Fluid and Electrolytes

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

Is the same solution as sodium chloride 0.9%, Is used to administer red blood cell transfusion, and Is used to treat hypotension due to fluid volume deficit.

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

Hypertension

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.

Hypokalemia, Hyponatremia, & Hypomagnesemia

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours & Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.

"Water and electrolytes are lost in approximately the same proportion as they exist in the body." & "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?

4+ pitting edema

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)?

A client with a history of alcoholism. The normal serum phosphorus level is 3.0 to 4.5 mg/dL (0.97-1.45 mmol/L) so a value of 2.0 mg/dL (0.64 mmol/L) is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply.

A client with pneumonia, A client with an ileostomy, & A client with a temperature of 102.5° F (39.2° C)

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider?

Administer hypertonic normal saline solution intravenously.

he nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client?

An increase in blood pressure

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Butter

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?

Calcitonin The normal serum calcium level is 9 to 10.5 mg/dL (2.2.5-2.75 mmol/L). This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

Generalized muscle weakness

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Increased specific gravity of the urine

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes. The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability, and hyperactive reflexes should be noted in a client with hypomagnesemia.

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions should the nurse initiate? Select all that apply.

Monitor the client for dysrhythmias, and Notify the primary health care provider (PHCP) of the laboratory results.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply.

Monitor vital signs, Monitor electrolyte levels., Monitor intake and output., Increase water intake orally., & Maintain sodium-reduced diet.

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply.

Monitor vital signs, monitor I&O, increase water intake orally, monitor electrolyte levels, provide sodium reduced diet.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?

Monitoring for decreased urine output and hypotension

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present?

Muscle weakness

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs.

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.

Positive Trousseau's sign & fine tremors noted in the hands.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

Presence of Chvostek's sign, presence of electrocardiogram abnormalities, presence of tingling in the fingertips and around the mouth, & presence of carpal spas, when blood pressure cuff is inflated above systolic blood pressure for a few minutes.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?

Prolonged bed rest

A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply.

Restrict fluid intake, & monitor electrolytes every 24 hours.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before eating. Etidronate is a bisphosphonate that works by slowing the resorption of bone and allowing new bone to be formed. Etidronate should be taken on an empty stomach 2 hours before meals. It should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron, or albumin.

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply.

Tetany, a positive Chvostek's sign, a positive Trousseau's sign.

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

The client consumed a total of 84 oz of fluid. Because 1 oz is equal to 30 mL, multiply 84 oz by 30 mL/oz. This yields 2520 mL

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

The client with a fast respiratory rate

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

The client with a ileostomy

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

The client with diabetes mellitus

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

The client with renal failure, & the client with chronic cirrhosis.

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply.

The client with renal failure, and the client with chronic congestive heart failure (CHF)

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic burn

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)?

U waves A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life-threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The primary health care provider (PHCP) prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse should utilize in performing this procedure. Select all that apply.

Utilize 30 mL of 0.9% normal saline for the irrigating solution. & After injecting the irrigating solution, pull back on the irrigation syringe.

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient?

Vitamin D

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

a client with a new burn injury, & a client diagnosed with acite kidney injury (AKI)

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.

flat neck veins, weakly palpable peripheral pulses, & heart rate of 104 beats per minute

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply.

severe burn injury, & untreated ketoacidosis

Which fluids are identified as insensible fluid losses? Select all that apply.

sweat & sputum

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply.

take the calcium carbonate with or just after meals, avoid foods such as beets spinach and bran in the diet, & take the medication with a full glass of water (8 oz/240 mL)

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.

use eggs as a source for protein, avoid eating lunch meats and bolognas, eat salads with cabbage and lettuce and avoid spinach.

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.

weakness in all extremities, confusion with garbled speech, and diarrhea with abdominal cramping.