fluid and electrolyte nclex
plasma
20% of ECF located within the vascular system functions as a transport system to the cells contains glucose clotting factors hormones amino acids protein
The nurse is caring for a client diagnosed with dehydration. Because of this, ADH and aldosterone are released, causing sodium and water retention. Which of the following organs retain water as a result of dehydration?
ADH and aldosterone signal the kidneys to conserve water and sodium. ADH and aldosterone do not affect the lungs, heart, or brain.
The nurse is preparing a presentation on monitoring fluid and electrolytes for new nurses during orientation training. Which of the following should the nurse include as an example of a cation?
Calcium is a cation, an ion that produces a positive charge. Other cations are sodium, potassium, and magnesium. Chloride, bicarbonate, and sulfate are anions, ions that produce a negative charge.
Ms. Jones has hypomagnesemia, so your expected findings include decreased deep tendon reflexes, depressed neuromuscular activity, weakness, and lethargy.
Decreased deep tendon reflexes, depressed neuromuscular activity, weakness, and lethargy are indicative of hypermagnesemia. Ms. Jones has hypomagnesemia, so correct expected findings would include muscle twitching, tremors, apathy, and laryngeal stridor.
A client admitted with a diagnosis of nausea and vomiting has a high urine-specific gravity. Upon assessment of the client, the nurse finds that the client is experiencing orthostatic hypotension and has dry skin and flat neck veins. The nurse should determine that which should be the top priority client concern when planning care?
Fluid volume deficit can be caused by nausea and vomiting with assessment findings of orthostatic hypotension, dry skin, and flat neck veins, which will lead to the priority nursing diagnosis of deficient fluid volume. The client is demonstrating fluid volume deficit. Therefore, ineffective tissue perfusion, impaired gas exchange, and impaired skin integrity are not priority nursing diagnoses for this client.
A client is admitted with complaints of nausea, vomiting, and diarrhea. Which clinical manifestation should the nurse anticipate the client will exhibit?
If a client has complaints of nausea, vomiting, and diarrhea, a decrease in fluid volume would be expected because fluid loss has occurred through other routes. Other symptoms of fluid volume deficit, or dehydration, include dry mucous membranes and an increased heart rate. Body temperature may increase during episodes of dehydration.
The nurse implements nursing interventions that promote and maintain fluid and electrolyte balance as well as cardiac, renal, and respiratory function depending on the client's needs. Which is an appropriate intervention related to fluid and electrolyte balance?
Monitor daily weight and measure 24-hr intake and output
The nurse is caring for a client experiencing diarrhea. Which data assessed should indicate to the nurse that the client is experiencing fluid volume deficit?
Orthostatic hypotension, increased heart rate, and poor skin turgor are acute manifestations of fluid volume deficit. Increases in urine output and weight gain are not acute manifestations of fluid volume deficit.
The nurse has explained how solutions may move across a semipermeable membrane by diffusion, or osmosis to a nurse during orientation. Which of the following descriptions of osmosis should indicate to the nurse that the new nurse needs no further instruction about diffusion or osmosis?
Osmosis is the diffusion of water across the cell membrane from a lower concentration to a higher concentration.
The following activities of the kidney regulate body fluids and electrolyte balance:
Regulate the volume and osmolality of extracellular fluid (ECF) by regulating water and electrolyte excretion Control the reabsorption of water from plasma filtrate and the amount excreted as urine Filter 135 to 180 L of plasma per day, yielding 1.5 L of urine Maintain electrolyte balance by selective retention and excretion Play a role in the regulation of the aciddash-base balance by excreting hydrogen ions and retaining bicarbonate
Fluid volume deficit: Decreased QRS complex and inverted T wave
The ECG of a client with fluid volume deficit would indicate tachycardia with a normal rhythm.
The nurse is caring for a client diagnosed with congestive heart failure. The client has gained 6.6 pounds in one week. Using the measurement that 1 kg (2.2 lb.) of weight gain equals one liter of fluid gain, the nurse should estimate the client has gained how many liters of fluid?
Weight is an appropriate indicator of fluid loss or gain. 1 kg (2.2 lb) of weight gain or loss equals 1 L of fluid gain or loss. 6.6 lb would be equal to approximately 3 kg (6.6/2.2 = 3) and an estimated 3 L of fluid gain. Two liters would be a weight gain of approximately 4.4 lb. One liter would be a weight gain of approximately 2.2 lb, and 4 L would be a weight gain of approximately 8.8 lb.
Mrs. Suzuki has a serum sodium level of 165 mEq/L, specific gravity 1.045, and serum osmolality of 350 mOsm/kg. Dietary adjustment: Increase fluid intake.
You decide to restart Mrs. Suzuki's IV and encourage her to drink more water. Mrs. Suzuki's sodium, specific gravity, and serum osmolality are all high, which indicates hypernatremia. A more appropriate dietary adjustment would be restricting intake of sodium and caffeine.
transcellualar fluids
are found in the epitheial lined spaces of the body help to lubricate the potential spaces of the body
people who drink all their daily intake at one time
can get hyponaturium and can become life threatening
insensible fluid loss
can not be perceieved by the senses or measured water is loss through the skin by diffusion and evaporation evaporation from the respiratory tract during exhale estimated 800-900 milliliters a day for every 2 liters loss escalated w. fever increased breathing skin burns lactation vomitting diarrhea increased temps increased body heat
obligatory water loss
daily minimal amount of water loss from the body there are 2 cateogories sensible and insensible fluid loss
intersititual fluid
helps maintain homeostasis delivers nutrirnts and messages to cells and protect and cushions cells
intracelluar fluid has a _______ concentration of and a ______ concentrations of
high concentration of potassium and magnesium and phosphate low concentrations of chloride and calicuk MAJOR CATION - potassium major anion - phosphate and protein
anion
negative charge examples are phosphate chloride bicarbonate sulfate
vasopressin
produced in hypothalamus secreted by posterior pitutary gland lower vasopressinproduction results in less fluid going back into the blood causing an increase in urine
The nurse instructs a client with fluid volume excess about dietary choices. Which meal choice should indicate to the nurse that teaching was effective?
Rationale: A meal of egg whites, turkey bacon, oatmeal, and wheat toast is the best choice to decrease the amount of sodium, because turkey bacon has the least amount of sodium. Choices that contain sausage, bacon, or ham are high in sodium and should be avoided.
The nurse is assessing a client with fluid volume deficit. Which finding should the nurse identify that supports fluid volume deficit?
Rationale: Increased hematocrit is a finding consistent with fluid volume deficit. Edema and weight gain are consistent with fluid volume overload. Wheezes upon auscultation of the lungs is not related to fluid imbalances.
The nurse is working with a new nurse that is caring for a client diagnosed with fluid and electrolyte imbalance. Prior to beginning care, the nurse questions the new nurse about the movement of solutes across the cell membrane. Which statement would indicate to the nurse that the new nurse recognizes the importance of active transport?
Active transport is a process that requires metabolic energy to support the movement of solutes across the cell membrane (such as sodium and potassium) from a solution that is less concentrated to one that is more concentrated. The sodium-potassium pump is an active transport mechanism that moves sodium from the cells into the plasma and moves potassium from the plasma into the cells to maintain a higher concentration of sodium in the extracellular fluid (ECF) (plasma), and a higher concentration of potassium in the intracellular fluid (ICF) (cells). Osmosis is the diffusion of water across a cell membrane from a solution of lower concentration to a solution of higher concentration to equalize the water and solute. Filtration is the process by which fluid and solutes (such as nutrients) move together across the cell membrane. Hydrostatic pressure in the vessels is the pressure exerted by blood against the vessel walls.
The nurse is evaluating assigned clients for potential fluid and electrolyte imbalances. Which client should the nurse identify as one that will benefit least from the body's thirst mechanism regulator?
Any client with an altered level of consciousness or inability to respond to the thirst trigger will not benefit from the body's thirst mechanism regulator. Older clients are also vulnerable due to a decrease in the mechanism that occurs with aging. A diabetes diagnosis does not alter or decrease the benefits of the thirst mechanism. A client who is receiving intravenous (IV) therapy would continue to benefit from the thirst mechanism. Diuretic therapy has no effect on the benefits the client can receive from the thirst mechanism.
The nurse is answering a question from a participant during orientation training about the fluids found in the two major body fluid compartments. Which information regarding extracellular fluid (ECF) should be included?
Extracellular fluid is found outside the cells and comprises one third of the total body fluid. The two compartments of the ECF are intravascular and interstitial. Intravascular fluid is also known as plasma and accounts for 20% of the ECF. Interstitial fluid accounts for 75% of the ECF and is the fluid that surrounds the cells.
The nurse is reviewing assigned clients. Which assigned client should be determined by the nurse to be at risk for the most insensible fluid loss by diffusion?
Fluid volume deficit can be caused by nausea and vomiting with assessment findings of orthostatic hypotension, dry skin, and flat neck veins, which will lead to the priority nursing diagnosis of deficient fluid volume. The client is demonstrating fluid volume deficit. Therefore, ineffective tissue perfusion, impaired gas exchange, and impaired skin integrity are not priority nursing diagnoses for this client.
The client admitted has a diagnosed fluid and electrolyte imbalance. In planning the care for this client, the nurse should determine that which of the following goals regarding fluid and electrolyte balance is most appropriate?
In planning care, you want the client to attain the following goals regarding fluid and electrolyte balance: bullet• The client will maintain or restore normal fluid balance. bullet The client will maintain or restore normal electrolyte balance bullet The client will maintain or restore normal respiratory rate and pattern. bullet The client will maintain cardiac output and neurologic function.
The nurse is evaluating mechanisms associated with the process of diffusion with a new nurse. The nurse determines there is not a need for further instruction if the new nurse states that which clinical manifestation will increase the rate of diffusion?
Increased body temperature increases the rate of diffusion of solutions from a higher concentration to a lower concentration. Excessive perspiration is an example of osmosis. Hypertension has no effect on the diffusion process but manifests with fluid volume excess. Chills and shivering have no direct effect on the diffusion process but are sometimes associated with a rising temperature.
The nurse is preparing a teaching plan on the physiology of fluids and electrolytes to discuss with a group of nurses during orientation. Which teaching points should the nurse include?
Intracellular fluid is found within the cell and is two thirds of the body's fluids. Intracellular fluid (ICF) contains oxygen, electrolytes, and glucose. Several fluid and electrolyte mechanisms function to keep the body in balance. The proper maintenance of fluids and electrolytes helps the body with muscle action, blood chemistry, and other processes. Interstitial fluid accounts for 75% of the extracellular fluid (ECF). This is the fluid that surrounds the cells. Solutes are substances that dissolve in liquids. Glucose, oxygen, carbon dioxide, amino acid, urea, and proteins are all solutes. Solvents are components of a solution that can dissolve a solute. Water is a solvent. When solutions with different concentrations need to merge to equalize their concentration, diffusion is a means to move the solutes across a semipermeable membrane from a higher concentration to a lower concentration. Next Question
Before concluding your shift, you assess each of your four patients. Based on each client's fluid or electrolyte imbalance, you expect to observe specific findings. Which client is paired with the appropriate set of expected findings?
Mr. Eddy has hypokalemia, so your expected findings include dyspnea, weak pulse, rapid respirations, muscle weakness, leg cramps, and an abnormal ECG. Dyspnea, weak pulse, rapid respirations, muscle weakness, leg cramps, and abnormal ECG are all indicative of hypokalemia.
Mr. Smith has hypercalcemia, so your expected findings include tetany, positive Chvostek's sign, positive Trousseau's sign, irritability, and hypotension.
Tetany, positive Chvostek's sign, positive Trousseau's sign, irritability, and hypotension are indicative of hypocalcemia. Mr. Smith has hypercalcemia, which causes decreased neuromuscular irritability, so correct expected findings would include muscle weakness, fatigue, confusion, and hypertension.
Hypercalcemia: A shortened QT interval and shortened ST segment
The ECG of a client with hypercalcemia would likely show a shortened QT interval and a shortened ST segment due to decreased neuromuscular irritability.
Hypokalemia: A tall peaked T wave, widened QRS, and frequent ectopy
The ECG of a client with hypokalemia would more likely show ST segment depression, a flattened T wave, the appearance of a U wave, ventricular dysrhythmias (especially PVCs), and heart block.
Hypomagnesemia: Prolonged PR interval, widened QRS complex, and an elevated T wave
The ECG of a client with hypomagnesemia would more likely show diminished P wave voltage; broad, flat, or inverted T waves; depressed ST segments; prolonged QT intervals; and possibly a prominent U wave.
When ADH and aldosterone are secreted, what change occurs in the body?
The release of ADH and aldosterone causes sodium and water to be retained by the kidneys. The secretion of ADH and aldosterone are part of the renindash-angiotensin aldosterone system. Angiotensin II constricts blood vessels, which raises blood pressure. Angiotensin also stimulates thirst, releases aldosterone (a hormone from the adrenal cortex) and acts directly on the kidneys, causing them to retain sodium and water. ADH regulates water excretion from the kidneys as a result of receiving changes in osmolality and blood volume through receptors in the hypothalamus. When ADH is present, more water is reabsorbed in the kidneys. Urine output falls, blood volume is restored, and serum osmolality drops as the water dilutes body fluids. Urine output is decreased. Hypovolemia stimulates regulatory mechanisms to maintain circulation to prevent further fluid deficit, which could lead to the depletion of intracellular fluid. Third-space shift is not caused by the release of ADH and aldosterone. Next Question
The nurse is preparing a plan of care for a client diagnosed with an extracellular fluid imbalance. Which interventions should the nurse anticipate implementing in the plan of care?
When caring for a client with hyponatremia, the nurse must focus on imbalanced fluid volume and potential for ineffective cerebral perfusion. Interventions for these clients should include monitoring intake and output, taking daily weights, monitoring serum electrolytes, and assessing neurologic status and mental status changes. Clients with hyponatremia are often on a fluid restriction and are unable to have an unlimited amount of oral intake.
body fluids contain
nonelectrolytes which have no electrical charge and do not dissociate in water examples lipid glucose urea creatinine solutes can dissolve examples oxygen carbon dioxide
sensible fluid loss
perceived by the senses and can be measured urine output increases when fluid intake increases
The nurse reviews intake and output with a graduate nurse. Which statement by the graduate nurse should cause the nurse concern?
Rationale: Accurate measurement and recording of fluid I&O provides important data about the client's fluid balance. Ice cream would be considered intake because it is a food that becomes liquid at room temperature. The other answers are appropriate. Other intake includes all oral fluids, ice chips, IV fluids, IV medications, tube feedings, and catheter or tube irrigants. Output would include urinary output, vomitus, liquid feces, tube drainage, and wound drainage. Next Question
The nurse is administering a blood transfusion to a client who is hemorrhaging. In which fluid compartment should the nurse identify that the client is experiencing a deficit?
Rationale: Blood loss causes a deficit in the intravascular fluid compartment, which is a subcompartment of extracellular fluid (ECF). Transcellular and interstitial fluids, along with lymph, make up the other compartments of ECF. Intracellular fluid is the other major fluid compartment in the body.
The nurse is preparing material on fluid compartments in the body. Which fluids should the nurse identify as the components of extracellular fluid?
Rationale: Body fluids found outside of the cell include intravascular, interstitial, and transcellular fluids. Conversely, intracellular fluids are found inside the cell.
The nurse is teaching a client ways to prevent fluid imbalances. Which fluids should the nurse encourage the client to avoid?
Rationale: Coffee should be avoided due to its diuretic effects. Water, Pedialyte, and juice are acceptable drinks to avoid fluid imbalances.
A nurse is caring for a client who has lost a large percentage of circulating body fluids as a result of excessive diuresis. Which medication would the nurse anticipate this client needing?
Rationale: Colloids expand fluid volume by the replacement of proteins or other large molecules. Diuretics are used to promote urine output, particularly associated with fluid overload. Electrolyte supplements are used to replace lost electrolytes. Crystalloids contain both electrolytes and other substances that mimic the body's extracellular fluid. These medications will assist in the replacement of depleted fluids while promoting urine output.
A client is prescribed furosemide. Which information should the nurse provide about this medication?
Rationale: Daily weight is recommended for a client taking furosemide. Increasing sodium intake and decreasing potassium intake can lead to fluid and electrolyte imbalances. It would be recommended to take furosemide in the morning due to the diuresis effect of the medication.
The nurse is determining a client's fluid balance. Which method should the nurse use to identify this client's fluid volume excess or deficit?
Rationale: Daily weight is the best indicator of fluid volume excess or deficit. Skin turgor, blood pressure, and intake and output are assessments that would be included in the care of a client with fluid imbalances, but daily weight is the best indicator of changes in fluid status.
The nurse reviews the care needs for a group of clients. Which condition should the nurse realize occurs from a fluid volume deficit?
Rationale: Fluid volume deficit, or dehydration, can occur when excessive amounts of fluids are lost through diarrhea or vomiting. Kidney failure causes water retention, leading to fluid volume excess, not deficit. Water intoxication results from excessive fluid intake and leads to fluid volume excess. Fluid volume excess, not deficit, can result in hypertension.
The nurse is evaluating the laboratory work of a client who is receiving replacement therapy for hypokalemia. Which value should the nurse identify that evaluates the effectiveness of the replacement therapy?
Rationale: Hypokalemia is a potassium level less than 3.5 mEq/L. A serum potassium of 4.2 mEq/L indicates improvement in hypokalemia. Serum chloride and serum calcium are not used to evaluate potassium level.
The nurse is teaching a marathon runner about the importance of maintaining fluid and electrolyte balance. Which situation puts runners at a higher risk for fluid and electrolyte imbalances?
Rationale: It is common for athletes to use electrolyte replacement fluids during exercise. The nurse should be sure that the athlete understands that these fluids could alter the delicate balance of individual electrolytes. Supplemental protein and calcium intake do not typically affect fluid and electrolyte balance. Although water is lost during sweating, it does not usually create issues during exercise.
The nurse prepares intravenous fluid for a client. Which mechanism should the nurse recall that represents the movement of fluid across cell membranes from an area of less concentration to an area of higher concentration?
Rationale: Osmosis is the movement of water across cell membranes, from the less-concentrated solution to the more-concentrated solution. Filtration is the process by which fluid and solutes move together across a membrane from one compartment to another. Active transport is a process by which substances move across the cell membrane and must combine with a carrier for transportation, requiring metabolic energy. With diffusion, the molecules move from a solution of higher concentration to a solution of lower concentration.
The nurse is completing a physical assessment with a client. On which part of the body should the nurse focus when determining fluid and electrolyte status? (Select all that apply.)
Rationale: Physical assessment for fluid and electrolyte status focuses on the skin, oral cavity and mucous membranes, eyes, cardiovascular and respiratory systems, and neurologic and muscular status. The ears and endocrine system are not a focus of fluid and electrolyte status assessment.
The nurse is performing an assessment on a client with fluid volume excess. Which finding should the nurse identify that supports fluid volume excess? (Select all that apply.)
Rationale: Pitting edema, weight gain, and crackles in the lungs upon auscultation are indicative of fluid volume excess. Tenting of skin and thirst are found in fluid volume deficit.
The nurse is assessing the urinalysis of a client with fluid volume deficit. On which component of the urinalysis should the nurse focus to determine the client's fluid balance?
Rationale: Specific gravity measures the concentration of urine. Glucose found in the urine is indicative of diabetes mellitus. Nitrites in the urine indicate a possible bacterial infection. Leukocyte esterase also can be indicative of a possible bacterial infection.
The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. For which imbalance should the nurse assess this client?
Rationale: The client receiving intravenous (IV) colloids or any IV fluid is at risk for fluid overload. It is, therefore, important to monitor the client for manifestations of fluid overload. Fluid deficit, hyperkalemia, and hypernatremia do not typically result when infusing colloids.
The nurse is reviewing the fluid needs for a group of clients. Which characteristic of the intracellular fluid compartment of the body should the nurse identify?
Rationale: The intracellular fluid compartment makes up about two thirds of total body fluid in adults and is found within cells. It is a medium for metabolic processes. Extracellular fluid makes up the other one third of total body fluid and is divided into intravascular, interstitial, and transcellular fluids. Cerebrospinal and peritoneal fluids are examples of transcellular fluids.
The school nurse notes that a school-age child is experiencing mild heat exhaustion after playing outside during recess. Which recommendation should the nurse make to help prevent future occurrences of heat-related illness?
Rationale: To prevent heat-related illness, it would be best to move recess from the hottest part of the day to a cooler part of the day. Children should be encouraged to take frequent water breaks and drink before they begin to feel thirsty, not just when they feel thirsty or only before recess. Children should also be encouraged to take frequent rest breaks during recess, not just afterward.
The nurse is caring for a hospitalized client who is experiencing anxiety-related hyperventilation. When calculating the client's intake and output, where would the nurse anticipate the need for an adjustment in fluid loss?
Rationale: With increased respirations, the client will experience a greater-than-normal insensible loss of fluid through the lungs. Hyperventilation will not affect the amount of fluid lost through the urine, sweat, or feces.
