Electrolyte Prep-U

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

Explain to the client why this is needed.

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

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

ICF

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

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume

A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?

The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.

The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?

The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion.

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

A client's PaCO2 is abnormal on an ABG report. What is the most likely medical diagnosis?

chronic obstructive pulmonary disease (COPD)

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess.

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

intracellular

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany

A nurse is caring for a young adult female client who has a folic acid deficiency. When educating the client about this condition, the nurse would include a discussion about the client's increased risk for:

neural tube deficits in the fetus.

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection."

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

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

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias Rationale: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A nurse is caring for a client with a gastrostomy tube in place. What is an accurate guideline for care of the insertion site?

If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

hypovolemia

A nurse is caring for a client who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment that correlates with a fluid volume deficit? Select all that apply.

increased pulse rate

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate

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

Which question about fluid balance would be appropriate when conducting a health history for a client?

"Describe your usual urination habits."

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 5.75 mg/dL (1.8 mEq/L)Based on these levels, the nurse would identify which imbalance?

Hypokalemia

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply.

Hypokalemia Hypocalcemia Hyperphosphatemia

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to:

45 degrees

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

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

The nurse is providing care to a client who has been experiencing emesis (vomiting) for 24 hours. Which fluid should the nurse anticipate incorporating into the client's plan of care?

hypotonic Rationale: A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. The other fluids are not appropriate to administer.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

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 been taking antacids almost every 2 hours over the past several days."

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year-old with congestive heart failure on furosemide

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr (1000/12)

A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?

Anemia

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

Banana Rationale: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?

ECF Deficient Fluid Volume

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.

Hypokalemia & Metabolic alkalosis Rationale: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia. Respiratory acidosis would be more likely to occur with an underlying lung disorder, such as asthma or emphysema. Vomiting leads to a loss of sodium, so elevated sodium levels would be unlikely. Imbalances of calcium are not typically associated with imbalances associated with vomiting.

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 Rationale: 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.

The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom does the nurse document that correlates with the admitting diagnosis?

Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting Rationale: Calcium is important in wound healing, synaptic transmission in nervous tissue, membrane excitability, and is essential for blood clotting. Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Slurred speech and reports of excessive urination are indicative of hypercalcemia.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

The nurse is caring for a client whose baseline weight is 125 lb (56.7 kg). The client weighs 115 lb (52.2 kg) today. How does the nurse document the client's status?

moderately dehydrated Rationale: Hypovolemia refers to a low volume of extracellular fluid. If untreated, it may result in dehydration. Mild dehydration is present when there is a 3% to 5% loss of body weight Moderate dehydration is associated with a 6% to 10% loss of body weight Severe dehydration, a life-threatening emergency, occurs with a loss of more than 9% to 15% of body weight. This client has lost 8% of body weight (10 pounds), and is therefore moderately dehydrated.

Which explanations from the student about fluid and electrolyte balance demonstrate that learning has taken place regarding the function of water? Select all that apply.

provides a medium for transporting substances throughout the body facilitates cellular metabolism and proper cellular chemical functioning helps maintain normal body temperature facilitates digestion and promotes elimination

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

"I should drink 2,500 mL/day of fluid." Rationale: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg?

24.8

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?

O negative Rationale: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood.

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 frequently.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?

Verify the orders for type of solution and amount of infusion.

By which route do oxygen and carbon dioxide exchange in the lung?

diffusion

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which client actions will the nurse document on the I&O record? Select all that apply.

infusion of intravenous solution urination vomiting drinking milk Rationale: Ingested solids, such as a sandwich, are not included in the intake and output.

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Infants have more total body fluid and ECF than adults.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes