Med Surg PrepU- Fluid and Electrolyte balance, Fluid and Electrolyte Review

A physician prescribes 150 mg of ibuprofen for a toddler whose temperature did not decrease after receiving acetaminophen. The oral suspension available contains 100 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place.

7.5 To perform this calculation, set up the following equation: 150 mg/X = 100 mg/5 mL X = 7.5 mL.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.

Distended neck veins Crackles in the lung fields Shortness of breath Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.

A client is to receive 1,000 mL of lactated Ringer's (LR) over 10 hours. The drip factor is 15 drops (gtts)/mL. How many gtts per minute should the client receive?

• 25 gtts/min To convert mL/h to gtts/min: 1,000 mL/h x 15 gtts/mL x 1 h/60 min = 25 gtts/min.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

• urine output greater than 30 ml/hour Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

A 13-month-old client is admitted to the pediatric unit with gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal dehydration. Which nursing interventions are correct to prevent further dehydration? Select all that apply.

• Give clear liquids in small amounts. • Encourage the child to eat non-salty soups and broth. • Monitor the intravenous (IV) solution per the physician's order. A child experiencing nausea and vomiting would not be able to tolerate a regular diet. The child should be given sips of clear liquids, and the diet should be advanced as tolerated. Non-salty soups and broths are appropriate clear liquids. Milk should not be given, because it can worsen the child's diarrhea. The nurse should monitor IV fluids, which are administered to maintain the fluid status and help to rehydrate the child. Solid foods may be withheld throughout the acute phase; however, clear fluids should be encouraged in small amounts (3 to 4 tablespoons [45 to 60 mL] every half hour).

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

• Serum sodium level of 124 mEq/L 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.

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

• Sodium Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

Which of the following is a factor affecting an increase in urine osmolality?

Syndrome of inappropriate antidiuretic hormone release (SIADH) Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN), 100 mg/dL, serum creatinine 6.5 mg/dL, potassium 6.1 mEq/L, and lethargy. Which of the following is the priority nursing assessment?

• Cardiac rhythm Manifestations of CKD result from loss of the renal regulatory functions of filtering metabolic waste products and maintaining fluid and electrolyte balance. These laboratory results indicate CKD, but the most significant result is the potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum creatinine level ranges from 0.7 to 1.5 mg/dL.

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?

• Deficient fluid volume related to nausea and vomiting Deficient fluid volume related to nausea and vomiting takes highest priority because vomiting causes loss of fluids and electrolytes. No evidence suggests that the client has a fluid volume excess or ineffective cardiopulmonary tissue perfusion. Although the client does have imbalanced nutrition, this nursing diagnosis isn't a high priority at this time.

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?

• Diabetes insipidus 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.

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?

• Elevate the head of the bed to 30 to 45 degrees and reassess JVD 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 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. 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.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

• Excess fluid volume A client with renal failure can't eliminate sufficient fluid. This issue increases his risk of fluid overload and consequent respiratory and electrolyte problems. This client shows signs of excess fluid volume and is acutely ill. Urine retention may cause renal failure but is a less urgent concern than fluid imbalance. Electrolyte disturbance and Toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they aren't life-threatening.

The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?

• Fluid volume deficit Initial treatment should focus on the child's fluid and electrolyte balance and rehydrating the child. Subsequent measures to identify the possible microorganisms responsible and resting the gastrointestinal tract should also be addressed.

A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider?

• Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes. Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child's tolerance level. Simple sugars aren't a good source of hydration because of their osmotic effects. The nurse shouldn't wait 72 hours before taking action if a child is vomiting or has diarrhea. Toddlers can become dehydrated in a short time. A physician should see a child whose vomiting or diarrhea persists for 24 to 36 hours. Wet diapers are a good source of determining hydration; however, three wet diapers each day isn't a normal finding for toddlers. A hydrated toddler should have six to eight wet diapers per day.

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

• Hypertonic The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.

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 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 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?

• Increase daily fluid intake to at least 2 to 3 L. 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 serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?

• K+, 3.2; Cl-, 92; Na+, 120 Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. For these reasons, persistent vomiting can lead to hypokalemia, hypochloremia, and hyponatremia. The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are consistent with persistent vomiting. Each of the other options includes at least two serum electrolyte levels that are normal or high. These are not consistent with persistent vomiting.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

• Loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

• Low serum potassium level Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

• Metabolic alkalosis Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

• Muscle weakness and a weak, irregular pulse The serum potassium level of 3.2 mEq/L is an indication of hypokalemia. Only 2% of the potassium is found in the extracellular fluid, and it is primarily responsible for neuromuscular activity. Muscle weakness and heart irregularities would be evident with hypokalemia. Potassium deficit is caused by diarrhea. Tetany and tremors are associated with hypokalemia. Headaches and poor tissue turgor are associated with hyponatremia.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect?

• Number of wet diapers the in the last 24 hours A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. Number of stools may indicate diarrhea, but is less accurate in determining dehydration status. Number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and cap refill are more essential with a cardiac issue.

A nurse is caring for a 12-month-old infant with dehydration with resulting metabolic acidosis. The infant exhibits lethargy and poor skin turgor. Which of the following actions by the nurse takes priority?

• Obtaining a patent intravenous site The nurse's priority is to correct the dehydration by first obtaining a patent IV line for the administration of fluids and medications. Obtaining a blood sample for a white blood count and blood cultures and a urine sample will not change the outcome of the need for fluid and electrolyte correction.

The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess?

• Potassium level Vomiting, diarrhea, and NG suction are all common causes of hypokalemia.

A nurse is conducting health teaching with the parents of a child who has chronic diarrhea. The parents state that they have treated the child with home remedies, including herbal medicine. What is the most important information for the nurse to communicate to the parents regarding the use of home remedies?

• Share home remedy information with healthcare professionals. The most important information related to home herbal remedies is to make sure the parents are sharing this information with medical professionals. This is to ensure that the child does not receive two different forms of the same drug or drugs that may counteract the home remedy.

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which of the following would be included in a focused assessment?

• Signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss. A focused assessment would usually indicate increased bowel sounds associated with the cramping. Kidney suppression would not be associated with diarrhea lasting 2 days; it might present with severe dehydration and hypovolemic shock. There is a loss of bicarbonate through the diarrhea, which would result in metabolic acidosis, not alkalosis.

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse?

• Slow the intravenous rate and notify the physician. The increased volume from too-rapid fluid infusion will result in increased heart rate. There can be pulmonary edema with resultant increase in the respiratory rate to compensate. Jugular vein distension also indicates fluid overload. The rate of the intravenous fluids would need to be slowed, and the physician notified for new orders. Repeating the vital signs in 1 hour is incorrect because the client is already in distress. Lowering the head of the bed will increase the symptoms. Although oxygen may help, the priority is to decrease fluid volume.

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?

• Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose. 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 primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

• Stop the magnesium sulfate infusion. Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

• The client may be developing hypocalcemia. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of fingers and lips, and irritability. Meperidine may cause tremors or seizures as an adverse effect, but not muscle twitching. Muscle twitching is not caused by a nutritional deficit, nor does it indicate that the client needs a muscle relaxant.

A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?

• The client may require fluid and electrolyte replacement. Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.

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 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.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess:

• Trousseau's sign. This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?

• Urine output of 250 ml/24 hours ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

Which client is most likely to exhibit dehydration?

• an 8-month-old infant with persistent diarrhea for 24 hours Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and replacement fluids given. Healthy young adults have a higher tolerance for fluid loss and can quickly regain their fluid balance when fluids are lost through normal activity. The 75-year-old woman who was placed on NPO status before surgery is not likely to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions present that would precipitate fluid loss. The 60-year-old client with pneumonia and a fever should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is actively losing fluids through diarrhea.

Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

• auscultation of moist crackles An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?

• canned tomato juice 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 with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:

• cardiac arrest. Hyperkalemia places the client at risk for serious cardiac arrhythmias and cardiac arrest. Therefore, the nurse should carefully monitor the client for cardiac arrhythmias and be prepared to treat cardiac arrest when caring for a client with hyperkalemia. Increased potassium levels do not result in pulmonary edema, circulatory collapse, or hemorrhage.

The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome?

• decreased abdominal girth Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?

• decreased deep tendon reflexes 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.

Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?

• evaluating laboratory results for electrolytes IV solutions are prescribed based upon the fluid and electrolyte status of the client, so laboratory results should be monitored first. Safety recommendations are for standard premixed solutions. If solutions are not premixed, additives are completed by the pharmacy, not at the bedside. Potassium chloride is never given by IV push because this could be fatal. Administration guidelines require no more than 10 mEq (10 mmol/L) of potassium chloride be infused per hour on a general medical-surgical unit. An infusion device or pump is required for safe administration.

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?

• hyperkalemia Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance?

• hypernatremia Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures.

For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate:

• hypocalcemia. A client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal of or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren't present with hypercalcemia, hypokalemia, or hyperkalemia.

A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?

• hypokalemia Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting.

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for:

• hypokalemia. Loss of electrolytes from the gastrointestinal tract through vomiting, diarrhea, or nasogastric suction is a common cause of potassium loss, resulting in hypokalemia. Hypermagnesemia does not result from excessive loss of gastrointestinal fluids. Common causes of hypernatremia are water loss (as in diabetes insipidus or osmotic diuresis) and excessive sodium intake. Common causes of hypocalcemia include chronic renal failure, elevated phosphorus concentration, and primary hypoparathyroidism.

The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to:

• maintain fluid and electrolyte balance. The primary purpose of fluid replacement therapy for a client receiving gastric suction is to maintain fluid and electrolyte balance. Gastric suctioning interrupts the normal intake and absorption of fluids. Fluids and electrolytes are lost through the nasogastric drainage. IV fluids are required to replace the fluid and electrolyte loss. Since the client with an NG tube is also NPO, IV fluids will help prevent a fluid volume deficit from developing and will help maintain an adequate urine output. IV fluids are not used for this client to promote urination. Postoperatively, IV fluids are not typically used to facilitate osmotic diuresis. The administration of IV fluids may help balance the client's fluid intake and output, but the primary reason for administering fluids is to maintain fluid and electrolyte balance.

What finding should the nurse interpret as indicating that a child is receiving too much IV fluid too rapidly?

• moist crackles in the lung fields Moist crackles in the lung fields are an indication that fluid is accumulating in the lungs due to overhydration or too rapid delivery of fluids. Abdominal girth would not provide information about the child's fluid status. Protein in the urine may be due to a disease process not fluid status. Dark amber-colored urine would be an indication of underhydration.

Which symptom is an early indication that the client's serum potassium level is below normal?

• muscle weakness in the legs An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby. If hypokalemia progresses, respiratory muscles become involved and the client becomes apneic. Hypokalemia also causes ECG changes. Diarrhea is common in hyperkalemia. Sticky mucous membranes are common in hypernatremia. Tingling in the fingers and around the mouth occurs in hypocalcemia.

The sudden onset of which sign indicates a potentially serious complication for the client receiving an IV infusion?

• noisy respirations A serious complication of IV therapy is fluid overload. Noisy respirations can develop as a result of pulmonary congestion. Additional symptoms of fluid overload include dyspnea, crackles, hypertension, bounding pulse, and distended neck veins.

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:

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

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

• urine output of 30 mL/h Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.

• 250 2,000 mL/8 hours = 250 mL/hour

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?

• Normal saline solution as this is considered an isotonic solution 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 is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

• Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. 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.

The nurse is completing an initial assessment of a client admitted with chronic renal failure. Which would support the nursing diagnosis of fluid volume excess?

• Weight gain When the kidneys are not functioning, fluid volume excess presents. Signs of fluid excess are indicated by weight gain. Cool, dry skin; dry cough; and poor tissue turgor do not indicate fluid volume excess.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:

• blood pressure. 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.

The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. The nurse should report which finding to the health care provider (HCP)?

• urine output, 20 mL/h The decrease in urine output may reflect inadequate renal perfusion and should be reported immediately. Urine output of 30 mL/h or greater is considered acceptable. A slight elevation in temperature is expected after surgery. Peristalsis returns gradually, usually the second or third day after surgery. Bowel sounds will be absent until then. A small amount of serosanguineous drainage is to be expected.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Cerebral edema Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply.

Extravasation Hematoma Phlebitis Local complications of intravenous therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings?

Hypokalemia Potassium is the major intracellular electrolyte. Hypokalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

Which could be a potential cause of respiratory acidosis?

Hypoventilation Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH Reason: Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Jugular vein distention SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution 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.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and Kidneys The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?

hypokalemia Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.

The physician prescribes furosemide, 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb (6.4 kg). The oral solution contains 10 mg/mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.

• 1.3 Perform the following calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg X = 12.8 mg. Then set up the following proportion to determine the volume of medication to administer: 10 mg/mL = 12.8 mg/X X = 1.3 mL.

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?

• A sunken fontanel In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?

• Fluid intake should be about equal to the urine output. Normally, fluid intake is about equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

• Hypertonic A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic.

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

• Maintain a low-sodium diet. 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.

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 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.

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 alkalosis and hypokalemia 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.

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 After treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cells, causing hypokalemia. Therefore, potassium, along with the replacement fluids, is generally supplied. Potassium will not correct hypercapnea or flaccid paralysis. Cardiac dysrhythmias are a result of excess or deficit of potassium.

A client received magnesuim sulfate during labor. Which condition should the nurse anticipate as a potenial problem in the neonate?

• Respiratory depression Magnesium sulfate crosses the placenta. Potenial neonatal effects include respiratory depression, hypotonia, and bradycardia. The serum blood glucose isn't affected by magnesium sulfate. The neonate would likely be floppy, not jittery.

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?

• decreased ability to detect thirst 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?

• decreased serum sodium level 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 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. 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.

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

• hypokalemia Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L). The physician orders an I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq (20 mmol/L) of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to:

• meet physiologic needs. A child with vomiting and diarrhea loses excessive fluids and electrolytes, which must be replaced. Fluid and electrolyte replacement can't eliminate the cause of diarrhea, which may result from various factors. Administration of I.V. fluids that contain glucose (such as dextrose 5% in water) may induce, not prevent, hyperglycemia. Fluid and electrolyte replacement has no effect on stool elimination.

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. 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.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if:

• the serum potassium is 4.0 mEq/L (4.0 mmol/L). 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.

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?

"I will not salt my food; instead I'll use salt substitute." The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

The physician orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. The nurse should run the I.V. infusion at a rate of:

• 32 drops/minute. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:

A client weighing 160 pounds diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the patient loses 1,000 mL of fluid in 24 hours. Choose the weight that would be consistent with this amount of fluid loss.

158 Ibs A loss of 0.5 kg or 1 lb represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2 lbs (160 - 2 = 158 lbs).

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

• Hypokalemia A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

Furosemide 40 mg intravenous push (IVP) is prescribed. Furosemide 10 mg/mL is available. How many mL should the nurse should administer? Record your answer using a whole number.

• 4 Desired amount (D) divided by what is available (H), times quantity (Q) = amount to administer. D = 40 mg divided by H = 10 mg/mL; equals 40 divided by 10 = 4 mL.

When a client's ventilation is impaired, the body retains which substance?

Carbon dioxide When ventilation is impaired, the body retains carbon dioxide (CO2) because the carbonic acid level increases in the blood. Sodium bicarbonate is used to treat acidosis. Nitrous oxide, which has analgesic and anesthetic properties, commonly is administered before minor surgical procedures. When ventilation is impaired, the body doesn't retain oxygen. Instead, the tissues use oxygen and CO2 results.

A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/hour. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number.

• 25 To administer IV fluids at 100 mL/hour using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula: 100 mL/60 min × 15 gtts/1 mL = 25 gtt/min.

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value?

• "The BUN is elevated because your daughter is dehydrated." A client with anorexia nervosa will have an elevated BUN as a result of dehydration. A decreased BUN isn't associated with anorexia nervosa or with hypothyroidism. An elevated BUN isn't associated with hypoglycemia. A client with anorexia nervosa will have hyperglycemia related to a drastic decrease in nutritional intake. A decreased BUN value isn't associated with anorexia nervosa or with hypertension. A client with anorexia nervosa will have hypotension caused by impaired cardiac functioning.

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:

• 21 gtt/minute The nurse can use various methods to calculate the gtts/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.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

With which condition should the nurse expect that a decrease in serum osmolality will occur?

Kidneys Failure Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance?

Metabolic acidosis The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur?

Metabolic alkalosis Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.

A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During the physical examination, the nurse detects tenting. This finding supports a nursing diagnosis of:

• Deficient fluid volume related to dehydration. Tenting, which indicates decreased skin turgor, is normal only in elderly clients and results from decreased elastin content. However, in other adults and in children, tenting more commonly results from dehydration. This finding supports a nursing diagnosis of Deficient fluid volume related to dehydration. The other diagnoses are inappropriate because capillary fragility, altered tissue perfusion, and hypoxia rarely are associated with gastroenteritis.

A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number.

• 83 1,000 mL/12 hours = 83 mL/hour

A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the highest priority for the nurse?

• Administering IV fluids with electrolyte correction Severe vomiting and diarrhea cause fluid and electrolyte imbalances. Water loss can be greater than the sodium loss, causing dangerously high serum sodium levels. Other electrolyte imbalances can occur that may require replacement.

A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored?

• Blood urea nitrogen (BUN) BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

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 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 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals:

• worsening dyspnea. Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.

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

• Metabolic alkalosis 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 client has been taking furosemide for 2 days. The nurse should assess the client for:.

• a decreased potassium level. 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 nurse is caring for a 19-month-old infant with dehydration and weight loss. The infant's mother states that her son doesn't like to eat and that she hates to make him eat. The nurse should:

• request that a dietitian talk with the parent about infants and nutrition. The infant's mother needs assistance in maintaining her child's diet. Requesting that a dietitian speak with the mother about the child's diet is within the nurse's scope of practice. The nurse shouldn't call the local police or the social worker on duty because there is no evidence of child abuse or neglect. Many infants are picky eaters and choose not to eat or drink. The nurse doesn't need to call the physician to have the infant put in isolation. Isolation isn't indicated for dehydration.

Which indicates hypovolemic shock in a client who has had a 15% blood loss?

• systolic blood pressure less than 90 mm Hg 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 nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which electrolyte imbalance is a common cause of digoxin toxicity?

• hypokalemia Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

A primary health care provider prescribes regular insulin 10 units intravenously (IV) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

• Hyperkalemia Administering regular insulin IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination does not help reverse the effects of hypercalcemia, hypernatremia, or hypermagnesemia.

The nurse is teaching the client with an ileal conduit how to prevent a urinary tract infection. Which measure would be most effective?

• Maintain a daily fluid intake of 2,000 to 3,000 mL. Maintaining a fluid intake of 2,000 to 3,000 mL/day is likely to be most effective in preventing urinary tract infection. A high fluid intake results in high urine output, which prevents urinary stasis and bacterial growth. Avoiding people with respiratory tract infections will not prevent urinary tract infections. Clean, not sterile, technique is used to change the appliance. An ileal conduit stoma is not irrigated.

The nurse is caring for a client following a motor vehicle incident with head trauma suspected of diabetes insipidus. Which nursing intervention is appropriate?

• Measure and record urinary output. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. Blood sugar has nothing to do with diabetes insipidus.

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

• Numbness • Tingling • Muscle twitching and spasms When the parathyroid gland is removed, the body may not produce enough parathyroid hormone to regulate calcium and phosphorous levels. The symptoms of hypocalcemia include peripheral numbness, tingling, and muscle spasms. Aphasia is not a symptom of calcium depletion. Polyuria and polydipsia are symptoms of diabetes mellitus.

Which indicates that the client with diabetes insipidus understands how to manage care?

• The client will maintain normal fluid and electrolyte balance. 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 recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

• increasing fluid intake to prevent dehydration. Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?

• poor skin turgor 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.

The nurse is administering an IV potassium chloride supplement to a client who has heart failure. When developing a plan of care for this client, the nurse should consider that:

• the administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L. When administering IV potassium chloride, the administration should not exceed 10 or a concentration of 40 via a peripheral line. These limits are extremely important to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq (mmol/L) of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because they affect the kidney's ability to excrete excess potassium. Metabolic alkalosis can cause potassium to shift into the cells, thus decreasing the client's serum potassium levels. Hypokalemia can lead to digoxin toxicity.