NSG 170 (Health Illness concepts) Fluid and Electrolyte Elsevier Quizzes (40)

Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)?

ANS: Monitor for cardiac dysrhythmias. Rationale: Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess?

ANS: 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 decreased.

Which food would a nurse instruct the client to include in the diet when being prescribed furosemide?

ANS: Bananas Rationale: Furosemide is a loop diuretic that increases potassium excretion by preventing renal absorption. Bananas have a significant amount of potassium. Bananas: 450 mg; cabbage: 243 mg; liver: 73.6 mg; apples: 100 to 120 mg.

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful?

ANS: 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 assessment finding indicates that sodium polystyrene sulfonate has been effective?

ANS: A decrease in serum potassium level Rationale: Sodium polystyrene sulfonate is given to treat hyperkalemia. The effectiveness of the medication is determined by a decreasing serum potassium level. Sodium polystyrene sulfonate binds with the potassium in the gastrointestinal system and often causes diarrhea. Sodium retention and hypernatremia may occur as an adverse effect; this does not indicate effectiveness. Sodium polystyrene sulfonate decreases serum calcium levels in a small number of clients but does not increase calcium.

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy?

ANS: Bounding pulse Presence of dependent edema 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.

Which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns?

ANS: Hematocrit (Hct) Rationale: An increased Hct level indicates hemoconcentration secondary to fluid loss. The BUN level may be used to indicate dehydration from burns, but interpretation can be complicated by other conditions accompanying burns that also cause an increase in the BUN. An increase in the sedimentation rate indicates the presence of an inflammatory process, not fluid loss. The pH level reflects acid-base balance.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency?

ANS: Leg cramps 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 medication requires the nurse to monitor the client for signs of hyperkalemia?

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

Which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure?

ANS: Daily weight Intake and output Monitor for edema Daily pulse oximetry 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 action is the function of antidiuretic hormone (ADH)?

ANS: Decreases water loss in urine Rationale: ADH is released by the posterior pituitary gland. It is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. ADH acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

Which principle explains how loop diuretics promote diuresis?

ANS: 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.

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client?

ANS: Serum potassium of 7.2 mEq/L (7.2 mmol/L) Rationale: Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135- 145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).

Which response would a nurse monitor for when a client is receiving furosemide to relieve edema?

ANS: Weight loss 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 statement about administration of IV potassium would a nurse make to a client with a diagnosis of hypokalemia?

ANS: 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?

ANS: Urinary output Last serum potassium level 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 action would the nurse take after identifying that a client's urinary output is less than 40 mL/h over the past 3 hours?

ANS: Assess breath sounds and obtain vital signs. Rationale: The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with the excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a health care provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed.

Which electrolyte deficiency triggers the secretion of renin?

ANS: 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.

A client is 36 hours after admission with severe burns and the nurse identifies the client's potassium level is 6.0 mEq/L (6.0 mmol/L). The nurse would recommend substituting current dietary fluids with which drink?

ANS: Tea Rationale: The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

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?

ANS: 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 physiological alteration will the nurse monitor to best determine the effectiveness of a client's hydrochlorothiazide therapy?

ANS: 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 client would a nurse recognize as having an age-related impairment of the thirst mechanism when reviewing the laboratory reports of a group of older adult clients? Client A serum sodium concentration 167mEq/L Client B. serum sodium concentration 143mEq/L Client C. serum sodium concentration 118mEq/L Client D. serum sodium concentration 101mEq/L

ANS: Client A Rationale: Older adult clients are at greater risk of fluid and electrolyte imbalances such as dehydration and hypernatremia due to age-related impairment of the thirst mechanism. The normal serum sodium concentration is between 135 and 145 mEq/L. Client A has a serum sodium concentration of 167 mEq/L, which is higher than normal, thereby indicating hypernatremia. Client B has a serum sodium concentration of 143 mEq/L, which is a normal value. The serum sodium concentration of client C is 136 mEq/L, which is a normal value. Client D has a serum sodium concentration of 140 mEq/L, which is in the normal range.

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet?

ANS: Decreased fluid retention Rationale: The purpose of a low-sodium diet for clients with heart failure is to decrease fluid retention. Clients with heart failure may or may not need weight loss, but a low-sodium diet will not help with weight control. Although sodium restriction may lower blood pressure in clients with hypertension, because of the Frank-Starling law, lower sodium intake may lead to improved cardiac output and higher blood pressures in clients with heart failure. Dietary sodium intake plays very little role in serum sodium levels (high serum sodium levels is called hypernatremia), which are controlled by multiple hormonal mechanisms, including antidiuretic hormone, aldosterone, and natriuretic peptide.

Which action is the nurse's priority when caring for client admitted for dehydration on an intravenous (IV) infusion of normal saline at 125 mL/h who begins screaming, "I can't breathe!" one hour after the IV is initiated?

ANS: Elevate the head of the bed and obtain vital signs. Rationale: Normal saline will not cause an allergic reaction and a mere 125 mL in a dehydrated client will not cause pulmonary edema, so it is important to further assess the patient to determine the cause of the client's distress. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress. Discontinuing the IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the health care provider at this time. There is no information to support changing the IV to an intermittent infusion device. There is not enough information to support calling the health care provider and obtaining a prescription for a sedative; further assessment is required.

Which disease increases the risk of hyperkalemia?

ANS: 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.

In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride?

ANS: 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.

After reviewing the chart of a client recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately?

ANS: 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 action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure 102/56 mm Hg?

ANS: Offer oral fluids at frequent intervals. Rationale: Replacement of fluids in dehydrated clients is best done through the oral route, when possible. In this healthy young adult whose vital signs indicate mild hypovolemia, the nurse would offer oral fluids to correct hypovolemia. Clients who cannot swallow oral fluids may need a nasogastric tube for fluid replacement. Because nausea and vomiting are not the cause of the client's dehydration, antiemetic medications are not needed. Intravenous fluid infusion is needed for clients who are unable to take adequate amounts of oral fluids.

Which cation regulates intracellular osmolarity?

ANS: Potassium Rationale: A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

Which electrolyte found in intracellular fluid would the nurse consider most important?

ANS: Potassium Rationale: The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.

Which rationale supports the nurse's instruction that a client with chronic kidney disease is to avoid all salt substitutes?

ANS: Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. Rationale Salt substitutes usually contain potassium, which can lead to hyperkalemia; dysrhythmias are associated with hyperkalemia. Chronic kidney disease already places the client at a higher risk for hyperkalemia because of poor elimination of fluids and electrolytes. Sodium, not salt substitutes, in the diet causes retention of fluid. Salt substitutes do not contain substances that influence blood urea nitrogen and creatinine levels; these are the result of protein metabolism. There is not a substance in the salt substitute that interferes with capillary membrane transfer. Anasarca is extensive fluid in the tissues throughout the body and more extensive than typical edema.

Which statement by a client receiving diuretic therapy indicates that the teaching about potassium supplements is understood?

ANS: "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.

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. The nurse will set the control device to deliver how many milliliters per hour? Record your answer using a whole number. mL/h

ANS: 167mL/h Rationale: The volume to be infused is 2000 mL. The total time of infusion is 12 hours. 2000 mL/ 12 hours = 167 mL/ hour.

A client is to receive 0.25 mg of digoxin intramuscularly. The ampule is labeled 0.5 mg = 2 mL. How many milliliters will the nurse administer? Record your answer using a whole number. mL

ANS: 1mL Rationale The prescribed dose is 0.25 mg. The available concentration is 0.5 mg in 2 mL. Use dimensional analysis and/or ratio and proportion to determine the appropriate amount to be administered in milliliters. 0.25 mg x 2 mL/0.5mg = 1 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?

ANS: 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 intravenous fluid is a hypertonic solution?

ANS: 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.

Which response would be given by a nurse providing discharge teaching to an older adult who was admitted to the hospital to be treated for dehydration when the client asks what to do about itchy, dry skin?

ANS: "Use a moisturizer on the skin daily to help reduce itching." Rationale: Lubricating the skin with a moisturizer effectively relieves dryness and, thus, the pruritus (itching). Wearing warm clothing will not lubricate the skin or relieve pruritus. Warm or cool, not hot, tub baths will reduce itching. Exposing the skin to the air causes further drying and will not relieve pruritus.

The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning?

ANS: Administering sodium polystyrene sulfonate Rationale: Increased potassium levels indicate hyperkalemia and are observed in clients with adrenal insufficiency. Administering potassium binding and excreting resin, such as sodium polystyrene sulfonate, can reduce the potassium levels. Potassium restriction should be initiated immediately to reduce the potassium levels. Monitoring glucose is required in a client with hypoglycemia, not hyperkalemia. Providing potassium-sparing diuretics may further lead to increase in potassium levels, and these diuretics should be avoided.

Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels?

ANS: Aldosterone Rationale: Aldosterone is mineralocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.

An infant with a 3-day history of decreased fluid intake and diarrhea is admitted with dehydration and lethargy. Which explanation would the nurse give the parent for the infant's rapid deterioration?

ANS: The extracellular fluid requirement per unit of body weight is greater in infants than in adults. Rationale: Complications of fluid loss occur much more rapidly in infants compared with children and adults because extracellular body fluid represents 45% of the body at birth, 25% at 2 years of age, and 20% at maturity. Another measurement is fluid's percentage of total body weight, which is 80% at birth, 63% at 3 years, and approximately 60% at 12 years. Cellular metabolism in children is stable, but its rate is higher than that in adults. The proportion of total body water in children (up to 2 years) is greater than it is in adults. Renal function is immature through the second year of life, not until school age, which makes it more difficult to maintain fluid balance.