CHAPTER 11: ASSESSMENT AND CARE OF PATIENTS WITH FLUID AND ELECTROLYTE IMBALANCES

21. A client in the emergency department has potassium of 2.9 mEq/L. For which disease process or condition does the nurse assess the client? a. Diabetes mellitus b. Addison's disease c. Hyperaldosteronism d. Diabetes insipidus

ANS: C Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing excretion of potassium. Therefore, any client with this condition is at high risk for the development of hypokalemia.

19. A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion? a. Measuring intake and output every shift b. Slowing the IV flow rate to 50 mL/hr c. Administering diuretic agents as prescribed d. Placing the client in Trendelenburg position

ANS: C Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating fluid excess is the best way to reduce confusion. The other interventions would not relieve the client's confusion.

8. Which client is at greatest risk for dehydration? a. Younger adult client on bedrest b. Older adult client receiving hypotonic IV fluid c. Younger adult client receiving hypertonic IV fluid d. Older adult client with cognitive impairment

ANS: D Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

26. The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. Notify the physician. b. Assess for a blood return. c. Document the finding. d. Stop the IV infusion.

ANS: D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

41. A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the client's previous or concurrent health problems is most likely to increase the client's risk for hypophosphatemia? a. Chronic alcoholic pancreatitis b. 50-pack-year smoking history c. Prostate cancer history d. Heart surgery 8 years ago

ANS: A Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia.

33. A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? a. Client who is NPO receiving intravenous D5W b. Client taking a sulfonamide antibiotic c. Client taking ibuprofen (Motrin) d. Client taking digoxin (Lanoxin)

ANS: A D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.

3. Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L? a. Measuring urine output b. Measuring abdominal girth c. Monitoring fluid intake d. Comparing radial versus apical pulses

ANS: A The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client.

43. The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention? a. Document the finding and continue to assess. b. Assess respiratory status immediately. c. Request an order for a serum calcium level. d. Administer a rapid bolus of intravenous phosphorus.

ANS: B Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound hyperphosphatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might want to know the calcium level, but this is less important than ensuring that the client has adequate respiratory function. Simply documenting the finding without intervening would not help the client.

28. Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia? a. "I have been weighing myself every day." b. "When I am constipated, I drink more fluids." c. "When my muscles feel weak, I eat a banana." d. "I check my pulse each morning and each night."

ANS: B The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations of hypokalemia are decreased peristalsis and constipation.

35. A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned about? a. Na+ 146 mEq/L b. K+ 3.6 mEq/L c. Ca2+ 8.2 mg/dL d. Mg2+ 1.1 mEq/L

ANS: C A common cause of hypocalcemia is hypothyroidism. The calcium value is low, correlating with this condition. The sodium level is only slightly high, and hypothyroidism is not related to sodium imbalances. The potassium level is normal. The magnesium level is low, but hypothyroidism can cause hypermagnesemia.

18. A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? a. Has had diabetes mellitus for 12 years b. Uses sodium-containing antacids frequently c. Just received 3 units of packed red blood cells d. Had abdominal surgery and has a nasogastric tube

ANS: C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

38. A client has a history of hypocalcemia. What intervention is most important for the nurse to add to this client's care plan? a. Push fluids to 2 L/day. b. Strain all urine output. c. Use nonslip footwear to get out of bed. d. Position the client supine twice a day.

ANS: C Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Having the client wear nonslip footwear to get out of bed can help prevent falls. The other interventions would not provide safety for this client.

32. A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has new hyperactive bowel sounds in all four quadrants. What analysis about the client's condition is correct? a. The hyponatremia is worse. b. The hyponatremia is the same. c. The hyponatremia is better. d. The client now has hypernatremia.

ANS: A Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy, decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes. Bowel sounds that are more hyperactive than on a previous assessment indicate that the condition is worsening.

9. Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause? a. "Do you take diuretics, or 'water pills'?" b. "What do you normally eat over a day's time?" c. "How many bowel movements do you have daily?" d. "Have you been diagnosed with diabetes mellitus?"

ANS: A Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration.

12. What intervention is most important to teach the client about identifying the onset of dehydration? a. Measuring abdominal girth b. Converting ounces to milliliters c. Obtaining and charting daily weight d. Selecting food items with high water content

ANS: C Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home. The other options would not be useful for early detection of dehydration.

1. The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? a. Notify the physician. b. Examine dependent body areas. c. Assess turgor on the client's forehead. d. Document the finding and continue to monitor.

ANS: C Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

22. A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? a. 2.9 mEq/L b. 3.8 mEq/L c. 5.0 mEq/L d. 6.0 mEq/L

ANS: A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.

24. A client has been treated for hypokalemia. Which clinical manifestation or condition indicates that treatment has been effective? a. Having a bowel movement daily b. Gaining 2 lb during the past week c. Electrocardiogram (ECG) showing inverted T-waves d. Fasting blood glucose level of 106 mg/dL

ANS: A Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia.

25. The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.

MSC: Integrated Process: Nursing Process (Evaluation) 29. A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. Client with heart failure using a salt substitute b. Client taking a thiazide diuretic for hypertension c. Client taking nonsteroidal anti-inflammatory drugs daily d. Client with type 2 diabetes taking an oral antidiabetic agent

ANS: A Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.

2. The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication? a. Fluid retention b. Hyperkalemia c. Hyponatremia d. Hypervolemia

ANS: B Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.

31. A client is being discharged and needs to self-monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client? a. Weighing self daily at the same time of day b. Assessing radial pulse for a full minute twice a day c. Ensuring an oral intake of a least 3 L of fluids per day d. Restricting sodium as well as potassium intake

ANS: B As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate, rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe. Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction may not be necessary.

11. A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. "I must drink a quart of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 PM so I won't have to get up at night."

ANS: B Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

10. Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion? a. Measuring intake and output every four hours b. Applying oxygen by mask or nasal cannula c. Increasing the IV flow rate to 250 mL/hr d. Placing the client in a high Fowler's position

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

16. A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe? a. "I will weigh myself at the same time daily wearing the same clothes." b. "When I feel lightheaded, I will drink a full glass of water." c. "I will decrease my fluid intake if my urine output increases." d. "If I forget to take my diuretic, I will take twice the dose next time."

ANS: B Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild dehydration can cause these problems, and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse. The other options would not prevent mild dehydration from progressing.

23. A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? a. "Do you use sugar substitutes?" b. "Do you use diuretics or laxatives?" c. "Do you have any kidney disease?" d. "Have your bowel habits changed recently?"

ANS: B Misuse and overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia in older adults and in clients with eating disorders. Sugar substitutes and bowel habits are not related to hypokalemia. The client with kidney disease would be more likely to have hyperkalemia.

40. A client has a calcium level of 14 mg/dL. Which intervention is the priority? a. Forcing fluids to 2 L/day b. Placing the client on a cardiac monitor c. Assessing for Chvostek's sign every 2 hours d. Administering IV calcium chloride

ANS: B This client has hypercalcemia. Both forcing fluids and providing cardiac monitoring are appropriate, but because calcium has significant cardiac effects, placing the client on a cardiac monitor takes priority. Assessing for Chvostek's sign and administering calcium would be appropriate for the client with hypocalcemia.

44. Which ethnic groups should the nurse screen specifically for hypocalcemia? (Select all that apply.) a. Whites b. Blacks c. Asians d. Hispanics e. American Indians

ANS: B, C, E Lactose intolerance can lead to hypocalcemia because people avoid milk and dairy products to control their symptoms. Although anyone can have lactose intolerance, the incidence is between 75% and 90% among Asians, blacks, and American Indians.

14. Which action does the nurse teach a client to reduce the risk for dehydration? a. Restricting sodium intake to no greater than 4 g/day b. Maintaining an oral intake of at least 1500 mL/day c. Maintaining a daily oral intake approximately equal to daily fluid loss d. Avoiding the use of glycerin suppositories to manage constipation

ANS: C Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

42. A client with hypophosphatemia is being discharged. Which activity demonstrated by the client indicates that discharge teaching has been effective? a. Assessing radial pulse rate and rhythm b. Interspersing daily activities with periods of rest c. Selecting foods high in phosphorus and low in calcium d. Weighing himself or herself correctly at the same time each day

ANS: C Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase his or her ingestion of phosphorus and to decrease ingestion of calcium because phosphorus and calcium exist in the blood in a balanced inverse relationship.

6. A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the dietary regimen? a. 1% or 2% milk b. Grilled salmon c. Poached eggs d. Baked chicken

ANS: C Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in potassium.

36. When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. Which intervention is most appropriate? a. Administer isotonic intravenous fluids. b. Remove the blood pressure cuff and give oxygen. c. Ensure the client has a patent intravenous line. d. Document the finding in the client's chart.

ANS: C Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. Flexion contractions that occur during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign. Client safety is a priority, and the nurse must ensure that the client has a working intravenous line. Seizure precautions and decreasing environmental stimuli are also important.

17. During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. Which question by the nurse is best? a. "Do you usually drink liquids that are hot or cold?" b. "How much salt do you add to your food?" c. "What kinds of liquids do you usually drink?" d. "Do you drink fluids with meals or between meals?"

ANS: C It is just as important to determine the types of fluids ingested as the amount, because fluids vary widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine, can contribute to fluid and electrolyte imbalances.

27. A client has been taught to increase potassium in the diet. What dietary meal selection indicates to the nurse that teaching has been effective? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a cup of strawberries c. Sausage, one slice of whole wheat toast, cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, cup of sliced peaches, and coffee

ANS: C Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

34. The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client? a. "Weigh yourself every morning and every night." b. "Check your radial pulse twice a day." c. "Read food labels to determine sodium content." d. "Bake or grill the meat rather than frying it."

ANS: C Most prepackaged foods have high sodium content. Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia. Daily self-weighing and checking the pulse are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking increases the sodium content of a meal, not the method of cooking.

20. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority? a. Document the observation in the chart. b. Measure urine specific gravity and volume. c. Assess the pulse and blood pressure. d. Assess the client's deep tendon reflexes.

ANS: C Neck veins in the normovolemic person are full in the supine position and flat in the sitting position. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine whether overhydration is present. Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give information on volume status at all. The nurse needs to document the finding, but interventions should not end there.

30. A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day. Which response by the nurse is best? a. "You are correct. Fruit is usually very high in potassium." b. "If you cook the fruit first, that lowers the potassium." c. "Berries, cherries, apples, and peaches are low in potassium." d. "Fresh fruit is higher in potassium than dried fruit."

ANS: C Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

15. Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated? a. The client has dry, scaly skin on bilateral upper and lower extremities. b. The client states that he gets up three or more times during the night to urinate. c. The client states that he feels lightheaded when he gets out of bed or stands up. d. The nurse observes tenting on the back of the hand when testing skin turgor.

ANS: C Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.

4. Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances? a. "My skin is always so dry, especially here in the Southwest." b. "I often use a glycerin suppository for constipation." c. "I don't drink liquids after 5 PM so I don't have to get up at night." d. "In addition to coffee, I drink at least one glass of water with each meal."

ANS: C Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration.

7. Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance? a. "I am often cold and need to wear a sweater." b. "I seem to urinate more when I drink coffee." c. "In the summer, I feel thirsty more often." d. "My rings seem to be tighter this week."

ANS: D A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance.

5. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. Chinese take-out, including steamed rice b. A grilled cheese sandwich with tomato soup c. Slices of ham and cheese on whole grain crackers d. A chicken leg, one slice of bread with butter, and steamed carrots

ANS: D Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The Chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food—a category of foods often high in sodium.

13. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy? a. Tenting of skin on the back of the hand b. Increased urine osmolarity c. Weight loss of 10 pounds d. Pulse rate of 115 beats/min

ANS: D Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with dehydration, oxygen therapy is indicated.

37. A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L. Which intervention by the nurse is most appropriate? a. Prepare to administer IV potassium chloride. b. Ask the lab to redraw and rerun the tests. c. Document findings and continue to assess. d. Prepare to administer aluminum hydroxide.

ANS: D The client's calcium is low. Treatment for hypocalcemia includes calcium replacement, administering drugs that increase calcium absorption, and giving medications to control bothersome neuromuscular effects. Aluminum hydroxide helps the body absorb calcium. The client's potassium is normal, so giving potassium is not warranted. Asking the laboratory to rerun the tests will not help the client's problem, although if this seems contradictory to the client's condition, it might be an option. Documenting findings and performing ongoing assessments will not help the client's problem.

39. Which client is at greatest risk for developing hypercalcemia? a. Client taking furosemide (Lasix) for heart failure b. Client with long-standing osteoarthritis c. Woman who is pregnant with twins d. Client with hyperparathyroidism

ANS: D The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing calcium resorption from the bones. All these actions increase the serum calcium level.