Fluid and Electrolyte Balance
A nurse is teaching a client about his newly prescribed diuretic and how it affects his fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte? Select all that apply. a) Phosphate b) Calcium c) Potassium d) Sodium e) Magnesium f) Chloride
Answer, Sodium, Chloride, Potassium, Magnesium *Only focus on Sodium and Potassium* Rationale: Diuretics are prescribed to increase the excretion of sodium, chloride, and water in clients with high blood pressure or with chronic heart, renal, or liver problems. At times, the medications may remove too much ECF from the body, resulting in a deficit. Diuretics, except for the potassium-sparing diuretics, also promote the excretion of potassium and magnesium from the body, increasing the risk of electrolyte deficits as well. Imbalances of calcium and phosphate are usually not associated with diuretic therapy.
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of: a) hyponatremia. b) fluid volume excess. c) hypovolemia. d) metabolic acidosis.
Answer: Fluid volume excess Rationale: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis and hyponatremia are not directly associated with the development of peripheral edema.
Hypovolemia (Water deficit) Nursing Interventions:
* rehydrate to increase fluid intake * oral care * monitor I/Os * vital signs * daily weights
Calcium (Ca2+)
* transmission of nerve impulses, heart and muscle contractions, blood clotting, formation of teeth and bone * needs vitamin D for absorption * normal ranges (8.6-10.2)
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? a) 3,000 b) 500 c) 1,000 d) 3,750
Answer: 3,000 Rationale: Fluid intake and output should approximately equal the same volume in order to maintain proper fluid balance.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? a) Dairy products b) Processed meat c) Bread products d) Apricots
Answer: Apricots Rationale: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? a) Fruit consumption b) Parenteral fluids c) Sips of water d) Frozen fluids
Answer: Fruit consumption Rationale: Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.
Potassium (K+)
* Major intracellular electrolyte * transmit nerve impulses to muscles, control skeletal, and smooth muscles * normal ranges (3.5-5) * increase level means poor kidney function (renal failure) * decrease levels with excessive urination, diarrhea, vomiting * always think of cardiac problems when thinking about potassium
Hypervolemia (Excess Water) Nursing Interventions:
* Monitor I/Os * Diuretics * Vital signs * daily weights * skin care
Hypervolemia (Excess Water) Signs and Symptoms:
* Swollen, edema * increase blood pressure, small pulse * kidneys are unable to excrete urine * weight gain * jugular vein distension * breath sounds (crackle) * dyspnea * anxiety * decrease in hemoglobin and hematocrit levels
Older adult considerations
* body weight decreased * losses of subcutaneous tissue (don't use skin tugor test, instead use daily weights) * decrease in thirst mechanism; prone to dehydration * muscoloskeletal changes * mental status changes: confusion * incontience: unable to hold elimination * decrease tenal function
Sodium (Na+)
* major extracellular electrolyte * controls/regulate water balance * normal ranges (135-145) * determines whether water is retained excreted, or moved * Hyper = too much sodium, not enough water, dehydrates * Hypo = not enough sodium, too much water, overhydrated * always think of neurological problems when thinking about sodium
Hypovolemia (Water deficit) Signs and Symptoms:
* thin weight * dry, warm skin * cognitively confusion; disoriented * thirsty * rapid, thready pulse (tachycardia) * low/decrease BP * palpation/skin tugor; will have decrease resilience * muscle weakness * cramping
A client's intake and output is being measured and recorded each shift. The client has had the following intake: 3 oz apple juice 4 oz tea 5 oz pureed chicken 2 oz mashed potatoes 4 oz orange gelatin 2 oz vanilla ice cream
Answer: 390 Rationale: Intake measurements include all oral and parenteral fluids. Oral fluids include any liquids ingested or any foods that become liquid at room temperature. Gelatin and ice cream are examples of solid foods to include. Pureed foods is not considered fluid intake nor is mashed potatoes. Based on the measurements, the client consumed 13 oz of fluid. One ounce is equal to 30 ml, so 13 oz of fluid is equal to 390 mL
A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a) "Try to drink at least six to eight glasses of water each day." b) "Try to limit your fluid intake to one quart of water daily." c) "Limit sugar, salt, and alcohol in your diet." d) "Report side effects of medications you are taking, especially diarrhea." e) "Temporarily increase foods containing caffeine for their diuretic effect." f) "Weigh yourself daily and report any changes in your weight."
Answer: A, C, D, F Rationale: Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.
The nurse is caring for a client who was found after spending 2 days without food or water in the desert and was admitted through the emergency department. The client is severely dehydrated. What are reasons why the human body requires fluid? Select all that apply. a) helps maintain normal body temperature b) provides free hydrogen ions for cells c) acts as a solvent for electrolytes d) supplies glucose for energy e) facilitates cellular metabolism
Answer: A, C, E Rationale: Water in the body functions primarily to provide a medium for transporting nutrients to cells and wastes from cells; to provide a medium for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells throughout the body; to facilitate cellular metabolism and proper cellular chemical functioning; to act as a solvent for electrolytes and nonelectrolytes; to help maintain normal body temperature; to facilitate digestion and promote elimination; and to act as a tissue lubricant. Water does not, by itself, provide hydrogen or glucose.
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a) Encourage foods and fluids with high sodium content. b) Administer oral K supplements as ordered. c) Caution the patient about eating foods high in potassium content. d) Discuss calcium-losing aspects of nicotine and alcohol use.
Answer: Administer oral K supplements as ordered Rationale: Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? a) Use an alcohol-based mouthwash to moisten your mouth. b) Eat crackers and bread. c) Use regular gum and hard candy. d) Avoid salty or excessively sweet fluids
Answer: Avoid salty or excessively sweet fluids Rationale: The patient is showing signs of hypernaterium. To to decrease the sodium leaves, it is best to avoid salty or excessively sweet fluids. Hypernaterium = the acronym SALT. S: seizures, convulsions A: agitates, restless, irritable L: lips are dry, sticky mucous membrane T: thirsty, increase temperature
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which of the following statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. a) "The kidneys react to hypovolemia by stimulating fluid retention." b) "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." c) "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." d) The adrenal glands regulate blood volume by secreting aldosterone." e) "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids."
Answer: B, C, D, E Rationale: The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys. The other statements made by the students are correct.
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? a) Increased renal blood flow b) An increased sense of thirst c) Increase in nephrons in the kidneys d) Cardiac volume intolerance
Answer: Cardiac volume intolerance Rationale: The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.
A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the d) Trendelenburg position, and call for assistance. d) Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.
Answer: Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Rationale: The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? a) ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. b) Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. c) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. d) Bowel motility will be restored within 24 hours after beginning supplemental K+.
Answer: ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Rationale: If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: a) anaphylaxis. b) pulmonary embolism. c) allergic reaction. d) fluid overload.
Answer: Fluid overload Rationale: Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.
During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect? a) Hemolytic transfusion reaction: incompatibility of blood product b) Bacterial reaction: bacteria present in the blood c) Allergic reaction: allergy to transfused blood d) Febrile reaction: fever develops during infusion
Answer: Hemolytic transfusion reaction: incompatibility of blood product Rationale: The symptoms in answer C occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever, hypertension, dry, flushed skin, and abdominal pain occur.
The nurse is caring for John, who was admitted after falling from a ladder. John has a brain injury which is causing the pressure inside his skull to increase, which may result in a lack of circulation and possible death to his brain cells. Considering this information, which intravenous solution would be most appropriate for John? a) Plasma b) Hypotonic c) Isotonic d) Hypertonic
Answer: Hypertonic Rationale: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? a) Hypernatremia b) Hypokalemia c) Hypomagnesemia d) Hyperchloremia
Answer: Hypokalemia Rationale: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: a) hypothyroidism. b) hypokalemia. c) hypoglycemia. d) hypocalcemia.
Answer: Hypokalemia Rationale: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L a) Hypercalcemia b) Hypokalemia c) Hyponatremia d) Hypermagnesemia
Answer: Hypokalemia Rationale: ll of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L). Therefore the client has hypokalemia.
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? a) Hypovolemia b) Circulatory overload c) Hypervolemia d) Edema
Answer: Hypovolemia Rationale: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.
A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a) Explaining the mechanisms involved in transporting fluids to and from intracellular compartments b) Keeping fluids readily available for the patient c) Emphasizing the long-term outcome of increasing fluids when the patient returns home d) Planning to offer most daily fluids in the evening
Answer: Keeping fluids readily available for the patient Rationale:
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's: a) low potassium. b) low calcium. c) high sodium. d) high magnesium
Answer: Low calcium Rationale: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a) Recording intake and output b) Testing skin turgor c) Reviewing the complete blood count d) Measuring weight daily
Answer: Measuring weight daily Rationale: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will the nurse be looking? a) diminished cognitive ability and hypertension b) muscle weakness, fatigue, and constipation c) muscle cramping and tetany d) nausea, vomiting, and constipation
Answer: Muscle cramping and tetany Rationale: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.
When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease: a) Na+ b) K+ c) Mg++ d) Ca++
Answer: Na+ Rationale:Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium
Which patient has more extracellular fluid? a) Female school-age child b) Adolescent man c) Newborn d) Adult woman
Answer: Newborn Rationale: Because newborns body weight is 80% of water; they would have the most extracellular fluid
Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? a) Aldosterone enhances renal excretion of potassium. b) Normal serum potassium ranges from 5.5 to 6.0 mEq/L. c) A person loses approximately 30 mEq of potassium. d) Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells.
Answer: Normal serum potassium ranges from 5.5 to 6.0 mEq/L. Rationale: Normal serum potassium ranges from 3.5 to 5 mEq/L
Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium. a) Give the client a fluid containing additional sodium to enhance the feeling of fullness. b) Offer the client sugar-free candy to help combat thirst. c) Apply a petroleum-based gel to the client's lips to prevent cracking. d) Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation.
Answer: Offer the client sugar-free candy to help combat thirst. Rationale:To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking.
A client with renal disease requires IV fluids. It is important for the nurse to a) Catch the rate up when it falls behind b) Place the fluids on an electronic device c) Administer the fluids through the dialysis access d) Check the intravenous rate once a shift
Answer: Place the fluid on an electronic device Rationale: An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a) Chloride b) Potassium c) Sodium d) Phosphorous
Answer: Potassium Rationale: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.
The primary extracellular electrolytes are: a) magnesium, sulfate, and carbon. b) sodium, chloride, and bicarbonate. c) phosphorous, calcium, and phosphate. d) potassium, phosphate, and sulfate.
Answer: Sodium, chloride, and carbon Rationale: The other electrolytes are either intracellular electrolytes are mixed with intracellular electrolytes.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Volume expander b) Total parenteral nutrition c) Blood transfusion therapy d) Cellular hydration
Answer: Total Parenteral nutrition Rationale: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? a) Risk for Infection related to inadequate personal hygiene b) Constipation related to immobility c) Pain related to surgical incision d) Acute Confusion related to cerebral edema
Answer: acute confusion related to cerebral edema Rationale: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
Major control over the extracellular concentration of potassium within the human body is exerted by: a) albumin. b) progesterone. c) testosterone. d) aldosterone.
Answer: aldoesterone Rationale: Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? a) Apply a warm compress. b) Apply antiseptic and a dressing. c) Position the client on the left side. d) Elevate the client's head.
Answer: apply a warm compress Rationale: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) increased intracranial pressure (ICP) b) muscle weakness c) cardiac irregularities d) metabolic acidosis
Answer: cardiac irregularities Rationale: Remember that potassium deals with cardiac problems. Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? a) Increased sodium levels b) Decreased oxygen levels c) Decreased potassium levels d) Increased potassium levels
Answer: decreased potassium levels Rationale: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a) distended neck veins b) fingerprinting over sternum c) nausea and vomiting d) muscle twitching
Answer: distended neck veins Rationale: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a) distended neck veins b) nausea and vomiting c) muscle twitching d) fingerprinting over sternum
Answer: distended neck veins Rationale: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
Edema happens when there is which fluid volume imbalance? a) extracellular fluid volume deficit b) water deficit c) water excess d) extracellular fluid volume excess
Answer: extracellular fluid volume excess Rationale: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which of the following intravenous solutions needs to be administered to this client? a) Isotonic solution b) Colloid solution c) Hypotonic solution d) Hypertonic solution
Answer: hypotonic solution Rationale: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert? a) Muscle weakness, fatigue, and constipation b) Nausea, vomiting, and constipation c) Muscle weakness, fatigue, and dysrhythmias d) Diminished cognitive ability and hypertension
Answer: muscle weakness, fatigue, dysrhthmias Rationale: When thinking of kalemia/potassium, think of cardiac problems. With hypokalemia there is not enough potassium in the body. Think of the acronym EATK. E: EKG changes; dysrhythmias, irregular/weak pulse A: abdominal distension, nausea/vomitting, increase bowel sounds T: tingling K: konfusion/confusion
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? a) Sodium is regulated by the renin-angiotensin- aldosterone system. b) If sodium is low, it means that there is not enough water. c) Normal serum sodium levels range from 145 to 155 mEq/L. d) Sodium is not regulated by natriuretic peptides.
Answer: sodium is regulated by the renin-angiotensin-aldosterone system Rationale: Normal serum sodium levels range from 135 to 145 mEq/L. Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.
A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. What nursing interventions would the nurse perform? (Select all that apply.) a) Place patient on left side in Trendelenburg position b) Rub or massage the affected area. c) Stop the infusion immediately. d) Restart the IV at another site. e) Monitor vital signs and pulse oximetry. f) Apply warm compresses as ordered by the primary care provider.
Answer: stop the infusion immediately; restart the IV at another site; and apply warm compresses as order by the primary care provider. Rationale: If a thrombus (blood clot) forms at the site of the IV the infusion should be stopped immediately in order to prevent the thrombus from becoming dislodged. Application of a warm moist compress will help to dissolve the thrombus, and the IV should be restarted in another site. The area should not be rubbed or massaged because this could cause the thrombus to become an embolus. Monitoring vital signs and pulse oximetry would not be necessary, nor would placing the patient in the Trendelenburg position
