NU373 Week 1 EAQ Evolve Elsevier: Fluids and Electrolytes (F&E)

A registered nurse (RN) is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? o "Edema results in the separation of skin from pigmented and vascular tissue." o "Pitting edema leaves an indentation on the site of application of pressure." o "Trauma or impaired venous return should be suspected in clients with edema." o "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

o "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given." · The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site leaves an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.

Which clinical manifestation would the nurse associate with successful fluid replacement therapy? o A trended urinary output of at least 30 mL/h o Central venous pressure reading of 1.5 mm Hg o Baseline pulse rate of 120 beats per minute decreasing to 110 beats per minute within a 15-minute period o Baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period

o A trended urinary output of at least 30 mL/h · The nurse would consider a urinary output rate of 30 mL/h adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats per min decreasing to 110 beats per minute within a 15-minute period and a baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period indicates improved tissue perfusion, but not necessarily adequate tissue perfusion. Compensatory mechanisms such as the renin-angiotensin-aldosterone system may continue reabsorption of fluids. Clinical manifestations reflecting adequate tissue perfusion also means the client does not need the compensatory mechanisms any longer, and urinary output increases.

A client with acute kidney failure reports fatigue and becomes lethargic. Upon reviewing the client's medical record, which finding would the nurse determine is the most likely cause of these clinical manifestations? o Hyperkalemia o Hypernatremia o A limited fluid intake o An increased blood urea nitrogen (BUN) level

o An increased blood urea nitrogen (BUN) level · An increased BUN level, indicating uremia, is toxic to the central nervous system and causes fatigue and lethargy. Hyperkalemia is associated with muscle weakness, irritability, nausea, and diarrhea. Hypernatremia is associated with firm tissue turgor, oliguria, and agitation. Dehydration can cause fatigue, dry skin and mucous membranes, and rapid pulse and respiratory rates.

When assessing a client who has lost a large amount of blood after an automobile collision, which finding would the nurse expect? o Urine output of 50 mL/h o Blood pressure of 150/90 mm Hg o Apical heart rate of 142 beats/minute o Respiratory rate of 16 breaths/minute

o Apical heart rate of 142 beats/minute · In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/h, because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure would decrease because of the decreased blood volume. Respiratory rate of 16 breaths/minute is within the accepted range of 12 to 20 breaths/minute; the respiratory rate is rapid with hypovolemic shock.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. o Assessment of skin turgor o Documentation of vital signs o Assessment of intake and output o Administration of antiemetic medications o Replacement of fluid and electrolytes

o Assessment of skin turgor o Administration of antiemetic medications o Replacement of fluid and electrolytes · 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.

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which medication will the nurse expect the health care provider to prescribe? o Calcium o Magnesium o Bicarbonate o Potassium chloride

o Calcium · 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.

A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? o Acidosis o Calcium depletion o Potassium retention o Sodium chloride depletion

o Calcium depletion · In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.

When caring for a client who has hyponatremia, the nurse would monitor for which symptom? o Increased urine output o Deep rapid respirations o Change in level of consciousness o Distended neck veins

o Change in level of consciousness · A normal sodium level is between 135 and 145 mEq/L (135-145 mmol/L) of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular overhydration, which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue, and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output.

The nurse assesses an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? o Sunken eyes o Dry, flaky skin o Change in mental status o Decreased bowel sounds

o Change in mental status · Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the older adult client.

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

o Clear breath sounds · 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.

The nurse is reviewing the laboratory reports of a group of older adult clients. Which client has an age-related impairment of the thirst mechanism? o Client A o Client B o Client C o Client D

o Client A · 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 finding by the nurse when assessing a client who is receiving intravenous (IV) fluids indicates need for a change in the fluid infusion rate? o Crackles in lungs o Supple skin turgor o Urine output of 480 mL over 8 hours o Heart rate decrease from 126 beats/minute to 96 beats/minute

o Crackles in lungs · Crackles in the lungs indicate the client is overloaded with fluids; the nurse would notify the health care provider and anticipate discontinuing or slowing the rate of the IV infusion. Supple skin turgor is a normal finding, indicating that the IV fluid is working. A urine output of 480 mL in 8 hours is adequate. A decrease in heart rate indicates improvement in hypovolemia.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? o Crackles in the lungs o Decreased heart rate o Decreased blood pressure o Cyanosis of nailbeds

o Crackles in the lungs · Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. o Daily weight o Intake and output o Monitor for edema o Daily pulse oximetry o Auscultate breath sounds

o Daily weight o Intake and output o Monitor for edema o Daily pulse oximetry o Auscultate breath sounds · 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 explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? o Body weight control o Decreased fluid retention o Lowering of blood pressure o Prevention of hypernatremia

o Decreased fluid retention · 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 won't help with weight. Sodium restriction may lower blood pressure with hypertension, because of the Frank-Starling law, lower sodium intake may lead to improved cardiac output & higher blood pressures in clients with heart failure. Dietary sodium intake plays very little role in serum sodium levels (high serum sodium levels is hypernatremia), which are controlled by multiple hormonal mechanisms, including antidiuretic hormone, aldosterone, & natriuretic peptide.

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. o Decreased urine o Hypotension o Dyspnea o Dry mucous membranes o Lung crackles o Poor skin turgor

o Decreased urine o Hypotension o Dry mucous membranes o Poor skin turgor · Decreased urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and crackles in the lungs may be caused by fluid overload.

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

o Distended jugular veins · 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 action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. o Diuretics o Low-salt diet o Daily weight checks o Fluid restriction o Intake and output

o Diuretics o Low-salt diet o Daily weight checks o Fluid restriction o Intake and output o Oxygen administration · Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. o Fatigue o Orthopnea o Pitting edema o Dry hacking cough o 4-pound weight gain

o Fatigue o Orthopnea o Pitting edema o Dry hacking cough o 4-pound weight gain · Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse's hand is used to perform this assessment? o Fingertips o Pads of fingertips o Ulnar surface of hand o Palmer surface of finger pads

o Fingertips · The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? o Skin condition o Fluid and electrolyte balance o Food intake o Fluid intake and output

o Fluid and electrolyte balance · Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

Which instructions would the nurse include when providing teaching to the parents of a child prescribed diuretics? Select all that apply. o Fluid intake should be adequate. o Diuretics should be taken on an empty stomach. o Diuretics should be taken at the same time each day. o Diuretics may interfere with normal laboratory test values. o Sun or heat exposure should be avoided because of the risks of skin darkening.

o Fluid intake should be adequate. o Diuretics should be taken at the same time each day. o Diuretics may interfere with normal laboratory test values. · The parents should ensure that their child has adequate fluid intake to prevent dehydration. The medication should be taken every day at the same time to facilitate maximum therapeutic action. The parents should be informed that diuretics may interfere with normal laboratory test values such as serum levels of sodium, potassium, magnesium, and chloride. Diuretics should be taken with food or milk to prevent gastric irritation. Sun and heat exposure may cause fluid loss and heat stroke.

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. o Intake of salty foods o Dietary fat intake o Medication compliance o Family stresses o Recent travel

o Intake of salty foods o Medication compliance o Recent travel · Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. Poor adherence to medication used to treat heart failure, such as angiotensin-converting-enzyme inhibitors and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake. Increased or decreased dietary fat intake will not cause fluid retention. Stress is not a contributor to fluid retention.

After reviewing the chart for a client who was recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately? o Pain medication o Intravenous fluids o Multiple antibiotics o Packed red blood cells

o Intravenous fluids · 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 finding for a client who has a potassium level of 2.8 mEq/L (2.8 mmol/L) would be of most concern to the nurse? o Abdominal cramps o Irregular heart rate o Decreased reflexes o Muscle weakness

o Irregular heart rate · The most serious complications of hypokalemia are due to changes in cardiac function, including potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation. Abdominal cramps occur with hypokalemia, but are not fatal. Decreased reflexes occur with hypokalemia, but are not fatal. Muscle weakness occurs with hypokalemia and may progress to paralysis, but is not immediately fatal.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. o Diplopia o Skin rash o Leg cramps o Tachycardia o Muscle weakness

o Leg cramps o Muscle weakness · 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 nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? o Monitor for cardiac dysrhythmias. o Inquire about changes in bowel patterns. o Assess for leg muscle twitching or weakness. o Assess for signs and symptoms of dehydration.

o Monitor for cardiac dysrhythmias. · 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 collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mm Hg? o Offer frequent oral fluids for several hours. o Administer 1 liter of normal saline over 2 hours. o Give fluid and electrolytes per nasogastric tube. o Infuse 500 mL of lactated Ringer's solution over 30 minutes.

o Offer frequent oral fluids for several hours. · Usually the least invasive means possible of rehydration is used for clients needing rehydration. Based on the heart rate and blood pressure, the client has mild dehydration, and oral fluids offered over several hours will improve hydration. Infusion of normal saline could be used, but is more invasive and has a small risk of infection associated with the use of an intravenous catheter. Nasogastric tube use is invasive and uncomfortable and not needed in this alert client, who can swallow liquids. Infusion of electrolyte solutions such as lactated Ringer's solution rapidly also is invasive and places the client at risk of infection.

When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. o Oliguria o Dyspnea o Hypotension o Pulmonary crackles o Tenting skin turgor

o Oliguria o Hypotension o Tenting skin turgor · With dehydration, the body tries to conserve fluid, resulting in lowered urinary output (oliguria). Dehydration leads to hypovolemia and less circulatory volume, causing decreased cardiac output and hypotension. Fluid volume deficit causes decreased skin turgor and skin tenting when pinched. Difficulty breathing (dyspnea) is a result of pulmonary congestion, which is associated with hypervolemia. Auscultation of crackles is a result of pulmonary congestion, which does not occur with dehydration.

Which hormone regulates blood levels of calcium? o Parathyroid hormone (PTH) o Luteinizing hormone (LH) o Thyroid-stimulating hormone (TSH) o Adrenocorticotropic hormone (ACTH)

o Parathyroid hormone (PTH) · Parathyroid hormone (PTH) regulates the blood levels of calcium and phosphorus. LH stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. TSH stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. ACTH promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next? o Perform a head-to-toe assessment. o Place the client on restricted fluid intake. o Discuss a restricted sodium diet with the client. o Document the findings in the health care record.

o Perform a head-to-toe assessment. · Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary crackles associated with left-sided heart failure. More assessment data is needed before deciding whether fluid restrictions are needed for this client. Restricting sodium in the diet is appropriate for most clients with heart failure, but assessment for symptoms of worsening heart failure is a higher priority. Documentation of findings is needed, but not as important as assessing the client for symptoms that may indicate a need for changes in the therapeutic plan.

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? o Implanted port o Midline catheter o 18-gauge peripheral venous catheter o Peripherally inserted central catheter (PICC) line

o Peripherally inserted central catheter (PICC) line · Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but require specialized needles and staff who are trained in accessing the port. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.

The nurse reviews the medical record of an older adult client admitted with chronic kidney disease. Which clinical finding is the priority requiring collaboration with the primary health care provider? o Sodium level o Potassium level o Creatinine results o Blood pressure results

o Potassium level · The client has an increased potassium level outside the expected range for an adult, placing the client at risk for a cardiac dysrhythmia; the higher priority is treatment for the increased potassium, because elevated levels can be lethal. The serum sodium of 135 mEq/L (135 mmol/L) is expected because of the electrolyte imbalance and the anemia related to the decreased production of erythropoietin by the kidney in the presence of chronic kidney failure. A creatinine clearance of 20 mL/min (0.33 mL/s) is low (normal range 95 mL/min in young women; 120 mL/min in young men); however, the client has chronic renal disease and this value reflects the disease process. The priority is the high potassium level. Clients with chronic kidney disease usually have hypertension, and notification is unnecessary.

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription would the nurse question? o Add table salt to each meal. o Fluid restriction of 1000 mL per day. o Assess neurological status every 2 hours. o Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h.

o Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h. · Because 0.45 % NaCl (one-half normal saline) is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. It is important for the nurse to assess for neurological changes.

When monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? Select all that apply. o Thirst o Seizures o Erythema o Confusion o Constipation

o Seizures o Confusion · Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures. Thirst is a symptom of hypernatremia; it may indicate dehydration. Erythema is not associated with hyponatremia. Diarrhea, not constipation, is associated with hyponatremia.

Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? o Complete blood count o Serum potassium level o Arterial blood gas panel o Urine osmolality test

o Serum potassium level · Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit.

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? o Serum sodium of 139 mEq/L (139 mmol/L) o Serum chloride of 100 mEq/L (100 mmol/L) o Serum calcium of 10.2 mg/dL (2.55 mmol/L) o Serum potassium of 7.2 mEq/L (7.2 mmol/L)

o Serum potassium of 7.2 mEq/L (7.2 mmol/L) · 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).

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? o Pain tolerance o Skin turgor o Ecchymosis formation o Tissue mass

o Skin turgor · Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? o Sodium o Calcium o Potassium o Magnesium

o Sodium · Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.

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? o Complete a head-to-toe assessment. o Start infusion of normal saline 500 mL. o Ask the client about current medications. o Obtain blood samples for laboratory testing.

o Start infusion of normal saline 500 mL. · 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.

Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse? o The serum potassium level is 3.1 mEq/L (3.1 mmol/L). o The client is confused about the date and time of day. o The client reports incisional pain at level 8 (0 to 10 scale). o Chest tube collection chamber has 150 mL of bloody fluid.

o The serum potassium level is 3.1 mEq/L (3.1 mmol/L). · Hypokalemia is a common complication after CABG and immediate infusion of potassium to correct hypokalemia is needed to prevent postoperative dysrhythmias. Confusion in the immediate postoperative period is common after cardiopulmonary bypass and will be monitored by the nurse, but does not require any other action at this time. Incisional pain is common after CABG and the nurse will administer prescribed pain medications, but pain is not a life-threatening complication. Chest tube drainage of 100 to 200 mL is not unusual in the first hours after CABG; the nurse will monitor the chest tube drainage hourly, but no other action is needed.

The nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. Which assessment will provide the nurse with the most significant data? o Weights every day o Urinary output every hour o Blood pressure every 15 minutes o Extent of peripheral edema every 4 hours

o Urinary output every hour · A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? o Weighing the client o Monitoring the intake and output o Assessing the extent of pitting edema o Asking the client about subjective symptoms

o Weighing the client · Because 1 liter of fluid weighs approximately 2.2 pounds (1 kg), daily weights are the best way to monitor fluid volume status. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client. Subjective symptoms such as dyspnea may vary for other reasons than fluid balance status.