Fluid and Electrolyte Balance
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed? 1. 1.5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (⅓ normal saline) 3. 0.225% sodium chloride (¼ normal saline) 4. 0.45% sodium chloride (½ normal saline)
1.5% dextrose in lactated Ringer's The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer's solution (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, would move into the cells via osmosis.
A client with chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis? 1.Vital signs and weight 2.Potassium level and weight 3.Vital signs and blood urea nitrogen level 4.Blood urea nitrogen and creatinine levels
1.Vital signs and weight Following dialysis the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.
The nurse is reviewing the laboratory test results for a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this value would be noted in which condition? 1.Diarrhea 2.Addison's disease 3.Diabetes insipidus 4.Dumping syndrome
2. Addison's Disease The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Many pathological conditions, including Addison's disease, adrenocortical insufficiency, anemia, burns, and ketoacidosis, result in an increased potassium level. Hyperkalemia can also cause abdominal cramping and diarrhea. The conditions in the remaining options would result in a decreased serum potassium level.
A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? 1.Sodium 2.Calcium 3.Potassium 4.Magnesium
2. Calcium After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek's and Trousseau's signs. The correct treatment is administration of calcium gluconate or calcium lactate. The remaining options are unrelated to the client's complaints.
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 (475 mL) of fluid per pound lost during practice
2.Asks the athletes to take a salt tablet before football practice Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz (475 mL) of fluid should be consumed for every pound lost.
The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? 1.Client with a major burn 2.Client with an ischemic stroke 3.Client with Laënnec's cirrhosis 4.Client with chronic kidney disease
2.Client with an ischemic stroke Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.
The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1.Disorientation to time only 2.Heart rate of 95 beats/minute 3.+1 palpable peripheral pulses 4.Urine output of 30 mL over the past 2 hours
2.Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.
The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? 1.Decreases the risk of peritonitis 2.Prevents disequilibrium syndrome 3.Increases osmotic pressure to produce ultrafiltration 4.Prevents excess glucose from being removed from the client
3.Increases osmotic pressure to produce ultrafiltration Increasing the glucose concentration makes the solution more hypertonic. The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange. The remaining options do not identify the purpose of the glucose.
The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority? 1.Pain 2.Disturbed body image 3.Insufficient fluid volume 4.Inability to tolerate activity
3.Insufficient fluid volume In a client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the placenta. Although the remaining options may also be appropriate problems for the client with sickle cell anemia, they are not the priority.
Calcium carbonate is prescribed for a client with hypocalcemia. How should the nurse instruct the client to take the medication? 1.With meals 2.Every 4 hours 3.Just before meals 4.1 hour after meals
4.1 hour after meals Calcium carbonate tablets should be taken with a full glass of water 30 to 60 minutes after meals; therefore, the remaining options are incorrect.
The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is the most appropriate datum to use in planning administration of intravenous fluids to this client? 1.A strict hourly rate of 100 mL 2.A strict hourly rate of 150 mL 3.One half of the previous hour's urine output 4.The number of milliliters in the previous hour's urine output
Intravenous fluids are managed very carefully after nephrectomy and renal transplantation. Fluids are usually given according to a formula that takes into account the previous hour's urine output. The desired urine output is generally high; therefore, options 1, 2, and 3 are incorrect.
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations
1.A client with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.
The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. 1."This medication will turn my urine orange." 2."I should decrease my oral fluids when I start this medication." 3."The amount of urine I make should increase if this medicine is working." 4."I need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5."I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin."
2."I should decrease my oral fluids when I start this medication." 5."I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin." In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an analog of ADH. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin is started, oral fluids should be decreased to prevent water intoxication. Therefore, clients with diabetes insipidus should decrease their oral fluid intake when they start desmopressin. Headache and drowsiness are signs of water intoxication in the client taking desmopressin and should be reported to the health care provider. Desmopressin does not turn urine orange. The amount of urine should decrease, not increase, when desmopressin is started. Desmopressin does not cause pancreatitis.
A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the health care provider to prescribe? 1.Increase intake of water with a diet high in carbohydrates. 2.Consume oral rehydration fluid, advancing to a regular diet. 3.Begin fluid replacement immediately with intravenous fluids. 4.Begin a diet of bananas, rice, apples, pears, and toast with juice.
2.Consume oral rehydration fluid, advancing to a regular diet. Mild dehydration is usually treated at home and consists of age-appropriate diet along with oral rehydration fluids. Bananas, rice, apples, pears, and toast with juice can be irritating to the gastrointestinal (GI) tract and does not provide the rehydration needed in a child who is dehydrated. Water does not provide electrolyte fluid replacement, a need during dehydration. Hospitalization and intravenous fluids is not required with mild dehydration.
The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? 1.Sodium level of 145 mEq/L (145 mmol/L) 2.Potassium level of 5.2 mEq/L (5.2 mmol/L) 3.Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 4.Magnesium level of 1.3 mg/dL (0.53 mmol/L)
2.Potassium level of 5.2 mEq/L (5.2 mmol/L) Interpretation of the arterial blood gas (ABG) indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.
The nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if which 24-hour intake and output totals are noted? 1.Intake 1500 mL, output 800 mL 2.Intake 3000 mL, output 2000 mL 3.Intake 2400 mL, output 2900 mL 4.Intake 1800 mL, output 1750 mL
4.Intake 1800 mL, output 1750 mL For the client on a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per day. The client's output in the same period should be about the same and does not include insensible losses, which are extra. Insensible losses are offset by the fluid in solid foods, which also is not measured.
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.
The nurse is planning a teaching session with a client who has chronic kidney disease (CKD) about managing the condition between dialysis treatments. The nurse should plan to include the instruction that weight gain between dialysis treatments should be ideally what value? 1. 11 to 13 lbs (5 to 6 kg) 2. 4.5 to 9 lbs (2 to 4 kg) 3. 2 to 3 lbs (1 to 1.5 kg) 4. 1 to 2 lbs (0.5 to 1.0 kg)
3. 2 to 3 lbs (1 to 1.5 kg) Limiting weight gain to 2 to 3 lbs (1 to 1.5 kg) between dialysis treatments helps prevent the hypotension that occurs with the removal of large volumes of fluid during dialysis. The nurse instructs the client in how to manage daily fluid allotment to assist the client in staying within a low fluid intake range to prevent excess weight gain. Options 1, 2, and 4 are incorrect.
The nurse is performing an assessment on a client who has been receiving total parenteral nutrition (TPN) at 125 mL/hour. On assessment, the nurse notes the presence of bilateral crackles in the lungs and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds (1.5 kg) in 5 days. Which nursing action would be most appropriate for this client? 1.Slow the infusion rate to 100 mL/hour. 2.Encourage the client to cough and deep breathe. 3.Notify the health care provider (HCP) of the assessment findings. 4.Administer the prescribed daily diuretic and reassess the client in 2 hours.
3.Notify the health care provider (HCP) of the assessment findings Crackles, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces and indicate signs of fluid retention and possible excess fluid intake. The problem may or may not be related to the TPN. Other possible causes of fluid retention are impaired respiratory and cardiovascular function and impaired kidney function. Deep breathing and coughing will have little, if any, effect on peripheral edema and weight gain. Administering the prescribed daily diuretic and reassessing in 2 hours may delay necessary and immediate treatment and is incorrect. Decreasing the rate of infusion by 25 mL is not very helpful; in addition, the nurse should obtain an HCP prescription for doing so because increasing or decreasing the rate of the infusion presents the potential for hyperosmolar diuresis, hypoglycemia, or hyperglycemia.
The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment? 1.Oliguria 2.Flat fontanels 3.Pale skin color 4.Moist mucous membranes
1.Oliguria In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.
The nurse is caring for a client with a diagnosis of fluid volume overload. The nurse reviews the laboratory test results and would expect to note which finding about the hematocrit level? 1.Normal 2.Increased 3.Decreased 4.Insignificant related to the condition
3.Decreased Because the hematocrit is measured as a proportion of red blood cells to the volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit levels. Conversely, an increase in fluids can cause a decrease in the hematocrit level. A client with a diagnosis of fluid volume overload would have a decreased hematocrit level.
The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? 1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST segment 4.Widened QRS complexes
3.Depressed ST segment The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.
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 reviews the electrolyte results of an assigned client 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 The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.
n older client takes a stimulant laxative for ongoing management of chronic constipation. Which findings should the nurse expect to note when reviewing the client's laboratory results? 1.Hypokalemia 2.Hyperkalemia 3.Hyponatremia 4.Hypernatremia
1.Hypokalemia Hypokalemia can result from long-term use of a stimulant laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The remaining options are not specifically associated with the use of this medication.
A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? 1.Thyroid 2.Pituitary 3.Parathyroid 4.Adrenal cortex
1. Thyroid The thyroid gland is responsible for a number of metabolic functions in the body. Among these are metabolism of nutrients such as fats and carbohydrates. Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. A client with increased activity of the thyroid gland will experience weight loss from the higher metabolic rate and will have an increased pulse rate. The anterior pituitary gland produces growth hormone, luteinizing hormone, and follicle-stimulating hormone. Antidiuretic hormone (ADH) and oxytocin are secreted by the posterior pituitary gland. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.
The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. 1.Ensure adequate fluid intake. 2.Implement safety measures to prevent falls. 3.Encourage low-fiber foods to prevent diarrhea. 4.Instruct the client about foods that contain potassium. 5.Encourage the client to obtain assistance to ambulate.
1.Ensure adequate fluid intake. 2.Implement safety measures to prevent falls. 4.Instruct the client about foods that contain potassium. 5.Encourage the client to obtain assistance to ambulate. Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.
The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. At which frequency should the nurse plan to check the IV sites of these clients? 1.Every hour 2.Every 2 hours 3.Every 3 hours 4.Every 4 hours
1.Every hour Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. The time periods in options 2, 3, and 4 are too infrequent. In addition, agency policy and procedures are always followed regarding care to an IV site.
A home health care nurse is visiting an older client at home. Furosemide is prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates the need for further teaching? 1."I will sit up slowly before standing each morning." 2."I will take my medication every morning with breakfast." 3."I need to drink lots of coffee and tea to keep myself healthy." 4."I will call my health care provider if my ankles swell or my rings get tight."
3."I need to drink lots of coffee and tea to keep myself healthy." Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Sitting up slowly prevents postural hypotension. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the health care provider is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath.
The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? 1.Skin turgor 2.Level of edema at burn site 3.Adequacy of capillary filling 4.Amount of fluid tolerated in 24 hours
3.Adequacy of capillary filling Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.
The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1.Tetany 2.Tremors 3.Areflexia 4.Muscular excitability
3.Areflexia Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.
Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. 1.Electrolyte levels 2.Exercise patterns 3.Intake and output 4.Pupillary response 5.Elimination patterns 6.Deep tendon reflexes
1.Electrolyte levels 3.Intake and output 5.Elimination patterns The client with bulimia nervosa is likely to induce frequent vomiting and use diuretics and laxatives excessively. This places the client at risk for fluid and electrolyte imbalances. The nurse should monitor for both of these in this client. Excessive exercise is a characteristic of anorexia nervosa, not a characteristic of clients with bulimia. Changes in pupillary response and deep tendon reflexes are monitored in other disorders but are not associated with bulimia.
A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply. 1.Glycosuria 2.Albuminuria 3.Dehydration 4.Diabetes insipidus 5.High creatinine level 6.Increased blood urea nitrogen (BUN)
1.Glycosuria 2.Albuminuria 3.Dehydration Specific gravity evaluates the kidneys' ability to regulate fluid balance and the hydration status of the body. A specific gravity level of 1.034 is high. Some causes for high specific gravity levels are dehydration, albuminuria, and glycosuria. BUN and creatinine levels do not evaluate hydration status. Diabetes insipidus is related to low specific gravity levels.
A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? 1.Iodine 2.Calcium 3.Phosphorus 4.Magnesium
1.Iodine Adequate dietary iodine is needed to produce T3 and T4. The other requirements for adequate T3 and T4 production are an intact thyroid gland and a functional hypothalamus-pituitary-thyroid feedback system. The remaining options are not responsible for the abnormal amounts of circulating T3 and T4.
A client with a recent history of total thyroidectomy has developed iatrogenic hypoparathyroidism. Which observed findings does the nurse determine are associated with the hypoparathyroidism? Select all that apply. 1.Laryngospasm 2.Nephrolithiasis 3.Muscle weakness 4.Positive Chvostek's sign 5.Positive Trousseau's sign
1.Laryngospasm 4.Positive Chvostek's sign 5.Positive Trousseau's sign Hypoparathyroidism is an uncommon condition associated with inadequate circulating parathyroid hormone (PTH). It is characterized by hypocalcemia resulting from a lack of PTH to maintain serum calcium levels. The most common cause is iatrogenic; for example, accidental removal of the parathyroid gland during neck surgery. Signs and symptoms of hypocalcemia include laryngospasm and positive Chvostek's and Trousseau's signs. The remaining options are incorrect.
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 normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.
The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Monitor intake and output. 3.Assess extremities for edema. 4.Maintain a high-sodium diet. 5.Maintain a low-potassium diet.
1.Monitor daily weight. 2.Monitor intake and output. 3.Assess extremities for edema. The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water.
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1.Place the client on a cardiac monitor. 2.Notify the health care provider (HCP). 3.Put the client on NPO (nothing by mouth) status except for ice chips. 4.Review the client's medications to determine if any contain or retain potassium. 5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
1.Place the client on a cardiac monitor. 2.Notify the health care provider (HCP). 4.Review the client's medications to determine if any contain or retain potassium. The normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). A potassium level of 7.0 is elevated. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify the HCP and also review medications to determine if any contain potassium or are potassium retaining. The client does not need to be put on NPO status. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly.
The nurse is admitting a client with suspected ascites. What radiology films would initially be prescribed to diagnose ascites? Select all that apply. 1.Plain film 2.Scout film 3.Small bowel series 4.Flat plate of the abdomen 5.Kidney ureters bladder (KUB) 6.Upper gastrointestinal (GI) series
1.Plain film 2.Scout film 4.Flat plate of the abdomen 5.Kidney ureters bladder (KUB) The initial radiology films to detect ascites are plain films, scout films, flat plate of the abdomen, and KUB. They are all the same type of abdominal exam but with different names. These films provide a baseline assessment of the abdomen and are done before any studies requiring a contrast medium. The other films involve the use of barium and might be done as follow-up if the initial film was inconclusive.
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 the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply. 1.Proteinuria 2.Hematuria 3.Positive ketones 4.A low specific gravity 5.A dark and smoky appearance of the urine
1.Proteinuria 2.Hematuria 5.A dark and smoky appearance of the urine In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. The specific gravity is elevated, and the urine may appear dark and smoky. Positive ketones are not associated with this condition but may indicate a secondary problem.
The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1.Restrict fluids as prescribed. 2.Care for the arteriovenous fistula. 3.Encourage foods high in potassium. 4.Administer analgesics as prescribed.
1.Restrict fluids as prescribed. Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).
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 The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.
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 waves 3.Inverted T waves 4.Depressed ST segment The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? 1.Serum electrolytes 2.Urine specific gravity 3.24-hour fluid intake and output without restricting food or fluid intake 4.Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland
3. 24-hour fluid intake and output without restricting food or fluid intake The first step in diagnosing DI is to measure a 24-hour fluid intake and output without restricting food or fluid intake. All of the other options may be done but would not be as definitive as a 24-hour fluid intake and output test
A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation? 1.Administer hypotonic saline. 2.Increase the ultrafiltration rate. 3.Decrease the ultrafiltration rate. 4.Administer magnesium sulfate.
3.Decrease the ultrafiltration rate. Muscle cramps during hemodialysis result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. The nurse corrects this situation by either slowing down the ultrafiltration rate on the hemodialyzer or administering hypertonic or isotonic normal saline. Magnesium sulfate is not prescribed to correct this occurrence.
A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1.Fever and bradycardia 2.Fever and hypertension 3.Tachycardia and hypotension 4.Bradycardia and hypertension
3.Tachycardia and hypotension Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.
An infant is seen in the health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems never to get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child? 1.Monitor intake and output. 2.Administer predigested formula. 3.Administer omeprazole before feeding. 4.Prepare the family for surgery for the child.
4.Prepare the family for surgery for the child. Infants with projectile vomiting after feeding that are fussy should be suspected of pyloric stenosis. The treatment for this diagnosis is surgery. The other options are treatment measures that may be prescribed for gastroesophageal reflux.
