Fluid & Electrolyte EAQ
Which nursing action has a specific gerontological implication the burse must consider when the caring for an older adult receiving chemotherapy for cancer whose severe nausea and vomiting causes dehydration requiring hospital admission for rehydration therapy?
Assessment of skin turgor Administration of antiemetic medications Replacement of fluid and electrolytes
Which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure?
Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds
For which reason would the clients receive IV fluids rather than total parenteral nutrition for GI problems to lose weight?
Deficient carbohydrate intake
List the actions in the order in which they will be performed by the nurse transfusing packed red blood cells prescribed for a client with anemia?
Ensure that the client signed consent for the transfusion Determine the clients vital signs Verify that the number on the blood product, laboratory record, and client arm band match. Don a pair of clean gloves Initiate the transfusion slowly
Which symptom in a client receiving hydrochlorothiazide would cause a nurse to notify the healthcare provider?
Generalized weakness
Which adverse medication effect will a nurse monitor for in a client with cirrhosis of the liver who develops ascites and is prescribed spironolactone?
Hyperkalemia
In which category of fluids would the nurse classify an IV solution of 0.45% sodium chloride?
Hypotonic
Which statement by a client receiving diuretic therapy indicates that the teaching about potassium supplements is understood?
"I will report any abdominal distress."
Which IV solution would a nurse anticipate administering when caring for a client with a history of sever diarrhea for the past 3 days who is admitted for dehydration?
0.9% sodium chloride
Which IV fluid is hypertonic solution?
5% dextrose in normal saline
A client with renal failure receives prescriptions fro vitamin D and calcium supplements. The client asks the nurse, "Why do I need to take these?" The nurse explains that, with renal failure, which condition exists?
A decrease in the active metabolite of vitamin D in the body
Which client would the nurse see first among this group of clients?
A toddler with diarrhea
Which client problem would the nurse expect to decrease in response to the administration of serum albumin intravenously to a client with ascites?
Abdominal girth
Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the IV fluid infusion rate for an older client with an infection?
Acute confusion
Which indicator of client status is important for the nurse to assess in a client receiving total parenteral nutrition?
Blood glucose
Which physiological alteration will the nurse monitor to best determine the effectiveness of a clients hydrochlorothiazide therapy?
Blood pressure
Which findings are consistent with hypercalcemia after prolonged immobility?
Bone pain & depressed deep tendon reflexes
Which nursing assessment finding is consistent with fluid volume overload from high-flow IV fluid replacement therapy?
Bounding pulse Presence of dependent edema Neck vein distention in the upright position
Which clinical manifestations would the nurse expect when assessing a client with hypercalcemia?
Cardiac dysrhythmias Hypoactive bowel sounds
Which medication will the nurse expect the healthcare provider to prescribe to a client who had a thyroidectomy and is pale with spasms of the hand when taking the blood pressure?
Calcium
The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful?
Clear breath sounds
Which action will the nurse take when a client appears flushed and complains of palpations ten minutes after the start of IV vancomycin scheduled to infuse over 30 minutes?
Contact the primary health care provider to obtain a prescription to decrease the infusion rate.
Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation?
Coolness
Which pressure change does the burse determine to be the cause of edema for a client with albuminuria?
Decrease in plasma colloid oncotic pressure
Which concern when caring for a client prescribed furosemide 40 mg everyday in conjunction with digoxin would prompt the nurse to ask the healthcare provider about potassium supplements?
Digoxin toxicity occurs rapidly in the presence of hypokalemia
When evaluating fluid loss for a client with burns, which relationship between a clients burned body surface area and fluid loss would the nurse consider?
Directly proportional
Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess?
Distended jugular veins
Which mechanism of action is responsible for the therapeutic effects of mannitol prescribed for a client with a head injury?
Drawing fluid from the brain cells into the bloodstream
Which clinical finding is important for the nurse to monitor for when a total parenteral nutrition (TPN) solution is prescribed to infuse at 1 liter every 12 hours?
Intake and output Glucose levels Serum electrolytes
Which fluid shift will the burse take into consideration when assessing a client with type 1 diabetes who is experiencing a fluid imbalance?
Intracellular to intravascular as a result of hyperosmolarity
A client with a femoral fracture and osteomyelitis is immobilized for 3 weeks. Which rationale explains the nurse's plan to assess for the development of renal calculi?
Lack of weight-bearing activity promotes one demineralization
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of electrolyte deficiency?
Leg cramps Muscle weakness
Which antidiarrheal medication would the nurse anticipate administering to a client with severe diarrhea who is prescribed IV fluids, sodium bicarbonate, and an antidiarrheal?
Loperamide
Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is NPO is reporting severe thirst. The client's urinary output has been 60mL/h for the past 10 hours. No bowel sounds are heard. What action would the burse take?
Moisten the clients lips with a wet 4 x 4 gauze.
Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide?
Muscle weakness
Which action would be most important for the nurse take when caring for a client who started furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L?
Notify the primary health care provider of the critically low result
Which action is important when administering blood?
Obtain baseline vital signs before beginning blood administration
Which statement about administration of IV potassium would a nurse make to a client with a diagnosis of hypokalemia?
Oliguria is an indication for withholding IV potassium
Which principle explains how loop diuretics promote diuresis?
Osmosis
Which purpose of insulin would a nurse identify when caring for a client prescribed insulin added to a solution of 10% dextrose in water after an intravenous solution containing potassium inadvertently was infused too rapidly?
Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level.
Which reason would an IV infusion of 5% dextrose with 0,45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric tube set to low intermittent suction?
Prevent electrolyte imbalance
Which electrolyte deficiency triggers the secretion of renin?
Sodium
Which medication requires the nurse to monitor the client for signs of hyperkalemia?
Spironolactone
When the client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/min, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first?
Start infusion of normal saline 500 mL
Which nursing assessment would be performed by a nurse before administering IV insuion of potassium chloride 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours?
Urinary output Last serum potassium level Patency of the intravenous access
Which response would a nurse monitor for when a client is receiving furosemide to relieve edema?
Weight loss Excessive loss of potassium ions
Which purpose would potassium chloride added to the intravenous solution of a client with diabetic ketoacidosis serve?
Prevents hypokalemia
Which factor is likely cause of hyponatremia?
Profuse diaphoresis Rapid IV infusion 5% dextrose in water
When assessing a client during the postoperative period of receiving a kidney transplant, the client creatinine level is 3.1 mg/dL. Which action would the nurse take first in response to this laboratory report?
Assess for decreased urine output
Which action will the nurse take when a client with an IV infusion containing 40 mEq of potassium reports a stinging pain at the IV site?
Assess the IV site Verify that the potassium is adequately diluted and not infusing too rapidly
An older client is admitted to the hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about?
Potassium
Which disease increases the risk of hyperkalemia?
End - stage renal disease
Which clinical finding indicated that a client taking digoxin may have developed digoxin toxicity?
Cardiac dysrhythmias
Which clinical manifestations would the nurse expect the client who has chronic kidney disease with hypocalcemia to exhibit?
Fractures Osteomalacia Eye calcium deposits
Why would the nurse advise the client who take furosemide and digoxin for heat failure to drink a glass of orange juice everyday?
Maintaining potassium levels
