Chapter 13 - Concepts of Fluid and Electrolyte Balance Nclex questions

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy?

3000 6300 9300 7000 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL

After receiving the change-of-shift report, which client does the nurse assess first?

67 year old with nausea and vomiting who reports abdominal cramps. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia?

A 26 year old with hyperparathyroidism A 70 year old who has alcoholism and malnutrition A 40 year old taking tetracycline for an infection A 35 year old athlete taking NSAIDs for joint pain Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia.

Which client will the nurse consider to be at greatest risk for dehydration??

A 75-year-old woman with chronic back pain A 25-year-old woman taking oral contraceptives A 75-year-old man who has a vitamin deficiency A 25-year-old man who has frequent esophageal reflux Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm?

A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion Rationale: Severe diarrhea can cause excessive calcium loss and result in hypocalcemia. Symptoms of hypocalcemia include tingling of the lips and mouth, muscle cramps (especially in the presence of hypoxia), positive responses to the Trousseaus' and Chvostek's test, and seizures. It is critical to identify whether the client has hypocalcemia before the condition progresses to seizures. Holding the drug may make the hypocalcemia worse. Listening to bowel sounds will no provide new information. Increasing the IV flow rate of normal saline will not help identify the problem or improve the serum calcium level.

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour?

A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol)mEq (mmol) D. 20 mEq (mmol) Rationale: 100 in 1000 mL = 0.10 mEq/mL (mmol/mL) x 150 = 15 mEq/hr (mmol/hr)

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply.

A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output Rationale: The most important body fluid compartment to maintain for function is the plasma volume of circulating blood. The most reliable indicators for effectiveness of IV fluid replacement to increase this volume are blood pressure and pulse. Urine output is also very sensitive to changes in plasma volume and is a reliable indicator of adequacy of fluid replacement therapy. Skin turgor changes do not occur quickly enough to use for evaluation of fluid replacement adequacy. Hand-grip strength and deep tendon reflex changes are less reliable and are affected by other factors.

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period?

A. Plasma volume osmolarity increases; blood pressure increases B. Plasma volume osmolarity decreases; blood pressure increases C. Plasma volume osmolarity increases; blood pressure decreases D. B. Plasma volume osmolarity decreases; blood pressure decreases Rationale: A 3% saline solution is hypertonic to body fluids and would immediately increase the osmolarity of the plasma volume, making it somewhat hypertonic to other body fluids. Not only does the 500 mL increase the plasma volume to raise blood pressure, the increased osmolarity of the plasma would cause the interstitial fluid to move into the plasma volume, contributing to blood pressure increase.

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)?

Checking pulse oximetry Measuring blood pressure Listening to bowel sounds in all four quadrants Observing the ECG for flat T-waves Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective?

Chvostek sign is negative. Respiratory rate is 22 breaths/min. Pulse rate is 76 beats/min and regular. Hematocrit is 42%. Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management.

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low?

Decreased blood volume; increased blood osmolarity Increased blood volume; decreased blood osmolarity Decreased blood volume; decreased blood osmolarity Increased The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity. blood volume; increased blood osmolarity

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation?

Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) Assessing for furrows on the tongue to determine dryness of oral mucous membranes Comparing blood pressure measurements in the lying, sitting, and standing positions Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening?

Nose and ears have a slightly yellow-tinged appearance. Neck veins are now distended in the sitting position. Breath sounds can be heard in the right lower lung lobe. Weight is unchanged from that obtained yesterday

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate?

Monitoring 24-hour urine output Monitoring the serum calcium levels Assessing the blood pressure hourly Asking the client whether a headache is present

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful?

Pulse pressure has decreased. Client reports feeling hungry. Hematocrit is 58% (0.58 volume fraction). Hourly urine output is greater than 15 mL. The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status.

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.)

Red meat Cereal Citrus fruit Salt substitutes Eggs Bread While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective?

Reports having a bowel movement daily. ECG shows an inverted T wave. Fasting blood glucose level is 106 mg/dL. Two lb weight gain during the past week. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess?

Serum chloride level is 100 mEq/L (mmol/L) Blood urea nitrogen (BUN) is elevated Arterial blood pH is 7.37 Hematocrit is 29% (0.29 volume fraction)

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?

Shortened QT-interval Absent P wave Prominent U wave Inverted T waves Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow.

Which serum electrolyte value indicates to the nurse that the client has hypernatremia?

Sodium 132 mEq/L (mmol/L) Potassium 3.5 mEq/L (mmol/L) Sodium 148 mEq/L (mmol/L) Potassium 5.3 mEq/L (mmol/L)

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)?

Teaching the client which foods to avoid Administering sodium polystyrene sulfonate orally Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet Initiating continuous cardiac monitoring

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.)

Tops of the forearms Skin of the shins Skin of the forehead Skin over the abdomen Skin over the sternum Back of the hand

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L?

Urge the client to drink more water. Notify the primary health care provider. Assess the client's deep tendon reflexes.. Document the finding as normal The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.)

eeping the client NPO during drug treatment Pushing the drug as a bolus slowly over 5 minutes Using an IV controller to deliver the drug Checking IV access for blood return after the infusion Initiating the IV in a hand vein for rapid access Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.)

management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Vegan diet Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Past history of hepatitis A

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia?

A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis Rationale: Insulin increases the activity of the sodium-potassium pump and forces more potassium from the extracellular fluid into the intracellular fluid. Although this is a desired response when managing hyperkalemia, the drug can cause hypokalemia in a client whose serum potassium level is initially normal. Spironolactone is a potassium-sparing diuretic that has the potential to raise serum potassium levels, not lower them. Ringer's lactate contains potassium and would not dilute serum potassium below normal. Infusions of red blood cells usually raise serum potassium levels, not lower them, because some blood cells are damaged during the infusion and release intracellular potassium.

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L?

A. Asking about the use of sugar substitutes. B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease Rationale: The serum potassium level is low and the client has hypokalemia. Misuse or overuse of diuretics, especially high ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia among older adults or clients with eating disorders. Sugar substitutes do not change serum potassium levels. A positive Chvostek sign or test occurs with hypocalcemia but not with hypokalemia. Kidney disease is associated with hyperkalemia.

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply.

A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate Rationale: Within cells and the blood, magnesium levels are related to the levels of potassium and calcium and help maintain proper balance of these electrolytes

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm?

A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth Rationale: Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias. It is the most important assessment to perform for a client with an elevated serum potassium level. Respiratory rate and depth are more affected by hypokalemia because of the accompanying muscle weakness. The reduction then affects oxygen saturation. Although deep tendon reflexes may be increased with hyperkalemia, cardiac changes are more critical.

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

A. Foot and ankle B. Forehead C. Sacrum D. Chest Rationale: In a client who is confined to bed, the most dependent area is the sacrum. This is the area that will show skin turgor changes first for dependent edema. The forehead, chest, and feet are not dependent what a client is in a recumbent position.

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss?

A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%. Rationale: The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium, or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures?

Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

checking for presence of dependent edema Assessing blood pressure Measuring intake and output Elevating the head of the bed Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.)

testing skin turgor Asking about any abdominal pain Assessing cognition Checking deep tendon reflexes Monitoring urine output Checking for the presence of fever