EAQ Chp 42 Electrolyte and Nursing Process

How much fluid is lost daily through feces in a healthy adult? Record your answer using a whole number. _____ mL

100mL Rationale The gastrointestinal system plays a major role in fluid and electrolyte balance in the body. Approximately 3 to 6 L of fluid enters the gastrointestinal system and is absorbed back into the body. Approximately 100 mL of fluid is excreted through feces daily. p. 938

Which condition may lead to an extracellular fluid volume deficit? Select all that apply. A. Burns B. Cirrhosis C. Heart failure D. Hemorrhage E. Adrenal insufficiency

A, D, E Rationale An extracellular fluid volume (ECV) deficit occurs when there is insufficient isotonic fluid in the extracellular compartment. Burns, hemorrhage, and adrenal insufficiency will lead to an ECV deficit. Cirrhosis and heart failure will lead to an ECV excess. p. 940

As the nurse is assessing the caseload of patients for the day, which patient would the nurse expect to be at the highest risk of developing dehydration? A. A 78-year-old patient with dementia B. A 47-year-old patient with hyperthyroidism C. A 53-year-old patient with pulmonary embolism D. A 32-year-old patient with a respiratory infection

A. A 78-year-old patient with dementia Rationale Older patients may become dehydrated because of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink. Patients who are in their 30s, 40s, or 50s with hyperthyroidism, pulmonary embolism, and respiratory infection are not at great risk for dehydration. Study Tip: Stay away from nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before test time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it. p. 947

Which electrolyte influences excitability of nerve and muscle cells and is necessary for muscle contraction? A. Calcium (Ca 2+) B. Potassium (K +) C. Phosphate (PO 4) D. Magnesium (Mg 2+)

A. Calcium Rationale Calcium influences the excitability of nerve and muscle cells and is necessary for muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth, and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary for the production of adenosine triphosphate (ATP), the energy source for cellular metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and is a cofactor for numerous enzymes. p. 941

Which factor can be a risk for causing extracellular volume deficit (ECV)? A. Hemorrhage B. Sodium-rich diet C. Intravenous therapy D. Oliguric renal disease

A. Hemorrhage Rationale There are many risk factors for fluid, electrolyte, and acid-base imbalances. Hemorrhage causes a deficit in the ECV. A sodium-rich diet is an environmental factor that causes ECV excess. Intravenous therapy and oliguric renal disease also cause ECV excess. p. 947

Which electrolyte abnormality is least likely to be caused by the use of laxatives? A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypomagnesemia

A. Hyponatremia Rationale Hyponatremia can be caused by the use of antidepressants. Hypokalemia, hypocalcemia, and hypomagnesemia can be caused by the use of laxatives. Therefore, in the patients with these conditions laxatives are contraindicated. p. 948

A patient is receiving treatment for chronic diarrhea. The nurse advises the patient to eat food items rich in potassium. What is the reason behind promoting a potassium-rich diet? A. Potassium improves smooth, skeletal, and cardiac muscle function. B. Potassium is necessary for production of adenosine triphosphate (ATP). C. Potassium decreases muscle wasting. D. Potassium acts as a cofactor for various enzymes.

A. Potassium improves smooth, skeletal, and cardiac muscle function Rationale Potassium is required for normal functioning of smooth, skeletal, and cardiac muscles, because it helps to maintain resting membrane potential. Phosphate, not potassium, is required for production of adenosine triphosphate (ATP). Potassium does not decrease muscle wasting. Magnesium acts as a cofactor for various enzymes. p. 941

Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply. -Edema -Thready pulse -Crackles in lungs -Postural hypotension -Dry mucous membranes

B, D, E Rationale A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Edema in dependent areas and crackles in the lungs are the physical findings of extracellular fluid volume excess. p. 940

A health care provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the health care provider hang with the transfusion? A. 5% dextrose in water B. 0.9% sodium chloride C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in lactated Ringer's solution

B. 0.9% sodium chloride Rationale The only solution appropriate for administration with whole blood or blood products is 0.9% sodium chloride, because it is a compatible saline solution; 5% dextrose in water, 5% dextrose in 0.9% sodium chloride, and 5% dextrose in lactated Ringer's solution are not compatible for transfusion with blood or blood products. They may cause the red blood cells to clump together. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass. p. 962

What is the normal range of values of phosphate in human blood? A. 1.5 to 2.5 mEq/L B. 2.7 to 4.5 mg/dL C. 3.5 to 5.0 mEq/L D. 4.5 to 5.3 mg/dL

B. 2.7 to 4.5mg/dL Rationale The normal range of values of phosphate in human blood is 2.7 to 4.5 mg/dL. The normal value of potassium is 3.5 to 5.0 mEq/L, the normal value of ionized calcium is 4.5 to 5.3 mg/dL, and the normal value of magnesium is 1.5 to 2.5 mEq/L. p. 935

Which patient would most likely need teaching regarding dietary sodium restriction? A. An 88-year-old scheduled for surgery for a fractured femur B. A 65-year-old recently diagnosed with heart failure C. A 50-year-old recently diagnosed with asthma and diabetes D. A 20-year-old with vomiting and diarrhea from gastroenteritis

B. A 65-year-old recently diagnosed with heart failure Rationale Heart failure commonly causes extracellular fluid volume (ECF) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na + and water. Dietary sodium restriction is important with heart failure because Na + holds water in the extracellular fluid, making the ECF excess worse. Study Tip: Remember prefix meanings to remember the differences between intracellular, intravascular, and extracellular. Intra- means within, so intravascular means within (blood) vessels, and intracellular means within the cells. Extra- means outside, so extracellular means outside of the cells. p. 940

The arterial pH of a patient is 7.3. How should the nurse record this pH in the patient case record? A. Alkalosis B. Acidosis C. Neutral pH D. Normal pH

B. Acidosis Rationale The normal acceptable range of pH for human beings is between 7.35 and 7.45. A pH less than 7.35 indicates acidosis, which implies that metabolic products acidic in nature are accumulated in the body. A pH greater than 7.45 indicates alkalosis, which implies that the body has lost hydrogen ions and has accumulated bicarbonate. A pH of 7 is considered a neutral pH; however, it is important to distinguish this from a normal pH. A pH value between 7.35 and 7.45 is considered a normal pH. Test-Taking Tip: Often you can use reason and logic, combined with your nursing judgment, to arrive at the correct answer. However, some information, such as normal pH, just has to be memorized. Commit to memorizing—by whatever means it takes—that normal arterial pH is 7.35 to 7.45. Be sure you also understand the difference between normal and neutral. p. 943

Which laboratory finding is consistent with a diagnosis of milk-alkali syndrome? A. Calcium level of 7 mg/dL B. Calcium level of 15 mg/dL C. Magnesium level of 1 mEq/dL D. Magnesium level of 3 mEq/dL

B. Calcium level of 15mg/dL Rationale Milk-alkali syndrome is a condition where increased intake and absorption of calcium occurs in the body. The normal serum calcium level ranges from 8.4 to 10.5 mg/dL. A calcium level greater than 10.2 mg/dL indicates hypercalcemia. Therefore, a calcium level of 15 mg/dL would be found in a patient with milk-alkali syndrome. A calcium level of 7 mg/dL indicates hypocalcemia. Abnormal magnesium levels are not associated with milk-alkali syndrome. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 942

Which acute condition will place the patient at a high risk for hyperkalemia? A. Cancer B. Crush injuries C. Chronic heart failure D. Bacterial pneumonia

B. Crush injuries Rationale Crush injuries place a patient at risk for hyperkalemia. Patients with cancer may develop hypercalcemia. Patients with chronic heart failure will be at risk for hypokalemia. Bacterial pneumonia will cause respiratory acidosis. p. 949

While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity. What is the rationale behind this intervention? A. Phlebitis B. Extravasation C. Local infection D. Circulatory overload

B. Extravasation Rationale Elevating the extremity would benefit a patient with extravasations (tissue damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new intravenous line should be started in another extremity if a patient develops a local infection. Circulatory overload of intravenous solutions occurs when a patient receives fluids too rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid volume deficit; raising the head of the bed is an appropriate intervention in this case. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 960

Patients should be taught to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? A. Tap water or bottled water B. Fluid that has sodium (salt) in it C. Fluid that has K +and HCO 3 - in it D. Coffee or tea, whichever they prefer

B. Fluid that has sodium (salt) in it Rationale Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced. Test-Taking Tip: Think of commercials for sports drinks when recalling how to replace fluids lost from sweat, vomiting, or diarrhea. Those drinks contain sodium. p. 965

Which fluid electrolyte imbalance may develop in a patient who consumes spironolactone? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypomagnesemia

B. Hyperkalemia Rationale Spironolactone is a potassium-sparing diuretic that may cause hyperkalemia. Hypokalemia and hypomagnesemia may be caused by potassium-wasting diuretics such as furosemide. Hyponatremia is caused by antidepressants such as fluoxetine. p. 948

Which drugs can cause hypokalemia? Select all that apply. A. Captopril B. Fluoxetine C. Prednisone D. Furosemide E. Spironolactone

C, D Rationale Furosemide and prednisone will cause hypokalemia. Captopril and spironolactone may cause hyperkalemia. Fluoxetine may cause hyponatremia. p. 948

What conditions place a patient at a higher risk for hypomagnesemia? Select all that apply. A. Polyuria B. Bone tumors C. Steatorrhea D. Chronic alcoholism E. Hyperparathyroidism

C, D Rationale Steatorrhea and chronic alcoholism place a patient at higher risk for hypomagnesemia. Polyuria may lead to hypokalemia. Bone tumors and hyperparathyroidism are associated with hypercalcemia. p. 942

The nurse is caring for a patient who has an accumulation of fluid in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids? Select all that apply. A. Serum B. Plasma C. Peritoneal fluid D. Synovial fluid E. Cerebrospinal fluid

C, D, E Rationale Transcellular fluids are secreted by epithelial cells. Fluid collection between the two layers of the peritoneum is an example of transcellular fluid. Fluid collection in the synovial space of a joint is secreted by the epithelial cells and is also an example of transcellular fluid. Cerebrospinal fluid is colorless fluid present in the brain and spinal cord. Serum and plasma are constituents of intravascular fluid, which is a part of extracellular fluids. Study Tip: Draw a diagram of the various fluid compartments in the body. Use different colors for different compartments: intracellular, extracellular, interstitial, intravascular, and transcellular. Show which compartments are subdivisions of other compartments. For example, show intravascular fluid as a subdivision of extracellular fluid. p. 935

A patient develops a mild allergic reaction during a blood transfusion. Which should the nurse administer to manage this allergic reaction? A. Sympathomimetics B. Corticosteroids C. Antihistamines D. Vasoconstrictors

C. Antihistamines Rationale Mild allergic reactions during blood transfusion are managed by administering antihistamines. Antihistamines prevent the release of histamine from the cells, thereby preventing the allergic reaction from getting worse. Epinephrine (a sympathomimetic) is used only in patients with anaphylaxis. Corticosteroids usually do not have an immediate action and are usually not required for mild allergic reactions. Vasopressors are required only during sepsis related to blood transfusion. Test-Taking Tip: The key to this question is that the allergic reaction is mild, so administering antihistamines would be appropriate. Careful reading of the question will prevent you from overreacting and choosing sympathomimetics. Be sure to read all choices before submitting your selection! p. 963

A patient with blood type O needs platelets. What should the nurse consider when choosing a donor for platelet transfusion? A. Rh compatibility is excluded. B. Donor can be of any blood group. C. Donor should be of blood group O. D. Donor can be exempted from screening for infections.

C. Donor should be of blood group O Rationale For platelet transfusion to a patient with blood group O, the donor must be of blood group O only. Any other blood type may cause a mismatch and lead to a transfusion reaction. Rh compatibility should be checked before transfusion, because it can also lead to a transfusion reaction. Donor specifications exist for platelet transfusions; not just any blood group is acceptable. The donor must be screened for all communicable diseases, including human immunodeficiency virus (HIV). p. 962

Which defining characteristics are consistent with fluid volume deficit? A. A weight loss of 1 lb (0.5 kg) in 1 week, pale yellow urine B. Engorged neck veins when upright, bradycardia C. Dry mucous membranes, thready pulse, tachycardia D. Bounding radial pulse, flat neck veins when supine

C. Dry mucous membranes, thready pulse, tachycardia Rationale A deficit of fluid volume includes a deficit of extracellular fluid volume (ECF), hypernatremia, and clinical dehydration. ECF deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECF deficit causes dark yellow urine rather than pale yellow urine, which is normal. p. 940

The nurse understands that various mechanisms in the body help move fluid from one compartment to another. Which transport mechanism is governed by oncotic and hydrostatic pressures? A. Osmosis B. Diffusion C. Filtration D. Active transport

C. Filtration Rationale A filtration process determines fluid movement in and out of capillaries and is governed by hydrostatic and oncotic pressure within the vascular and interstitial space. Osmosis is the movement of water molecules across semipermeable membranes. Diffusion is the passive movement of electrolytes down the concentration gradient. Active transport refers to the transportation of electrolytes against the concentration gradient via adenosine triphosphate (ATP). p. 936

A patient on antidepressant therapy has developed hyponatremia. Which drug might have led to this condition? A. Losartan B. Captopril C. Fluoxetine D. Furosemide

C. Fluoxetine Rationale Fluoxetine is an antidepressant that leads to hyponatremia. Losartan is an angiotensin II receptor blocker that causes hyperkalemia. Captopril is an angiotensin-converting enzyme inhibitor that also causes hyperkalemia. Furosemide is a diuretic that causes hypokalemia and hypomagnesemia. p. 948

A patient reports intense thirst and decreased alertness. The patient's serum sodium level is 170 mEq/L. What condition should the nurse document in the patient's medical chart? A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia

C. Hypernatremia Rationale Hypernatremia is a condition in which water shifts out of cells into the extracellular fluid, resulting in dehydration. Therefore, a patient with hypernatremia experiences intense thirst and decreased alertness or level of consciousness. Transient abdominal cramps and diarrhea indicate hyperkalemia. Anorexia and confusion indicate hypercalcemia. Decreased indicate hypercalcemia. Lethargy and bradycardia indicate hypermagnesemia. p. 940

After reviewing a patient's laboratory reports, the nurse instructs him or her to consume dairy products. Which electrolytic imbalance may have prompted this instruction? A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypercalcemia

C. Hypocalcemia Rationale Hypocalcemia is characterized by decreased calcium levels. Dairy products such as milk are rich sources of calcium; therefore, the nurse instructs the patient to consume dairy products. The nurse should instruct a patient with hypokalemia to consume a potassium-rich diet. The nurse would recommend a potassium-free diet to a patient with hyperkalemia. The consumption of dairy products can further increase the risk of hypercalcemia. p. 941

While performing a general examination of a patient, the nurse finds that the patient has tetany and is positive for Chvostek's sign and Trousseau's sign. Which electrolyte disturbance is responsible for this clinical presentation? A. Hypokalemia B. Hyponatremia C. Hypocalcemia D. Hypermagnesemia

C. Hypocalcemia Rationale Positive Chvostek's sign, Trousseau's sign, and presence of tetany indicate hypocalcemia. Low levels of calcium may affect the excitability of the nerve and muscle cells, causing cramps and abnormal muscle movements. Hypokalemia presents with muscular weakness and cardiac rhythm disturbances. Hyponatremia usually presents with nausea, vomiting, confusion, and seizures. Hypermagnesemia is an abnormally high magnesium concentration in the blood. Chvostek's sign and Trousseau's sign are associated with hypomagnesemia. p. 942

Which electrolyte is necessary for the production of adenosine triphosphate? A. Calcium (Ca 2+) B. Potassium (K +) C. Phosphate (PO 4 3-) D. Magnesium (Mg 2+)

C. Phosphate Rationale Phosphate (PO 4 3-) is necessary for the production of adenosine triphosphate. Calcium (Ca 2+) is necessary for muscle contractions. Potassium (K +) is necessary for normal muscle function. Magnesium (Mg 2+) influences the function of neuromuscular junctions. p. 941

A patient with cardiac failure is found to have excess extracellular fluid of normal tonicity. Which life-threatening complication is this patient most likely to suffer? A. Coma B. Seizures C. Pulmonary edema D. Hypovolemic shock

C. Pulmonary Edema Rationale The most likely life-threatening complication that can occur in a patient who has excess extracellular fluid of normal tonicity is pulmonary edema. The excess fluids may filter out of the pulmonary blood vessels and pool in the pulmonary tissue, causing pulmonary edema. Coma and seizures are likely complications of hypernatremia and hyponatremia. Hypovolemic shock is seen in conditions associated with extracellular fluid depletion. p. 940

A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The nurse is reviewing the patient's laboratory report. Which are likely findings in the laboratory report? A. Serum K + levels are more than 5 mEq/L. B. Total serum Ca 2+ is greater than 10.5 mg/dL. C. Serum K + levels are less than 3.5 mEq/L. D. Serum Mg 2+ levels are greater than 2.5 mEq/L.

C. Serum K+ levels are less than 3.5 mEq/L Rationale Chronic diarrhea and vomiting can cause electrolyte imbalances in the body. Diarrhea and vomiting can result in the loss of electrolytes from the body, resulting in decreased potassium levels. Potassium, magnesium, and calcium levels may increase in the case of increased intake and absorption of these electrolytes. Test-Taking Tip: Notice similarities and differences among the choices. For this question, three of the four choices show increased levels of electrolytes. Because you know that nausea and vomiting cause loss of electrolytes, you have the answer in the choice that indicates a decreased potassium level. pp. 941-942

Which can cause an excess of extracellular fluid volume? A. Vomiting B. Diarrhea C. Hemorrhage D. Chronic heart failure

D. Chronic heart failure Rationale Chronic heart failure results in an excess of extracellular fluid volume, because there is a decrease in urine output due to elevated aldosterone. Vomiting and diarrhea cause a loss of fluids and electrolytes, which results in extracellular volume deficit. Hemorrhage also decreases the extracellular volume due to loss of fluids. p. 940

How might sepsis manifest? A. Cough B. Crackles C. Dyspnea D. Circulatory shock

D. Circulatory shock Rationale Circulatory shock is a manifestation of sepsis. Cough, crackles, and dyspnea are manifestations of circulatory overload. p. 964

The nurse finds redness, heat, and swelling at the catheter-skin entry point and purulent drainage in a patient on intravenous infusion. Which complication does the nurse suspect? A. Phlebitis B. Bleeding C. Extravasation D. Local infection

D. Local infection Rationale A local infection is characterized by redness, heat, and swelling at the catheter-skin entry point, and possible purulent drainage. Fresh blood evident at the venipuncture site and sometimes pooling under the extremity are the assessment findings of bleeding at the venipuncture site. The assessment findings of phlebitis are redness, tenderness, pain, and warmth along the course of the vein. Edematous, blanched skin that is cool to the touch indicates extravasation. p. 960

Which electrolyte influences the function of the neuromuscular junctions? A. Calcium (Ca 2+) B. Potassium (K +) C. Phosphate (PO 4 3-) D. Magnesium (Mg 2+)

D. Magnesium Rationale Magnesium (Mg 2+) influences the function of the neuromuscular junctions. Potassium (K +) is necessary for normal muscle function. Calcium (Ca 2+) is necessary for muscle contraction. Phosphate (PO 4 3-) is necessary for the production of adenosine triphosphate. p. 941

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K + intravenously over 8 hours. Which assessment finding should cause the nurse to clarify the order with the health care provider before hanging this fluid? A. Flat neck veins B. Tachycardia C. Hypotension D. Oliguria

D. Oliguria Rationale Administration of KCl (increased K + intake) to a person who has oliguria (decreased K + output) can cause hyperkalemia. Test-Taking Tip: Potassium imbalances are serious imbalances that can be life-threatening because every body system is affected. Be alert to avoid potassium imbalances when answering these questions. p. 940

A patient has extracellular volume deficit due to diarrhea. How should the nurse correct the volume deficit in the patient? A. Provide caffeinated fluids. B. Provide low-sodium fluids. C. Provide fluids that contain lactose. D. Provide fluids that contain sodium.

D. Provide fluids that contain sodium Rationale The nurse should use fluids such as an electrolyte replacement, which contains sodium to correct extracellular volume deficit. The sodium in the fluids helps to prevent fluid loss through retention. Caffeinated fluids, low-sodium fluids, and fluids containing lactose are not ideal to correct the extracellular volume deficit of diarrhea. These fluids tend to promote fluid loss and cause dehydration. pp. 940, 955

Which symptom can be seen in a patient with phlebitis? A. Blanched skin B. Edematous skin C. Purulent drainage D. Redness of the skin

D. Redness of the skin Rationale Inflammation of the inner layer of a vein is known as phlebitis. In this condition, the patient will have redness of the skin. Blanched skin and edematous skin are associated with extravasation. Purulent drainage is a sign of a local infection. p. 961

A patient with a cardiac history is taking the diuretic furosemide and is seen in the emergency department for muscle weakness. Which laboratory value should the nurse assess first? A. Serum albumin B. Serum sodium C. Hematocrit D. Serum potassium

D. Serum potassium Rationale Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness. Study Tip: Create a memory aid to recall the names of the most common potassium-wasting diuretics. Potassium imbalances are serious imbalances that can be life-threatening because every body system is affected. It is worth the time to memorize the potassium-wasting diuretics! p. 942

While receiving a blood transfusion, a patient develops chills, tachycardia, and flushing. What is the nurse's priority action? A. Notify a health care provider. B. Insert an indwelling catheter. C. Alert the blood bank. D. Stop the transfusion

D. Stop the transfusion Rationale Development of chills, tachycardia, and flushing during a blood transfusion indicate an acute hemolytic reaction. The nurse should stop the transfusion immediately so no more of the incompatible blood reaches the patient. Test-Taking Tip: Remember that the nurse's number 1 priority is the patient's safety! Although the nurse may eventually notify the health care provider and alert the blood bank, stopping the transfusion is the first priority, and thus the best response. p. 963