Module 2 - Fluid & Electrolytes

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations

1. A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

21. The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1. Daily weight 2. Urinary output 3. IV fluid intake 4. NG tube intake

1. Daily weight Rationale: Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

27. The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? 1. Heparin 2. Platelets 3. Antibiotic 4. Clotting factors

1. Heparin Rationale: During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1. Malnutrition Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1. Prolonged bed rest 2. Renal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1. Tetany 2. Tremors 3. Areflexia 4. Muscular excitability

3. Areflexia Rationale: Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A patient has a serum potassium level of 6.4 mEq/L and an arterial pH of 7.22. Which medication, if ordered by the physician, should the nurse question? 1. Calcium Glutinate IV 2. Furosemide (Lasix) IV 3. Spironolactone (Aldactone) by mouth 4. Regular insulin and Glucose IV

3. Spironolactone (Aldactone) by mouth

What is a major indicator of extracellular fluid volume deficit (FVD)? 1. Increase in body weight 2. Full and pounding pulse 3. Pitting edema of lower extremities 4. Drop in postural blood pressure

4. Drop in postural blood pressure

Positive Chvostek and Trousseau signs indicate which electrolyte imbalance? 1. Hypokalemia 2. Hypercalcemia 3. Hyperkalemia 4. Hypocalcemia

4. Hypocalcemia

A nurse is reviewing lab reports. The nurse recalls blood plasma is located in which of the following fluid compartments? 1. Intracellular fluid (ICF) 2. Extracellular fluid (ECF) 3. Interstitial fluid 4. Intravascular fluid

4. Intravascular fluid

D5 1/2 NS

Dextrose 5% in 0.45 saline -Hypertonic

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG)

1. Hypotension Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? 1. Prominent U waves 2. Prolonged PR interval 3. Depressed ST segment 4. Widened QRS complexes

3. Depressed ST segment Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse administers a hypertonic intravenous solution. Which of the following would be expected to result? 1. Intracellular swelling (cells swell) 2. Increased intracellular fluid (ICF) volume 3. Intracellular dehydration (cells shrink) 4. Decreased extracellular flip (ECF) volume

3. Intracellular dehydration (cells shrink)

The mechanism of action of angiotensin II is: 1. Vasoconstriction 2. Potassium retention (Hyperkalemia) 3. Sodium excretion (Hyponatremia) 4. Decreased blood pressure

1. Vasoconstriction

A faculty member asks a student to identify the appropriate term for the movement of a solute from an area of greater to lesser concentration. Which answer indicates the nursing student understood the teaching? 1. Hydrostatic pressure 2. Diffusion 3. Osmosis 4. Active transport

2. Diffusion

A student nurse is reading a chart and sees the term oncotic pressure. The student recalls that oncotic pressure (colloid osmotic pressure) usually tends to pull water into the circulatory system and it is the opposing force to hydrostatic pressure. The oncotric pressure is determined by: 1. The concentration of sodium 2. Plasma proteins, notably albumin. 3. Hydrostatic pressure. 4. The anitdiuretic hormone (ADH)

2. Plasma proteins, notably albumin.

A patient hs a serum potassium level of 3.1 mEq/L. It is most appropriate for the nurse to take which action? 1. Immediately stop the infusion of the maintenance IV, which has 30 mEq of potassium in it. 2. Prepare to administer the ordered intravenous dose of Furosemide [Lasix]. 3. Administer the prescribed sustained-release potassium tablets [K-dur]. 4. Administer the prescribed dose of sodium Polystyrene Sulfonate [Kayexalata].

3. Administer the prescribed sustained-release potassium tablets [K-dur].

D5W

-Dextrose 5% in water -Crystalloid solution -Isotonic (in the bag) *Physiologically hypotonic (260 mOsm)

1/2 Normal Saline (1/2 NS)

0.45% NaCl in Water (Crystalloid) -Hypotonic

Normal Saline (NS)

0.9% NaCl in Water (Crystalloid) -Isotonic

Colloids

Contain large molecules (proteins) that DONT pass through semipermeable membrane. -given to keep fluid in blood vessels -ALBUMIN, DEXTRAN -longer duration of action than crystalloids

Crystalloids

Dextrose, L/R, Sodium Chloride (NS) -Contain small molecules that flow easily across semipermeable membranes. -Isotonic, hypotonic, hypertonic

D5NS

Dextrose 5% in 0.9 saline -Hypertonic

RAAS system steps

Na+ deficiency, dehydration or hemorrhage => Renin from kidney is released and it triggers Angiotensin 1. It is then converted to angiotensin 2 with ACE (enzyme) in lungs. Angiotensin 2 (vasoconstricts) > increases the BP. Adrenal cortex releases aldosterone. In kidneys, increases Na+ & H2O. This increases blood volume which increases blood pressure (through vasoconstriction).

Lactated Ringer's (LR)

Normal saline with electrolytes & buffer -Isotonic

The nurse is preparing to administer blood transfusion for a patient with gastrointestinal (GI) bleeding. Which IV solution should the nurse prepare to be used with blood transfusion? 1. 0.9% sodium chloride 2. 5% dextrose in 0.45% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. Lactated Ringer's

1. 0.9% sodium chloride

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? 1. 10% dextrose in water (D10W) 2. 0.45% sodium chloride (1/2 NS). 3. Total parental nutrition (TPN) 4. 0.9% sodium chloride (NS) 5. Lactated Ringers (LR) 6. 3% sodium chloride

1. 10% dextrose in water 2. 0.45% sodium chloride 4. 0.9% sodium chloride

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. 1. 10% dextrose in water 2. 0.45% sodium chloride 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 5. 5% dextrose in 0.225% saline 6. 5% dextrose in lactated Ringer's solution

1. 10% dextrose in water 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 6. 5% dextrose in lactated Ringer's solution Rationale: Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1. Blood transfusions 2. Metabolic alkalosis 3. Bleeding or hemorrhage 4. Decreased sodium excretion 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium

1. Blood transfusions 3. Bleeding or hemorrhage 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium Rationale: With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. 1. Bounding pulse 2. Difficulty breathing 3. Increased urine output 4. Presence of dependent edema 5. Neck vein distention in the upright position

1. Bounding pulse 2. Difficulty breathing 4. Presence of dependent edema 5. Neck vein distention in the upright position Rationale: Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload. {[In Fluid volume excess, urine output decreases}

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1. Dehydration 2. Hypertension 3. Physiological stress 4. Decreased blood volume 5. Decreased plasma osmolarity

1. Dehydration 3. Physiological stress 4. Decreased blood volume Rationale: ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

*The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. 1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 3. Encourage low-fiber foods to prevent diarrhea. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate.

1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate. Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis. {PLEASE note that hypokalemia may be caused by DIARRHEA}

When considering water balance, which statement is the correct balance? 1. Hypotonic fluid causes cellular swelling 2. Hypertonic fluid causes increased cellular swelling 3. Isotonic fluids cause increased cellular swelling 4. Isotonic fluids causes cellular swelling

1. Hypotonic fluid causes cellular swelling

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1. Monitor the client for dysrhythmias. 2. Encourage increased intake of phosphate antacids. 3. Discontinue any magnesium-containing medications. 4. Encourage intake of foods such as ground beef, eggs, or chicken breast.

1. Monitor the client for dysrhythmias. Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1. Peas 2. Nuts 3. Cheese 4. Cauliflower 5. Processed oat cereals

1. Peas 2. Nuts 4. Cauliflower Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take? 1. Take no action. 2. Order a stat hemodialysis treatment. 3. Page the health care provider (HCP) with the results. 4. Recheck the labs because these values are all abnormal.

1. Take no action. Rationale: No action is needed because all of the blood levels are normal for a hemodialysis client before a treatment. The normal adult ranges of serum electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98 to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28 mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).

Which clients are most likely to be at risk for the development of third spacing? Select all that apply. 1. The client with cirrhosis 2. The client with liver failure 3. The client with diabetes mellitus 4. The client with a minor burn injury 5. The client with chronic kidney disease

1. The client with cirrhosis 2. The client with liver failure 5. The client with chronic kidney disease Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1. Twitching Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? 1. An oral temperature of 98.8°F (37.1°C) 2. A urine specific gravity of 1.043 3. A urine output that is pale yellow 4. A blood pressure of 120/80 mm Hg

2. A urine specific gravity of 1.043 Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8°F (37.1°C) is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? 1. Hang the solution. 2. Contact the health care provider (HCP). 3. Check the client's daily laboratory results. 4. Ask the client if any liver study tests have ever been done.

2. Contact the health care provider (HCP). Rationale: The nurse must contact the HCP before administering the solution. Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.

4. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2. Raisins 3. Potatoes 4. Cantaloupe 6. Strawberries Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? 1. Confusion 2. Muscle weakness 3. Mental status changes 4. Depressed deep tendon reflexes

2. Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (559 mmol/L)

2. Requires nasogastric suction The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output.

2. Resume full activity level. Rationale: Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? 1. Tap water 2. Sterile water 3. 0.9% sodium chloride 4. 0.45% sodium chloride

3. 0.9% sodium chloride Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? 1. A client with ulcerative colitis 2. A client with Cushing's syndrome 3. A client admitted 6 hours ago with a 40% burn injury 4. A client who has a history of long-term laxative abuse

3. A client admitted 6 hours ago with a 40% burn injury Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1. Bradycardia 2. Elevated blood pressure 3. Changes in mental status 4. Bilateral crackles in the lungs

3. Changes in mental status Rationale: A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? 1. Document this assessment finding. 2. Call another nurse to verify this finding. 3. Check skin turgor over the client's sternum. 4. Call the health care provider (HCP) to obtain a prescription for fluid replacement.

3. Check skin turgor over the client's sternum. Rationale: In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1. Client in heart failure 2. Client in acute kidney injury 3. Client with diabetes insipidus 4. Client with controlled hypertension

3. Client with diabetes insipidus Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

3. Integumentary output Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? 1. Tremors 2. Hyperactive reflexes 3. Respiratory depression 4. No specific signs or symptoms because this value is a normal level

3. Respiratory depression Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes

3. Tall peaked T waves 5. Widened QRS complexes Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank. _______ mL

30 mL Rationale: The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So, if the client drank 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid this day.

The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored? 1. Edema 2. Bradycardia 3. Hypertension 4. Hyperkalemia

4. Hyperkalemia Rationale: Hyperkalemia is the most significant adverse effect of triamterene, especially when it is used alone. Edema, bradycardia, and hypertension are not adverse effects of this medication. Triamterene is a potassium-retaining diuretic, so the nurse needs to monitor the client for hyperkalemia. Triamterene should never be used in conjunction with another potassium-retaining diuretic or with potassium supplements or salt substitutes. In addition, caution is needed if the medication is combined with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, or direct renin inhibitor. Common side effects include nausea, vomiting, leg cramps, and dizziness.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? 1. Tetany 2. Twitches 3. Positive Trousseau sign 4. Loss of deep tendon reflexes

4. Loss of deep tendon reflexes Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

4. Prolonged QT interval 5. Prolonged ST segment Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

The nurse is caring for a client suffering from heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a hypovolemic shock. Which assessment finding would the nurse note in a client with this condition? 1. Weight gain 2. Increased blood pressure 3. Decreased hematocrit 4. Rapid heart rate

4. Rapid heart rate

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? 1. Tap water 2. Sterile water 3. Distilled water 4. Sodium chloride

4. Sodium chloride Rationale: A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do? 1. Administer a Fleet enema. 2. Administer an oil retention enema. 3. Wait 30 minutes and then administer another enema. 4. Stop administering the enemas until the health care provider (HCP) is notified.

4. Stop administering the enemas until the health care provider (HCP) is notified. Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

A male client is on a continuous cardiac monitor and is receiving a transfusion of whole blood for a hemorrhage following a perforation of a gastric ulcer. He becomes dyspenic, complains of precordial chest pain, has distended neck veins and develops crackles/rales on auscultating lung sounds. What action should the nurse take FIRST based on the client's symptoms? 1. Examine the client's EKG for evidence of myocardial infraction. 2. Offer a prescribed nitroglycerin tablet to ease the chest pain. 3. Obtain an infusion pump so that the transfusion flow can be better regulated. No source found. 4. Stop the transfusion and place the client in semi-Fowler's position.

4. Stop the transfusion and place the client in semi-Fowler's position.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus

4. The client with kidney disease and a 12-year history of diabetes mellitus Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032

4. Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

D5 LR

Dextrose 5% in Lactated Ringer's -Hypertonic

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1. Dehydration 2. Hypokalemia 3. Fluid overload 4. Hypernatremia

1. Dehydration Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. 1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 4. Monitor for numbness and tingling around the mouth. 5. Prevent complications during potassium administration.

1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 5. Prevent complications during potassium administration. Rationale: The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

33. The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? 1. Pour the aspirate into the NG tube through a syringe with the plunger removed. 2. Dilute with water and inject into the NG tube by putting pressure on the plunger. 3. Discard properly and record as output on the client's intake and output (I&O) record. 4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

1. Pour the aspirate into the NG tube through a syringe with the plunger removed. Rationale: After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and should not be discarded.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply. 1. Tetany 2. Constipation 3. Renal calculi 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

1. Tetany 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign Rationale: The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased, and the client will experience hypotension. A low serum calcium level could also lead to s

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

3. The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1. U waves 3. Inverted T waves 4. Depressed ST segment Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

1. Weight loss and poor skin turgor Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1. Weighs athletes before, during, and after football practice 2. Asks the athletes to take a salt tablet before football practice 3. Schedules fluid breaks every 30 minutes throughout practice 4. Tells the athletes to drink 16 oz (475 mL) of fluid per pound lost during practice

2. Asks the athletes to take a salt tablet before football practice Rationale: Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz (475 mL) of fluid should be consumed for every pound lost.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? 1. Client with a major burn 2. Client with an ischemic stroke 3. Client with Laënnec's cirrhosis 4. Client with chronic kidney disease

2. Client with an ischemic stroke Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

Which of the following is the most common effect of both hypokalemia and hyperkalemia, which if not rated promptly could be fatal? 1. Constipation 2. Polyuria 3. Cardiac arrhythmias (dysrhythmias) 4. Increased serum pH (alkalosis)

3. Cardiac arrhythmias (dysrhythmias)

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1. Sodium 135 mEq/L (135 mmol/L) 2. Sodium 140 mEq/L (140 mmol/L) 3. Potassium 3.0 mEq/L (3.0 mmol/L) 4. Potassium 5.0 mEq/L (5.0 mmol/L)

3. Potassium 3.0 mEq/L (3.0 mmol/L) Rationale: The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures. 1. Pinching the skin on the thigh 2. Pushing on the skin in the ankle area 3. Assessing the skin in the radial pulse area 4. Pulling up and releasing the skin on the sternal area

4. Pulling up and releasing the skin on the sternal area Rationale: Click on the Rationale Video button. When preparing to place a client on I&O, the nurse explains the procedure to the client. This provides the client with information about the purpose and procedure and allows client participation, if feasible, such as contacting the nurse when oral intake is consumed or if the bathroom is used. The nurse also performs a baseline assessment for later comparison and checks for signs of fluid imbalance, including measuring the client's vital signs, weight, and skin turgor. Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor. The actions in options 1, 2, and 3 would not assess turgor.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.