Chap. 40: fluid and electrolytes

What commonly used intravenous solution is hypotonic? lactated Ringer's 0.45% NaCl 5% dextrose in 0.45% NaCl 0.9% NaCl

0.45% NaCl; .9%NS isotonic; 3%+ hypertonic

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? 75 mL/hr for the first 15 minutes, then 200 mL/hr As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids

1.The client who is taking diuretics

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 20- to 25-degree angle 30- to 35-degree angle 10- to 15-degree angle 40- to 45-degree angle

10-15 degree angle

A loss of 1kg of weight is equal to the loss of how much water?

1L 1=1 not lbs. but kg. unit same

How far upstream should a tourniquet be applied?

3-4 inch upstream of vein

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply. O AB A B

A B AB O

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? hypertonic hypotonic isotonic hypotonic, followed by isotonic

A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? Have the client perform the Valsalva maneuver. Apply pressure to the site with sterile gauze until hemostasis is achieved. Measure the catheter and compare it with the length listed in the chart. Apply a tourniquet to the client's upper arm

Apply a tourniquet to the client's upper arm In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

hypercalcemia mnemonic

BACK ME UP. bone pain, arrhythmia, constipation, kidney stones, excess urination, polydipsia.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. Change the site every three to four days. Clean the insertion site daily using sterile technique. Flush the catheter every six hours with hypertonic solution if the IV is not in constant use

Change the site every three to four days.

Which is a common anion? chloride magnesium calcium potassium

Chloride Cl-. all other options are cations

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Hypervolemia management Electrolyte management Monitoring edema Fluid restriction Intravenous therapy Nutrition management

Electrolyte management Intravenous therapy Nutrition management

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:

FVE

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply. Urticaria Fever Hematuria Low back pain Facial flushing

Fever Hematuria Low back pain Facial flushing also, low BP

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? Hyperphosphatemia Hyponatremia Hypermagnesemia Hypokalemia

Hyperphosphatemia CPKNA. inverse rel b/t phophorus and Ca

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? Chloride Sodium Phosphorous Potassium

Potassium. thiazide diuretics are potassium wasting.

How is control over the extracellular concentration of potassium within the human body is exerted? progesterone. aldosterone. testosterone. albumin.

aldosterone.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? an infant age 4 months an adolescent age 17 years a woman age 45 years a man age 50 years

an infant age 4 months

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? Apricots Dairy products Processed meat Bread products

apricots

What is the most accurate way to measure fluid status of a patient. specific gravity daily weight blood pressure intake and output

daily weight.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and intracellular dehydration decreased blood volume and intracellular dehydration decreased blood volume and extracellular overhydration increased blood volume and extracellular overhydration

decreased blood volume and intracellular dehyrdation

Why would an obese person be more prone to dehydration?

fats hold less water than lean muscle.

What type of solution is used for flushing a CVAD and what type is used for a peripherally inserted catheter?

heparin and/or NS for CVAD and NS for

Which types of fluids should be administered in a large vein?

hypertonic, blood transfusions, irritating medications, and rapidly infused meds.

A positive Chokev's sign would indicate what electrolyte imbalance?

hypocalcemia. C in chokev for Calcium and V points downward indicating HYPOcalcemia.

How does early sepsis affect Ph?

increased respiratory rate (hyperventilation) would lead to alkalosis

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? Toddler Preschool-aged child School-aged child Infant

infant

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size removal of waste transportation of nutrients maintenance of blood volume

maintenance of cell size

what is this?

needleless connector/access point

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? O negative B positive AB negative A positive

o negative

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

offer small amounts of preferred beverage

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? pH: 7.28; PaCO2: 52; HCO3: 32 pH: 7.60; PaCO2: 64; HCO3: 42 pH: 7.32; PaCO2: 26; HCO3: 18 pH: 7.32; PaCO2: 28; HCO3: 24

pH: 7.60; PaCO2: 64; HCO3: 42

A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? Packed cells Whole blood Platelets D5W 1000 mL White blood cells

packed cells

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? palpating the veins on the nondominant hand placing the tourniquet on the upper arm for 2 minutes asking the client to pump their fist several times asking if the client is right or left handed

placing the tourniquet on the upper arm for 2 minutes

How to remove IV

pressure with dry gauze proximal to insertion site. pull at angle of insertion. apply pressure.

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. sodium, chloride, and bicarbonate. magnesium, sulfate, and carbon. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate.

What should be done if a patient receiving an IV exhibits chest pain, tachycardia, tacyapnea, low BP, and confusion. What should the nurse do?

suspected embolism; stop IV by pinching it (clamping may not work because embolism comes from hole in line upstream) and place in Trendelenburg position. monitor oximeter.

Magnesium level

1.5-2.5

How often are IV solutions changed to prevent infection?

24 hours

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes insipidus 4.Client with controlled hypertension

3.Client with diabetes insipidus. low antidiuretic hormone means more urination and lower fluid.

Standard rate of microdrip?

60gtt/min.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Position the client on the left side. Apply a warm compress. Apply antiseptic and a dressing. Elevate the client's head.

Apply a warm compress.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1.Dehydration 2.Hypokalemia 3.Fluid overload 4.Hypernatremia

Dehydration. When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Call the primary care provider to see whether anti-inflammatory drugs should be administered. Discontinue the IV and relocate it to another site. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site

Discontinue the IV and relocate it to another site

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? Muscle weakness, fatigue, and dysrhythmias Nausea, vomiting, and constipation Diminished cognitive ability and hypertension Muscle weakness, fatigue, and constipation

Muscle weakness, fatigue, and dysrhythmias

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "My spouse would also like to donate blood." "I have never given blood before." "My blood type is B positive." "I received a blood transfusion in the United Kingdom."

My spouse would also like to donate blood

A client is receiving IV fluids. The solution has an osmolarity of 300 mOsm/L. The nurse would expect which event to occur with the body's fluids? No shifting of fluids occurs. Fluids move into the cells. Intracellular fluid moves to the intravascular space. Fluids move into the insterstitial space.

No shifting of fluids occurs

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? B positive A positive AB negative O negative

O negative

hyponatremia mnemonic

SALT LOSS stupor, anorexia, lethargy, tendon relfexes diminished, limp muscles, orthostatic hypotension, stomach cramps, seizures

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? If sodium is low, it means that there is not enough water. Sodium is not regulated by natriuretic peptides. Sodium is regulated by the renin-angiotensin-aldosterone system. Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L).

Sodium is regulated by the renin-angiotensin-aldosterone system Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily weights output measurements daily electrolyte monitoring daily BUN and serum creatinine monitoring

daily weights

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? hypotonic solution colloid solution hypertonic solution isotonic solution

hypertonic solution

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 4+ 3+ 1+ 2+

1+ The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

The nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse should expect the hematocrit level for this client to be noted at which level? 1.60% (0.60) 2.47% (0.47) 3.45% (0.45) 4.32% (0.32

1.60% (0.60). since proportion of plasma is lower, hemocrit proportion becomes higher.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1.Hypotension 2.Increased heart rate 3.Bounding peripheral pulses 4.Shortened QT interval on electrocardiography (ECG)

1.Hypotension

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? 1.An oral temperature of 98.8º F (37.1º C) 2.A urine specific gravity of 1.043 3.A urine output that is pale yellow 4.A blood pressure of 120/80 mm Hg

2.A urine specific gravity of 1.043

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes

3.Tall peaked T waves 5.Widened QRS complexes Taller T and wider=hyperkalmemia Shorter T and narrower ST

How often are CVAD dressings changed assuming the site has no drainage?

5-7 days; at least every two days if drainage and gauze used.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Risk for Infection related to inadequate personal hygiene Pain related to surgical incision Constipation related to immobility Acute Confusion related to cerebral edema

Acute Confusion related to cerebral edema

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Apply antiseptic and a dressing. Position the client on the left side. Apply a warm compress. Elevate the client's head.

Apply a warm compress. Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply pressure to insertion site for at least 3 minutes. Ask client to perform Valsalva maneuver. Apply petroleum-based ointment and sterile occlusive dressing. Instruct client to remain flat for 30 minutes.

Apply pressure to insertion site for at least 3 minutes. normally 1 min.

A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? 1.Folate 2.Biscodyl 3.Ferrous sulfate 4.Cyanocobalamin

Biscodyl The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. Laxatives will compound the potential risk for the client. These clients are at risk for deficiencies of folate, iron, and cyanocobalamin and should receive them as supplements if necessary.

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid in the tissue space between and around cells." "Fluid outside cells."

Fluid in the tissue space between and around cells."

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Hypokalemia Hyperchloremia Hypomagnesemia Hypernatremia

Hypokalemia

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Hyperchloremia Hypokalemia Hypernatremia Hypomagnesemia

Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? "This surgery has a very low chance of hemorrhage, so you will not need blood." "We now have artificial blood products, so giving your own blood is not necessary." "Unfortunately, your own blood cannot be reinfused during surgery." "Let me refer you to the blood bank so they can provide you with information."

Let me refer you to the blood bank so they can provide you with information

The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains the buffer systems to the students. Which buffer systems will be discussed by the instructor? Select all that apply. Phosphate buffer system Carbonic acid-sodium bicarbonate buffer system Respiratory buffer system Protein buffer system Potassium buffer system

Phosphate buffer system Carbonic acid-sodium bicarbonate buffer system Protein buffer system

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Remove the IV. Elevate the arm. Slow the rate of IV fluids. Apply a warm compress.

Remove the IV. The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Start an IV of normal saline as prescribed. Encourage fluid intake. Allow nothing by mouth. Give the client a glass of orange juice with added sugar.

Start an IV of normal saline as prescribed.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? Prepare to give an antihistamine. Administer oxygen. Infuse saline at a rapid rate. Stop the transfusion immediately

Stop the transfusion immediately

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply.

The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client (it will decrease what is given because it will increase fluid volume) A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the administration of blood.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 47-year-old who had a colon resection yesterday and is reporting pain a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

Suggestions for fluid restriction patients with thirst

avoid sweets as they relieve temporarily but cause dehydration over time. gargle with water avoid excessively salty or sweet foods

What should be done with an IV that is partially dislodged but still functioning?

leave in and mointor for infiltration more often.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: low calcium. low potassium. high sodium. high magnesium.

low calcium

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Ensure that the prescribed solution is clear and transparent. Select a primary tubing of about 37 inches (94 cm) long. Avoid replacing IV solutions every 24 hours. Use half-instilled IV solutions before infusing a new one.

nsure that the prescribed solution is clear and transparent.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the prioritynursing action? Assess for visible rash. Call for assistance. Assess oxygen levels. Stop the transfusion.

stop transfusion

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1.Malnutrition 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome

1.Malnutrition

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D

1.Prolonged bed rest The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take? 1.Take no action. 2.Order a stat hemodialysis treatment. 3.Recheck the labs because these values are all abnormal. 4.Page the primary health care provider (PHCP) with the results.

1.Take no action. Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Uric acid level of 9.4 mg/dL (557 mcmol/L)

2.Requires nasogastric suction Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL (240 to 501 mcmol/L).

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

2500ml/day. one Coke 2L

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? 1.Tap water 2.Sterile water 3.0.9% sodium chloride 4.0.45% sodium chloride

3.0.9% sodium chloride Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client? every 24 hours every 72 hours every 12 hours every 36 hours

72 hours. IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Squeeze drip chamber and allow it to fill one-quarter full.

Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've had a fever for the past 3 days that just doesn't seem to go away." "I was breathing so fast because I was so anxious and in so much pain." "I've been taking antacids almost every 2 hours over the past several days." "I've had a GI virus for the past 3 days with severe diarrhea."

"I've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosi

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1.Blood transfusions 2.Metabolic alkalosis 3.Bleeding or hemorrhage 4.Decreased sodium excretion 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium

1.Blood transfusions3.Bleeding or hemorrhage5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1.Daily weight 2.Urinary output 3.IV fluid intake 4.NG tube intake

1.Daily weight. I&O would be better but was not an option.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1.Dehydration 2.Hypertension 3.Physiological stress 4.Decreased blood volume 5.Decreased plasma osmolarity

1.Dehydration 3.Physiological stress 4.Decreased blood volume

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. 1.Ensure adequate oxygenation. 2.Provide assistance to prevent falls. 3.Monitor medication administration of diuretics. 4.Monitor for numbness and tingling around the mouth. 5.Prevent complications during potassium administration.

1.Ensure adequate oxygenation. 2.Provide assistance to prevent falls. 3.Monitor medication administration of diuretics. 5.Prevent complications during potassium administration.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1.Monitor the client for dysrhythmias. 2.Encourage increased intake of phosphate antacids. 3.Discontinue any magnesium-containing medications. 4.Encourage intake of foods such as ground beef, eggs, or chicken breast.

1.Monitor the client for dysrhythmias.

Which clients are most likely to be at risk for the development of third spacing? Select all that apply. 1.The client with cirrhosis 2.The client with liver failure 3.The client with diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic kidney disease

1.The client with cirrhosis 2.The client with liver failure5.The client with chronic kidney disease

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

1.Twitching (ie tetany). also would see bradycardia

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex

1.U waves3.Inverted T waves4.Depressed ST segment

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1.Weighs athletes before, during, and after football practice 2.Asks the athletes to take a salt tablet before football practice 3.Schedules fluid breaks every 30 minutes throughout practice 4.Tells the athletes to drink 16 oz of fluid per pound lost during practice

2.Asks the athletes to take a salt tablet before football practice

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries

2.Raisins 3.Potatoes 4.Cantaloupe6.Strawberries

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)

3.An increase in blood pressure and increased respirations Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1.Bradycardia 2.Elevated blood pressure 3.Changes in mental status 4.Bilateral crackles in the lungs

3.Changes in mental status

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? 1.Document this assessment finding. 2.Call another nurse to verify this finding. 3.Check skin turgor over the client's sternum. 4.Call the primary health care provider (PHCP) to obtain a prescription for fluid replacement.

3.Check skin turgor over the client's sternum In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3.Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? 1.Tremors 2.Hyperactive reflexes 3.Respiratory depression 4.No specific signs or symptoms because this value is a normal level

3.Respiratory depression Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 3,000 1,000 500 3,750

3000ml?

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? 1. Tetany 2.Twitches 3.Positive Trousseau's sign 4.Loss of deep tendon reflexes

4.Loss of deep tendon reflexes Mg, Ca & K are directly related. The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn

4.The client who has sustained a traumatic burn The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium (K is normally stored INSIDE cells) in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1.Urine pH of 6 2.Urine that is pale yellow 3.Urine output of 40 mL/hr 4.Urine specific gravity of 1.032

4.Urine specific gravity of 1.032. normal is 1.00-1.0030