Fluid and Electrolytes
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)
Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.
A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Eggs Chicken Apples Spinach
Spinach Explanation: Sardines, whole grains, and green leafy vegetables also provide calcium.
The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 23-year-old with ulnar and radial fracture 34-year-old whose urinary catheter was discontinued yesterday 48-year-old who has had a bowel movement after surgery 55-year-old with congestive heart failure on furosemide
55-year-old with congestive heart failure on furosemide Explanation: Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.
A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? Discontinue the IV. Attempt to aspirate. Flush with 3-mL normal saline. Slow the rate of infusion by 50%.
Discontinue the IV. Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.
The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? Remove the IV catheter and reinsert another in a different location. Decontaminate the visible portion of the catheter, and then gently reinsert. Apply a new dressing and observe for signs of infection over the next several hours. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.
Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.
Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water deficit water excess extracellular fluid volume excess
extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching? "I will take my pain medications according to the schedule we developed." "I will increase my fluid and calcium intake." "I'll schedule a follow-up visit with my physician as soon as I get home." "I'll call my physician if I notice tingling around my lips." TAKE ANOTHER QUIZ
"I will increase my fluid and calcium intake." Explanation: The client requires additional teaching if he states that he will increase his calcium intake. Hyperparathyroidism causes extreme increases in serum calcium levels. The client should increase his fluid intake, but he should limit his calcium and vitamin D intake. The client should continue to take pain mediations as scheduled and have regular follow-up visits with his physician. Tingling around the lips is a sign of hypercalcemia and should be reported to the physician immediately.
The nurse is preparing to administer IV fluids for a patient with ketoacidosis who has a history of hypertension and congestive heart failure. What order for fluids would the nurse anticipate infusing for this patient? D5W 0.9% normal saline 0.45 normal saline D5 normal saline TAKE ANOTHER QUIZ
0.45 normal saline Explanation: Half-strength NS (0.45%) solution (also known as hypotonic saline solution) may be used for rehydration of patients with hypertension or hypernatremia and those at risk for heart failure.
The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.
4000 Explanation: A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.
Which client will have more adipose tissue and less fluid? A woman A man An infant A child
A woman
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? Continue to monitor the woman's temperature every 4 hours; this finding is normal. Notify the health care provider about this elevation; this finding reflects infection. Obtain a urine culture; the woman most likely has a urinary tract infection. Inspect the perineum for hematoma formation.
Continue to monitor the woman's temperature every 4 hours; this finding is normal. Explanation: A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should: Encourage fluid intake, if possible, to dilute the urine. Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. Limit fluids to 1,000 mL/day to minimize stress on the renal tubules. Modify the diet to acidify the urine, thus preventing uric acid crystallization.
Encourage fluid intake, if possible, to dilute the urine. Explanation: To prevent renal damage, it is helpful to dilute the urine by increasing fluids as tolerated.
While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? "How much do you typically urinate during the day?" "How often do you usually have a bowel movement?" "How often do you experience leg cramps? "How much coffee do you drink during a typical day?
How much do you typically urinate during the day?" Explanation: Questions and leading statements about fluid balance are part of a comprehensive health history. Urinary output is one factor to consider in fluid balance. Bowel movements, especially if a client is having multiple loose stools a day, may affect fluid balance but is not the most appropriate question to ask. Leg cramps can occur when there is an electrolyte imbalance but is not the most appropriate question. Lastly, coffee can have diuretic-like properties but is also not the most appropriate question to ask to assess fluid balance.
Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? Infant School-age child Adolescent Young adult
Infant Explanation: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.
Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Hepatic Renal TAKE ANOTHER QUIZ
Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.
The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure? an hourly urine output of 50 to 70 mL a urine specific gravity reading of 1.021 a serum BUN of 70 mg/dL a serum creatinine of 1.0 mg/dL TAKE ANOTHER QUIZ
a serum BUN of 70 mg/dL Explanation: These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.
Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce: cardiac workload. cardiac output. pulmonary efficacy. oxygenation. TAKE ANOTHER QUIZ
cardiac workload. Explanation: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output. There is no reason for reducing pulmonary efficacy. There is no reason for reducing oxygenation.
Which is a common anion? magnesium potassium chloride calcium
chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: electrolytes. nonelectrolytes. colloid solution. interstitial fluid.
electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? isotonic hypotonic hypertonic plasma
hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.
A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis? increasing occipital frontal circumference evidence of seizure activity increased body temperature decreased level of consciousness TAKE ANOTHER QUIZ
increasing occipital frontal circumference Explanation: Hydrocephalus is an increase in cerebrospinal fluid in the ventricles of the brain. The nurse should assess the infant's head circumference and note any increases. Hydrocephalus is associated with an increased occipitofrontal diameter. When palpated, the head has widened sutures with wide, open fontanels. Typically the fontanels will feel tense and bulging. Other, less specific signs of hydrocephalus include poor feeding, "setting sun" eyes, vomiting, lethargy, prominent veins, and seizure activity due to increased intracranial pressure. Meningitis can develop and result in fever.
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention? lung congestion nausea temperature blood pressure TAKE ANOTHER QUIZ
lung congestion Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms.
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: phlebitis. an infiltration. a systemic blood infection. rapid fluid administration.
phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.
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 maintain appropriate glucose levels in the blood to restore sodium stores that were lost from the burns to improve skin integrity and maintain a barrier TAKE ANOTHER QUIZ
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. The client has severe burns, so improving skin integrity is not an issue at this time.
A nurse must deliver 1,000 ml of normal saline solution over 8 hours. The I.V. tubing has a drop factor of 10 gtt/ml. The nurse should set the flow rate as 20.5 gtt/minute 21 gtt/minute 25 gtt/minute 31 gtt/minute TAKE ANOTHER QUIZ
21 gtt/minute The nurse can use various methods to calculate the gtt/minute. One method is dividing the total volume by the total time in minutes, and multiplying that number by the drop factor. 8 X 60 minutes equals 480 minutes. 1,000 divided by 480 equals 2.08. 2.08 X 10 equals 20.8, which rounds to 21.
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr
A urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? Changing the dressing on a client's peripheral IV site Initiating a client's transfusion of packed red blood cells Deaccessing a client's implanted port Removing a client's PICC in anticipation of the client's discharge
Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess TAKE ANOTHER QUIZ
Dehydration Explanation: The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances.
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? Discontinue the IV and relocate it to another spot. Call the physician and ask if anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.
Discontinue the IV and relocate it to another spot. Explanation: The nurse should inspect the IV site for presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleaning with alcohol or chlorhexidine is not recommended and does not reduce the phlebitis. The nurse does not need to call the physician for anti-inflammatory medications
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Select a primary tubing of about 37 inches (94 cm) long. Ensure that the prescribed solution is clear and transparent. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours.
Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hyperkalemia Hypocalcemia Hypokalemia Hypercalcemia
Hypercalcemia Explanation: The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
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? Hypocalcemia Hyponatremia Hyperkalemia Hypermagnesemia TAKE ANOTHER QUIZ
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.
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? Hypokalemia Alkalosis Hypovolemia Bradycardia TAKE ANOTHER QUIZ
Hypokalemia Explanation: PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (e.g., exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia.
A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution? Isotonic Hypotonic Hypertonic Volume expander TAKE ANOTHER QUIZ
Isotonic Explanation: Isotonic fluids have an osmolarity of 250 to 375 mOsm per liter, which is the same osmotic pressure as that found within the cell. Isotonic fluids are used to expand the intravascular compartment and thus increase circulating volume. Because these solutions do not alter serum osmolarity, interstitial and intracellular compartments remain unchanged (Smeltzer, Bare, Hinkle, & Cheever, 2010). An isotonic solution is helpful for hypotension caused by hypovolemia in dehydration. When a hypotonic solution is infused, it lowers serum osmolarity, causing body fluids to shift out of the blood vessels and into the cells and interstitial space. For this reason, hypotonic fluids are administered when a client needs cellular hydration. Hypertonic fluids have an osmolarity of 375 mOsm per liter or higher and a greater osmotic pressure than the cell. When a hypertonic solution is infused, serum osmolarity is increased, pulling fluid from the cells and the interstitial tissues into the vascular space. The primary use for these solutions are management of intracranial hypertension and shock. Volume expanders, such as albumin, a plasma protein contained within the plasma, is used to restore intravascular volume and to maintain cardiac output in clients with hypoproteinemia.
After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next? Notify the healthcare provider. Prepare the woman for hospitalization. Prepare for a paracentesis. Place the woman on bed rest. TAKE ANOTHER QUIZ
Notify the healthcare provider. Explanation: Ovarian hyperstimulation syndrome is caused by an excessive response to the medications used to produce eggs and make them grow. With the increased number of growing follicles, the estradiol levels are increased, leading to fluid leaks in the abdomen. There is increased vascular permeability that causes rapid accumulation of fluid in the peritoneal cavity, thorax, and pericardium. Some symptoms of the problem are an increased weight gain of 3 pounds or more over a 2-day period, shortness of breath, abdominal pain, dehydration, vomiting, and the production of blood clots. The healthcare provider should be notified as soon as possible. The woman may require hospitalization and a paracentesis. If the woman is not admitted to the hospital, the woman should be instructed to stop the medication, rest, and drink large amounts of electrolyte fluids.
The nurse would be most concerned when the glomerular filtrate contains: Protein Sodium Potassium Water TAKE ANOTHER QUIZ
Protein Explanation: The glomerular filtrate has a chemical composition similar to plasma, but it contains almost no proteins because large molecules do not readily cross the glomerular wall. Potassium, sodium, and water would be filtered.
The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication? Administer 10 gtt/min over 30 seconds Ensure 50 gtt/min is given over 1 minute Regulate flow to allow 25 gtts every 15 seconds Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds TAKE ANOTHER QUIZ
Regulate flow to allow 25 gtts every 15 seconds Administration may be achieved by gravity infusion, which requires the nurse to calculate the infusion rate in drops per minute. If using a gravity or free-flowing IV, calculate the drip rate required to achieve the desired infusion rate. A standard formula using dimensional analysis method to calculate is gtts/min (drops per min) is below. 1000 mL X 1 hour X 60 gtt = gtt/min = 60000 = 100 gtt/min (Why = Cancel units = mL units cancel each other, hours cancel each other, left with the units = gtts/min) 10 hours 60 min mL 600 The nurse can consider placing a time tape on the infusion bag to monitor hourly infusion rates and serve as a quick reference to monitor the rate at which the solution is entering the client. The tape gives an hourly indication of where the fluid level should be at a given time to avoid fluid infusing too quickly.
The nurse is determining a site for an IV infusion. What guideline should the nurse consider? Scalp veins should be selected for infants because of their accessibility. Antecubital veins should be used for long-term infusions. Veins in the leg should be used to keep the arms free for the client's use. Veins in surgical areas should be used to increase the potency of medication.
Scalp veins should be selected for infants because of their accessibility. Explanation: Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? Encourage oral fluids. Administer furosemide (Lasix) 20 mg IV Start hemodialysis after a temporary access is obtained. Start IV fluids with a normal saline solution bolus followed by a maintenance dose. TAKE ANOTHER QUIZ
Start IV fluids with a normal saline solution bolus followed by a maintenance dose. Explanation: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.
A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority? avoidance of infection constipation prevention administration of immunoglobulins consumption of a low-fat diet
avoidance of infection Explanation: Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.
A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? replace fluid and electrolytes administer blood products provide protein supplements treat the client's infection
replace fluid and electrolytes Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost due to the NPO order, and the loss of fluid and electrolytes due to the nasogastric suctioning.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: an access route to administer medications intravenously. replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis. TAKE ANOTHER QUIZ
replacement of fluids for those lost from vomiting and diarrhea. Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
