Fluid and Electrolyte McCuistion Questions

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first? Administer 1 liter 0.9% saline IV. Insert an indwelling urinary catheter. Obtain an abdominal x-ray. Draw a complete blood count (CBC) with hematocrit and hemoglobin.

Administer 1 liter 0.9% saline IV. Explanation: The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

Mr. Morris has a serum phosphate (P) level of 5.0 mg/dl. Treatment measures to correct this imbalance include: Increase dietary intake of turkey, whole gains, fish, and eggs Encourage the intake of whole milk. Administration of proximal diuretics. Administration of sodium phosphate intravenously

Administration of proximal diuretics. Explanation: Mr. Morris has hyperphosphatemia. He should avoid foods that are high in P such as those mentioned in choices 1 and 2. Proximal diuretics facilitate the renal excretion of P. Sodium phosphate solutions contain P and would further increase P levels.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Sunken eyeballs and spasticity Confusion and seizures Tetany and increased blood urea nitrogen (BUN) levels Flaccidity and thirst

Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated? SIADH secretion Diabetic ketoacidosis Diabetes mellitus Diabetes insipidus

Diabetes insipidus Explanation: Diabetes insipidus is characterized by a great thirst (polydipsia) and large amounts of dilute, waterlike urine with a specific gravity of 1.001 to 1.005. Diabetes mellitus presents with polydipsia, polyuria, and polyphagia, but the client also has hyperglycemia. Diabetic ketoacidosis presents with weight loss, polyuria, and polydipsia, and the client has severe acidosis. A client with SIADH cannot excrete dilute urine; the client retains fluid and develops a sodium deficiency.

Administration of normal saline solution _____________. Does not cause any net fluid shift Causes fluid to shift from the cells to the bloodstream Causes fluid to shift from the bloodstream into the cells Causes excess fluid to be expelled via the gastrointestinal system

Does not cause any net fluid shift Explanation: Correct answer is 1. Normal saline solution is an isotonic solution and does not cause any net fluid shift.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Monitor skin warmth and turgor. Observe neurologic function every 15 minutes. Observe the puncture site for swelling and bleeding. Monitor the laboratory values.

Observe the puncture site for swelling and bleeding

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has: a lower daily fluid requirement than an adult. a lower percentage of body water than an adult. immature kidney function. a more rapid respiratory rate than an adult.

immature kidney function. Explanation: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to: prevent seizures. increase diuresis. slow the process of labor. reduce blood pressure.

prevent seizures. Explanation: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

Fluid remobilization after burn treatment may lead to:

Fluid shift from the interstitial space into the intravascular space Explanation: After burn treatment, fluid shift from the interstitial space into the intravascular space can cause hypervolemia. Hypervolemia is also due to an excessive intake of sodium. Excessive isotonic fluid loss is hypovolemia. Water intoxication is due to an excess amount of low-sodium fluid that moves from the extracellular space into the intracellular space.

Which of the following individuals is experiencing increased insensible fluid loss? Jean, who is having a panic attack and is breathing quite rapidly An infant with severe diarrhea Monica, who took a diuretic this morning A teenager experiencing vomiting after contracting a gastrointestinal virus

Jean, who is having a panic attack and is breathing quite rapidly Explanation: Correct answer is 1. Rapid breathing increases the amount of insensible fluid loss through the lungs. Severe diarrhea and vomiting cause sensible (or measureable) fluid loss. A diuretic causes increased urination, which causes sensible fluid loss.

Which has the highest priority in the care of a client with chronic renal failure?

Maintain a low-sodium diet. Explanation: It is appropriate for the client to be on a low-sodium diet to help decrease fluid retention. Dry skin and pruritus are common in renal failure. Lotions are used to relieve the dry skin, and antihistamines may be used to control itching; corticosteroids are not used. Pain is not a major problem in chronic renal failure, but analgesics that are excreted by the kidneys must be avoided. It is not necessary to measure abdominal girth daily because ascites is not a clinical problem in renal failure.

A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis Explanation: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

A multiparous client thought to be at 14 weeks' gestation based on uterine size has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for: white blood cells. glucose. ketones. albumin.

ketones. Explanation: When a client is not able to eat, the intake of carbohydrates is dramatically reduced, causing fat to be burned for energy. Improper fat metabolism results in ketones in the urine from the starvation this client is experiencing. Presence of white blood cells in the urine would suggest a possible urinary tract infection. Albumin in the urine is associated with kidney or heart disease. Glucose in the urine is associated with diabetes mellitus.

Mrs. James has a serum chloride (Cl) level of 90 mEq/L. An appropriate treatment measure would be: Administration of Ringer's lactate solution IV Administration of ammonium chloride Administration of sodium bicarbonate Administration of loop diuretics

Administration of ammonium chloride Explanation: The correct answer is "administration of ammonium chloride." Mrs. James is hypochloremic and needs Cl. The other options decrease Cl levels.

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do? Use the mineral oil regularly on a weekly basis to prevent constipation. Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Take the mineral oil with fruit juice to increase the action of the mineral oil. Avoid mineral oil because it can lead to vitamin C deficiency in pregnant clients.

Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Explanation: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? Dextrose 5% in water as this is considered an isotonic solution Lactated Ringer's solution as this is considered an isotonic solution current guidelines suggest that no priming is needed since blood products must be infused alone Normal saline solution as this is considered an isotonic solution

Correct response: Normal saline solution as this is considered an isotonic solution Explanation: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS

A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client? Metabolic acidosis Lack of erythropoietin factor Hemoconcentration Hemodilution

Hemodilution Explanation: Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbunimemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced HCT level in this situation. Erythropoietin factor is reduce if kidney failure occurs; however, lack of erythropoietin factor doesn't impact hematocrit level.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? Half-normal saline solution 5% dextrose and normal saline solution Lactated Ringer's solution 10% dextrose in water

Lactated Ringer's solution Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? Metabolic alkalosis Metabolic acidosis Hypercalcemia Respiratory acidosis

Metabolic alkalosis Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

Calcium gluconate is administered when: Mg levels are low If serum Mg is 1.8 mEq/L Reflexes are diminished and flaccid paralysis occurs Chvostek's sign is present

Reflexes are diminished and flaccid paralysis occurs Explanation: The correct answer is "Reflexes are diminished and flaccid paralysis occurs." Diminished reflexes and flaccid paralysis are signs of hypermagnesia, which, in acute emergencies, can require that calcium gluconate (a Mg antagonist) be administered. 1.8 mEq/L is within normal serum Mg range. Chvostek's sign may be present in hypomagnesia.

A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation? Check the power source of the pump. Adjust the height of the IV bag. Change the IV bag. Reposition the child's extremity.

Reposition the child's extremity. Explanation: The most likely reason for difficulty running an IV in this age group is a positional issue of the child or extremity because of the child's activity level.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl Serum sodium level of 124 mEq/L

Serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply. Nutrition Vital signs Urine output Peripheral pulses Gait Skin color

Vital signs Skin color Urine output Peripheral pulses Explanation: Shock is a medical emergency in which the organs and tissues of the body are not receiving adequate blood flow. Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys and peripheral pulses all provide assessment data relating blood volume and circulation. Nutrition and gait is not related to blood circulation.

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink: at least 1,000 mL more than usual. at least 3,000 mL of fluids daily. as much water or juice as possible. twice as much fluid as usual.

at least 3,000 mL of fluids daily. Explanation: Instructions should be as specific as possible, and the nurse should avoid general statements such as "as much as possible." A specific goal is most useful. A mix of fluids will increase the likelihood of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 L more than she usually drinks if her intake was inadequate to begin with.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? rapid pulse rate decreased deep tendon reflexes tingling in the toes cool skin temperature

decreased deep tendon reflexes Explanation: Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which complication? pulmonary hypertension hypostatic pneumonia orthostatic hypotension fluid imbalances

fluid imbalances Explanation: Clients receiving TPN are at risk for a number of complications, including fluid imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary hypertension, and orthostatic hypotension are not complications of TPN.

After having surgery to reduce the invagination of intussusception, an infant has a nasogastric tube in place, is receiving IV fluids, and is allowed nothing by mouth. In addition to body weight, what parameter is most important to use to calculate the amount of IV fluid and electrolyte solution to infuse over the next 24 hours? stool output degree of temperature elevation urine output gastric output

gastric output Explanation: The volume of parenteral fluids needed is based on fluid requirements determined according to body weight and, in this situation, gastric output. If these fluids are not replaced with an appropriate IV solution, serious fluid and electrolyte imbalances could develop. Although stool output, urine output, and temperature are monitored, they are not used to calculate maintenance and replacement needs.

The nurse is coaching a client with hear failure about the most effective way to reduce sodium retention elevating the feet low-sodium diet walking for 20 minutes 3 times a week

low-sodium diet Explanation: In clients with fluid retention, sodium restriction may be necessary to promote fluid loss. Increasing exercise will not reduce fluid retention. Exercise will promote circulation, but will not manage the fluid retention. Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and promote improved fluid balance. Elevating the client's feet helps promote venous return and fluid reabsorption but in itself will not reduce the volume of excess fluid.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.34, PaCO2: 60 mm Hg,HCO3: 34 pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: moderate to severe hypotension. green-tinged urine. periorbital edema. polyuria.

periorbital edema. Explanation: Periorbital edema is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? Metabolic acidosis and hyperkalemia Metabolic acidosis and hypokalemia Metabolic alkalosis and hypokalemia Metabolic alkalosis and hyperkalemia

Metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used? To prevent signs of hypovolemic shock and restore circulation To restore sodium stores that were lost from the burns To maintain appropriate glucose levels in the blood To improve skin integrity and maintain a barrier

To prevent signs of hypovolemic shock and restore circulation Explanation: Lactated Ringer's is infused to restore circulating fluid volume and prevent signs of hypovolemic shock. Intravenous administration of dextrose to restore glucose is not the priority at this time. Lactated Ringer's will not affect sodium, and this is not a priority. The client has severe burns, so improving skin integrity is not an issue at this time.

The nurse is caring for an adolescent client who is in the intensive care unit after a suicide attempt with barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure (MAP) below 30 and a urine output that has decreased from 30 mL/hr to 2 mL/hr. Serum creatinine and potassium are both elevated. The parents of the client notice the small amount of urine in the indwelling catheter drainage bag and ask why there is so little. What is the best response by the nurse? "Alcohol immediately destroys the cells of the kidneys." "There is not enough blood getting to the kidneys." "The potassium has crystallized in the renal tubules." "The body is conserving fluids to dilute the barbiturates."

acute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic.

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate?

chicken broth and juice Explanation: Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Regular salted (not low salt) chicken or beef broth and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

Which adverse effects occur when there is too rapid an infusion of TPN solution? hypoglycemia circulatory overload negative nitrogen balance hypokalemia

circulatory overload Explanation: Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

11. A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? a. Little is known about iron-deficiency anemia and its relationship to infection in children. b. Children with iron deficiency anemia are more susceptible to infection than are other children. c. Children with iron-deficiency anemia are less susceptible to infection than are other children. d. Children with iron-deficient anemia are equally as susceptible to infection as are other children.

Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend? Place the child on a low-residue diet for several days. Offer fruit juices and gelatin as the child will tolerate. Encourage the child to take chicken or beef broth. Continue with breast milk or lactose-free formula.

Continue with breast milk or lactose-free formula. Explanation: Water, breast milk, and lactose-free formula are low-sodium fluids that are often used during maintenance fluid therapy. Fruit juices, carbonated soft drinks, and gelatin have a high carbohydrate content, very low electrolyte content, and high osmolarity, so they are not used to manage diarrhea. Caffeinated soda is a mild diuretic, so its use may lead to increased loss of water and sodium. Chicken or beef broth has excessive sodium and inadequate carbohydrate content. The BRAT (bananas, rice, applesauce, and toast or tea) diet has little nutritional value.

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? urine output body weight urine specific gravity body temperature

During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and daily body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP is not used. After the first 48 to 72 hours, urine output is a less reliable guide to fluid needs. The victim enters the diuretic phase as edema reabsorption occurs, and urine output increases dramatically. During the first 48 to 72 hours, fluid replacement is critical and is based on hourly urine output. Daily body weight does not provide enough information on which to base fluid replacement amounts. Body temperature is not a reliable guide for fluid replacement. IV fluid rates will be adjusted to keep urine output greater than 30 mL/h. Specific gravity measures the kidneys' ability to concentrate urine.

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? Eliminate dairy products from the diet. Strain urine at home regularly. Increase daily fluid intake to at least 2 to 3 L. Follow measures to alkalinize the urine.

Increase daily fluid intake to at least 2 to 3 L. Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

Which of the following statements concerning phosphate (P) balance in the body is accurate? P is the primary anion in extracellular fluid. As P levels increase, calcium (Ca) levels increase Breast-fed babies are more prone to hyperphosphatemia than babies who drink cow's milk. Mild to moderate hypophosphatemia does not usually cause symptoms.

Mild to moderate hypophosphatemia does not usually cause symptoms. Explanation: Mild to moderate hypophosphatemia does not usually cause symptoms. P is the primary anion in intracellular fluid. As P levels increase, Ca levels decrease. Babies who drink cow's mild are more prone to hyperphosphatemia than breast-fed babies because cow's milk contains more P than breast milk.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do? Observe for swelling of the neck, tracheal deviation, and severe pain. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Monitor laboratory values daily for elevated thyroid-stimulating hormone. Evaluate the quality of the client's voice postoperatively, noting any drastic changes.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Explanation: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

Which indicates that the client with diabetes insipidus understands how to manage care? The client will exhibit serum glucose level within normal range. The client will select a diabetic diet correctly. The client will maintain normal fluid and electrolyte balance. The client will state dietary restrictions.

The client will maintain normal fluid and electrolyte balance. Explanation: Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Assessing the client's vital signs every 4 hours Weighing the client daily at the same time each day Checking the client's lungs for crackles during every shift Measuring and recording fluid intake and output

Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: magnesium. sodium. phosphorus. potassium.

phosphorus. Explanation: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply. Slow the administration rate. Use a higher volume of formula because the formula may be too hypotonic. Use a diluted formula, gradually increasing the volume and concentration. Anticipate changing to a lactose-free formula. Change the feeding apparatus every 24 hours.

Change the feeding apparatus every 24 hours. Slow the administration rate. Use a diluted formula, gradually increasing the volume and concentration. Anticipate changing to a lactose-free formula.

A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow? Encourage plenty of fluids. Avoid dairy products. Order a high-fiber diet. Serve the client a regular diet.

Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom? passage of a liquid stool with a watery ring production of one to two light brown stools daily ability to fall asleep easily after each feeding spitting up of a tablespoon of formula after feeding

passage of a liquid stool with a watery ring Explanation: The mother demonstrates understanding of the discharge instructions when she says that she should contact the HCP if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.

On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n): additional fluid intake. antihypertensive medication. diuretic medication. increased oxygen liter flow rate.

The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

A client is receiving parenteral nutrition through a central venous catheter. As the nurse is changing the dressing at the catheter site, the client asks why this type of catheter is being used instead of a regular peripheral IV. Which is the best response by the nurse to explain the use of the central venous catheter? "The central venous catheter allows nutrients to be administered at a much greater pace." "The nutrients that are being administered are too concentrated for a peripheral IV." "The solution is hypotonic and can be given only through a central venous catheter." "Central venous catheters are inserted when peripheral veins can no longer be used."

The nutrients that are being administered are too concentrated for a peripheral IV." Explanation: Parenteral nutrition solutions have five to six times the concentration of nutrients of blood. They would be very irritating to the vascular intima if delivered via a peripheral vein. When administered via a central venous catheter, concentrated solutions are rapidly diluted to isotonic levels. The other answers are incorrect because the principal reason for the central venous catheter is to provide concentrated nutrition; fluids and electrolytes can be restored via regular IVs. Parenteral nutrition is not hypotonic, but hypertonic, and therefore cannot be administered peripherally. Central venous catheters are not accessed if peripheral veins have been overused; a cut down and deeper peripheral veins are then used.

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings? bradycardia hypertension polyuria poor skin turgor

poor skin turgor Explanation: In a client with persistent nausea and vomiting, the nurse should anticipate that the client may be dehydrated and exhibit signs of a fluid deficit, such as poor skin turgor. Other typical findings include lethargy, dry mucous membranes, tachycardia, weight loss, and decreased urine output. Blood pressure is usually within normal limits in the case of a mild to moderate fluid deficit because of the compensatory mechanisms of sympathetic nervous system stimulation of the heart (causing tachycardia) and peripheral vasoconstriction.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if: the pulse is weak and irregular. there is muscle weakness on physical examination. the serum potassium is 4.0 mEq/L (4.0 mmol/L). the ECG is showing tall, peaked T waves.

the serum potassium is 4.0 mEq/L (4.0 mmol/L). Explanation: Following crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate is a potassium binding resin. The resin combines with potassium in the colon and is then eliminated, and serum potassium levels should come back to normal. Normal serum potassium is 3.5 to 5.3. Weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.

Water intoxication can be due to: A mental health problem Rapid infusion of normal saline solution Lack of antidiuretic hormone Blood transfusion

A mental health problem Explanation: Choice 1 is correct. Psychogenic polydipsia is the intake of large amounts of water even when not thirsty. Water intoxication is due to rapid infusion of hypotonic solutions, and excessive amounts of ADH. Blood transfusion does not lead to water intoxication.

Cations________________________. Are negatively charged ions Include bicarbonate and phosphate Normally outnumber anions in concentration Are substances that separate, in solution, into electrically charged particles

Are substances that separate, in solution, into electrically charged particles Explanation: Choice 4 is correct. Choice 1: Cations are positively charged. Choice 2. Bicarbonate and phosphate are negatively charged. Choice 3: Anions and cations should be equal in number to achieve a state of electroneutrality.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. Which of the following is the best nursing intervention? Obtain orthostatic blood pressure readings Document the finding as the only action Elevate the head of the bed to 30 to 45 degrees and reassess JVD Notify the healthcare provider

Elevate the head of the bed to 30 to 45 degrees and reassess JVD Explanation: Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? Wrapping the arm in an elastic bandage from wrist to elbow Administering an as-needed analgesic Placing an ice pack on the hand Elevating the hand and wrapping it in a warm towel

Elevating the hand and wrapping it in a warm towel Explanation: Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol? Encourage a high fluid intake. Give foods that are high in potassium. Omit carbonated fluids.

Encourage a high fluid intake. Explanation: Destruction of malignant cells during chemotherapy produces large amounts of uric acid. The child's kidneys may not be able to eliminate the uric acid, and tubular obstruction from the crystals could result in renal failure and uremia. Allopurinol interrupts the process of purine degradation to reduce uric acid buildup. The child should be encouraged to increase fluid intake to further assist in eliminating uric acid. Carbonated fluids need not be omitted when allopurinol is administered. An intake of foods high in potassium is not necessary nor is limiting foods high in natural sugar.

A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? Encourage more fluid intake. Check for signs of puerperal infection. Check the client's breasts for red, swollen areas. Assess lochia for foul odor.

Encourage more fluid intake. Explanation: A slight temperature elevation from dehydration is common during the first 24 hours after giving birth. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after giving birth, excluding the first 24 hours. A slightly elevated temperature isn't an indication for the nurse to assess for odor in the lochia, breast-abnormalities, or puerperal infection.

A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Administer oxygen using a mask. Ensure adequate hydration before the anesthetic is administered. Place the woman supine with her legs raised. Administer ephedrine to raise her blood pressure.

Ensure adequate hydration before the anesthetic is administered. Explanation: Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery? Hyponatremia Hypermagnesemia Hyperkalemia Hypocalcemia

Hypocalcemia Explanation: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.

A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action? Offer the client proportioned fluids in the day and less during the night. Eliminate the liquids between meal times. Notify the dietary department of a clear fluids order. Divide the fluids equally among the three 8-hour nursing shifts.

Offer the client proportioned fluids in the day and less during the night. Explanation: The client and nurse should make a fluid schedule that takes into consideration factors such as periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding night fluids will decrease risk for aspiration. Other answers do not provide the client with autonomy of care, and good sleep patterns are essential for overall health.

Which of the following statements about magnesium (Mg) balance in the human body is true? Mg is most abundant in extracellular fluid. The normal serum range of Mg is 1.5 to 3.0 mEq/L. Dairy products are high in Mg. Serum Mg level may not accurately reflect the actual amount of Mg in the body.

Serum Mg level may not accurately reflect the actual amount of Mg in the body. Explanation: Since Mg is most abundant in the intracellular fluid, the serum level does not reflect the total amount of Mg in the body. Dairy products are high in Ca. The normal serum range of Mg is 1.8 to 2.5 mEq/L.

A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. His family members report that he has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? Hemoglobin of 9.8 g/dl (98 g/L) Serum calcium level 13.8 mg/dl (0.766 mmol/L) Serum sodium level of 133 mEq/L (133 mmol/L) Platelet count 300,000/mm3 (0.3 L)

Serum calcium level 13.8 mg/dl (0.766 mmol/L) Explanation: Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms.

A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see? Serum potassium level of 6.8 mEq/L (6.8 mmol/L) Blood urea nitrogen (BUN) level of 2.3 mg/dl (0.1 mmol/L) Serum glucose level of 236 mg/dl (13.1 mmol/L) Serum sodium level of 156 mEq/L (156 mmol/L)

Serum potassium level of 6.8 mEq/L (6.8 mmol/L) Explanation: A serum potassium level of 6.8 mEq/L indicates hyperkalemia, which can occur in adrenal insufficiency as a result of reduced aldosterone secretion. A BUN level of 2.3 mg/dl is lower than normal. A client in addisonian crisis is likely to have an increased BUN level because the glomerular filtration rate is reduced. A serum sodium level of 156 mEq/L indicates hypernatremia. Hyponatremia is more likely in this client because of reduced aldosterone secretion. A serum glucose level of 236 mg/dl indicates hyperglycemia. This client is likely to have hypoglycemia caused by reduced cortisol secretion, which impairs glyconeogenesis.

A nurse is assessing a post-surgical client who has been receiving nasogastric suctioning for 3 days. The client is restless, confused, and has generalized edema. What is the nurse's best intervention? Administer IV morphine sulfate 4 mg every 2 hours PRN Infuse 100 ml bolus of 3% saline if serum sodium decreases to less than 128 mEq/L. Administer IV metoclopramide 10 mg every 6 hours PRN for nausea. Stop the infusion of 5% dextrose in water (D5W) at 100 mL/hr.

Stop the infusion of 5% dextrose in water (D5W) at 100 mL/hr. Explanation: Hyponatremia is decrease in serum Na concentration < 136 mEq/L caused by an excess of water relative to solute. Because the client's gastric suction has been depleting electrolytes, the client is displaying signs of fluid volume overload and hyponatremia. Clinical manifestations are primarily neurologic due to an osmotic shift of water into brain cells causing edema. They include headache, confusion, and stupor. D5W becomes hypotonic as it is metabolized and could worsen fluid volume overload. The action of the nurse should be to recognize the symptoms and stop the D5W IV infusion. Once completed, the IV solution should be changed to a solution that includes electrolyte (sodium) replacement. The client is not in acute pain therefore morphine should not be given. Metoclopramide is given for a client who has nausea and vomiting.

Which of the following statements about potassium is correct? The normal range of serum potassium is 3.0 to 5.5. Potassium is an anion. The majority of potassium is located in intracellular fluid. The body is able to store potassium efficiently.

The majority of potassium is located in intracellular fluid. Explanation: The correct answer is 3. Choice1: the normal range is 3.5 to 5.0 mEq/L. Choice 2: Potassium is a cation. Choice 4: The body can not store potassium.

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem? poorly functioning temperature control center little skin pigment to prevent sunburn poor ability to concentrate urine abnormally high salt loss through perspiration

abnormally high salt loss through perspiration Explanation: One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Extra salt is almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual. In the child with cystic fibrosis, the functioning of the sweat glands is the problem, causing abnormal amounts of salt to be lost with perspiration. The ability to concentrate urine is not the problem. Little skin pigment is not a condition associated with cystic fibrosis. A poorly functioning temperature control center is not a condition related to cystic fibrosis.

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate? chicken broth and juice milk and diet soda coffee and milkshakes water and eggnog

CHICKEN BROTH AND JUICE

A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention? Prepare to give the child a transfusion of platelets. Encourage meticulous handwashing by the client and visitors. Prepare to give the child a transfusion of packed red blood cells. Encourage mouth care with a soft toothbrush.

encourage meticulous handwashing by the client and visitors.

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: hyperkalemia. hypokalemia. hypernatremia. hypercalcemia.

hyperkalemia. Explanation: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

An initial bolus of crystalloid fluid replacement for a child in shock is 20 ml/kg. The nurse is preparing to administer how many milliliters of fluid for a child weighing 30 kg? 300 mls 900 mls 600 mls 700 mls

600 mls Explanation: Fluid volume replacement must be calculated using the child's weight to avoid overhydration. Initial fluid bolus is administered at 20 ml/kg, followed by another 20 ml/kg bolus if there is no improvement in fluid status.

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention? Urine specific gravity 1.010. Serum potassium 4 mEq/L. Serum sodium 140 mEq/L. Ketones in urine.

Ketones in urine. Explanation: Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.

Aldosterone is secreted by the _____________. Kidneys Parathyroid glands Thyroid gland Adrenal glands

Adrenal glands Explanation: The correct answer is the "adrenal glands." The kidneys regulate sodium and potassium balance. The parathyroid glands secrete parathyroid hormone. The thyroid gland secretes calcitonin.

____is an example of a potassium-sparing diuretic. Lasix HydroDIURIL Aldactone Zaroxolyn

Aldactone Explanation: The correct answer is "Aldactone." Aldactone antagonizes aldosterone in the distal tubules, increasing sodium and water excretion, but sparing potassium.

A patient has received a dangerously high amount of dextrose 5% in normal saline solution. As a result:

Body cells will shrink. Explanation: Dextrose 5% in normal saline solution is a hypertonic solution. An excessive hypertonic solution may cause too much fluid to move from the cells into the bloodstream, thus causing the cells to shrink.

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Administer IV bicarbonate. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Suction the client's airway.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: Crackles. Dyspnea. Intermittent claudication. Dependent edema.

Dependent edema. Explanation: Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

Water intoxication can be due to the rapid infusion of:Normal saline solution Hypertonic solutions Dextrose 5% in water Albumin

Dextrose 5% in water Explanation: Water intoxication can be the result of rapid infusion of hypotonic solutions such as dextrose 5% in water.

Administration of a hypertonic solution requires the process of _______________ to equalize concentration within and outside of the cells.

Diffusion Explanation: During diffusion fluids move passively across a semipermeable membrane from an area of higher concentration to an area of lower concentration.

Negatively charged ions: Are referred to as cations Include chloride Outnumber positively charged ions in concentration Work to oppose a state of electroneutrality

Include chloride Explanation: Negatively charged ions are anions and include chloride. They should equal the number of positively charged ions in concentration to achieve a desired state of electroneutrality.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? Bilateral crackles Cyanosis of the lips Leg edema Productive cough

Leg edema Explanation: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

Your patient has an ionized calcium (Ca) level of 5.6 mg/dl. You would expect to find: Trousseau's sign Prolonged ST segment Painful muscle spasms Low albumin levels

Painful muscle spasms Explanation: The correct answer is "painful muscle spasms." This ionized Ca level indicates hypercalcemia, which causes painful muscle spasms. The remaining signs are indicative of hypocalcemia.

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? Calcium Sodium Potassium Chloride

Sodium

Decreased serum calcium (Ca) levels cause: The release of PTH Stimulation of the thyroid gland Inhibition of phosphorus excretion Shortened QT interval

The release of PTH Explanation: The correct answer is "the release of PTH." Low Ca levels trigger the parathyroid glands to release PTH. Elevated levels of Ca stimulate the thyroid gland to release calcitonin and cause a shortened QT interval.

A client's intravenous catheter has become occluded. The nurse knows that the reason for the occlusion is which of the following? Dressing and tape above the IV insertion site An IV infusion rate of 75 mL per hour Localized infection Thrombosis at the site

Thrombosis at the site Explanation: The catheter occlusion may have been caused by inadequate flushing. It is usually a lipid build use, not particulate matter. The other choices are incorrect because they are not common causes. The IV rate is appropriate, infection is not the most common cause of catheter occlusion if the catheter is changed per hospital protocol, and dressing and tape should not occlude flow.

A client has been taking furosemide for 2 days. The nurse should assess the client for: an elevated potassium level. an elevated blood urea nitrogen (BUN) level. an elevated sodium level. a decreased potassium level.

a decreased potassium level. Explanation: Furosemide is a loop diuretic and inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle. Furosemide promotes sodium diuresis, resulting in a loss of potassium and serious electrolyte imbalances. Furosemide does not affect the BUN level.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. heart rate. temperature.

blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet? beef tenderloin whole wheat bread apples canned tomato juice

canned tomato juice Explanation: Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.

A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: cardiac arrhythmia. dehydration. paresthesia. pruritus.

cardiac arrhythmia. Explanation: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.

Mrs. Gray's pH is 7.50. This indicates: An increase in hydrogen ions A decrease in bicarbonate A normal pH A state of alkalosis

A state of alkalosis Explanation: A pH of 7.50 indicates alkalosis. This could be due to a decrease in hydrogen ions or an increase in base, such as bicarbonate.

The carbonic acid-bicarbonate system: Works mainly in the red blood cells Is the body's primary buffer system Acts by combining hemoglobin with free hydrogen Works most efficiently in the kidneys

Is the body's primary buffer system Explanation: It is the primary buffer system. The hemoglobin-oxyhemoglobin system works in the red blood cells and acts by combining hemoglobin with free hydrogen. The phosphate buffer system works most efficiently in the kidneys.

If hyponatremia exists when extracellular fluid volume is equal to intracellular fluid volume, it is referred to as ________________________. Hypervolemic hyponatremia Excess fluid hyponatremia Hypovolemia hyponatremia Isotonic hyponatremia

Isotonic hyponatremia Explanation: Choice 4 is correct. The other choices refer to alterations in fluid volume.

Hypercapnia is associated with: Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis Explanation: Respiratory acidosis occurs due to a reduced alveolar ventilation. The lungs can't expel enough carbon dioxide from the body, which leads to hypercapnia.

Dehydration triggers the body to attempt to conserve water by: Secreting ADH Diluting urine Decreasing sodium levels Increasing diaphoresis

Secreting ADH Explanation: Correct answer is 1. Antidiuretic hormone conserves water. The urine becomes concentrated, sodium levels are increased, and diaphoresis is decreased.

Mrs. Harrison is sitting in the waiting room of her doctor's office. She is waiting to learn the results of a breast biopsy. She begins to breathe rapidly and becomes dizzy and light headed. It is likely that her ABG results would show: An abnormally low pH A PaCO2 of 49 mm Hg A bicarbonate of 20 mEq/L A state of respiratory alkalosis

A state of respiratory alkalosis Explanation: Deep, rapid respirations (due to anxiety in this case) cause the lungs to excrete large amounts of carbon dioxide, decreasing acid content and leading to respiratory alkalosis. A state of acute respiratory alkalosis would show a high pH, a low PaCO2, and a normal bicarbonate level.

A patient who is taking large amounts of Triamterene may have a chloride level of: 105 mEq/L 95 mEq/L 100 mEq/L 112 mEq/L

112 mEq/L Explanation: Choice 4 is correct. Intake of large amounts of Triamterene may cause elevated chloride levels and choice 4 is the only choice that indicates elevation. Choices 1 and 3 are normal levels. Choice 2 is a reduced level.

Your patient is complaining of intense thirst and is having some difficulty breathing. His urinary output is reduced and his mucous membranes are dry. You are not surprised to find that his serum sodium level is: 140 mEq/L 128 mEq/L 145 mEq/L 150 mEq/L

150 mEq/L Explanation: Choice 4 is correct. These are signs and symptoms of hypernatremia and choice 4 is an elevated sodium level. Normal serum sodium levels are 135-145 mEq/L. Choice 1 is a normal level. Choice 2 indicates hyponatremia. Choice 3 is a normal level.

A patient who is in renal failure may have a magnesium level of ___________. 2.0 mEq/L 1.5 mEq/L 2.8 mEq/L 2.5 mEq/L

2.8 mEq/L Explanation: Choice 3 is correct. A patient in renal failure may have an elevated magnesium level and choice 3 indicates hypermagnesia. Choices 1 and 4 are normal. Choice 2 indicates hypomagnesia.

Which of the following results indicates a normal phosphorus level? 4.0 mg/dl 2.2 mg/dl 5.0 mg/dl 4.8 mg/dl

4.0 mg/dl Explanation: Choice 1 is correct. Choice 2 is a reduced level. Choice 3 is an elevated level. Choice 4 is an elevated level.

Jeremy works in a highly competitive organization. His job is stressful and he takes antacids throughout the day and evening for heartburn and "acid" stomach. His doctor finds that Jeremy is hypertensive and bradycardic. You are not surprised that his ionized calcium level is: 4.8 mg/dl 5.8 mg/dl 4.2 mg/dl 5.0 mg/dl

5.8 mg/dl Explanation: Choice 2 is correct. Jeremy's symptoms plus the fact that he is taking large amounts of antacids leads you to suspect that his ionized calcium level is elevated. Choices 1 and 4 are normal ionized calcium levels. Choice 3 indicates hypocalcemia.

Which of one the following individuals has the lowest percentage of body water content? An infant Adult male 45-year-old female 65-year-old male

65-year-old male Explanation: Correct answer is 4. Water percentage decreases with age so that after age 60 it is about 45%.

If body cells swell, it might be assumed that _______________. A hypertonic IV solution was administered. An isotonic IV solution was administered. A hypotonic IV solution was administered. A blood transfusion was administered.

A hypotonic IV solution was administered. Explanation: Hypotonic solution causes fluid to move into the cells in an attempt to equalize concentration of solutes. Hypertonic solutions cause cells to shrink, isotonic solutions should have no effect on cells, and blood transfusions, if administered correctly, should not have adverse effects on cells.

Which of the following statements accurately describes the influence of atrial natriuretic peptide (ANP) on fluid balance? ANP suppresses serum renin levels When blood pressure and blood volume rise, the atria relax ANP is a cardiac hormone that is released when atrial pressure decreases ANP enhances the influence of the renin-angiotensin-aldosterone system

ANP suppresses serum renin levels Explanation: Choice 1 is correct. Choice 2: When blood pressure and blood volume rise, the atria stretch. Choice 3: ANP is released when atrial pressure increases. Choice 4: ANP counteracts the influence of the renin-angiotensin-aldosterone system.

A serum phosphorus level of 4.9 mg/dl requires which of the following interventions? Encourage the intake of dairy products, whole grains, and fish Administer IV saline solutions Administer IV sodium phosphate Encourage the use of phosphorus-based laxatives

Administer IV saline solutions Explanation: The correct answer is 2: This phosphorus level is elvated and IV saline solutions will facilitate renal excretion of phosphorus. The other choices increase phosphorus levels and are treatments for reduced phosphorus levels.

You may treat a patient with a serum potassium level of 5.5 mEq/L by __________. Administering loop diuretics Encouraging intake of foods such as bananas, apricots, and dried fruits and nuts Administering IV potassium supplements Administering non-steroidal anti-inflammatory drugs

Administering loop diuretics Explanation: The correct choice is 1. This is a treatment for hyperkalemia, as indicated by an abnormally high potassium level. The remaining 3 choices are interventions for hypokalemia.

Which of the following statements concerning calcium regulation is accurate? Calcitonin facilitates bone reabsorption of calcium. When calcium levels are low, parathyroid hormone is released. The active form of vitamin D inhibits calcium reabsorption. Phosphorus facilitates calcium absorption in the intestine.

Administration of normal saline solution intravenously Explanation: Choice 2 is correct. NSS administration is a treatment for hypochloremia. The other choices are interventions for hyperchloremia.

Which of the following statements describes a characteristic of albumin? Albumin is water soluble because of its strong positive charge. Albumin acts as a pulling force to attract water and retain it within the capillary. Albumin is a protein molecule that normally passes through the capillary membrane. Albumin has a circulating life span of 30 days.

Albumin acts as a pulling force to attract water and retain it within the capillary. Explanation: Choice 2 is correct. Choice1: Albumin has a negative charge. Choice 3: Albumin is too large to pass through capillary membranes. Choice 4: Albumin has a circulating life span of 12 to 20 days.

Excessive levels of serum magnesium may cause: CNS depression Rapid, deep respirations Tachycardia Hyperactive reflexes

CNS depression Explanation: Choice 1 is a sign of hypermagnesia. The other choices indicate hypomagnesia.

An ionized calcium level of 4.0 mg/dl: Causes contraction of the upper lip, nose, or side of the face when the patient's facial nerve is tapped. Could be due to excessive intake of antacids. Should be treated by infusing normal saline solution. Produces a shortened ST segment on an ECG.

Causes contraction of the upper lip, nose, or side of the face when the patient's facial nerve is tapped. Explanation: Choice 1 is correct. It is a sign of hypocalcemia and is referred to as Chvostek's sign. The ionized calcium level of 4.0 mg/dl indicates hypocalcemia. Choice 2 is a cause of hypercalcemia. Choice 3 is a treatment for hypercalcemia. Choice 4 is a sign of hypercalcemia.

Hypovolemia is characterized according to the degree of fluid loss. With 15% fluid loss, you can expect to notice: Signs of irritability and confusion Increased pulse rate and cool extremities Decrease in central venous pressure Coma

Choice 2 is correct with a mild loss of fluid (15%). Choice 1: These signs occur with moderate (about 25 %) fluid loss. Choice 3: Also a sign of moderate (25%) loss. Coma occurs in severe (40%) fluid loss.

When serum sodium levels are decreased,_____________________. Concentration of solutes is greater inside the cell compared to outside the cell. Extracellular fluid moves from inside the cell to outside the cell. Cells shrink. Fluid concentrates inside and outside of the cell are equal.

Concentration of solutes is greater inside the cell compared to outside the cell. Explanation: Choice 1 is correct. Choice 2: Extracellular fluid moves from outside to the inside of the cell. Choice 3: Cells swell Choice 4: Concentration is greater inside the cell.

When assessing a patient with a serum potassium level of 3.2 mEq/L you would expect to find which of the following symptoms? Tall, tented T waves on an ECG Oliguria or anuria Smooth muscle hyperactivity Constipation or paralytic ileus

Constipation or paralytic ileus Explanation: Correct choice is 4. This can be a consequence of hypokalemia, which is indicated by the 3.2 mEq/L potassium level. The other 3 choices are signs of hyperkalemia

When dehydration occurs, __________________. Solute concentration increases Osmolality decreases Cells swell Serum sodium levels decrease

Correct answer is 1. Choice 2: Osmolality is the term for solute concentration, which increases with dehydration. Choice 3: Cells shrink during dehydration as water moves from the cells to the bloodstream. Choice 4: Serum sodium levels increase with dehydration.

Diagnostic findings in hypervolemia include: Elevated hematocrit Elevated serum potassium Decreased blood urea nitrogen levels Decreased sodium levels

Decreased blood urea nitrogen levels Explanation: Correct choice is 3. Hematocrit and potassium are decreased and sodium is increased

Reduced levels of serum magnesium may cause: Depressed ST segments and broad, flattened T waves on an ECG Bradycardia, weak pulse, and/or heart block Slow, shallow respirations Flaccid paralysis

Depressed ST segments and broad, flattened T waves on an ECG Explanation: Choice 1 is correct. The other choices are signs of hypermagnesia.

Which of the following statements about fluid movement is accurate? During diffusion, solutes move from areas of lower concentration to higher concentration. During osmosis, fluid moves passively from areas with more fluid to areas of less fluid. During active transport, fluids move passively from areas of lower concentration to higher concentration. During capillary filtration, fluids and solutes are forced through the walls of the veins.

During osmosis, fluid moves passively from areas with more fluid to areas of less fluid. Explanation: Correct choice is 2. This defines osmosis. Choice1: During diffusion, solutes move from areas of higher concentration to lower concentration. Choice 3: During active transport, energy is required to move solutes from an area of lower concentration to an area of higher concentration. Choice 4: During capillary filtration, fluids and solutes are forced through the walls of the capillaries. These are the only blood vessels with walls thin enough to allow such movement.

Osmotic diuretics, such as Osmitrol, work by:____________________ Increasing osmotic pressure of glomerular filtrate Inhibiting sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle Working high in the distal tubule of the nephron to prevent sodium and chloride reabsorption Antagonizing aldosterone in the distal tubules

Increasing osmotic pressure of glomerular filtrate Explanation: Choice 1 is correct. Choice 2 describes how loop diuretics work. Choice 3 describes how thiazide diuretics work high in the distal tubule. Choice 4 describes how potassium-sparing diuretics work.

If your patient has a serum magnesium level of 1.4 mEq/L, which of the following interventions is appropriate? Encourage the intake of dry beans and peas and whole grains. Administer loop diuretics such as Lasix. Administer calcium gluconate in an emergency. Facilitate the intake of fluids.

Encourage the intake of dry beans and peas and whole grains. Explanation: The correct choice is 1. The patient's magnesium level is low and these kinds of foods are high in magnesium. Choices 2 and 3 are interventions for hypermagnesia. Choice 4 could further deplete magnesium levels.

Which of the following statements concerning hypervolemia is correct? Hypervolemia is described as an excess of isotonic fluid in the intracellular spaces. Osmolality is significantly affected with hypervolemia. Hypervolemia may be due to a shift in fluid from the interstitial space into the intravascular space. Hypervolemia occurs with excessive sodium loss.

Hypervolemia may be due to a shift in fluid from the interstitial space into the intravascular space. Explanation: Choice 3: This is correct. Choice 1: It is an excess of isotonic fluid in the extracellular spaces. Choice 2: Since fluids and solutes are gained in equal proportion, osmolality is not affected. Choice 4: Hypervolemia can be due to excessive sodium intake, not loss.

Water intoxication causes: Low-sodium fluid to move from the intracellular space into the extracellular space Fluid moves by osmosis out of the cells Cell shrinkage Increased intracranial pressure due to increased cellular fluid content

Increased intracranial pressure due to increased cellular fluid content Explanation: Choice 4 is correct. Choice 1: Fluid moves from the extracellular space to the intracellular space. Choice 2: Fluid moves into the cells. Choice 3: Cells swell rather than shrink.

Which of the following statements pertaining to antdiuretic hormone (ADH) and fluid balance is correct? The pituitary gland senses low blood volume and increased serum osmolality and signals the hypothalamus to secrete ADH into the bloodstream. The release of ADH increases the kidney's excretion of water. The kidneys are triggered to secrete ADH when stimulated by the hypothalamus. ADH secretion causes water retention that boosts blood volume and decreases serum osmolality.

It is the hypothalamus that senses low blood volume and increased serum osmolality and signals the pituitary gland to secrete ADH. Choice 2: ADH causes the kidneys to reabsorb water. Choice 3: The kidneys do not secrete ADH, the pituitary gland does.

The renin-angiotensin-aldosterone system helps to maintain a balance of sodium and water when: Blood flow to the glomerulus increases. Juxtaglomerular cells near each glomerulus secrete an enzyme called renin. Renin travels to the nephrons where it is converted to angiotensin I. Angiotensin I travels to the liver where it is converted to angiotensin II.

Juxtaglomerular cells near each glomerulus secrete an enzyme called renin. Explanation: Choice 2 is correct. Choice 1: The renin-angiotensin-aldosterone system is triggered when blood flow to the glomerulus decreases, not increases. Choice 3: Conversion takes place in the liver, not in the nephrons. Choice 4. Angiotensin I travels to the lungs, not the liver, where it is converted to angiotensin II.

Administration of large amounts of half-normal saline: May cause cells to swell May cause cells to shrink Should have no effects on cells Should diminish capillary pressure

May cause cells to swell Explanation: Choice 1 is correct. Half-normal saline is hypotonic and causes cells to swell.

The kidneys are powerful regulators that: May lose efficiency in older adults Respond immediately to changes in pH Cause excess hydrogen ions to unite with phosphate for reabsorption Cause the formation of bicarbonate in the renal tubules in response to an elevated pH

May lose efficiency in older adults Explanation: The kidneys may not function as efficiently in older adults. It may take hours or days for them to respond and correct an imbalance. Excess hydrogen ions unite with phosphate to form titratable acids that are excreted in urine. An elevated pH indicates too much base and this would lead to a decrease in bicarbonate formation.

Interpret the following ABG results: pH - 7.25 PaCO2 - 40 mm Hg Bicarbonate - 18 mEq/L Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis Explanation: Metabolic acidosis is the correct answer. The pH indicates an acidic state. The PaCO2 is normal, but the base is decreased, indicating that the cause of the acidosis is metabolic.

The passive movement of fluid from areas with more fluid and fewer solutes to areas with less fluid and greater solutes is: Diffusion Active transport Capillary filtration pressure Osmosis

Osmosis

One of these groups of people is at risk for dehydration. Which one and why? Infants, because their kidneys produce overly concentrated urine Patients who are bedridden, because they have difficulty accessing fluids Younger adults, because their kidneys have not yet reached maximum function Patients who are elderly, because they are usually senile

Patients who are bedridden, because they have difficulty accessing fluids Explanation: Choice 2 is correct. Choice 1: Infants kidneys are immature and can't concentrate urine efficiently. Choice 3: Younger adults have efficient, mature kidney function. Choice 4: You can't assume elderly patients are senile. They are at higher risk for dehydration because they have a diminished sensation of thirst.

Which of the following statements concerning acid/base balance is correct? Acids are substances that accept hydrogen ions. Venous blood is used to measure pH. Solutions with a pH less than 7 are acidic. An accumulation of hydrogen ions is reflected by a pH greater than 7.45.

Solutions with a pH less than 7 are acidic. Explanation: Solutions with a pH less than 7 are acidic. Acids are substances that can "give up" hydrogen ions. Arterial blood is used to measure pH. An accumulation of hydrogen ions is indicative of an acidic solution, which would have a pH of less than 7.

When treating a patient with COPD, it is important to remember that: He is at risk for respiratory alkalosis O2 should be administered at high concentrations The hypoxic drive stimulates the patient to breathe The administration of bronchodilators is contraindicated

The hypoxic drive stimulates the patient to breathe Explanation: A patient with COPD is at risk for respiratory acidosis. The state of chronic hypoxia actually stimulates the patient to breath (the hypoxic drive). O2 is administered at lower concentrations and bronchodilators are part of the treatment.

Which of the following statements about the kidney's role in fluid balance is accurate? Nephrons filter about 75 ml of blood per minute. The kidneys normally excrete at least 20 ml of urine every hour. Excess fluid stored in the body causes secretion of ADH. Fluid excess causes the kidneys to excrete more concentrated urine.

The kidneys normally excrete at least 20 ml of urine every hour. Explanation: Choice 2 is correct. Choice 1: Nephrons filter about 125 ml of blood per minutes. Choice 3: ADH is antdiuretic hormone, which works to conserve water and decrease output. Choice 4: The urine is more diluted if there is excess fluid.

An increase in carbon dioxide: Triggers the kidneys to retain acid Leads to decreased carbonic acid production Triggers chemoreceptors in the brain to increase the rate and depth of respirations Elevates pH

Triggers chemoreceptors in the brain to increase the rate and depth of respirations Explanation: An increase in carbon dioxide leads to increased carbonic acid production, which triggers chemoreceptors to increase rate and depth of respirations to remove excess carbon dioxide. An increase in carbon dioxide leads to a more acidic state, indicated by a decrease in pH.

A serum sodium level of 152 mEq/L _______________. Causes the cells to swell Triggers the thirst center in the hypothalamus May be linked to diuretics Indicates the concentration of solutes is greater inside the cell

Triggers the thirst center in the hypothalamus Explanation: The correct choice is 2. This level indicates hypernatremia, which triggers the thirst mechanism to encourage fluid intake to balance the extra concentrations of solutes. Choice 1: Cells shrink in hypernatremia. Choice 3: Diuretics are linked to hypovolemia hyponatremia. In hypernatremia, concentration of solutes is greater inside the cell.

Which of the following statements concerning calcium regulation is accurate? Calcitonin facilitates bone reabsorption of calcium. When calcium levels are low, parathyroid hormone is released. The active form of vitamin D inhibits calcium reabsorption. Phosphorus facilitates calcium absorption in the intestine.

When calcium levels are low, parathyroid hormone is released.

Which of the following ABG results indicate a state of metabolic alkalosis with partial respiratory compensation? pH - 7.58 PaCO2 - 52 mm Hg Bicarbonate - 28 mEq/L pH - 7.38 PaCO2 - 40 mm Hg Bicarbonate - 25 mEq/L pH - 7.52 PaCO2 - 28 mm Hg Bicarbonate - 25 mEq/L pH - 7.30 PaCO2 - 47 mm Hg Bicarbonate - 26 mEq/L

pH - 7.58 PaCO2 - 52 mm Hg Bicarbonate - 28 mEq/L Explanation: The pH is alkaline, the corresponding reading is an elevated bicarbonate, and the PaCO2 is also elevated in an attempt to compensate for the alkalotic state.

Which indicates hypovolemic shock in a client who has had a 15% blood loss? pupils unequally dilated respiratory rate of 4 breaths/minute pulse rate less than 60 bpm systolic blood pressure less than 90 mm Hg

systolic blood pressure less than 90 mm Hg Explanation: Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

The rate at which IV fluids are infused is based on the burn client's: lean muscle mass and body surface area (BSA) burned. height and weight and BSA burned. total body weight and BSA burned. total BSA and BSA burned.

total body weight and BSA burned. Explanation: During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: fluid intake and output. vital signs. weight. urine specific gravity.

weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Draw samples for hemoglobin and hematocrit every 6 hours." "Infuse I.V. fluids at 83 ml/hour." " Monitor urine output every hour." "Administer oxygen by nasal cannula at 3 L/minute."

"Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Draw samples for hemoglobin and hematocrit every 6 hours." "Monitor urine output every hour." "Administer oxygen by nasal cannula at 3 L/minute." "Infuse I.V. fluids at 83 ml/hour."

"Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

Mr. Adams is lethargic and exhibiting Kussmaul's respirations. He is also dehydrated. You are not surprised to find that his serum chloride (Cl) level is: 120 mEq/L 104 mEq/L 90 mEq/L 95 mEq/L

120 mEq/L Explanation: The correct answer is "120 mEq/L "1. Mr. Adams is exhibiting signs of elevated Cl level. Dehydration is also a cause of hyperchloremia. 120 mEq/L is an elevated serum Cl. 104 mEq/L and 95 mEq/L are within normal limits. 90 mEq/L is a reduced serum level.

In the event of acute hypocalcemia, IV calcium gluconate is administered: In normal saline solutions At a rate of 2 g/hour If calcium chloride is not available because the two solutions are identical Cautiously since infiltration can lead to tissue necrosis

Cautiously since infiltration can lead to tissue necrosis Explanation: Calcium gluconate should be administered in 5% dextrose in water at a rate no faster than 1 g/hour. Calcium chloride and calcium gluconate are DIFFERENT solutions and should not be used interchangeably.

What discharge instructions should the nurse give the parents of an infant with a temporary colostomy? Give the infant plenty of liquids to drink. Expect the stoma to become dusky red within 2 weeks. Flush the stoma with tap water at least once a day. Allow the diaper to absorb the colostomy drainage.

Give the infant plenty of liquids to drink. Explanation: Because of decreased fluid reabsorption from the colon, the child with a colostomy benefits from a liberal fluid intake. Infants also dehydrate more quickly than adults do because of immature kidneys, larger body surface area, and more fluid in the extracellular spaces. Therefore, the parents need instructions about giving the infant plenty of liquids to drink. Tap water flushes of the stoma are contraindicated in infants because of the risk for absorption of free water and the potential for fluid overload. An appliance should be fitted over the stoma for stool collection to help prevent skin breakdown. The stoma should always be reddish-pink and moist. A dusky-red stoma may indicate impaired circulation to the area.

Vasopressin affects fluid balance when:

It triggers the kidneys to retain water. Explanation: Vasopressin or ADH affects fluid balance when the hypothalamus senses low blood volume and increased serum osmolality. ADH makes the kidneys retain water. ADH is secreted by the pituitary gland. ANP is stored in the atrial cells. Water retention increases blood volume and leads to more concentrated urine.

A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? To block dopamine receptors To inhibit labor To lower blood pressure To prevent seizures

To prevent seizures Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors.

The physician orders 20 mEq of potassium chloride to be added to the IV solution of a client in diabetic ketoacidosis. The nurse is aware that the reason for this is which of the following? Replacement of electrolyte deficit Prevention of flaccid paralysis during rehydration Treatment of cardiac dysrhythmias Treatment of hypercapnia

cute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic.

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids? diminished liver function increased production of antidiuretic hormone decreased ability to detect thirst decreased production of aldosterone

decreased ability to detect thirst Explanation: The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased, and dissolved particles in the extracellular fluid compartment become more concentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and aldosterone as a normal part of aging.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? increased osmolality of the plasma decreased serum sodium level increased urine output decreased blood pressure

decreased serum sodium level Explanation: SIADH is characterized by excess antidiuretic hormone (ADH, vasopressin) secretion, despite low plasma osmolality. Excess ADH causes water to be retained. As blood volume expands, plasma becomes diluted resulting in dilutional hyponatremia. Aldosterone is suppressed, resulting in increased renal sodium excretion. Water moves from the hypotonic plasma and the interstitial spaces into the cells.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: chloride and magnesium abnormalities. calcium and phosphorus abnormalities. sodium and chloride abnormalities. sodium and potassium abnormalities.

sodium and potassium abnormalities. Explanation: In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

A 10 kg infant is receiving IV fluid replacement. The nurse should suspect that the infant is receiving too little IV fluid replacement when the child exhibits which sign or symptom? an increase in blood pressure over the past 3 hours urine specific gravity of 1.033 urine output of 26 mL for the past hour increasing irritability

urine specific gravity of 1.033 Explanation: The specific gravity of urine increases as the kidneys are forced to conserve water, a sign of dehydration. Normal specific gravity for a child should range from 1.002 to 1.030. Thus, a urine specific gravity of 1.033 is increased, suggesting too little fluid replacement. Irritability may be related to numerous factors and is not a reliable indicator of the need for more fluids. Normal minimal urine output for an infant is 1 to 2 mL/ kg/hour. A decrease, not increase, in blood pressure would indicate that too little fluid is being infused.