. 0.5 ml/kg/hr. B. 2 ml/kg/hr. C. 7.5 ml/kg/hr. D. 15 ml/kg/hr.
B: 2ml/kg/hr. Rationale: The expected urinary output for infants up to the age of 1 year is 2ml/kg/hr. An infant who is not dehydrated should produce this amount of urine. - 0.5 ml/kg/hr.: This amount of urine indicates that the infant is still dehydrated. - 7.5 ml/kg/hr.: This amount is outside the expected reference range of urinary output for an infant who is 6 months old. - 15 ml/kg/hr.: The expected urinary output for adults is 15 mL/kg/hr.
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria
B: Fatigue Rationale: The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia. - Pitting edema: The nurse should expect to find pitting edema when the client has hypernatremia. - Dyspnea: The nurse should expect to find the client with dyspnea with hypernatremia. - Oliguria: The nurse should expect to find the client with polyuria with hypokalemia due to inability to produce concentrated urine.
A nurse is taking care of an infant with diabetes insipidus. Which assessment data are most important for the nurse to monitor while the infant has a prescription for fluid restriction? A. oral intake B. urine output C. oral mucosa D. vital signs
B: Urine output Explanation: An infant with the diagnosis of diabetes insipidus has decreased secretion of antidiuretic hormone (ADH). The infant is at risk for dehydration so monitoring urinary output is the most important intervention. The child's oral intake has been ordered. Monitoring a child who is under fluid restriction includes assessing the oral mucosa; however, urine output is the most important assessment for this patient. Vital signs are part of a basic assessment.
A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? A. Elevated serum creatinine B. Hyperkalemia C. Hyperphosphatemia D. Elevated urea and nitrogen
C. Hyperphosphatemia Explanation: Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? A. The client says that he has been urinating less frequently at night. B. The client says he has been hungry in the evening. C. The client says his rings have become tight and are difficult to remove. D. The client says he is short of breath when ambulating.
C. The client says his rings have become tight and are difficult to remove. Explanation: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Heart rate of 130/min. B. Respiratory rate of 24/min. C. Urine specific gravity 1.015. D. Capillary refill greater than 3 seconds.
C: Urine specific gravity 1.015 The expected reference range for urine specific gravity is 1.010 to 1.025. A result of 1.015 indicates the child is hydrated. A result greater than 1.025 indicates dehydration. Dehydration results when the total output of fluid exceeds the total intake. Infants and children who have diarrhea and dehydration should be treated first with oral rehydration therapy, such as Pedialyte and Infalyte. After rehydration, oral rehydration therapy can be alternated with a low-sodium solution, such as water, breast milk, lactose-free formula, or half-strength lactose-containing formula. - HR 130/min: An increased heart rate is a sign of moderate to severe dehydration. The expected reference range for the heart rate for a 3-year-old child is 70 to 110/min. - Respiratory Rate: Although this value is in the upper limits, a respiratory rate alone is not an indication of hydration status. The clinical manifestations of dehydration in children include weight loss, increased pulse rate, decreased blood pressure, and increased urine specific gravity. - Cap refill: Capillary refill should be less than 3 seconds. A value of greater than 3 seconds, along with other manifestations, such as decreased turgor, indicates dehydration.
K+ (potassium) P-Potassium P-Priority since it P-Pumps the heart and muscles
3.5-5.0 mEq/L
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output
B. Fluid resuscitation Explanation: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
A nurse is providing instructions to anew nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? A. Furosemide. B. Hydrochlorothiazide. C. Metolazone. D. Spironolactone.
D: Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia. - Furosemide: is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia. - Hydrochlorothiazide: is a thiazide diuretic that increases the risk of hypokalemia, not hyperkalemia. - Metolazone: a thiazide diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.
When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality? Hypercalcemia Hyperkalemia Hypomagnesemia Hyponatremia
Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? lack of free water intake lack of solid food lack of exercise increased fiber
lack of free water intake Explanation: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.
