Unit 3: Fluid & Electrolyte balance

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate?

Urine output below 1 ml/hour Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed, not bulging, fontanels; excessive weight loss, not gain; decreased skin turgor; dry mucous membranes; and urine specific gravity above, not below, 1.012.

The nurse is caring for a client post thyroidectomy. As the nurse is taking the client's blood pressure, the client experiences a hand spasm and reports a hoarse voice and numbness around the mouth. Which nursing intervention is the priority?

Administer calcium gluconate I.V. This client is experiencing symptoms of hypocalcemia, a potential complication of a thyroidectomy. Although the other interventions may be appropriate for a post thyroidectomy client, they would not take priority over treating the hypocalcemia. The client could experience tetany, which may cause airway occlusion.

The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take?

Report the finding to the healthcare provider. Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid that should be immediately reported to the healthcare provider. Flushing the catheter could enhance the development of an abdominal infection. The client receiving peritoneal dialysis is in renal failure and most likely is on a fluid restriction. Additional fluids will not affect the presence of cloudy dialysate. It is beyond the nurse's scope of practice to instill an additional liter of dialysate. This action could alter the client's fluid and electrolyte balance.

During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is smaller now than when he was born. After teaching the mother about the infant's condition, which statement by the mother indicates that the teaching has been effective?

"It seems like the fluid is being reabsorbed." A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis. As fluid is being absorbed, scrotal size decreases. Elevation of the infant's bottom, massage, or keeping the infant quiet or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.

The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?

"There is not enough blood circulating to the kidneys." The best answer directly and simply explains to the parents that the kidneys are not getting perfused and therefore cannot function. Acute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic. Barbiturates are cleared renally and do commonly cause oliguria after an overdose. It is also common to require hemodialysis after a severe overdose.

A client in the intensive care unit has a critically low potassium level of 1.9 mEq/l (mmol/l). What would be the best way to replace this client's potassium?

Administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each The nurse should administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each to safely and rapidly correct this client's potassium. IV potassium will be absorbed more fully and more quickly than oral potassium replacement. Potassium should never be given as an IV bolus, as it can result in severe cardiac dysrhythmias and sudden death. Sodium polystyrene is used in the treatment of hyperkalemia, and lowers potassium levels, so it is not indicated for this client.

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply.

Change the feeding apparatus every 24 hours. Slow the administration rate. Use a diluted formula, gradually increasing the volume and concentration. Anticipate changing to a lactose-free formula. Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol-containing medications, the nurse should assess for other possible causes. Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea. Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping.

A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation?

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

An older adult client diagnosed with end-stage renal disease (ESRD) presents with fluid volume excess. Which nursing intervention is the priority?

Assess the client's lung sounds. All interventions are important for the client with fluid volume excess, but airway takes priority. Fluid volume excess can lead to fluid in the lungs causing respiratory difficulty.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

Observe the puncture site for swelling and bleeding. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

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

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:

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

A client is admitted with a 45% partial and full thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours?

urine output of less than 30 mL/hr It is critical that the nurse monitor the vital signs, hemodynamics and urine output during the emergent and resuscitative phase of the burn injury. The urine output of less than 30 mL/hr is an indication of hypovolemia in this client. The serum creatinine, serum potassium, and the oxygen saturation level are all within acceptable limits.

A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?

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

Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take?

Assess the client, call the physician, and then hang the ordered solution. This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error.

A client is scheduled for a creatinine clearance test. What should the nurse do to prepare the client?

Instruct the client about the need to collect urine for 24 hours. A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to increase fluids to 3,000 mL.

Blood administration is ordered for a client receiving chemotherapy. The nurse is obtaining all supplies needed for infusion. Which intravenous solution is obtained?

Normal saline solution (0.9 NS) is the only fluid compatible with blood administration. Lactated Ringers and dextrose solutions are not infused with blood products due to compatibility.

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.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is greater than 35 mL/h. A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

Which finding would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?

absence of tear formation The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration.

A multiparous client at 14 weeks' gestation has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for which value?

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

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority?

replacing fluid and electrolytes After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. The burns will be covered with sterile saline-soaked dressings until the client is stabilized. Positioning to promote normal anatomic alignment is not a priority at this time. There is no reason to suspect that blood flow to the lower extremities is affected, but it might occur if the injury causes circumferential constriction of the legs.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

intake and output After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

Which statement 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.

The return for a client receiving peritoneal dialysis is sluggish. Which action should the nurse take to facilitate the drainage of the fluid? Select all that apply.

Raise the head of the bed. Inspect the tubing for kinks. Turn the client from side to side. The care of the client receiving peritoneal dialysis includes monitoring the client during the draining phase of the treatment. If the fluid does not drain, the head of the bed can be raised or the client turned from side to side. Inspecting the tubing for kinks should also be done. The catheter is not irrigated and should never be pushed further into the peritoneal cavity.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. Which finding indicates the drug has been effective?

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 parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which is the best measure that the nurse should suggest?

Elevate the head of the child's bed. The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops, or limiting television, may be comforting but will not relieve the swelling.

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.

The nurse is caring for assigned clients on the oncology unit. Which client is at greatest risk for dehydration?

a 48-year-old having intracavitary radiation for cancer of the cervix Dehydration can occur from fluid loss secondary to tissue destruction at the site of irradiation at any age. After radical vulvectomy, wound drains are generally removed by postoperative day four or five, and don't create a significant risk of dehydration. Tamoxifen therapy is unrelated to dehydration. Although urine may escape through the vagina as a result of a vesicovaginal fistula, it does not cause the loss of an unusual amount of urine or other fluid.

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. How much fluid should the nurse tell the client to drink?

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

A preschool child presents with a history of vomiting and diarrhea for 2 days. Which assessment finding indicates that the child is in the late stages of shock?

bradycardia Bradycardia is a sign of late shock in a child. Cardiovascular dysfunction and impairment of cellular function lead to lowered perfusion pressures, increased precapillary arteriolar resistance, and venous capacitance. Decreased cardiac output occurs in late shock if the circulating volume isn't replaced. Sympathetic nervous innervation has limited compensation mechanisms if the volume isn't replaced. Tachycardia and irritability occur during the early phase of shock as compensatory mechanisms are implemented to increase cardiac output. Normal pediatric urine output is 1 to 2 ml/kg/hour; volumes less than this would indicate a decrease in renal perfusion and activation of the renin-angiotensin-aldosterone system to decrease water and sodium excretion.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?

low sodium A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

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 with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair in no evident distress with the legs in a dependent position. What should the nurse do first?

Elevate the client's legs on a foot stool Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs. It is not necessary for the client to return to bed. Support stockings are not indicated at this time. The client is not having difficulty breathing or other signs of distress; it is not necessary to take the vital signs.

The nurse is caring for a client with gestational trophoblastic disease (GTD) and is experiencing nausea and vomiting. Which interventions will the nurse include in the client's plan of care? Select all that apply.

Measure the fundal height. Monitor potassium levels. Administer ondansetron IV. GTD is a condition where tumors develop due to abnormal growth of cells inside the uterus. Clinical manifestations of GTD are very similar to those of a spontaneous abortion at about 12 weeks of pregnancy. The uterus measures larger than expected for pregnancy dates. Human chorionic gonadotropin levels are extremely high with GTD. Because of the high hCG levels, there is persistent, often severe nausea and vomiting. Ondansetron administration would be warranted for the vomiting. Electrolytes should be monitored for imbalances due to excessive vomiting. Fetal heart tones are absent, and there is an inability to palpate fetal parts. The client may experience brownish vaginal bleeding/spotting.

The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention?

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

A client exhibits pressured speech, a labile affect, euphoria, and hyperactivity. The client states, "I am the savior of the city." The family states that the client has hardly slept or eaten for days. Which client need is a priority in the nurse's plan of care?

physical The client's physical needs are a priority in the nurse's plan of care. The lack of fluid and caloric intake can lead to dehydration and cardiac collapse. The lack of sleep and rest can lead to exhaustion and death. Social, spiritual, and cultural needs are important client needs but not as important as the physical needs during an acute manic episode.

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet? The diet will:

prevent the development of ketosis. High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.

The client is in the oliguric phase of acute renal failure. For which risk should the nurse assess the client?

pulmonary edema Pulmonary edema can develop during the oliguric phase of acute renal failure because of decreased urine output and fluid retention. Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

A nurse is planning to administer a sodium polystyrene sulfonate enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema should include having the client

retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. Sodium polystyrene sulfonate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, sodium polystyrene sulfonate must be in contact with the bowel for at least 30 minutes. Sorbitol in the sodium polystyrene sulfonate enema causes diarrhea, which increases potassium loss and decreases the potential for sodium polystyrene sulfonate retention.

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

sodium Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc?

whole grains and meats Good sources of zinc include whole grains, meats, dairy products, and seafood. Fruits are good sources of vitamin C, and vegetables are a good source of many vitamins and minerals, but not zinc. Yeast is a good source of chromium, and legumes are a good source of copper, manganese, and molybdenum.

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.

The nurse is admitting a client who takes digoxin daily, reported seeing green halos around the lights, and has not wanted to eat breakfast. The laboratory report shows that serum sodium = 135 mEq/L, potassium = 3.2 mEq/L, magnesium = 2.5 mg/dL, and calcium = 10.2 mg/dL. Which nursing action is appropriate?

Administer a potassium supplement. This client is exhibiting signs of digoxin toxicity. Hypokalemia can increase the risk of digoxin toxicity and should be replaced, as the value is low. The sodium, magnesium, and calcium levels are all within normal limits and will not require intervention.

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 child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary. This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

A nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's laboratory report. Which finding indicates the need for intervention?

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

In which order should the nurse perform actions for a newborn receiving phototherapy who breastfeeds and presents with numerous loose watery stools, a decrease in urine output, and delayed capillary refill? All options must be used.

Insert a peripheral IV. Administer intravenous fluid bolus. Monitor strict intake and output. Educate family on the need for the infant to breastfeed frequently. One of the side effects of standard phototherapy is frequent, loose stools. Frequent, loose stools in an infant who is not breastfeeding sufficiently may cause dehydration. Decreased urinary output (UOP) and delayed capillary refill time may indicate dehydration and hypovolemia. The nurse should first start a peripheral IV. Then the nurse should administer IV fluids to rehydrate the infant. Monitoring the intake and output would be a form of evauation of the intervention of the IV fluid bolus. The last thing would be to educate the family about the need to feed frequently.

Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status?

Weigh the child. When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therfore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration.

To determine the I.V. drip rate, a nurse must know the drip factor, which is

the number of drops in one milliliter. The drip factor is the number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops, infused per hour.

The serum calcium level remains low in a client with hypoparathyroidism despite taking calcium supplements. What should the nurse ask the client related to these findings?

"Have you been taking vitamin D along with your calcium supplements?" A client with hypoparathyroidism has a decreased serum calcium level. Vitamin D enhances the absorption of calcium from the gastrointestinal tract and is the most important factor in improving the client's response to the calcium supplements. Even if the client increased dietary intake of calcium, without adequate vitamin D, this calcium would also be poorly absorbed. Thiazide diuretic therapy is linked to hypercalcemia, not hypocalcemia. Levothyroxine is given to treat hypothyroidism, not hypoparathyroidism.

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

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

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem?

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

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

A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F;(38.6°C;). The health care provider orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.

42 Calculate the flow rate using the formula below:(Total volume ordered) ÷(Number of hours) = Flow rate1,000 ml/8 hours = 125 ml/h125 ml/h X 1 h/60 min X 20 gtt/ml = 42 gtt/min

A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client?

Continue to maintain normal sodium intake while at home. Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased. Reduced sodium intake can lead to lithium toxicity. Nursing is not allowed to tell a client to adjust dosages of any drugs. A low-protein snack is not reflective or needed with this drug. Avoiding participation is not a therapeutic discussion.

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 client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What 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 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.

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

daily weight Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss.

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 with chronic obstructive pulmonary disease (COPD) and cor pulmonale had been prescribed a loop diuretic to treat peripheral edema. The nurse should monitor the client closely for what side effect of loop diuretic therapy that could worsen the client's hypercapnia?

hypokalemia All the options offered are potential side effects of loop diuretics, but only hypokalemia would directly pose the risk for increasing hypercapnia. When potassium levels are low, hydrogen ions shift into the intracellular space to liberate potassium into the extracellular space, and this contributes to metabolic alkalosis. To compensate for metabolic alkalosis, hypoventilation occurs in an attempt to retain carbon dioxide (the respiratory acid) and decrease the client's pH. Therefore, hypokalemia can worsen hypercapnia. Diuretics must be used with caution in clients with COPD. However, diuretics may be prescribed to treat peripheral edema that results from right ventricular dysfunction and the resulting systemic venous congestion.

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

increased serum amylase and lipase levels Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.

A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for?

muscle cramping Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.

A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority?

neurological status Clients experiencing dialysis for the first time often have confusion and even seizures and should be monitored closely. Vital signs and laboratory values are important assessments but do not specifically address dialysis disequilibrium syndrome. Pain in the flank region is not associated with dialysis.

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.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the mostimportant?

limiting fluid intake During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number.

12 First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg.Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms:0.2g/kg X 60 kg = 12 g.

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.

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?

Decrease foods high in potassium. Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.

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.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV 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.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate?

administering fluids to the client A client that receives an MRI with contrast will need to have fluids offered to facilitate kidney excretion of the contrast medium. There is no need to numb the client's throat for this procedure so the client's gag reflex should not be affected. There is no need to restrict the client's activity. The nurse should assess for the presence of metal implants prior to the MRI, not after.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea. The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance?

hyperkalemia Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.

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.

A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see?

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

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?

urine output at 0.5 mL/kg/hour Hourly urine output is often used as an indicator of effective fluid resuscitation, with about 0.5 mL/kg/hr for an adult considered adequate. Blood pressure changes are less reliable because significant hypotension does not develop until volume losses exceed 30%. Degree of orientation is not used as an indicator of adequate fluid resuscitation. If fluid resuscitation is adequate, the heart rate should be lower than 120 beats/minute or in the upper limits of normal for the client's age. However, the fear, anxiety, and pain that accompany burn injuries often increase the heart rate.

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 which electrolyte imbalance?

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.

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.

A client with colon cancer had a left hemicolectomy 3 weeks ago. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. The nurse should recommend to the health care provider which nutritional support to maintain the nutritional needs of the client?

total parenteral nutrition through a central catheter Total parenteral nutrition solutions supply the body with sufficient amounts of dextrose, amino acids, fats, vitamins, and minerals to meet metabolic needs. Clients who are unable to tolerate adequate quantities of foods and fluids and those who have had extensive bowel surgery may not be candidates for enteral feedings. The nurse would anticipate total parenteral nutrition via central catheter to promote wound healing. IV dextrose does not supply all the nutrients required to promote wound healing.

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.

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.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first?

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

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do?

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

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well.The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess?

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. This helps to determine the severity of the dehydration. Knowing the amount of fluid intake for 24 hours also helps assess the severity of the dehydration.If the baby is bottle fed the mother could give a specific amount.If breast fed the nurse would want to know how many times fed and for how long each time. Just knowing the number of feeds in 24 hours will not give accurate information to determine dehydration status. The 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 capillary refill assessment could indicate a perfusion problem.

The nurse is placing an intravenous (IV) catheter in a client who has a risk of impaired skin integrity due to dehydration. Place the steps in order for this procedure. All options must be used.

Palpate and select an appropriate vein. Cleanse client's skin with an antiseptic. Hold skin taut 1-2 inches below the site. Insert catheter and observe for blood return. Stabilize catheter and flush with saline. The client with fluid volume deficit due to dehydration would likely require an IV infusion of fluids as a treatment for this. Having an improved skin turgor with decreased dehydration will reduce the client's risk for impaired skin integrity. The client would have the catheter inserted and then flushed with saline once the appropriate vein was selected, the skin cleansed, and then the skin held taut below the site to stabilize the vein for IV insertion. Avoid touching the cleansed area to maintain this antisepsis.

A nurse is assessing a postsurgical client who has been receiving nasogastric suctioning for 3 days. The client is restless, confused, and has generalized edema. What is the nurse's best intervention?

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

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag.There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output?

The client's intake was 300 ml greater than output. The nurse should conclude that the client's intake was 300 ml greater than output. To reach this conclusion, the nurse should add the nasogastric drainage (300 ml) and the urinary output (200 ml) to get an output of 500 ml. The nurse should add the amount of IV fluid that infused during the shift (300 ml) to the amount of liquid consumed (500 ml) to get 800 ml for the client's intake. The nurse should then compare the output (500 ml) to the intake (800 ml) and determine that the intake was 300 ml greater than the output (800 ml - 500 ml = 300 ml).

The nurse is administering a high dose of furosemide to a client with nephrotic syndrome. What potential complication is the nurse most concerned with for the client?

electrolyte imbalance Furosemide is a loop diuretic that can cause the excretion of potassium, sodium, and magnesium. The client receiving high doses should be monitored for electrolyte imbalance. Visual disturbances and altered levels of consciousness are not common complications. The nurse expects clients to have increased urine output with furosemide.

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

initiating caloric and nutritional therapy as ordered A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.

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.

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 6-month-old infant is assessed to have 4% volume depletion related to a gastrointestinal illness. What intervention would the nurse recommend to the parents based on the infant's condition?

oral electrolyte replacement solutions, breast milk, or lactose-free formula A volume depletion of 4% is considered mild and is based on total body water loss calculated via percentage of weight loss. In cases of mild hypovolemia, oral electrolyte replacement solutions, breast milk, or lactose-free formula may be given in small amounts. IV fluids are usually reserved for clients experiencing moderate to severe hypovolemia, and the treatment requires hospitalization. Fruit juices, carbonated soft drinks, and the BRAT diet, all of which are high in carbohydrates and low in electrolytes, are not recommended.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting?

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

Which action 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.

A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals

peripheral edema. Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

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 who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence and has decreased the fluid intake because of the incontinence. What is the nurse's best response to the client?

"Drink eight glasses of water a day and urinate every 2 hours." Clients who have undergone TURP need to be instructed to maintain an adequate fluid intake despite urinary dribbling or incontinence. The client should be advised to drink at least eight glasses of water a day to dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours can help decrease incidents of incontinence. Teaching the client Kegel exercises is also beneficial for strengthening sphincter tone. The nurse should not encourage the client to decrease fluids. It is not necessarily true that a decreased intake will cause renal calculi. Threatening the client with a catheter is not beneficial, and it is not the treatment of choice for a client who is experiencing incontinence from TURP.

The nurse is flushing a peripheral intravenous access device. Place the steps in the order that the nurse should perform them. All options must be used.

Cleanse the end cap with an antimicrobial swab. Insert the saline flush syringe into the cap on the extension tubing. Pull back on saline flush syringe to aspirate the catheter for blood return. Instill saline solution over 1 minute. Remove the syringe and reclamp the extension tubing. Remove gloves and perform hand hygiene. The first step is to cleanse the end cap with an antimicrobial swab to reduce the risk for contamination. The second step is to insert the saline flush syringe into the cap on the extension tubing to prepare to flush the intravenous site. The third step is to pull back on saline flush syringe to aspirate the catheter for blood return to confirm patency. The fourth step is to instill saline solution over 1 minute to maintain patency of the peripheral intravenous access device site. The fifth step is to remove the syringe from the peripheral intravenous access device because the normal saline has been administered and reclamp the extension tubing to prevent air from entering the peripheral intravenous access device. The sixth step is to remove gloves and perform hand hygiene to reduce the risk of transmission of microorganisms.

Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol?

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

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV administration of lactated Ringer's The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

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.

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.

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?

daily weight The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

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.

A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug?

deep tendon reflexes Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. It is administered by IV; 4 g of a 50% solution in 250 mL D5W can be given as a bolus before the dose is titrated for continuous infusion. Magnesium sulfate is a general inhibitor of neurotransmission. As such, the two largest complications are the loss of deep tendon reflexes and the suppression of breathing. These are the priority assessments. If deep tendon reflexes decrease or the respiratory rate is 12 breaths/min or less, the medication should be discontinued and calcium gluconate administered. Magnesium sulfate is excreted entirely through the kidneys so intake and output should be evaluated hourly. The mother becomes very hot and flushed. This is a normal response. The fetal heart rate should not decrease from the drug.

On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription?

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

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

encouraging increased fluid intake During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) 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 I.V. 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.

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.

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has:

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

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time?

maintaining fluid and electrolyte balance Although monitoring vital signs frequently is important, for the first few days the primary concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury and are lost. These must be replaced. Once the child's fluid and electrolyte status has been addressed and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the child's pain can be initiated.

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information?

measuring the infant's weight Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available immediately, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant.

A client presents to the emergency department, reporting that they have 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.

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?

orthostatic blood pressure changes Fluid volume deficit is characterized by hypotension, tachycardia, increased body temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and potential fluid excess.

Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia?

potato, peas, and chicken Potatoes, peas, chicken, green vegetables, and fortified cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While pudding (made with fortified milk) and green vegetables contain some iron, the better diet has protein and iron from the chicken and potato.

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.

The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider?

protamine sulfate The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit.

During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?

serum creatinine level of 2.5 mg/dL (221 µmol/L) Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).

The nurse is recording information in the electronic health record for a client with dehydration who is at risk for skin breakdown. Which documentation demonstrates an area of insensible fluid loss for this client?

temperature The client with a fever of 102.5 Fahrenheit (39.2 Celsius) has insensible fluid loss through the skin and it can cause this through the lungs. However, the client's respiratory rate is within normal limits, as are the blood pressure and heart rate. Urine output and chest tube drainage represent sensible fluid loss, as these can be measured for determining fluid balance.

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 nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.