Prep U: Chapter 27
Which question about fluid balance would be appropriate when conducting a health history for a client?
"Describe your usual urination habits."
The nursing instructor hears students discussing fluid and electrolyte balance. Which of the following statements would warrant further instruction?
"The kidneys store and release antidiuretic hormone to increase water retention."
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
+1
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first?
A newly admitted 88-year-old with a two-day history of vomiting and loose stools
A nurse is caring for a post-operative client who complains that he feels dizzy when getting up from bed. The nurse suspects extracellular fluid (ECF) volume deficit and assesses the effect that position change has on pulse rate and blood pressure. Which of the following would the nurse interpret as indicative of ECF volume deficit?
An increase in pulse rate of more than 20 beats per minute
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
An infant age 4 months
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?
Apricots
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" Which of the following would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
A client's PaCO2 is abnormal on an ABG report. Which of is the most likely be the medical diagnosis?
COPD
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours.
A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?
Decreased blood volume and intracellular dehydration
A nurse is administering a potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation?
Dilute it
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client 's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?
ECF deficient fluid volume
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
Fluid volume excess and acidosis
A nurse suspects a patient with electrolyte imbalances is experiencing hypomagnesemia. What nursing assessment finding may indicate hypomagnesemia?
Hyperactive deep tendon reflexes (DTRs)
The nurse is caring for John, who was admitted after falling from a ladder. John has a brain injury which is causing the pressure inside his skull to increase, which may result in a lack of circulation and possible death to his brain cells. Considering this information, which of the following intravenous solutions would be most appropriate for John?
Hypertonic
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?
Hyponatremia
The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid?
Hypotonic fluid
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?
Increased respiratory rate
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by which of the following?
Increasing ventilation through the lungs
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?
Infants have more total body fluid and ECF than adults.
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will you be looking?
Muscle cramping and tetany
A patient's most recent arterial blood gases indicate a pH of 7.52 with decreased PaCO and decreased HCO-. What is this patient experiencing?
Respiratory alkalosis with compensation
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?
Risk for Deficient Fluid Volume
A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?
The nurse recognizes these symptoms of hypokalemia.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
arterial-blood gas
The nurse is administering albumin to a patient to promote movement of fluid into the capillaries. What is the "pulling force" of fluid by use of a protein such as albumin known as?
colloid osmotic pressure
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. Which of the following would the nurse expect to find when assessing the client's gastrointestinal system?
diarrhea
By what route do oxygen and carbon dioxide exchange in the lung?
diffusion
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?
fluid volume excess
A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed?
increased depth and rate
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which of the following fluid compartments?
intracellular
A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat?
oranges, bananas, broccoli
Who is responsible for maintaining the proper flow rate of the IV solution?
the nurse
