pharm - fluid and electrolytes

assessment before giving loops/thiazides diuretics (Furosemide, Hydrochlorothiazide, Chlorthalidone)

*weight *BP HR RR Na *K (hypokalemia) Cl *to watch for fluid status and water retention

Magnesium (Mg) normal range

1.8-2.6 mEq/L

examples of hypotonic IV fluids

1/2 normal saline - 0.45% NaCl dextrose 5% in water (D5W) *isotonic in the bag...hypotonic in the body less common

Hemoglobin normal levels

12 - 17.4 g/dl

sodium (N+) normal range

135-145 mEq/L

Albumin normal range

3.4-5.4 g/dL

Calcium (Ca2+) normal range

8.2-10.2 mEq/L

What urine output best demonstrates the effective kidney function? A. 20 mL/hr B. 30 mL/hr C. 40 mL/hr D. 50 mL/hr

Answer: D. The higher the urine output, the better the kidney function. The bare minimum urine output to be considered adequate kidney function is 30ml/hr.

fluid volume deficit

DEHYDRATION: fluid intake is not sufficeint to meet the fluid needs of the body

D5 1/2 NS IV fluid

Description dextrose 5% in 0.45% in saline osmolarity hypertonic (406 mOsm) uses useful for rehydration and daily maintenance of body fluids and nutrition - DKA after initial treatment w/ NS considerations - DKA -> use only when glucose fails <250 mg/dl -> prevents hypoglycemia and cerebral edema - common postoperative fluid

Diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

Rh+ can receive from

Rh+ and Rh-

Hypermagnesemia

Symptoms nausea vomiting neurological impairment abnormally low blood pressure (hypotension) flushing headache Causes - kidney failure - lithium therapy - hypothyroidism - Addison's disease - milk-alkali syndrome - drugs containing magnesium, such as some laxatives and antacids - familial hypocalciuric hypercalcemia

oncotic pressure

The pressure of water to move, typically into the capillary, as the result of the presence of plasma proteins.

risk factors for fluid and electrolyte imbalance

anything affecting intake/input (eating disorders, diarrhea, vomiting) - direct impact to F/E altered absorption access - clean water, nutritious foods meds - diuretics, laxatives, corticosteroids, IV fluids condition/disease - kidney issues, burns, heart failure, hemmorhage

contraindications for IV fluids

depends on fluids/condition ex: - hypertonic -> FVD - hypotonic -> HF / cerebral edema

D5W IV Fluid

description - dextrose 5% in water - crystalloid osmolarity - isotonic (in the bag) * physiologically hypotonic 260 mOsm Uses raises total fluid volume - dehydration due to fluid loss - hypernatremia considerations - solution is isotonic initially, becomes hypotonic when dextrose is metabolized -> dextrose becomes calories - do not use for resuscitation -> too little stays in the vasculature - caution in pts w/ renal or cardiac disease -> can cause fluid overload

Potassium functions

fluid balance transmission of nerve impulses muscle contraction

healthy kidney vs unhealthy kidney

healthy: functions - sodium and water removal - waste removal - hormone production unhealthy: problems - fluid overload - elevated wastes such as urea, creatinine, and potassium - changes in hormone levels controlling: blood pressure, making red blood cells, uptake in calcium

blood transfusion reaction

immune response reactions

IV fluid assessment

is it indicated? appropriate?

Diuretics

loops thiazide potassium sparing osmotic cause kidneys to get rid (excrete) Na & H2O decreases fluid volume instances when it would be helpful to remove fluid from the body - HTN - Heart failure - kidney diseases - edema - liver disease decreased volume = decreased work of heart and decreased preload

albumin function

maintain osmotic pressure

examples of isotonic IV fluids

normal saline - 0.9% NaCl Lactated saline (LR) most common

Rh- can receive from

only Rh-

primary prevention of fluid and electrolyte imbalences

patient teaching dietary measures - what to eat or avoid fluid management - adequate intake with vomiting or diarrhea (#1 cause peds deaths) - limiting intake when prone to edema (HF, kidney failure) safety

Magnesium functions

protein synthesis cellular energy production and storage stabilization of cells DNA synthesis nerve signal transmission bone metabolism cardiac function the conduction of signals between muscles and nerves glucose and insulin metabolism blood pressure

precautions for IV fluids

renal diseases -> easy to fluid overload cardiac diseases head injury -> could increase risk of cerebral edema -> can treat cerebral edema with hypertonic solution

precautions for loops/thiazides diuretics (Furosemide, Hydrochlorothiazide, Chlorthalidone)

severe renal disease, diabetes, hx of gout, pregnancy, those taking meds that lower potassium (insulin)

potassium sparing diuretics (Spironolactone) side effects

side effect: hyperkalemia nursing intervention: avoid K+ foods, take w/ loop/thiazide (if prescribed), educate pt on s/sx * why would we use insulin -> lowers K+ moves into the cell -> give w/ glucose/dextrose side effect: menstrual irregularities - irregular or skipped side effect: impotence/gynecomastia - less prescribed in men, often used in short duration

assessment for fluids and electrolyte imbances

symptoms are nonspecific, consider symptoms in the context of the risk factors present *red flags include a history of: - vomiting - diarrhea - organ failure (kidney, heart, liver) - unexplained nausea, fatigue, dizziness, shortness of breathe, muscle cramping, edema, sudden changes of weight

osmolality

the concentration of solutes in body fluids - concentration of a solution expressed as the total number of solute particles per kilogram - calculated considering the mass of solution - unit is osmol/L - does not depend on the temperature and pressure

hydrostatic pressure

the pressure within a blood vessel that tends to push water out of the vessel

osmolarity

total concentration of all solute particles in a solution - concentration of a solution expressed as osmoles of solute particles per liter of solution - calculated considering the volume of solution - unit is mol/L - depends on the temperature and pressure

populations at greatest risk for fluid and electrolyte imbalance

very young: - increased metabolic rate - increased fluid use and loss - organs immature very old - decreased organ function - decreased thirst - increased rate of chronic conditions

hypotonic solutions

* less concentrated than blood D5W-5% dextrose in water - initially isotonic; provides sugar (be cautious in diabetics) - when delivered , dextrose metabolizes quickly -> water remains

isotonic solutions

* same concentration as blood (same osmolarity) -normal saline - 0.9% sodium chloride (NaCl) in water - lactated ringers - sodium chloride, sodium lactate, potassium chloride, calcium chloride

evaluation of diuretics

*did the drug decrease fluid volume? remember why given in first place - CO - lung sounds - weight - I/O's - BP - energy levels - HR - SPO2 interactions: - digoxin -> increased risk of toxicity w/ hypokalemia - lithium -> retained w/ diuretics - ototoxicity -> +loop - NSAID's -> nephrotoxic - HTN meds -> lower HR/BP

hypertonic solutions

*more concentration than blood 3% saline

assessment before giving potassium sparing diuretics (Spironolactone)

*weight *BP HR RR Na *K (hyperkalemia) Cl *to watch for fluid status and water retention

additional interventions for fluid and electrolyte imbalances

- daily weight - monitoring fluid intake and output - safety - comfort measures - oral hygiene - dietary teaching

colloids

- high molecular weight substances, similar to plasma proteins - molecular size is large and do not cross capillary membrane ("intravascular space expanders") - intravascular t 1/2 = 2-8hrs - maintain plasma colloid osmotic pressure - have good capillary perfusion - edema insignificant - risk of anaphylaxis is more - expensive -not very readily available indications - fluid resuscitation prior to arrival of blood - severe hypoglobuminemia - burns - fluid boluses in critically ill patient where crystalloid use would be excessive

nursing intervention for fluid overload

- stop infusion - diuretic (loops) - fluid restriction - sodium intake - ted stockings/SCD's - mobility - elevate legs respiratory - TCDB (turn, cough, deep breathe) - IS (incentive spirometer)

ADH and osmolarity

-> increase in osmolarity -> increase in ADH release -> increase water reabsorption -> decrease plasma osmolarity -> decrease ADH release ->

Sodium functions

-Regulating fluid balance -Regulating blood pressure -Transmitting nerve impulses -Contracting muscles -Helping nutrient transport

blood and blood products

-whole blood -packed red blood cells -fresh frozen plasma - platelets -albumin (colloid solution)

fluid compartments

1st - intravascular 2nd - interstitial (ex: edema) 3rd - trapped/ not easily retreived

Potassium (K+) normal range

3.5-5.2 mEq/L

RBC count

3.6 - 5.4 x 10^6 / ul

hematocrit normal levels

36% - 48%

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (a loop diuretic) and digoxin. What does the nurse determine is the most likely cause of the depletion? A Diuretic therapy B Inadequate oral fluid intake C Continuous dyspnea D Sodium restriction

A Diuretic therapy that affects the loop of Henle generally involves the use of drugs (e.g., bumetanide, furosemide) that directly or indirectly increase urinary sodium, chloride, and potassium excretion. Sodium restriction may be present in HF overall as an intervention to reduce fluid retention, but usually doesn't change concentration of electrolytes on its own. Dyspnea does not directly result in a depletion of electrolytes. Excessive oral fluid intake may cause dilution of electrolytes; prolonged inadequate oral fluid intake may cause increased concentration levels of electrolytes.

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? A Maintaining potassium levels B Preventing increased sodium levels C Limiting the drugs' combination effects D Correcting the associated dehydration

A Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither drug increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore, the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide.

The nurse determines that additional discharge teaching is needed when the patient with chronic heart failure says: A "I should weigh myself every morning and go on a diet if I gain 2-3 lbs." B "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." C "I will take my pulse every day and call the clinic if it is irregular or less than 50." D "I should hold my digoxin and call the doctor if I experience nausea and vomiting."

A Rationale: All of the statements are correct except the need to "go on a diet" if weight gain of 2-3 lbs is present. A patient with chronic heart failure would need additional teaching that educates that the weight gain is due to fluid balance problems, and the provider needs to be notified.

A client is experiencing parathyroid dysfunction. Which serum calcium concentration in the client would support the diagnosis? A 7.8 mg/dL B 8.9 mg/dL C 9.7 mg/dL D 10.2 mg/dL

A The normal serum calcium concentration usually ranges from 8.6 to 10.2 mg/dL. Within this reference range, a serum calcium concentration below 8.6 mg/dL indicates hypocalcemia and a serum calcium concentration above 10.2 mg/dL indicates hypercalcemia. Parathyroid hormone maintains calcium balance in the body. Hypocalcemia reflects hypoparathyroidism and hypercalcemia suggests hyperparathyroidism. The serum calcium concentration of 7.8 mg/dL is below the normal range and indicates hypocalcemia. Therefore, the client may have hypoparathyroidism, which is a parathyroid dysfunction. Serum calcium concentrations of 8.9 mg/dL, 9.7 mg/dL, and 10.2 mg/dL are all normal findings. *Also be familiar with Trousseau and Chvostek's sign for hypocalcemia (see image)

blood types

A+/-, B +/-, AB+/- and O+/-. Type O- is the universal donor AB+ blood is known as the universal recipient.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. A Weighing and recording all wet diapers B Obtaining an accurate stool count C Changing breastfeedings to bottle-feedings D Restricting fluids prior to weighing the child E Obtaining an accurate daily weight

A, B, & E There is no need to restrict fluids before weighing the patient, and while changing breast feeding to bottle feeding may make it easier to record intake in mL, breast feeding is encouraged whenever possible, and an infant may be weighed prior to and after a breast feed to measure changes in weight that may be ascribed to intake. Otherwise, as mentioned a daily weight, recording/weighing wet diapers, and keeping track of stools will be accurate.

The nurse is reviewing a patients complete blood count (CBC) following the administration of 2 units packed red blood cells. The nurse anticipates which values will have changed as a a result of that administration: A RBC Count B Platelets C WBC Count D Hct E Hgb

A, D, & E Packed red blood cells will not contain platelets or WBCs.

Which of the following are symptoms of fluid volume deficit from dehydration? Select all that apply. A. Hematocrit of 68% B. Decreased specific gravity C. Jugular vein distention D. Cap refill greater than 3 seconds E. Orthostatic hypotension

Answer: A, D, E. Normal hematocrit values are 36-48%. A hematocrit of 68% indicates that the patient is dehydrated because their % of RBCs is higher than normal since there is less plasma/water in the blood. An increased specific gravity (greater concentration of urine) would be expected in dehydration. JVD is only evident in fluid volume overload. Cap refill can be expected to be longer or greater than 3 seconds since there is less blood to perfuse the tissues. Orthostatic hypotension and a low BP can be evident in fluid volume deficit.

Which of the following foods would you NOT recommend to a heart failure patient with +3 edema on their lower extremities? Select all that apply. A. Canned minestrone soup B. Dash salt substitute C. McDonalds Mcdouble cheeseburger D. Smoked salami E. Frozen microwavable lasagna dinner

Answer: A,C,D, E. Canned food, prepackaged food, and fast food are all high in sodium. Smoked, cured, salted, and canned meats are also high in sodium. You would want this patient to eat a low sodium diet to decrease the amount of excess water on board their body. Dash salt substitute is a K+ salt substitute that would be appropriate for a low sodium diet.

A patient with a potassium level of 2.1 has been taking Furosemide daily. Which medication will the nurse anticipate the patient being switched to? A. Spironolactone B. It is not necessary to switch medications. C. Hydrochlorothiazide D. It is not necessary to switch medications, rather, it would be a good idea to increase the dosage of Furosemide.

Answer: A. Spironolactone. The client is experiencing hypokalemia as a result taking a potassium wasting diuretic daily. Spironolactone is a potassium sparing diuretic. Spironalactone would continue to help the patient lose fluids, while making sure their potassium stays within the normal range of 3.5-5.2.

Which of the following is the best indicator that Kayexalate has achieved the desired effect? A. Potassium (K+) of 3.8 B. Potassium (K+) of 3.4 C. 5 stools in 3 hours D. Firm medium brown stool within 30 minutes of Kayexalate administration

Answer: A. The desired effect of Kayexalate is to decrease K+ into the normal range (between 3.5 and 5.2), not induce defecation. A K+ of 3.4 is considered hypokalemic, which is not the desired effect of the medication. While Kayexalate can cause diarrhea, this is not the measure that Kayexalate was effective.

Which of the following are possible manifestations of a hemolytic transfusion reaction? Select all that apply. A. HR of 45 B. Hypotension C. Fever D. RR of 30

Answer: B, C, D. A blood transfusion reaction manifests in an immune reaction! Possible manifestations include: hypotension, fever and chills, tachypnea, chest pain, and possible hives. (A) is incorrect because you would see TACHYCARDIA!

Stimulation of the facial nerve via the masseter muscle causes twitching of the nose/lips in hypocalcemia is known as? A. Trousseau's Sign B. Chvostek's Sign C. Homan's Sign D. Goodell's Sign

Answer: B. A positive Chvostek's is a sign of hypocalcemia. Stimulation of the masseter muscle causes twitching of the nose and lips.

A nurse educator is assessing a nursing student's knowledge about the relationship of potassium and digoxin. Which of the following statements by the student nurse demonstrates a need for further teaching? A. "I should educate my patients on vision changes because that is a sign of digoxin toxicity" B. "Potassium and digoxin share the same receptors on the cell so having too much potassium can increase the effectiveness of digoxin" C. "If I notice the client's potassium level is 3.0, I need to hold the drug and call the provider" D. "I need to take the client's apical pulse heart rate before administering this medication"

Answer: B. Although K+ and digoxin do share the same receptor on the cells, having too much K+ will actually DECREASE the effectiveness of digoxin. Since digoxin and K+ fight for the same receptor site, having too much K+ will prevent the binding of digoxin on the receptors, thus decreasing the effectiveness of the drug. A correct answer would be "...having too little potassium (hypokalemia) can increase the effectiveness of digoxin" since digoxin does not have any competition and thus works too effectively. (A) is incorrect because this is an important education point to provide to your patients about any vision changes since this is a sign of digoxin toxicity. (C ) is incorrect because 3.0 is indicative of hypokalemia, and again, hypokalemia is contraindicated to giving digoxin because it can increase the risk of digoxin toxicity. (D) is incorrect because this is an appropriate way to assess HR in a client taking digoxin. You need to monitor HR on the apical pulse for a full 60 seconds before administration.

A patient with fluid volume excess has 2+ edema on their body. Which of the following fluid spacings is this an example of? A. 1st spacing B. 2nd spacing C. 3rd spacing D. 4th spacing

Answer: B. Fluid accumulating in the interstitial space is an example of 2nd fluid spacing. 1st fluid spacing is fluid in the vasculature. 3rd fluid spacing is when fluid is trapped in an abnormal location, such as a body cavity. This will not fix itself naturally and requires intervention. 4th fluid spacing does not exist.

A patient presents to the ED with muscle cramps in their calves and diarrhea. Upon further assessment, the patient states it feels as if their "heart is fluttering". Blood is pulled for an electrolyte panel and the provider orders an EKG which shows peaked T waves. Which of the following electrolytes imbalances might you anticipate for this patient while waiting for their labs to come back? A. Hypokalemia B. Hyperkalemia C. Hypercalcemia D. Fluid volume excess

Answer: B. Hyperkalemia is characterized by dysrhythmias with peaked T waves, muscle cramps, and diarrhea. Hypokalemia is characterized by bradycardia and palpitation with a flat or inverted T wave, cramps, and constipation. Hypercalcemia is characterized by dysrhythmias, muscle weakness with decreased reflexes, and constipation. Fluid volume excess is not an electrolyte and does not mimic the same signs and symptoms as hyperkalemia.

An elderly patient comes into the clinic with the complaint of watery diarrhea for several days and has developed abdominal & muscle cramping in the last few hours. The nurse realizes that this patient is demonstrating which of the following? A. hypernatremia B. hyponatremia C. fluid volume excess D. hypomagnesemia

Answer: B. Hyponatremia. Diarrhea contributes to the loss of sodium. Abdominal and muscle cramps are also indicators of hyponatremia. diarrhea can also be a sign of hypernatremia so focus on what other symptoms are involved.

A patient's magnesium level is 0.9. The doctor orders Magnesium Sulfate IV. Which nursing intervention takes PRIORITY? A. Assessing for hypertension B. Monitoring a decrease in muscle reflexes C. Monitoring potassium levels D. Monitoring skin turgor

Answer: B. Monitoring for a decrease in muscle reflexes is the priority. The development of a decrease in muscle reflexes would indicate that the patient may have been over treated with Magnesium Sulfate, and is now in a state of hypermagnesemia.

A patient's electrolyte panel comes back and states the following: Sodium (Na+): 125 Potassium (K+): 3.2 Calcium (Ca2+): 8.3 Magnesium (Mg2+): 2.5 Which of the following electrolyte imbalances is most concerning and should be reported to the provider first? A. Na+ B. K+ C. Ca2+ D. Mg2+

Answer: B. Normal K+ labs are 3.5 to 5.2. An imbalance of potassium is life-threatening because of the dysrhythmias it can cause. Na+ is out of balance (normal range 135-145), however is not as life-threatening as a K+ imbalance. Ca2+ and Mg2+ levels are within range.

You are providing education to a client with a new diagnosis of heart failure who is newly prescribed Furosemide (Lasix). Which of the following patient statements demonstrates a need for further teaching about Furosemide? A. "I should sit at the edge of my bed before changing positions" B. "I should buy a scale and take my weight every other day" C. "I should eat potassium-rich foods like bananas and potatoes" D. "If I notice new onset shortness of breath at rest, I need to call my provider right away"

Answer: B. This client needs further teaching because heart failure patients need to take their weights DAILY in order to notice any symptoms of worsening heart failure. Taking daily weights is one of the most important interventions for clients with HF because even a 2-3lb change in weight can indicate FVE which can have a lot of consequences for HF clients. (A) is incorrect because patients need to be aware of orthostatic hypotension. (C ) is incorrect because Furosemide is a K-wasting medication and clients should eat foods rich in K to prevent hypokalemia. (D) is incorrect because new onset SOB can indicate fluid in the lungs, which is an emergency finding for clients with HF and needs to be addressed right away.

You are reassessing a client receiving an IV bolus infusion and are preparing to administer their morning medication. After careful reassessment, you notice they are short of breath, their skin is clammy, and there are crackles in their lungs. What is your priority nursing intervention for this client? A. Perform the 8 medication checks B. Stop the infusion C. Assess vital signs D. Place patient in Fowler's position

Answer: B. This client who is receiving a bolus of IV fluids is experiencing FVE and exhibiting signs of pulmonary edema. If you notice pulmonary edema, the priority nursing intervention is to STOP the infusion to prevent further complications. Although assessing vitals is an important priority to determine the client's current status, the FIRST thing you would do is stop the infusion, and then check their vitals. Placing a patient in Fowler's position is an appropriate intervention to help expand their lungs, but not the top priority. Performing the 8 checks is always important, but for this client who is experiencing an acute exacerbation of FVE, addressing the acute problem is the priority at this time.

Which of the following are clinical manifestations of hypomagnesemia? Select all that apply. A. Vasodilation B. Decreased deep tendon reflexes C. Tetany D. Muscle weakness E. Tremors

Answer: C and E only. Clinical manifestations of hypomagnesemia are: increased BP, increased muscle reflexes, tetany, and tremors.

A patient is presenting with a thready and weak pulse of 58, and decreased bowel tones. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? A. Potassium level of 7.0 B. Potassium level of 3.5 C. Potassium level of 2.4 D. None of the options are correct

Answer: C. Potassium level of 2.4. Hydrochlorothiazide is a potassium wasting diuretic. Symptoms of hypokalemia include bradycardia and decreased bowel tones.

You are providing home health education to a client with Type 2 Diabetes taking Hydrochlorothiazide to manage their symptoms of edema from their HF. Which of the following patient statements indicates an understanding of the education provided? A. "I will take this medication with my dinner to avoid GI symptoms" B. "I don't need to monitor my diet since I have insulin to keep my blood sugar in check" C. "I will monitor my blood sugar regularly" D. "I should be worried about having too much potassium in my diet, so I need to restrict my potassium"

Answer: C. Since Hydrochlorothiazide is a K+ wasting diuretic, one of the adverse side effects is hyperglycemia (K+ is important for the reuptake of glucose into the cells. Without K+, glucose stays in the blood and is not able to enter the cells). Clients with diabetes need to monitor their blood sugar regularly since K+ wasting diuretics can cause an increase in blood sugar. (A) is incorrect because it is advised that clients taking diuretics should take their medications in the morning to avoid nocturia. (B) is incorrect because clients on diuretics should be monitoring their diet to prevent any other electrolyte imbalances. (D) is incorrect because clients on K+ wasting diuretics should be encouraged to eat foods rich in potassium instead of restricting it.

You are caring for a new client with cerebral edema and reviewing their orders. Which of the following orders would you question? A. D5LR IV solution B. Mannitol (Osmotic Diuretic) C. STAT 0.45% NaCl solution D. Continuous mental status assessment

Answer: C. You would question the order for 0.45% NaCl because this is a hypotonic solution. Hypotonic solutions are contraindicated for clients with cerebral edema because these solutions increase the hydration of cells and this will significantly worsen their edema! Remember, hypo sounds like hippo! Your cells will swell if given a hypotonic solution. (A) is an appropriate intervention because hypertonic solutions are used to treat cerebral edema. (B) is an appropriate intervention because Mannitol--an osmotic diuretic--is used as a treatment to decrease the edema. (D) is appropriate because clients with cerebral edema should have their mental status continually assessed in order to determine if the interventions are working.

A patient is being discharged home after hospitalization for hypocalcemia. Which statement by the patient indicates she understood the dietary instructions? A. "I will avoid sardines." B. "I'll avoid salt and Vitamin-D supplements." C. "I will avoid consuming milk and spinach." D. "I will be sure to eat lots of cheese and spinach."

Answer: D. Dietary sources of calcium include green leafy vegetables and dairy. The patient should be encouraged to eat dietary sources of calcium after experiencing hypocalcemia.

You are preparing to administer Spironolactone for a client with acute exacerbations of HF. Which of the following assessment findings would cause you to HOLD the dose? A. BP of 120/82 (PT's baseline BP is 125/80) B. K level of 3.7 C. Bounding pulse D. K level of 5.5

Answer: D. Spironolactone is a K+-sparing diuretic which means it retains K+. The contraindications for this medication is hyperkalemia. A client who's K level is at 5.5 indicates that they are already in a state of hyperkalemia, so you would hold this dose in order to prevent further complications. (A) is incorrect because the client's BP is normal. (B) is a normal K level. (C ) is a symptom of FVE, so giving a K+ sparing diuretic would be indicated for this client.

The nurse is coming on shift to care for a 62 year-old woman with type B+ blood receiving a packed RBC transfusion. Upon entering the room, the nurse goes to check the donor blood bag and patency of the IV line. The donor blood type is A-. Which of the following steps should the nurse perform first? A. Walk outside the patient's room and call the provider so as not to B. alarm the patient. C. Take the patient's vital signs and listen to lung sounds. D. Stop the transfusion E. Call the nurse manager to report the previous nurse's error

Answer: D. Type A- blood is NOT compatible with B+ blood. Stopping the transfusion is the priority step since the transfusion is causing harm to the patient. Calling the provider would be the next step. After completing the doctor's orders to address the blood incompatibility and if the patient is safe and out of harm, taking the patient's VS and gathering other assessment data could be appropriate. Reporting the previous nurse's error is the last priority.

The nurse is reviewing the laboratory reports of a group of older adult clients. Which client sodium lab value demonstrates an age-related impairment in thirst mechanism? A 145 mEq/L B 167 mEq/L C 134 mEq/L D 140 mEq/L

B Older adult and/or elderly clients are at greater risk of fluid and electrolyte imbalances such as dehydration and hypernatremia due to age-related impairment in the thirst mechanism. The normal serum sodium concentration is between 135-145 mEq/L. A serum sodium concentration of 167 mEq/L, is higher than normal, thereby indicating hypernatremia. Two of the lab values are in the normal range. The value of 134 mEq/L is very close to normal and on the lower side which does not relate to impaired thirst mechanism leading to hypernatremia.

The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply. A Bowel sounds sluggish in all four quadrants B Oriented to person, place, and time C Capillary refill of nail beds 3 seconds D Poor skin turgor E Peripheral pulses present and full

B, C, E If the client is not experiencing an alteration in perfusion, the client should be alert and oriented, skin would have rapid turgor, capillary refill would be 3 seconds or less, and present and full pulses. A client experiencing problems with perfusion may demonstrate a change in level of consciousness (to less than alert), hypoactive bowel sounds, and prolonged/poor skin turgor.

It is determined that a client has dysfunction of the pituitary gland due to a traumatic brain injury (TBI). The client is experiencing over-secretion of antidiuretc hormone (ADH). What assessment data would the nurse expect to see? A Hyperkalemia B Hypokalemia C Hypernatremia D High urine specific gravity E Hyponatremia

B, D, & E Excessive production of ADH will lead to fluid retention in the body. This contributes to dilution of the electrolytes, and hyponatermia (most concerning) and hypokalemia (as well as hypocalcemia, hypophospatemia, and to a lesser degree, hypomagnesemia) will occur. Due to excess ADH, the kidneys are not making as much urine, and the concentration or specific gravity of the urine will most likely be high.

sources of potassium

Bananas, oranges, cantaloupe, honeydew, apricots, grapefruit (some dried fruits, such as prunes, raisins, and dates, are also high in potassium) Cooked spinach Cooked broccoli Potatoes Sweet potatoes Mushrooms Peas Cucumbers Zucchini Pumpkins Leafy greens Orange juice Tomato juice Prune juice Apricot juice Grapefruit juice Certain dairy products, such as milk and yogurt, are high in potassium (low-fat or fat-free is best). Tuna Halibut Cod Trout Rockfish Lima beans Pinto beans Kidney beans Soybeans Lentils Salt substitutes (read labels to check potassium levels) Molasses Nuts Meat and poultry Brown and wild rice Bran cereal Whole-wheat bread and pasta

Calcium functions

Blood clotting cardiac function nerve transmission smooth muscle contractility

A client with heart failure has an Ejection Fraction (EF) of 40%. (to best answer this question, look up "ejection fraction" or review HF case study answer key after posted). Which assessment finding best represents this diagnostic? A Decreased heart rate B Clear lung sounds C Dyspnea at rest D Shortness of breath with activity

C A client with HF and 40% EF will likely experience symptoms of very low cardiac output. While SOB with exertion will happen with a reduced EF%, difficulty breathing (dyspnea) at rest best represents a key symptom of an EF of 40%. SOB only with activity is common with borderline EF between 41-49%.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment is the most objective indicator of the client's fluid and electrolyte balance? A Client statement "I've been drinking lots of water" B Skin turgor C Blood labs D Intake and output results

C Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and may not be reliable in a client with dementia.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? A "Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded." B "If my skin becomes dry and itchy I can apply extra lotion." C "I should drink more water when I feel thirsty or becoming irritable" D "Dehydration is only a problem in the summer months when it's hot outside."

C Rationale: Early stages of dehydration in the average adult include increased thirst and mental status changes that may include irritability. Later manifestations of dehydration will include s/sx of FVD such as dry skin, poor perfusion to the brain (orthostatic hypotention). Dehydration can occur in any setting, season, weather, or climate.

The major goal of nursing care for a client with heart failure and pulmonary edema is to: A Enhance comfort B Decrease peripheral edema C Increase cardiac output D Get accurate daily weights

C The primary goal of heart failure therapy is to optimize cardiac output. When this goal is met, the improvement in left heart function will normally improve enough that pulmonary edema will lessen.

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? A Increases cardiac conduction B Reduces edema C Slows and strengthens cardiac contractions D Increases rate of ventricular contractions

C Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.

When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory value is the priority for the nurse to monitor? A Calcium of 8.6 mEq/L B Sodium of 130 mEq/L C Hematocrit of 40% D Potassium of 3.1 mEq/L

D

Which of the following nursing actions is the priority for a patient experiencing a potential transfusion reaction? A Re-type and crossmatch B Apply oxygen C Administer epinephrine D Stop the transfusion

D

A 3-year-old with dehydration has vomited three times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. They have a normal saline lock in their right hand, and have had less than adequate urine output in the last 4 hours. The nurse calls the health care provider with the recommendation for which prescription? A Giving a dose of an antidiarrheal B Establishing an indwelling catheter C Beginning an IV antibiotic D Starting a fluid bolus of normal saline

D A bolus of fluid is a volume of fluid administered over a defined period of time, which would be helpful considering increased fluid loss (from vomiting and diarrhea) and low urinary output. Giving an antidirrheal would not be helpful because the child is eliminating the pathogen via feces. Instead, fluid and electrolyte support as needed to balance the loss is priority. The nurse would not request an antibiotic because the patient has a virus.

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? A Sodium of 147 mEq/L B Magnesium of 1.9 mEq/L C Calcium of 9.5 mg/dL D Potassium of 6.3 mEq/L

D The normal level of serum potassium is between 3.5-5.0 mEq/L. Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum sodium are 135-145mEq/L, a slight elevation in this case would not typically lead to those specific complications. normal levels of serum calcium are usually between 8.6-10.2 mg/dL. Normal levels of Magnesium are usually 1.5-2.5 mEq/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.

sources of calcium

Dairy, broccoli, kale, grains, egg yolk, fish

normal saline (NS) IV fluid

Description - 0.9% NaCl in water - crystalloid solution osmolarity - isotonic (308 mOsm) uses increases circulating plasma volume when red cells are adequate - shock - DKA - hyponatremia - blood transfusions - metabolic alkalosis - hypercalcemia considerations - caution in pts w/ heart failure, and hypernatremia -> NS replaces extracellular fluid and can result in fluid overload - replaces losses w/o significantly altering fluid concentration - helpful for Na+ replacement - can cause hyperchloremic (non-anion gap) metabolic acidosis (Cl displaces the HCO3)

1/2 normal saline (1/2 NS) IV fluid

Description -0.45% NaCl in water - crystalloid solution osmolarity hypotonic (154 mOsm) uses raises total fluid volume: - water replacement - DKA after initial NS and before dextrose infusion - hypertonic dehydration - Na+ and Cl- depletion - gastric fluid loss from nasogastric suctioning or vomiting considerations - use cautiously as may cause cardiovascular collapse or increase intracranial pressure - not recommenced for pt's w/ liver disease, trauma, or burns - useful for daily maintenance of body fluids particularly in diabetics and pt's w/ renal failure

D5NS IV fluid

Description dextrose 5% in 0.9% saline osmolarity hypertonic (560 mOsm) uses replaces fluid Na+, Cl-, and calories - hypotonic hedydration - temporary treatment of circulatory insufficiency and shock is plasma expenders are not available - SIADH - addisonian crisis considerations - caution in pt's w/ cardiac or renal failure -> increased risk for HF and pulmonary edema - monitor for fluid volume overload

D5LR IV fluid

Description dextrose 5% in lactated ringers osmolarity hypertonic (575 mOsm) uses same as LR, plus provides ~180cal/1000cc - replaces fluid and buffers pH - hypovolemia d/t third spacing - dehydration - burns - lower GI fluid loss (diarrhea) considerations - contradicted in newborns -> risk of fetal cefriaxone-calcium salt precipitation - contradicted in pts w/ known hypersensitivity to sodium lactate

3% NaCl IV fluid

Description hypertonic saline osmolarity hypertonic (1026 mOsm) uses pulls fluid into the vasculature - cerebral edema - volume resuscitation - hyponatremia considerations - must monitor Na+ closely - increased risk for HF, pulmonary edema, fluid overload

7.5% NaCl IV fluid

Description hypertonic saline osmolarity hypertonic (2566 mOsm) uses marked osmotic shift of fluid from Intracellular to the interstitial and intravascular space - cerebral edema - volume resuscitation - hyponatremia considerations - must monitor Na+ closely - high risk for HF, pulmonary edema, fluid overload

lactated ringers (LR) IV fluids

Description normal saline w/ K+, C++ and lactate (buffer) osmolarity isotonic (273 mOsm) uses replaces fluid and buffers pH - hypovolemia d/t third spacing - dehydration - burns - lower GI fluid loss (diarrhea) considerations - contains K+ -> caution in pts w/ renal failure -> hyperkalemia - caution in pts w/ liver disease -> cannot metabolize lactate - often used during surgery

Normosol-R IV fluid

Description normosol osmolarity isotonic (295 mOsm) uses useful for replacing acute extracellular volume losses and buffering pH - surgery - trauma - burns -shock considerations often used in conjunction w/ blood products due to hemorrhage or acute blood loss

A client with a history of heart failure admits to the nurse that an 1800mg sodium diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. What other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply. A Thready pulse B Dizziness when standing up C Decreased blood pressure D Headache E Crackles on lung auscultation

E & D Cerebral edema caused by hypervolemia may cause a headache. Crackles on lung auscultation indicate the presence of fluid in the alveoli (pulmonary edema). Increased fluid volume in the intravascular compartment (overhydration) will cause the pulse to feel full and bounding, rather than weak or thready. The blood pressure will increase, not decrease, with hypervolemia. Dizziness when standing up occurs when pooling of blood in the peripheral vessels causes orthostatic (postural) hypotension, and also when there is decreased cardiac output from heart failure.

Loop Diuretics

Furosemide (Lasix) - potassium wasting (cautious of hypokalemia) - most powerful diuretic GOALS: - treat pulmonary edema from HF - treat edema in other areas of the body - treat HTN that isn't controlled with other meds Routes: PO, IV, IM, give IV slowly

Thiazide diuretics

Hydrochlorothiazide (HCTZ) Chlorthalidone - block reabsorption of Na/Cl - potassium wasting GOALS: - first line treatment for HTN - can also be used to treat edema Routes: PO, IV, IM, give IV slowly

fluid volume excess

OVERHYDRATION: fluid intake or fluid retention exceeds fluid needs of the body

Potassium sparing diuretics

Spironolactone (Aldactone) - blocks action of aldosterone GOALS: - treat edema - treat HF symptoms - to counteract potassium loss from other diuretics - prescribed w/ loop/thiazide routes: oral, wear gloves when crushing to prevent endocrine/reproductive harm to nurse

Hypernatremia symptoms

Symptoms - may not cause any symptoms, meaning that a person may not be aware that they have it. - The main symptom of hypernatremia is excessive thirst. - Other symptoms include fatigue and confusion. - In advanced cases, a person may experience muscle twitching or spasms, as sodium is important for the function of muscles and nerves. With severe elevations of sodium, seizures and coma may occur. Causes dehydration vomiting kidney disease uncontrolled diabetes diabetes insipidus extreme diarrhea dementia fever delirium certain medications large areas of burned skin Certain people are more likely than others to develop hypernatremia. At-risk populations include: people receiving intravenous (IV) treatments or undergoing nasogastric feeding people with an altered mental state infants older adults

Hyperkalemia

Symptoms Abdominal (belly) pain and diarrhea. Chest pain. Heart palpitations or arrhythmia (irregular, fast or fluttering heartbeat). (peaked T waves) Muscle weakness or numbness in limbs. Nausea and vomiting. Causes - A high-potassium diet, which can result from potassium supplements and salt substitutes. - Medications that contain potassium, such as certain high blood pressure medicines. You may be more at risk if you have: - Addison's disease. - Alcohol use disorder (alcoholism). - Burns over a large part of your body. - Congestive heart failure. - Diabetes. - Human immunodeficiency virus (HIV). - Kidney disease.

Hypomagnesemia

Symptoms Early signs of low magnesium include: - nausea - vomiting - weakness - decreased appetite As magnesium deficiency worsens, symptoms may include: - numbness - tingling - muscle cramps - seizures - muscle spasticity - personality changes - abnormal heart rhythms Causes - decreased absorption of magnesium in the gut - increased excretion of magnesium in the urine. - low dietary intake of magnesium - excessive loss of magnesium - use of diuretics

Hypercalcemia

Symptoms Kidneys. Excess calcium makes your kidneys work harder to filter it. This can cause excessive thirst and frequent urination. Digestive system. Hypercalcemia can cause stomach upset, nausea, vomiting and constipation. Bones and muscles. In most cases, the excess calcium in your blood was leached from your bones, which weakens them. This can cause bone pain and muscle weakness. Brain. Hypercalcemia can interfere with how your brain works, resulting in confusion, lethargy and fatigue. It can also cause depression. Heart. Rarely, severe hypercalcemia can interfere with your heart function, causing palpitations and fainting, indications of cardiac arrhythmia, and other heart problems. Causes Overactive parathyroid glands (hyperparathyroidism). This most common cause of hypercalcemia can stem from a small, noncancerous (benign) tumor or enlargement of one or more of the four parathyroid glands. Cancer. Lung cancer and breast cancer, as well as some blood cancers, can increase your risk of hypercalcemia. Spread of cancer (metastasis) to your bones also increases your risk. Other diseases. Certain diseases, such as tuberculosis and sarcoidosis, can raise blood levels of vitamin D, which stimulates your digestive tract to absorb more calcium. Hereditary factors. A rare genetic disorder known as familial hypocalciuric hypercalcemia causes an increase of calcium in your blood because of faulty calcium receptors in your body. This condition doesn't cause symptoms or complications of hypercalcemia. Immobility. People who have a condition that causes them to spend a lot of time sitting or lying down can develop hypercalcemia. Over time, bones that don't bear weight release calcium into the blood. Severe dehydration. A common cause of mild or transient hypercalcemia is dehydration. Having less fluid in your blood causes a rise in calcium concentrations. Medications. Certain drugs — such as lithium, used to treat bipolar disorder — might increase the release of parathyroid hormone. Supplements. Taking excessive amounts of calcium or vitamin D supplements over time can raise calcium levels in your blood above normal.

Hypocalcemia

Symptoms confusion or memory loss muscle spasms numbness and tingling in the hands, feet, and face depression hallucinations muscle cramps weak and brittle nails easy fracturing of the bones Causes - poor calcium intake over a long period of time, especially in childhood - medications that may decrease calcium absorption - dietary intolerance to foods rich in calcium - hormonal changes, especially in women - certain genetic factors - malnutrition - malabsorption - low levels of vitamin D, which makes it harder to absorb calcium - medications, such phenytoin, phenobarbital, rifampin, corticosteroids, and drugs used to treat elevated calcium levels - pancreatitis - hypermagnesemia and hypomagnesemia - hyperphosphatemia - septic shock - massive blood transfusions - renal failure - certain chemotherapy drugs

Hypokalemia

Symtoms Weakness Fatigue Muscle cramps or twitching Constipation Arrhythmia (abnormal heart rhythms) (flat or Inverted T wave) Hypokalemia can affect your kidneys. You may have to go to the bathroom more often. You may also feel thirsty. You may notice muscle problems during exercise. In severe cases, muscle weakness can lead to paralysis and possibly respiratory failure. Causes vomiting diarrhea kidneys or adrenal glands don't work well You take medication that makes you pee (water pills or diuretics) It's possible, but rare, to get hypokalemia from having too little potassium in your diet. Other things sometimes cause it, too, like: Drinking too much alcohol Sweating a lot Folic acid deficiency Certain antibiotics Diabetic ketoacidosis (high levels of acids called ketones in your blood) Laxatives taken over a long period of time Certain types of tobacco Some asthma medications Low magnesium

sources of sodium

Table salt, processed foods, butter

A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills, and a headache. In addition, the patient's temperature is now 99.8'F from 98'F. Your next nursing action is: A. Stop the transfusion B. Notify the physician C. Decrease the rate of the transfusion D. Reassure the patient that this is normal and will resolve in 30 minutes.

The answer is A. The patient is possibly having a transfusion reaction. FIRST, the nurse should STOP the transfusion and then disconnect the IV tubing at the access site and replace it with NEW tubing. In addition, have normal saline infusion to keep the vein open. THEN the nurse will notify the physician and blood bank.

Which patient below is considered hypernatremic? A. A patient with a sodium level of 156 B. A patient with a sodium level of 145 C. A patient with a sodium level of 120 D. A patient with a sodium level of 136

The answer is A: A patient with a sodium level of 156. The expected range of sodium is between 135-145mEq/L (Reference: NRS 326 Lab Sheet on Teams Page).

tonicity of IV fluid

consider the effects of the three types of IV fluids what effects are there from the different osmolarities? - isotonic: stays in vasculature - hypotonic: leaves vasculature - hypertonic: pulls towards vasculature What is we give too much total volume? how will we know? - FVE (fluid volume overload), edema *especially with iso/hypo what can we go? - stop infusion, diretics, positioning, TCDB, IS - if cerebral edema -> give hypertonic

examples of hypertonic IV fluids

dextrose 5% in LR (D5LR) dextrose 5% in NS (D5NS) 3% NaCl rare

contraindications for potassium sparing diuretics (Spironolactone)

hyperkalemia

digoxin toxicity can result from

hypokalemia

Contraindications for loops/thiazides diuretics (Furosemide, Hydrochlorothiazide, Chlorthalidone)

hypokalemia since they are potassium wasting

if you are Blood type A- you can receive from_____________ and you can donate to _________________

receive: A+/- and AB+/- donate: o- and A-

if you are Blood type A+ you can receive from_____________ and you can donate to _________________

receive: A+/- and O+/- donate: A+ and AB+

if you are Blood type AB+ you can receive from_____________ and you can donate to _________________

receive: AB+ donate: universal

if you are Blood type AB- you can receive from_____________ and you can donate to _________________

receive: AB+/- donate: O-, A-, B-, and AB-

if you are Blood type B+ you can receive from_____________ and you can donate to _________________

receive: B+ and AB+ donate: O+/- and B+/-

if you are Blood type B- you can receive from_____________ and you can donate to _________________

receive: B+/- and AB+/- donate: O- and B-

if you are Blood type O+ you can receive from_____________ and you can donate to _________________

receive: O+, A+, B+, AB+ donate: O+/-

if you are Blood type O- you can receive from_____________ and you can donate to _________________

receive: universal donate: O-

loops/thiazides diuretics (Furosemide, Hydrochlorothiazide, Chlorthalidone) side effects to monitor for

side effect: hyponatremia, hypochloremia, dehydtarion nurse intervention: monitor, notify provider, fluid restriction side effect: hypotension nurse intervention: monitor/ orthostatic hypotension side effect: hypokalemia nursing intervention: monitor/ diet teaching/notify side effect: ototoxicity nursing intervention: pt education side effect: hyperglycemia nursing intervention: higher concentration glucose remaining side effect: hyperuricemia nursing intervention: tender/painful swollen joints -> notofy *if already hypo or toxic will make them worse

Crystalloids

substances in a solution that diffuse through a semipermeable membrane (dissolves easily) - aqueous solutions of low molecular weight ions with or without glucose - readily pass through semi-permeable membrane ("extra vascular space expanders") - intravascular t 1/2 = 20-30min - reduce plasma colloid osmotic pressure - have poor capillary perfusion - risk of over hydration/tissue edema is obvious - no anaphylactic reaction - inexpensive - readily available indications - Rx of dehydration of any cause - hypoglycemia (5% 10% D) - hypochloremia, hyponatremia of any cause preloading fluid in regional block (SA) - Iintraoperative/postoperative maintenance fluid

Hyponatremia

symptoms Nausea and vomiting Headache Confusion Loss of energy, drowsiness and fatigue Restlessness and irritability Muscle weakness, spasms or cramps Seizures Coma causes - Certain medications. Some medications, such as some water pills (diuretics), antidepressants and pain medications, can interfere with the normal hormonal and kidney processes that keep sodium concentrations within the healthy normal range. - Heart, kidney and liver problems. Congestive heart failure and certain diseases affecting the kidneys or liver can cause fluids to accumulate in your body, which dilutes the sodium in your body, lowering the overall level. - Syndrome of inappropriate anti-diuretic hormone (SIADH). In this condition, high levels of the anti-diuretic hormone (ADH) are produced, causing your body to retain water instead of excreting it normally in your urine. - Chronic, severe vomiting or diarrhea and other causes of dehydration. This causes your body to lose electrolytes, such as sodium, and also increases ADH levels. - Drinking too much water. Drinking excessive amounts of water can cause low sodium by overwhelming the kidneys' ability to excrete water. Because you lose sodium through sweat, drinking too much water during endurance activities, such as marathons and triathlons, can also dilute the sodium content of your blood. - Hormonal changes. Adrenal gland insufficiency (Addison's disease) affects your adrenal glands' ability to produce hormones that help maintain your body's balance of sodium, potassium and water. Low levels of thyroid hormone also can cause a low blood-sodium level.

precautions for potassium sparing diuretics (Spironolactone)

those taking medications that raise potassium (ACE's/ ARB's

kayexalate diuretics

traps K+ in the GI tract for excretion - used to lower serum potassium levels - given PO or PR (rectal) assessment: - K+, Na+, cardiac rhythm monitoring - heart rhythm - constapation - gastric irritation - diarrhea - sodium retention - hypokalemia - diarrhea is normal evaluation - did it work? - K+ level