Module 8 Fluid & Electrolytes EAQs

Which adverse medication effect will a nurse monitor for in a client with cirrhosis of the liver who develops ascites and is prescribed spironolactone? A. Bruising B. Tachycardia C. Hyperkalemia D. Hypoglycemia

C. Hyperkalemia Rationale: Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse would monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

Which medication requires the nurse to monitor the client for signs of hyperkalemia? A. Furosemide B. Metolazone C. Spironolactone D. Hydrochlorothiazide

C. Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect. Furosemide, metolazone, and hydrochlorothiazide generally cause hypokalemia.

Which purpose would potassium chloride added to the intravenous solution of a client with diabetic ketoacidosis serve? A. Treats hyperpnea B. Prevents flaccid paralysis C. Prevents hypokalemia D. Treats cardiac dysrhythmias

C. Prevents hypokalemia Rationale: Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with replacement fluids, is needed to prevent hypokalemia. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. There is no mention of dysrhythmias in the scenario; they are not a universal finding in diabetic ketoacidosis (and are commonly absent) and hypokalemia does not always cause these to occur.

Which clinical manifestation would the nurse expect the client who has chronic kidney disease with hypocalcemia to exhibit? (SATA) A. Acidosis B. Lethargy C. Fractures D. Osteomalacia E. Eye calcium deposits

C. Fractures D. Osteomalacia E. Eye calcium deposits Rationale: Because of calcium loss from the bone, fractures, osteomalacia, and eye calcium deposits occur. Acidosis decreases calcium that binds to albumin, resulting in more ionized calcium (free calcium) in the blood. Lethargy and weakness are associated with hypercalcemia.

In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? A. Isotonic B. Isomeric C. Hypotonic D. Hypertonic

C. Hypotonic Rationale: Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. Isomeric relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the intravenous fluid infusion rate for an older client with an infection? A. Pruritus B. Erythema C. Acute confusion D. General malaise

C. Acute confusion Rationale: The nurse would consider the development of dehydration if acute confusion occurs in an older client with an infection and contact the health care provider. Additional fluids would not be helpful if pruritus, erythema, or general malaise develop in a client with an infection.

Which action is important when administering blood? A. Warm the blood to body temperature to prevent chilling the client. B. Obtain baseline vital signs before beginning blood administration. C. Draw a blood sample from the client before each unit is transfused. D. Maintain patency of the intravenous catheter with dextrose solution.

B. Obtain baseline vital signs before beginning blood administration. Rationale: Baseline vital sign assessment is needed to have a basis for comparison should the client develop complications during administration. Warming the blood to body temperature may cause clotting and hemolysis. Blood samples may be drawn after, not before, a transfusion, but this is not routinely done. Dextrose solution will cause lysis of the red blood cells (RBCs); saline must be used.

Which client would the nurse see first among this group of clients? A. A toddler with diarrhea B. An adult who is nauseated C. An adult who has vomiting because of food poisoning D. An older adult whose last bowel movement was 3 days ago.

A. A toddler with diarrhea Rationale: The toddler child will be at higher risk for fluid and electrolyte imbalance because of higher fluid content of the body and decreased ability to regulate fluid balance, which put this client in a life-threatening situation. Care of an adult client with nausea is not a priority because the client's body has a higher ability to regulate fluid and electrolyte balance compared with the child. Care of an older adult having difficulty with bowel movements is not a nursing priority because it is not a life-threatening situation. Care of an adult with vomiting is not a nursing priority because this client has a higher ability to regulate fluid and electrolyte balance compared with the child.

After reviewing the chart of a client recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately? A. Pain medication B. Intravenous fluids C. Multiple antibiotics D. Packed red blood cells

B. Intravenous fluids Rationale: The client probably is experiencing hypovolemic shock, as evidenced by the vital signs (elevated pulse and respirations and low blood pressure). Intravenous fluids will help correct the hypovolemia. Analgesics should not be administered until after the client is assessed fully, particularly for a head injury. Antibiotics may be prescribed eventually, but this is not the initial intervention. Packed red blood cells eventually may be administered, but this depends on an additional physical assessment and hematologic laboratory tests.

Which factor is a likely cause of hyponatremia? (SATA) A. Diabetes insipidus B. Profuse diaphoresis C. Excess sodium intake D. Removal of the parathyroid glands E. Rapid intravenous (IV) infusion of 5% dextrose in water (D 5W)

B. Profuse diaphoresis E. Rapid intravenous (IV) infusion of 5% dextrose in water (D 5W) Rationale: Because perspiration contains high levels of sodium, this is a cause of hyponatremia. Common causes of hyponatremia from loss of sodium-rich body fluids include draining wounds, diarrhea, vomiting, and primary adrenal insufficiency. Inappropriate use of sodium-free or hypotonic IV fluids (like D 5W) causes hyponatremia from water excess. Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and hypernatremia. Excess sodium intake can lead to hypernatremia. Removal of the parathyroid glands can lead to hypocalcemia.

Which purpose of insulin would a nurse identify when caring for a client prescribed insulin added to a solution of 10% dextrose in water after an intravenous solution containing potassium inadvertently was infused too rapidly? A. Glucose with insulin increases metabolism, which accelerates potassium excretion. B. Increased potassium causes a temporary slowing of the pancreatic production of insulin. C. Increased insulin accelerates the excretion of glucose and potassium, thereby decreasing the serum potassium level. D. Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level.

D. Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level. Rationale: Potassium follows glucose into the cells of the body, thereby raising the intracellular potassium level and preventing fatal dysrhythmias. Potassium is not excreted as a result of this therapy; it shifts into the intracellular compartment. The potassium level has no effect on pancreatic insulin production. Insulin does not cause the excretion of these substances.

For which reason would clients who receive intravenous (IV) fluids rather than total parenteral nutrition for gastrointestinal problems lose weight? A. Lack of bulk in the diet B. Deficient carbohydrate intake C. Insufficient intake of water-soluble vitamins D. Increasing concentrations of electrolytes in the cells

B. Deficient carbohydrate intake Rationale: IV fluids supply minimal calories; a client receiving only IV fluids will lose weight and become malnourished. Lack of bulk in the diet is not related to weight; lack of bulk in the diet results in constipation. Vitamins are not related to weight loss. Intracellular electrolytes are not related to weight loss.

Which client problem would the nurse expect to decrease in response to the administration of serum albumin intravenously to a client with ascites? A. Confusion B. Urinary output C. Abdominal girth D. Serum ammonia level

C. Abdominal girth Rationale: An increased serum albumin level increases the osmotic effect and pulls fluid back into the intravascular compartment. This will increase renal flow and urine output, with a resulting decrease in abdominal girth. Confusion will not be impacted. Urinary output therapy will increase blood volume and blood flow to the kidney, thereby increasing urinary output. Albumin therapy has no effect on blood ammonia levels. An increased, not decreased, blood ammonia level causes hepatic encephalopathy.

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? (SATA) A. Pulse quality B. Pulse pressure C. Bounding pulse D. Presence of dependent edema E. Neck vein distention in the upright position

C. Bounding pulse D. Presence of dependent edema E. Neck vein distention in the upright position Rationale: Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? (SATA) A. Diplopia B. Skin rash C. Leg cramps D. Tachycardia E. Muscle weakness

C. Leg cramps E. Muscle weakness Rationale: Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.

Which intravenous fluid is a hypertonic solution? A. Ringer solution B. 5% dextrose in water C. Lactated Ringer solution D. 5% dextrose in normal saline

D. 5% dextrose in normal saline Rationale: An isotonic solution has the same osmolarity as body fluids. A hypertonic solution has a higher osmolarity than body fluids; it pulls fluid from cells, causing them to shrink and the extracellular space to expand. The hypertonic solution (5% dextrose in normal saline) provides 586 mOsm/kg. Ringer and Lactated Ringer [273 mOsmol/kg] are isotonic, whereas 5% dextrose in water [252 mOsmol/kg]) is slightly hypotonic.

When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider ? A. Equal B. Unrelated C. Inversely related D. Directly proportional

D. Directly proportional Rationale: There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which medication will the nurse expect the health care provider to prescribe to a client who had a thyroidectomy and is pale with spasms of the hand when taking the blood pressure? A. Calcium B. Magnesium C. Bicarbonate D. Potassium chloride

A. Calcium Rationale: These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.

Why would the nurse advise the client a client who takes furosemide and digoxin for heart failure to drink a glass of orange juice every day? A. Maintaining potassium levels B. Preventing increased sodium levels C. Limiting the medications' synergistic effects D. Correcting the associated dehydration

A. Maintaining potassium levels Rationale: Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither medication increases sodium levels. Orange juice will not prevent an interaction between digoxin and furosemide. Digoxin does not potentiate the action of furosemide; therefore the client should not experience dehydration.

Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity? A. Constipation B. Decreased urination C. Cardiac dysrhythmias D. Metallic taste in the mouth

C. Cardiac dysrhythmias Rationale: The development of cardiac dysrhythmias is often a sign of digoxin toxicity. Constipation is not a sign of toxicity; gastrointestinal signs and symptoms of toxicity include anorexia, nausea, vomiting, and diarrhea. Decreased urination is not a sign of toxicity. Digoxin does not cause a metallic taste in the mouth.

Which concern when caring for a client prescribed furosemide 40 mg every day in conjunction with digoxin would prompt the nurse to ask the health care provider about potassium supplements? A. Digoxin causes significant potassium depletion. B. The liver destroys potassium as digoxin is detoxified. C. Lasix requires adequate serum potassium to promote diuresis. D. Digoxin toxicity occurs rapidly in the presence of hypokalemia.

D. Digoxin toxicity occurs rapidly in the presence of hypokalemia. Rationale: Furosemide promotes potassium excretion, and low potassium (hypokalemia) increases cardiac excitability. Digoxin is more likely to cause dysrhythmias when potassium is low. Digoxin does not affect potassium excretion. Furosemide causes potassium excretion. Potassium is excreted by the kidneys, not destroyed by the liver. Furosemide causes diuresis and consequent potassium loss regardless of the serum potassium level.

Which electrolyte deficiency triggers the secretion of renin? A. Sodium B. Calcium C. Chloride D. Potassium

A. Sodium Rationale: Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

Which findings are consistent with hypercalcemia after prolonged immobility? (SATA) A. Bone pain B. Convulsions C. Muscle spasms D. Tingling of extremities E. Depressed deep tendon reflexes

A. Bone pain E. Depressed deep tendon reflexes Rationale: Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia

Which disease increases the risk of hyperkalemia? A. Crohn disease B. Cushing disease C. End-stage renal disease D. Gastroesophageal reflux disease

C. End-stage renal disease Rationale: One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? A. Clear breath sounds B. Positive pedal pulses C. Normal potassium level D. Decreased urine specific gravity

A. Clear breath sounds Rationale: Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

Which principle explains how loop diuretics promote diuresis? A. Osmosis B. Filtration C. Diffusion D. Active transport

A. Osmosis Rationale: Loop diuretics inhibit the reabsorption of sodium and water in the ascending loop of Henle. The increased sodium load in the distal tubule causes the passive transfer of water from the glomerular filtrate to urine through the process of osmosis. Filtration refers to solutes; solutes are not being passed into the urine. Diffusion is not specific to fluid; osmosis is. Active transport requires energy; water is passively moved from tubule cells to the urine.

A client with renal failure receives prescriptions for vitamin D and calcium supplements. The client asks the nurse, 'Why do I need to take these?' The nurse explains that, with renal failure, which condition exists? A. A decrease in the inactive forms of vitamin D in the body B. A decrease in the active metabolite of vitamin D in the body C. An increase in the conversion of skin cholesterol into vitamin D D. An increase in the vitamin D-associated intestinal absorption of calcium

B. A decrease in the active metabolite of vitamin D in the body Rationale: Renal failure results in a decrease in the active metabolite of vitamin D because inactive vitamin D gets activated in the liver and then in the kidneys. Food sources of vitamin D and sunlight contribute to an inactive form of the hormone in the body. Inactive vitamin D will decrease if foods rich in vitamin D are not consumed or exposure to sunlight is reduced. Conversion of skin cholesterol to vitamin D depends on exposure to sunlight and not renal impairment. In renal failure there is less active vitamin D and therefore less intestinal absorption of calcium.

A client with a femoral fracture and osteomyelitis is immobilized for 3 weeks. Which rationale explains the nurse's plan to assess for the development of renal calculi? A. The client's dietary patterns have changed since admission. B. The client has more difficulty urinating in a supine position. C. Lack of weight-bearing activity promotes bone demineralization. D. Fracture healing requires more calcium, which increases calcium metabolism.

C. Lack of weight-bearing activity promotes bone demineralization. Rationale: All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position because of an inability to assume the preferred anatomic position and the emotional effects of using a urinal, it usually does not predispose the client to developing renal calculi. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.

Which antidiarrheal medication would the nurse anticipate administering to a client with severe diarrhea who is prescribed intravenous fluids, sodium bicarbonate, and an antidiarrheal medication? A. Psyllium B. Bisacodyl C. Loperamide D. Docusate sodium

C. Loperamide Rationale: Loperamide inhibits peristalsis and prolongs transit time by its effect on the nerves in the muscle wall of the intestines. Psyllium is not an antidiarrheal; it is a bulk laxative that promotes easier expulsion of feces. Bisacodyl is a laxative, not an antidiarrheal; it increases gastrointestinal motility. Docusate sodium corrects constipation, not diarrhea; water and fat are increased in the intestine, permitting easier expulsion of feces

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? A. Prevent constipation B. Prevent dehydration C. Prevent vomiting D. Prevent electrolyte imbalance

D. Prevent electrolyte imbalance Rationale: When clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern. Constipation is usually not a concern in this situation. Although dehydration is a possible effect of an NG tube that removes gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.

Which statement by a client receiving diuretic therapy indicates that the teaching about potassium supplements is understood? A. "I will report any abdominal distress." B. "I should use salt substitutes with my food." C. "The medication must be taken on an empty stomach." D. "The dosage is correct if my urine output increases."

A. "I will report any abdominal distress." Rationale: Potassium supplements can cause gastrointestinal ulceration and bleeding. Most salt substitutes contain potassium, and their use with potassium supplements can cause hyperkalemia. Because they can be irritating to the stomach, potassium supplements should not be taken on an empty stomach. An increase in urine output is the therapeutic effect of diuretic therapy, not potassium supplements. An adverse effect of potassium supplements is oliguria.

Which intravenous (IV) solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration? A. 3% sodium chloride B. 0.9% sodium chloride C. 5% dextrose and 0.9% sodium chloride D. 5% dextrose and lactated Ringer solution

B. 0.9% sodium chloride Rationale: An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. Three percent sodium chloride is a high-concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. Five percent dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer solution may be appropriate fluids to infuse after 0.9% sodium chloride.

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? A. Rapid, thready pulse B. Distended jugular veins C. Elevated hematocrit level D. Increased serum sodium level

B. Distended jugular veins Rationale: Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decrease

Which mechanism of action is responsible for the therapeutic effects of mannitol prescribed for a client with a head injury? A. Decreasing the production of cerebrospinal fluid B. Limiting the metabolic requirements of the brain C. Drawing fluid from brain cells into the bloodstream D. Preventing uncontrolled electrical discharges in the brain

C. Drawing fluid from brain cells into the bloodstream Rationale: Mannitol, an osmotic diuretic, pulls fluid from the brain to relieve cerebral edema. Mannitol's diuretic action does not decrease the production of cerebrospinal fluid. Mannitol does not affect brain metabolism; rest and lowered body temperature reduce brain metabolism. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium, not mannitol.

Which nursing action has a specific gerontological implication the nurse must consider when caring for an older adult receiving chemotherapy for cancer whose severe nausea and vomiting causes dehydration requiring hospital admission for rehydration therapy? (SATA) A. Assessment of skin turgor B. Documentation of vital signs C. Assessment of intake and output D. Administration of antiemetic medications E. Replacement of fluid and electrolytes

A. Assessment of skin turgor D. Administration of antiemetic medications E. Replacement of fluid and electrolytes Rationale: When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic medications; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

Which physiological alteration will the nurse monitor to best determine the effectiveness of a client's hydrochlorothiazide therapy? A. Blood Pressure B. Decreasing edema C. Serum potassium level D. Urine specific gravity

A. Blood Pressure Rationale: Diuretics promote urinary excretion, which reduces the volume of fluid in the intravascular compartment, thus lowering blood pressure. The measure of blood pressure is the best determination of effectiveness because it is a direct measure of the desired outcome. A reduction in edema reflects effectiveness; however, multiple physiological processes, including venous competence, gravity, and disuse, maintain a significant degree of edema even when the diuretic is optimally effective. A lowered potassium level would indirectly indicate that the medication is working; however, this does not provide a good measure of effectiveness. Although specific gravity decreases with increased urinary output and thus would demonstrate that the medication is working, it is not a direct measure of the desired outcome. A measure of the reduction in intravascular pressure is preferable

Which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure? (SATA) A. Daily weight B. Intake and output C. Monitor for edema D. Daily pulse oximetry E. Auscultate breath sounds

A. Daily weight B. Intake and output C. Monitor for edema D. Daily pulse oximetry E. Auscultate breath sounds Rationale: Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.

Which statement about administration of IV potassium would a nurse make to a client with a diagnosis of hypokalemia? A. Oliguria is an indication for withholding IV potassium. B. Rapid infusion of potassium prevents burning at the IV site. C. Clients with severe deficits should be given IV push potassium. D. Average IV dosage of potassium should not exceed 60 mEq in 1 hour.

A. Oliguria is an indication for withholding IV potassium. Rationale: Potassium chloride should not be given unless renal flow is adequate; otherwise, the potassium chloride will accumulate in the body, causing hyperkalemia. Rapid infusion may cause severe pain at the infusion site and precipitate cardiac arrest. Potassium chloride must be well diluted or it will precipitate cardiac arrest. A dose of 60 mEq per hour of potassium chloride is too high.

Which nursing assessment would performed by a nurse before administering intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? A. Urinary output B. Deep tendon reflexes C. Last bowel movement D. Arterial blood gas results E. Last serum potassium level F. Patency of the intravenous access

A. Urinary output E. Last serum potassium level F. Patency of the intravenous access Rationale: Before administering IV potassium, the urinary output must be normal. If the urine output is low, a potassium infusion may damage renal cells. The last serum potassium level should also be checked to ensure potassium replacement is appropriate. A patent IV access is essential because potassium is very irritating and painful to subcutaneous tissue. The infusion of KCL 40 mEq in 100 mL of 5% dextrose and water has no direct effect on bowel movement patterns, arterial blood gases, or deep tendon reflexes. These items are not required to be assessed before the administration of this medication

Which response would a nurse monitor for when a client is receiving furosemide to relieve edema? (SATA) A. Weight loss B. Negative nitrogen balance C. Increased urine specific gravity D. Excessive loss of potassium ions E. Pronounced retention of sodium ions

A. Weight loss D. Excessive loss of potassium ions Rationale: Each liter of fluid weighs 2.2 pounds (1 kilogram). Assessing weight loss is an objective measure of the effectiveness of the medication. Furosemide is a potent diuretic that is used to provide rapid diuresis in clients with pulmonary edema; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. A negative nitrogen balance would not be monitored. Furosemide does not affect protein metabolism. With increased fluid loss, the specific gravity is likely to be lowered. Furosemide inhibits the reabsorption of sodium.

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? A. Pain B. Coolness C. Localized swelling D. Cessation in flow of solution

B. Coolness Rationale: When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75°F [23.9°C]), whereas body temperature is approximately 98.6°F (37°C); therefore the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation inflow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may narrow the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution

When a client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? A. Complete a head-to-toe assessment. B. Start infusion of normal saline 500 mL. C. Ask the client about current medications. D. Obtain blood samples for laboratory testing.

B. Start infusion of normal saline 500 mL. Rationale: The low blood pressure, tachycardia, and report of being outside for several hours on a hot day suggest hypovolemia, indicating a need for immediate fluid replacement. The head-to-toe assessment is important, but can be completed after the intravenous fluids are started. Asking about the client's usual medications is necessary, but this information would not affect the decision for fluid infusion in this hypovolemic client. The client will need to have blood drawn to check electrolytes and renal function, but the infusion of fluids to prevent complications such as acute kidney injury is the priority.

When assessing a client during the postoperative period of receiving a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mmol/L). Which action would the nurse take first in response to this laboratory report? A. Notify the primary health care provider. B. Obtain current blood test results. C. Assess for decreased urine output. D. Check the intravenous (IV) infusion.

C. Assess for decreased urine output. Rationale: The expected serum creatinine range is 0.7 to 1.4 mg/dL (62-124 mmol/L). The nurse would obtain additional information that may indicate acute rejection; therefore the nurse must first assess for decreased urine output and changes in vital signs. Once additional data are collected (e.g., urine output, current blood work reports) and the IV infusions are checked, the nurse should contact the primary health care provider, explain the situation, and implement further prescriptions. Eventually the nurse would ensure proper infusion rates, along with IV medications, are being maintained after the client is first assessed for decreased urine output and for changes in vital signs. After the client is assessed for decreased urine output and changes in vital signs, the nurse would obtain current blood reports.

Which action will the nurse take when a client with an intravenous (IV) infusion containing 40 mEq of potassium reports a stinging pain at the IV site? (SATA) A. Restart the IV in a different vein. B. Assist the client through guided imagery. C. Assess the IV site. D. Ask the health care provider for pain medication. E. Verify that the potassium is adequately diluted and not infusing too rapidly

C. Assess the IV site. E. Verify that the potassium is adequately diluted and not infusing too rapidly Rationale: It is important to first make sure that the IV catheter is patent and that there is no infiltration. The potassium dosage is large and can be very irritating to veins if it isn't sufficient diluted or if it infuses too rapidly. A 40-mEq dose should be diluted in at least 1 L of IV solution. Rstarting the IV in another vein without assessment does not address the complaint. Although imagery may help distract the client from discomfort, this response provides no information as to why the stinging sensation is occurring. Asking the provider for an analgesic doesn't address the underlying problem.

Which action will the nurse take when a client appears flushed and complains of palpitations ten minutes after the start of intravenous (IV) vancomycin scheduled to infuse over 30 minutes? A. Stop the infusion. B. Continue the infusion but monitor the client. C. Contact the primary health care provider to obtain a prescription to decrease the infusion rate. D. Contact the primary health care provider to obtain a prescription for an antianxiety medication

C. Contact the primary health care provider to obtain a prescription to decrease the infusion rate. Rationale: The rate of the infusion should be decreased. Administering vancomycin too rapidly can produce "red man syndrome," characterized by flushing, an increased heart rate, and a decrease in blood pressure. These clinical findings can usually be alleviated by slowing the rate of infusion of the dose to at least 1 hour per dose. It is not necessary to stop the infusion because slowing its rate will alleviate the problem. Red man syndrome is expected only if the IV flow rate is too rapid; the rate must be decreased. The client does not need an antianxiety agent

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? A. Give the client orange juice by mouth. B. Increase the client's intravenous (IV) flow rate. C. Moisten the client's lips with a wet 4 × 4 gauze. D. Offer the client 4 oz (120 mL) of water by mouth.

C. Moisten the client's lips with a wet 4 × 4 gauze. Rationale: No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary health care provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary health care provider's prescription.

Which action would be most important for the nurse take when caring for a client who started furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L (2.8 mmol/L)? A. Hold the morning dose of the diuretic. B. Continue to monitor the level to ensure that it stays within the normal limits. C. Notify the primary health care provider of the critically low result. D. Anticipate a prescription for an increase in the dosage of the furosemide.

C. Notify the primary health care provider of the critically low result. Rationale: The health care provider should be notified because a potassium level of 2.8 mEq/L (2.8 mmol/L) is low. Normal range for serum potassium is 3.5 to 5 mEq/L (3.5-5 mmol/L). Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. The nurse should not hold the diuretic or repeat the laboratory test unless advised by the health care provider. The client's serum potassium level is critically below the normal limit, and the health care provider should be notified. An increase in furosemide would cause an increased loss of potassium.

An older client is admitted to the hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? A. Calcium B. Chlorides C. Potassium D. Phosphates

C. Potassium Rationale: Potassium, sodium, and bicarbonate are the electrolytes most often lost with diarrhea. With diarrhea, these electrolytes are excreted via the gastrointestinal tract before they can be absorbed. Hypokalemia can cause cardiac dysrhythmias. Serum calcium levels are related to parathyroid function and calcium metabolism. Although the chloride level may be affected by diarrhea, it is not the greatest concern. Phosphate levels are regulated by calcium metabolism and parathormone.

Which clinical manifestation would the nurse expect when assessing a client with hypercalcemia? (SATA) A. Muscle tremors B. Abdominal cramps C. Increased peristalsis D. Cardiac dysrhythmias E. Hypoactive bowel sound

D. Cardiac dysrhythmias E. Hypoactive bowel sound Rationale: When the serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.

Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? A. Decrease in tissue hydrostatic pressure B. Increase in plasma hydrostatic pressure C. Increase in tissue colloid osmotic pressure D. Decrease in plasma colloid oncotic pressure

D. Decrease in plasma colloid oncotic pressure Rationale: Because the plasma colloid oncotic pressure is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.

Which symptom in a client receiving hydrochlorothiazide would cause a nurse to notify the health care provider? A. Insomnia B. Nasal congestion C. Increased thirst D. Generalized weakness

D. Generalized weakness Rationale: Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy. Insomnia is not known to be related to hypokalemia or hydrochlorothiazide therapy. Although a stuffy nose is unrelated to hydrochlorothiazide therapy, it can occur with other antihypertensive medications. Increased thirst is associated with hypernatremia. Because this medication increases excretion of water and sodium in addition to potassium and chloride, hyponatremia, not hypernatremia, may occur.

List the actions in the order in which they will be performed by the nurse transfusing packed red blood cells prescribed for a client with anemia. 1. Ensure that the client signed a consent for the transfusion. 2. Determine the client's vital signs. 3. Verify that the number on the blood product, laboratory record, and client arm band match. 4. Don a pair of clean gloves. 5. Initiate the transfusion slowly.

Rationale: A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. Clean gloves must be worn before inserting the spike of the blood administration set. The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed.

Which indicator of client status is important for the nurse to assess in a client receiving total parenteral nutrition? A. Blood glucose B. Occult blood in stool C. Urine specific gravity D. Presence of bowel sounds

A. Blood glucose Rationale: Blood glucose that exceeds the renal threshold for glucose reabsorption in the kidney tubules (approximately 160-180 mg/dL) will cause cellular osmotic diuresis, resulting in dehydration. Stool for occult blood determines the presence of digested blood in the stool; it is unrelated to total parenteral nutrition. An altered specific gravity is nonspecific; increases can result from causes other than glycosuria. Checking the abdomen for bowel sounds assesses for increased or decreased peristalsis; it is unrelated to total parenteral nutrition.

Which clinical finding is important for the nurse to monitor for when a total parenteral nutrition (TPN) solution is prescribed to infuse at 1 liter every 12 hours? (SATA) A. Activity tolerance B. Intake and output C. Orthostatic vital signs D. Glucose levels E. Serum electrolytes

B. Intake and output D. Glucose levels E. Serum electrolytes Rationale The solution is hyperosmolar and is a concentrated source of glucose, electrolytes, and other nutrients; therefore it is essential to monitor glucose levels, intake and output, and serum electrolytes. Monitoring of activity tolerance and orthostatic vital signs is not routinely done for TPN administration.

Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide? A. Chvostek sign B. Muscle weakness C. Anxious behavior D. Abdominal cramping

B. Muscle weakness Rationale: With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue and muscle weakness. Chvostek sign, the contraction of the facial muscles in response to a light tap over the facial nerve in front of the ear, is associated with hypocalcemia; low calcium levels allow sodium to move into excitable cells, increasing depolarization and nerve excitability. Anxiety and irritability are associated with hyperkalemia. Hyperkalemia affects the nervous and muscular systems; fatigue, weakness, and lethargy are associated with hypokalemia. Decreased gastrointestinal motility occurs with hypokalemia; abdominal cramping is associated with hyperkalemia and is caused by hyperactivity of smooth muscles.

Which fluid shift will the nurse take into consideration when assessing a client with type 1 diabetes who is experiencing a fluid imbalance? A. Intravascular to interstitial as a result of glycosuria B. Extracellular to interstitial as a result of hypoproteinemia C. Intracellular to intravascular as a result of hyperosmolarity D. Intercellular to intravascular as a result of increased hydrostatic pressure

C. Intracellular to intravascular as a result of hyperosmolarity Rationale: The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.