EAQ #8 Fluid and Electrolytes-Grief, Loss, and Dying
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? - Rapid, thready pulse - Distended jugular veins - Elevated hematocrit level - Increased serum sodium level
Distended jugular veins
The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? - Hypercalcemia - Hypocalcemia - Hyperkalemia - Hypokalemia
Hypokalemia
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? - Sodium - Calcium - Chloride - Potassium
Potassium
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? - Vesicular - Bronchial - Crackles - Rhonchi
crackles
A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? - Pulse rate - Tissue turgor - Specific gravity - Body temperature
tissue turgor
The nurse reviews the medical record of a patient who is eligible to receive end-of-life care. What are the criteria for a patient to receive this type of care? - When the patient is nearing death - When the expected death of the patient is within 6 months - When the patient seeks no aggressive disease management - When a family member has signed an informed consent form - When the patient has been issued a "do not resuscitate" order
B,C,E
A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? - Bargaining - Frustration - Depression - Rationalization
Bargaining
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? - Skin turgor - Intake and output results - Client's report about fluid intake - Blood lab results
Blood lab results
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? - Sunken eyes - Dry, flaky skin - Change in mental status - Decreased bowel sounds
Change in mental status
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? - Perform a finger stick glucose test and call the primary healthcare provider with the results. - Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. - Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. - Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.
Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? - Diplopia - Skin rash - Leg cramps - Tachycardia - Muscle weakness
C,E
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? - Clear breath sounds - Positive pedal pulses - Normal potassium level - Decreased urine specific gravity
Clear breath sounds
An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is doing what? - Trying to avoid her situation - Coping with her impending death - Attempting to reduce family dependence on her - Hurting because the family will not take her home to die
Coping with her impending death
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? - Crackles in the lungs - Decreased heart rate - Decreased blood pressure - Cyanosis
Crackles in the lungs
A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? - Cohesiveness - Educational level - Cultural background - Socioeconomic status
Cultural background
A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? - Lactated Ringer solution - 5% dextrose and water - 0.9% normal saline - 0.45% normal saline
0.9% normal saline
Which nursing interventions enhance comfort in an imminently dying patient in the hospital? - Frequently repositioning the patient - Maintaining oral hygiene in the patient - Limiting frequent visits of the family members - Measuring the vital signs of patient frequently - Applying body lotion to the patient's skin daily
A,B,E
The nurse understands that the action of an antidiuretic hormone (ADH) is to do what? - Reduce blood volume - Decrease water loss in urine - Increase urine output - Initiate the thirst mechanism
Decrease water loss in urine
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? - Shift of fluid into the interstitial spaces - Weakening of the cell wall - Increased intravascular compliance - Increased intracellular fluid volume
Shift of fluid into the interstitial spaces
A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? - "Edema results in the separation of skin from pigmented and vascular tissue." - "Pitting edema leaves an indentation on the site of application of pressure." - "Trauma or impaired venous return should be suspected in clients with edema." - "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 am the healthcare provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the 8-hour shift? Record your answer using a whole number.
863 ml
The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number.
970 ml
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? - Tetany - Seizures - Confusion - Weakness - Dysrhythmias
C,D,E
A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? - Thrombocytopenia - Oxygen deficiency - Clotting factor deficiency - Low hemoglobin
Clotting factor deficiency
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? - Crohn disease - Cushing disease - End-stage renal disease - Gastroesophageal reflux disease
End-stage renal disease
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? - Skin condition - Fluid and electrolyte balance - Food intake - Fluid intake and output
Fluid and electrolyte balance
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? -Hypernatremia - Hyponatremia - Hyperkalemia - Hypokalemia
Hyponatremia
A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? - Presence of dry skin - Loss of body weight - Decrease in blood pressure - Altered general appearance
Loss of body weight
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? - The nurse should wait for the court's order to give blood to the client. - The nurse should proceed with the transfusion in order to save the client's life. - The nurse should inform the primary healthcare provider and not give blood to the client. - The nurse should explain to the family member that the client needs this transfusion.
The nurse should inform the primary healthcare provider and not give blood to the client.
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? - Sodium - Calcium - Potassium - Phosphorus
calcium
Which assessment finding of the skin refers to elasticity? - Turgor - Edema - Texture - Vascularity
turgor
When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number.
1515 ml
The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number. mL
495
A patient who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? - Chemotherapy - Repositioning - Regular oral care - Blood transfusion - Radiation therapy
A,D,E
What interventions should the nurse perform while caring for an actively dying patient? - Admit the patient in hospice care. - Perform aggressive laboratory tests. - Provide patient and family reassurance. - Keep the patient undisturbed for long time. - Perform symptom management in the patient.
C,E
A nurse is assessing the grief response of a family member whose relative has died. What must the nurse consider first about the family to conduct an effective assessment? - Personality traits - Educational level - Socioeconomic class - Cultural background
Cultural background
When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? - Sodium - Potassium - Calcium - Calcitonin
Potassium
The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for? - Pain tolerance - Skin turgor - Ecchymosis formation - Tissue mass
Skin turgor
A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? - Headache - Pallor - Paresthesias - Blurred vision
Paresthesias
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? - Monitor for signs of electrolyte imbalance. - Change the tube at least once every 48 hours. - Connect the nasogastric tube to high continuous suction. - Assess placement by injecting 10 mL of water into the tube.
Monitor for signs of electrolyte imbalance.
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? - Sodium - Potassium - Chloride - Calcium
sodium
