Funds lippincott Fluid and electrolyte ex 4
As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value?
"The BUN is elevated because your daughter is dehydrated."
An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply.
Collect specimens for lab examination. Assess vital signs. Initiate support for the respiratory system. Monitor fluid and electrolyte status. Provide anti-emetics, as prescribed.
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.
The mother of a child with moderate diarrhea asks how to manage her child's illness. What should the nurse suggest?
Continue the child's regular diet.
A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?
Decrease foods high in potassium.
A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate?
Encourage more fluid intake.
When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?
Evaluate laboratory results for electrolytes.
A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
Fluid intake should be about equal to the urine output.
A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption?
I.V.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
Increase daily fluid intake to at least 2 to 3 L.
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?
K+, 3.2; Cl-, 92; Na+, 120
A parent brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the primary care provider's prescriptions? All options must be used.
Obtain vital signs and weight. Apply a urine collection bag. Insert an IV and infuse fluids as prescribed. Draw blood for laboratory tests.
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?
The client may be developing hypocalcemia.
A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?
The client may require fluid and electrolyte replacement.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess
Trousseau's sign.
Which client is most likely to exhibit dehydration?
an 8-month-old infant with persistent diarrhea for 24 hours
Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
auscultation of moist crackles
An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply.
fluid restriction vital signs every 4 hours instead of every shift bed alarm Foley catheter strict intake and output repeat electrolytes, urine for sodium and specific gravity in the morning
The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention?
low-sodium diet
The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to:
maintain fluid and electrolyte balance.
A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time?
maintaining fluid and electrolyte balance
Immediately after surgery to create an ileostomy, which goal has the highest priority?
maintaining fluid and electrolyte balance
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information?
measuring the infant's weight
What finding indicates that a child is receiving too much IV fluid too rapidly?
moist crackles in the lung fields
A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. At the beginning of the client's hospitalization, the most important nursing action is to:
monitor the client's vital signs, serum electrolyte levels, and acid-base balance.
What instruction should the nurse's discharge teaching plan for the client with heart failure include?
obtaining daily weights at the same time each day
A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration?
oliguria
The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration?
orthostatic hypotension
The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?
potassium level of 6.5 mEq/L (6.5 mmol/L)
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?
respiratory acidosis
Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply.
weakness irregular pulse decreased muscle tone potassium level of 3.1 mEq/L ventricular arrhythmias
A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is
weight.
Which finding is a risk factor for hypovolemic shock?
hemorrhage
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
respiratory alkalosis
A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. The client's family members report that the client has been confused for the last day. Which laboratory value is mostlikely responsible for this client's symptoms?
serum calcium level 13.8 mg/dl (0.766 mmol/L)
A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication?
cardiac arrest
When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply.
decreased muscle tone decreased respirations
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance?
decreased serum sodium level
The nurse should assess a client who is in the emergent phase of burn management for:
hyperkalemia.
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?
hypokalemia
A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance?
hypokalemia
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?
serum potassium level of [3 mEq/L (3.0 mmol/L)]
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of
sodium and potassium abnormalities.
