Week 3 Fluid & electrolytes

To prevent septic shock in the hospitalized client, what should the nurse do?

Use aseptic technique during all invasive procedures

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply.

stridor, hypotension, dyspnea

The nurse is treating a client for leakage of a nonvesicant intravenous (IV) solution into the extravascular tissue. In what order should the nurse treat the infiltration?

To stop infiltration via central venous catheter, the first step of the nurse will involve stopping the infusion and removing the central venous catheter after the identification of the problem. The next step would involve application of sterile dressing if weeping from the tissue occurs. The third step for the nurse is to elevate the extremity. Next, the nurse should use warm or cold compresses according to the solution infiltrated and the organization policy. The fifth step is to insert the new catheter in the opposite extremity. The nurse should then obtain the study to determine the problem causing the infiltration. The final step of the procedure would involve the nurse rating the infiltration using the INS Infiltration Scale and document the procedure.

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which affirmative statement by the leader reflects an appropriate way to manage the stress?

"I will get enough sleep"

Which intravenous fluid should the nurse classify as hypertonic?

5% dextrose in normal saline

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

7.20

The nurse is caring for four clients. Which client would the nurse anticipate to have decreased skin turgor?

A -trauma B- severe dehydration C -anxiety D -chronic exzema The answer is B

What is a stressor?

A stressor is any stimuli that can produce tension and cause instability within the system.

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis?

An elevated pH, decreased PCO2

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply.

Bounding pulse pressure of dependent edema neck vein distention in the upright position

While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. What could be the reason for this condition?

Fluid and electrolyte imbalance results in pitting edema of the skin.

What is a nursing priority to prevent complications in clients with respiratory acidosis?

Monitoring breathing status

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client?

Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?

Take vital signs and notify the healthcare provider

While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion?

Urine output is 25mL per hr

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

blood lab results

The nurse is assessing four clients in a healthcare setting who have respiratory disorders. Which client's findings indicate possible metabolic acidosis? 1) Tachypnea 2) pursed-lip breathing 3) kussmaul respirations 4) abd paradox

client 3

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

diarrhea, weakness, dysrhythmias

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply.

dyspnea diaphoresis tachycardia

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?

electrolyte imbalance

Which first line medication would the nurse state is used to treat anaphylactic reactions?

epinephrine

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

parasthesias

Which hormone is released in response to low serum levels of calcium?

parathyroid hormone If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis.

What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.

pruritus wheezing bronchospasm

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

rapid pulse decreased urinary output

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

respiratory and urinary

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

restlessness

The nursing student is learning about submersion injuries. Which component of sea water does the nurse know to be responsible for making it hypertonic compared to body fluids?

salt

What is a clinical manifestation of hypernatremia in burns?

seizures