Ch 11 - Fluid & Electrolyte Balance
A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first?
Respirations Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus respiratory status should be assessed first in any patient who might have hypokalemia.
As adults age, which common physiologic change is likely to alter their hydration status?
Decreased muscle mass
When treating a patient for hyponatremia, which type of drug must be altered to decrease sodium loss?
Diruetics
A patient with cerebral edema was prescribed a hyperosmotic intravenous (IV) solution. What is the purpose of this intervention?
Pull excessive water from the interstitial volume to reduce edema
What is a consequence of fluid overload?
Pulmonary edema Pulmonary edema may occur due to accumulation of fluid in the air spaces of lungs due to fluid retention.
A patient with heart failure is hospitalized with shortness of breath and lower extremity pitting edema. Furosemide 5 mg intravenous (IV) push is ordered. Which patient outcome indicates that the medication is effective?
increased urine output
The nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them?
"Offer fluids that meet the patient's dietary restrictions on a regular schedule.
The nurse is performing discharge dietary teaching for a patient with hyperkalemia. Which statement does the nurse include in the teaching?
"You may eat apples, strawberries, and peaches. The patient with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches.
A patient with severe hypokalemia is prescribed parenteral administration of potassium. How does the nurse administer potassium to the patient?
1 mEq of potassium to 10 mL intravenous solution
Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration?
2-year-old woman appearing to be at least 20 pounds overweight The thirst mechanism is less sensitive in older adults, making them more at risk for dehydration. Women of any age have less total body water than men of similar sizes and ages, because men have more muscle mass than women and women have more body fat. (Muscle cells contain mostly water, and fat cells have little water.) In addition, the 72-year-old woman is overweight, with an increased percentage of body fat compared to lean body mass, especially skeletal muscle. An obese person has less total water than a lean person of the same weight because fat cells contain almost no water.
How much fluid should a healthy adult consume each day to maintain adequate urine output?
2.3 L or 2300mL
Which total urine output for the previous day would place a patient at risk for accumulating waste products?
500mL
A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. The provider has ordered fall precautions. Which interventions does the nurse implement as part of fall precautions? Select all that apply.
Activate the bed alarm. Orient the patient frequently. Assess for orthostatic hypotension Place the bed in the lowest position with brakes locked.
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure, and hypertension. His current medications are digoxin, chlorothiazide, and potassium supplements. He tells a nurse that he has had flul-ike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the patient's intravenous therapy (IV) and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication?
Added to an IV, not to exceed 20 mEq/hr
A patient with severe vomiting and diarrhea was brought to the emergency department in a semiconscious condition. What interventions does the nurse implement to stabilize the patient? Select all that apply.
Administer replacement fluids intravenously. Administer drugs to correct the cause of dehydration
An older adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. What are the immediate nursing interventions to stabilize the patient? Select all that apply.
Administering diuretics Administering 0.9% saline Administering 5% dextrose in 0.45% sodium chloride
Which will the nurse take into consideration when assessing a patient's fluid balance? Select all that apply.
Age Gender Body fat When assessing fluid balance, the nurse must consider the patient's age, gender, and body fat, as these three items can impact fluid balance within the body.
Which assessment findings will indicate the need for continuation of prescribed fluid replacement therapy in a patient diagnosed with dehydration? Select all that apply
Pulse pressure of 28 mm Hg Urine output of 400 mL per day Pulse pressure below 40 mm Hg and urine output below 500 mL are abnormal and require continuation of the fluid replacement therapy.
Which nursing action is recommended when providing care to a patient with hypokalemia?
Question the continued administration of bumetanide Bumetanide is a loop diuretic, which contributes to potassium loss
A patient who recently experienced an anterior neck injury reports frequent and painful muscle spasms in the calf during sleep. Which condition does the nurse suspect in the patient?
Body temperature of 40°C for more than 8 hrs
Which drug therapy might be used to manage symptoms of hypocalcemia?
Calcium chloride
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The patient with which electrolyte laboratory value is assigned to the LPN/LVN?
Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this patient to an LPN/LVN.
Hyponatremia most affects the cells of which body systems? Select all that apply.
Cerebral Cardiovascular Neuromuscular
Hyponatremia most affects the cells of which body systems? Select all that apply.
Cerebral Cardiovascular Neuromuscular The cells of the cerebral, cardiovascular, and neuromuscular systems are most affected by hyponatremia. The cells of the endocrine and respiratory systems are not as affected.
What is the most appropriate nursing intervention in a patient with fluid overload and edema to prevent skin breakdown on pressure areas?
Changing position ever 2 hours
Which mucous membrane assessments can the nurse use to evaluate a patient for dehydration? Select all that apply.
Color, Turgor, and Moisture
A patient with diabetes mellitus who is prescribed diuretic medication reports giddiness and a dry mouth when in dry climates. After assessing the vital signs, the patient is diagnosed as having mild dehydration. Which is the best nursing intervention
Consume small amounts of sugar-free fluids hourly
The nurse is admitting a 78-year-old patient with severe diarrhea in the emergency department. Which assessment findings indicate that the patient may be dehydrated? Select all that apply.
Dizziness Temp of 99.4 Newly reported confusion Postural hypotension causing dizziness may occur with dehydration. Because of decreased perfusion to the brain, confusion is common in older adults. Low-grade fever is a common result of dehydration. With dehydration, neck veins are flat, not distended; peripheral pulses are weak, not bounding.
A patient develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?
Elevates the head of the bed Elevating the head of the bed will ease breathing for the patient, so it should be done first.
What is fluid overload or overhydration?
Fluid intake is greater than body's fluid needs Fluid overload or overhydration is an excess of body fluid. It is a condition in which fluid intake or retention is greater than the body's fluid needs.
What is the reason for relative dehydration?
Fluid shift from plasma to interstitial space
A patient is admitted to the intensive care unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which treatments does the nurse anticipate for this patient?
Furosemide (Lasix) Tolvaptan (Samsca) Conivaptan (Vaprisol)
Which condition could be evident in laboratory reports of a hypervolemic patient?
Hemodilution
The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?
Hourly deep tendon reflexes (DTRs)
A patient is brought to the emergency department with symptoms of diarrhea, chest discomfort, and paresthesia. The patient has a heart rate of 60 beats per minute. The electrocardiogram (ECG) of the patient shows missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. Which laboratory finding would be consistent with the patient's condition?
HyperKalemia Laboratory data confirms hyperkalemia if serum potassium levels are above 5.0 mEq/L. Hyperkalemia clinically manifests with cardiovascular changes such as bradycardia, hypotension, and ECG changes that include missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. A neuromuscular change associated with hyperkalemia is numbness around the mouth, or paresthesia. Intestinal changes include frequent and watery bowel movements.
The primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient?
Hyperkalemia
A patient reports painful muscle spasms in the lower legs at rest, a tingling sensation in the hands and lips, and abdominal cramping and diarrhea. The nurse reviews the patient's laboratory results for the presence of which disorder?
Hypocalcemia
A patient who recently experienced an anterior neck injury reports frequent and painful muscle spasms in the calf during sleep. Which condition does the nurse suspect in the patient?
Hypocalcemia
Which condition is assessed using Trousseau's and Chvostek's signs?
Hypocalcemia
Which electrolyte imbalance should be anticipated and monitored in a patient with hyperphosphatemia?
Hypocalcemia
Which age-related change of the kidney increases an older adult patient's risk for dehydration?
Increased water loss
The nurse is providing care for a patient who has hyperkalemia. Which disease process documented in the patient's medical record is the cause for this electrolyte imbalance?
Renal failure
A patient who is suffering from chronic fluid overload asks the nurse to suggest necessary dietary changes. What dietary changes suggested by the nurse apart from restricting fluid intake would be effective to minimize fluid overload?
Intake of 2 to 4 g/day of sodium
What is the function of aldosterone in the body?
It promotes reabsorption of water and sodium
Which output source would the nurse exclude from the total output from the previous shift?
Lung vaporization
Which laboratory value requires a priority response by the nurse to notify the primary health care provider? Sodium 133 mEq/L Calcium 9.0 mg/dL Potassium 5.0 mEq/L Magnesium 4.2 mEq/L
Magnesium 4.2 mEq/L A magnesium level of 4.2 is markedly elevated (normal 1.3-2.1 mEq/L). Manifestations are not usually apparent until levels exceed 4 mEq/L. Patients with severe hypermagnesemia are in danger of cardiac arrest, so a level of 4.2 mEq/L requires prompt attention.
The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit. Which lab result is severely abnormal?
Magnesium 6.2 A magnesium level of 6.2 mEq/L is greatly elevated. Patients with severe hypermagnesemia are in grave danger of cardiac arrest.
Which assessment finding is consistent with fluid overload?
Moist crackles in the lungs upon auscultation
A patient is being discharged from the hospital before completely resolving the problem of fluid overload. What instructions should the nurse give to the caretaker in order to avoid the recurrence of fluid overload? Select all that apply.
Monitor fluid intake Monitor the sodium intake Monitor the weight gain of the pt
A patient is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first?
Obtaining a pulse oximetry reading Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the patient's respiratory status should be assessed first.
Which newly written prescription does the nurse administer first?
Oral potassium chloride (KCl) to a patient whose serum potassium is 3 mEq/L Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the patient with hypokalemia.
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling?
Orthostatic blood pressure changes
What route of fluid loss is nonmeasurable?
Perspiration Fluids lost by perspiration and vaporization through the lungs are nonmeasurable.
Which written order does the nurse clarify with the provider when caring for a patient with a serum sodium level of 149 mEq/L?
Placing the patient on nothing by mouth (NPO) status.
A patient is brought to the emergency department with symptoms of diarrhea, chest discomfort, and paresthesia. The patient has a heart rate of 60 beats per minute. The electrocardiogram (ECG) of the patient shows missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. Which laboratory finding would be consistent with the patient's condition?
Serum potassium levels above 5.0 mEq/L
Which conditions may contribute to a patient's insensible water loss? Select all that apply.
Severe diarrhea Respiratory rate of 36/min Got, dry home environment Insensible water loss occurs through the skin, lungs, and stool. Factors that contribute are a hot, dry environment, fever, tachypnea (a respiratory rate higher than 20 breaths per minute), and severe diarrhea.
Which are common symptoms of hypokalemia? Select all that apply
Shallow respirations Weak, thready pulse Musculoskeletal weakness
Which electrolyte excess results in irritability and severe cellular dehydration?
Sodium
The nurse finds that a patient has dry skin, a heart rate of 115 beats per minute, a respiratory rate of 28 breaths per minute, and weight loss of 1 pound in 1 day. What does the nurse infer about the patient's condition?
The patient is suffering from dehydration The best indicator of fluid loss or fluid overload is daily weight.
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?
Transferring the patient from the bed to a stretcher using a lift sheet Transferring patients is a nursing skill that is included in UAP education and scope of practice.
Which intervention does the nurse include in caring for a patient with generalized edema who is receiving a loop diuretic?
Turning the pt every 2 hours
The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a patient who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply.
Urinary output Pulse rate and quality Pulse rate and quality as well as urinary output best reflect improving volume status with rehydration therapy.
Which assessment finding is likely in a patient reporting diarrhea and vomiting with an elevated body temperature of 103° F for 2 days who is brought to the emergency department?
Urine output of 350 mL/day Normal urine output should be not less than 500 mL/day. A urine output of 350 mL/day indicates dehydration.
What is the reason for isotonic dehydration?
Water and sodium are lost from the body in proportionately equal amounts.
The nurse is providing care to a patient diagnosed with dehydration. The patient asks, "Why is my urine so dark?" Which response by the nurse is most appropriate?
Your kidneys are concentrating your urine to maintain fluid balance. In response to dehydration, the kidneys will concentrate the urine to decrease further fluid loss. The dark color of the urine is not due to a medication or a urinary tract infection. The urine is not dilute due to the intravenous fluids.