adults 1 fluid & electrolytes

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess

Dehydration Explanation: The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Rapid respiration Elevated blood pressure Subnormal temperature Low heart rate

Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Give medications that promote fluid retention. Teach client behaviors that decrease urination. Assess for dehydration. Limit sodium and water intake.

Limit sodium and water intake. Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.

A priority nursing intervention for a client with hypervolemia involves which of the following? Monitoring respiratory status for signs and symptoms of pulmonary complications. Establishing I.V. access with a large-bore catheter. Drawing a blood sample for typing and crossmatching. Encouraging the client to consume sodium-free fluids.

Monitoring respiratory status for signs and symptoms of pulmonary complications. Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? Calcium: 10 mg/dL Potassium: 5.8 mEq/L Sodium: 138 mEq/L Magnesium: 2 mEq/L

Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Potassium level of 6 mEq/L Sodium level of 137 mEq/L Sodium level of 150 mEq/L Potassium level of 3.8 mEq/L

Sodium level of 150 mEq/L Explanation: Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Bradycardia Shortness of breath Distended neck veins Decreased blood pressure Crackles in the lung fields

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

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

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

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l (145 mmol/L). Should the nurse start salt tablets when caring for this client? Yes, along with the hypotonic IV. No, start with the sodium chloride IV. No, sodium intake should be restricted. Yes, this will correct the sodium deficit.

No, sodium intake should be restricted. Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 52-year-old with diarrhea A 72-year-old with a total knee repair A 65-year-old with a myocardial infarction A 7-year-old with a fracture tibia

A 52-year-old with diarrhea Explanation: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

Hypokalemia can cause which symptom to occur? Production of concentrated urine Decreased sensitivity to digitalis Excessive thirst Increased release of insulin

Excessive thirst Explanation: If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia.

A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings? Clammy skin, blood pressure 86/46, headache Headache, blood pressure 90/54, dry skin Blood pressure 188/120, nausea, vomiting Confusion, respiratory rate 8 breaths/min, dry skin

Clammy skin, blood pressure 86/46, headache Explanation: Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? hydrochlorothiazide metolazone furosemide spironolactone

furosemide Explanation: Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absoprtion.

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows:sodium 147 mEq/L (147 mmol/L)potassium 3.0 mEq/L (3.0 mmol/L)chloride 112 mEq/L (112 mmol/L)Magnesium 2.3 mg/dL (0.95 mmol/L)What laboratory value is consistent with the client's symptoms? potassium 3.0 mEq/L (3.0 mmol/L) magnesium 2.3 mg/dL (0.95 mmol/L) sodium 147 mEq/L (147 mmol/L) chloride 112 mEq/L (112 mmol/L)

potassium 3.0 mEq/L (3.0 mmol/L) Explanation: Potassium is the major intracellular electrolyte. Hypokalemia (potassium levels lower than 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias. The sodium, chloride, and magnesium levels listed are within normal limits.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "I will be sure to buy frozen vegetables when I grocery shop." "A good breakfast for me will include milk and a couple of bananas." "I can use laxatives and enemas but only once a week." "I will take a potassium supplement daily as prescribed."

"I can use laxatives and enemas but only once a week." Explanation: The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? "I need to check to see whether my cola beverage has potassium in it." "I will not salt my food; instead I'll use salt substitute." "I'll drink cranberry juice with my breakfast instead of coffee." "Bananas have a lot of potassium in them; I'll stop buying them."

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

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "It is normal to be a little confused following surgery, and it is safe not to urinate at night." "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids."

"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." Explanation: In elderly clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

Which solution is hypotonic? 0.9% NaCl Lactated Ringer solution 5% NaCl 0.45% NaCl

0.45% NaCl Explanation: Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution is hypertonic.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? 0.9% sodium chloride 5% glucose in water 0.45% sodium chloride 5% glucose in normal saline solution

0.45% sodium chloride Explanation: Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

Which is considered an isotonic solution? 0.45% normal saline Dextran in normal saline 0.9% normal saline 3% NaCl

0.9% normal saline Explanation: An isotonic solution is 0.9% normal saline (NaCl). Dextran in normal saline is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.

A patient who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue and a body temperature of 99.3°F. The urine specific gravity is 1.020. What is the most likely serum sodium value for this patient? 140 mEq/L 155 mEq/L 110 mEq/L 165 mEq/L

155 mEq/L Explanation: In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/ kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.

A client weighing 160 pounds (72.6 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss? 156 lbs (70.8 kg) 159 lbs (72.1 kg) 158 lbs (71.7 kg) 157 lbs (71.2 kg)

158 lbs (71.7 kg) Explanation: A loss of 0.5 kg, or 1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2 lbs (0.9 kg), bringing the client's weight to 158 lbs (71.7 kg).

The nurse knows which is the normal serum value for potassium? 3.5-5.0 mEq/L (3.5-5.0 mmol/L). 135-145 mEq/L (135-145 mmol/L). 8.5-10.5 mg/dL (2.13-2.63 mmol/L). 96-106 mEq/L (96-106 mmol/L).

3.5-5.0 mEq/L (3.5-5.0 mmol/L). Explanation: Serum potassium must be within normal limits to prevent cardiac dysrrhythmia. Normal serum sodium is 135-145 mEq/L (3.5-5.0 mmol/L). Normal serum chloride is 96-106 mEq/L (96-106 mmol/L). Normal total serum calcium is 8.5-10.5 mg/dL (2.13-2.63 mmol/L).

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. An elevated hematocrit level Low protein level in the urine A low urine specific gravity Absence of ketones in urine Electrolyte imbalance

An elevated hematocrit level Electrolyte imbalance Explanation: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Cool and pale skin Dark, concentrated urine Distended jugular veins Crackles in the lung fields

Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L). The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving? Increase the rate of the intravenous lactated Ringer solution. Change the lactated Ringer solution to 2.5% dextrose. Change the lactated Ringer solution to 3% saline. Discontinue the intravenous lactated Ringer solution.

Discontinue the intravenous lactated Ringer solution. Explanation: The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Drink caffeinated beverages to retain fluid. Drink carbonated beverages to help balance fluid volume. Drink at least eight glasses of fluid each day.

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Low white blood count Elevated hematocrit level Low urine specific gravity Abnormal potassium level

Elevated hematocrit level Explanation: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? Fluid volume status Potassium balance Calcium balance Nutritional status

Fluid volume status Explanation: A specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? Decreased hemoglobin Decreased serum potassium Increased platelets Increased serum sodium

Increased serum sodium Explanation: Increased serum sodium causes increased osmotic pressure, increased thirst, and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Polyuria Tetanic contractions Jugular vein distention Weight loss

Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Jugular vein distention Polyuria Tetanic contractions Weight loss

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

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Potassium Calcium Magnesium Phosphorus

Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Endocrine system Musculoskeletal system Gastrointestinal system Neurological system

Neurological system Explanation: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.

A client has questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? When the client is severely dehydrated resulting in neurologic signs and symptoms When a client's fluid volume deficit is due to acute or chronic kidney disease Never, because it rapidly enters red blood cells, causing them to rupture. When the client is in excess of calcium and/or magnesium ions

Never, because it rapidly enters red blood cells, causing them to rupture. Explanation: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? No, sodium intake should be restricted. No, start with the sodium chloride IV. Yes, along with the hypotonic IV. Yes, this will correct the sodium deficit.

No, sodium intake should be restricted. Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Administer the ordered furosemide 60 mg po. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema. Administer the ordered potassium 40 mg IV push. Monitor intake and output every shift.

Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Explanation: Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output.

The calcium concentration in the blood is regulated by which mechanism? Thyroid hormone (TH) Androgens Parathyroid hormone (PTH) Adrenal gland

Parathyroid hormone (PTH) Explanation: The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Elevating the head of the client's bed to 90 degrees Administering vasopressin as ordered Restricting sodium intake to 1 gm/day

Restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Increased urine output Tachycardia Bradycardia Vasodilation

Tachycardia Explanation: Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? A frozen, packaged low-fat dinner with a side salad Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad Tomato juice, low-fat cottage cheese, and three slices of bacon

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Explanation: Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW d. 3% NS c. 0.45% NS

b. 5% DW Explanation: A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 130 mEq/L (130 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is consistent with the client's symptoms? chloride 94 mEq/L (94 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) sodium 137 mEq/L (137 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L)

calcium 12.9 mg/dL (3.2 mmol/L) Explanation: More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion. The listed sodium, potassium, and chloride levels are within normal limits.

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? hypercalcemia hyperkalemia hypervolemia dehydration

dehydration Explanation: Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.

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

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

Early signs of hypervolemia include increased breathing effort and weight gain. thirst. moist breath sounds. a decrease in blood pressure.

increased breathing effort and weight gain. Explanation: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? anasarca third-spacing pitting edema hypovolemia

third-spacing Explanation: Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anascara is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid.

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? tingling sensation in the fingers polyuria flank pain hypertension

tingling sensation in the fingers Explanation: Tingling or numbess in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? intake and output edema vital signs weight

weight Explanation: Daily weight provides the ability to monitor fluid status. A 2-lb (0.9 kg) weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.