fluid and electrolyte homework quiz
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year old with a 2-day history of vomiting and loose stools
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?
distended neck veins
A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?
potassium level
The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?
"when i take my medication, I will eat a banana or take it with a glass of orange juice"
When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply.
-encourage fluid intake, unless contraindicated -record volume and character of the urine -maintain a closed urinary catheter system
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.
-intravenous therapy -electrolyte management - nutrition management
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?
3,000
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?
ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+ rich foods from diet
The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?
acute kidney injury
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?
anxiety
The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?
assess the client for dehydration
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorous
The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?
cardiac function
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities
A nurse is caring for a client who reports frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved?
clear fruit juices
A student has joined the marching band at high school and the band begins practicing outside during hot summer weather. Which health promotion guidance will the school nurse teach the student?
consume commercial oral rehydration drinks on practice days
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?
dehydration
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
dizziness when you change position can occur when fluid volume is decreased
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. Which action should the nurse take to help alleviate the edema?
elevate the legs
Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?
encourage fluid intake
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?
hypocalcemia
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 likely to find?
hypokalemia
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?
hypokalemia
An older adult client who takes diuretics for management of hypertension, informs the nurse that they take laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of what health problem?
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?
hypovolemia
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?
inadequate intake of liquid
An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?
include more bananas in the diet
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?
increased hydrostatic pressure
Which flow sheet provides the health care provider with information on an ongoing record of fluid loss?
intake and output graphic sheet
In which fluid compartment is most of the body's fluid is located?
intracellular
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of what abnormal value?
low calcium
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 (2.05 mmol/L). For what assessment findings will the nurse be looking?
muscle cramping and tetany
A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?
muscle weakness, fatigue, and arrythmias
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?
notify the health care provider for additional orders
A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?
place the client in a flat position with legs elevated 45 degrees
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
sacral area
The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?
skin turgor response 5 seconds
The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?
skin turgor response of 6 seconds
The primary extracellular electrolytes include which of the following?
sodium, chloride, and bicarbonate
The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?
strongly aromatic, dark amber
The nurse is reviewing a client's laboratory report. The report indicates the client's albumin level is 2.89 g/L (4.19 mmol/L). Which inference can the nurse make about the laboratory result?
the client has malnutrition
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?
the client is dehydrated
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
maintenance of cell size
The nurse is caring for a client with an identified nursing concern of fluid volume deficiency. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next?
modify the plan of care and interventions to meet the client's needs
A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?
monitor the client closely and promote fluid intake
The nurse is caring for a client who has an excess of antidiuretic hormone. What phenomenon will inform the nurse's choice of assessments?
the client renal system retain more water
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition
An older adult client has diminished thirst sensation. What teaching will the nurse give the client to help the client get enough fluid?
try drinking something savory like broth
The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?
verify the prescription for type of solution and amount of infusion
Which statement most accurately describes the process of osmosis?
water moves from an area of lower solute concentration to an area of higher solute concentration
