NUR 2 Fluid & Electrolytes
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective?
"I need to drink liquids with some sodium in them." Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.
The registered nurse discusses normal renal function with the client. Which statements made by the client are correct regarding regulatory functions of the kidney?
"They play a role in acid-base balance." "They play a role in fluid and electrolyte balance." Maintaining the acid-base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (erythropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control.
A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
21. Flow rate = Ordered rate (ml/min) x Drop factor 2.08ml/min x 10gtt/mil
What is the maximum length of time a nurse should allow an intravenous bag of solution to infuse?
24 hours. After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often, such as 6 hours, 12 hours, or 18 hours.
A 6-month-old infant weighing 15 lb (6.8 kg) is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg electrolyte replacement over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?
28 ml. At 15 lb (6.8 kg) the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The other amounts (32 mL, 38 mL, 42 mL) are too much.
The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output?
495. Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL. I & O difference: 1100 - 605 = 495 mL
An adolescent is hospitalized for dehydration. An intravenous infusion of 1000 mL of 0.9% sodium chloride with 20 mEq/L of potassium chloride is prescribed. Hospital policy states that potassium should be mixed in a 500-mL bag of 0.9% sodium chloride. The potassium chloride label reads "2 mEq/mL." How many milliliters of potassium chloride should the nurse add to the 500-mL bag?
5 ml. Desired 10 mg/Have 2 mg.
What is a normal Calcium range?
8.5-10.5 mg/dL
A nurse is caring for a client with end-stage renal disease. For which clinical indicator should the nurse monitor the client?
Azotemia. Azotemia is an increase in nitrogenous waste (particularly urea) in the blood, which is common with end-stage renal disease. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency because of the inability to concentrate urine. Jaundice is common to biliary obstruction, not to end-stage renal disease. The blood pressure may be elevated as a result of hypervolemia associated with increased total body fluid.
Which degree of edema will result in a 6-mm deep indentation upon pressure application? A. 4+ B. 3+ C. 2+ D. 1+
B. 3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
Blood lab results. Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems.
A client is receiving hydrochlorothiazide. What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy?
Blood pressure. Diuretics promote urinary excretion, which reduces the volume of fluid in the intravascular compartment, thus lowering blood pressure. Edema reflects multiple physiologic processes including venous competence, gravity, and disuse. The serum sodium level remains stable unless the dosage is excessive; an altered sodium level is not a therapeutic response. Although specific gravity decreases with increased urinary output, this does not reflect the desired reduction in intravascular pressure.
The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful?
Broccoli. Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.
Which hormone is released in response to low serum levels of calcium? A. Renin B. Erythropoietin C. Parathyroid hormone D. Atrial natriuretic peptide
C. Parathyroid hormone If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis. Renin is a hormone released in response to decreased renal perfusion; this hormone is responsible for regulating blood pressure. Erythropoietin is released by the kidneys in response to poor blood flow to the kidneys; it stimulates the production of red blood cells. Atrial natriuretic peptide is produced by the right atrium of the heart in response to increased blood volume. This hormone then acts on the kidneys to promote sodium excretion, which decreases the blood volume.
A nurse in the mental health unit is working with a group of adolescent girls with the diagnosis of anorexia nervosa. What does the nurse recall is the major health complication associated with intractable anorexia nervosa?
Cardiac dysrhythmias resulting in cardiac arrest. These clients have severely depleted levels of potassium and sodium because of the starvation diet and energy expenditure; these electrolytes are necessary for adequate cardiac function. Although endocrine imbalance resulting in amenorrhea, slowed metabolism resulting in cold intolerance, and glucose intolerance resulting in protracted hypoglycemia may occur, they are not the major health problem.
An obese client had an adjustable gastric banding procedure performed to reduce weight. At a follow-up visit the client reports episodes of abdominal pain and vomiting after eating. What should the nurse encourage the client to do?
Chew food thoroughly before swallowing. Chewing helps to slow down the eating process and breaks down food into smaller pieces. Well-chewed food is less likely to cause esophageal distention, abdominal cramps, or vomiting. Fluid intake should be limited with meals. Eating regimens are three to six meals high in protein and low in carbohydrates and fat. Nutrient-dense, not calorie-dense, foods should be ingested by the client with a gastric banding.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? A. Provide pretzels as a snack daily. B. Restrict fluid intake to 1000 mL per day. C. Assess neurologic status every 2 hours. D. Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
D. Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr. Because one-half NS 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. Therefore it is important for the nurse to assess for neurologic changes.
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner?
Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.
What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration?
Depressed anterior fontanel. A depressed anterior fontanel is a classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid.
A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?
Electrolyte imbalance. When clients do not receive nutrients or fluids by mouth and have loss of electrolytes through the removal of gastric secretions via an NG tube, then electrolyte imbalance is a primary concern. Constipation is usually not a concern in this type of situation. Although dehydration is a possible effect of an NG tube removing gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.
A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client?
Electrolyte imbalances. An ileostomy directs liquid feces out of the body, bypassing the large intestine where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance.
A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure?
Ensure that the consent form is signed. Assess the client for iodine sensitivity. Administer an enema or cathartic to the client. The presence, position, shape, and size of kidneys, ureters, and bladder can be evaluated using an intravenous pyelogram (IVP). The contrast medium used in the procedure may cause hypersensitivity reactions. Therefore, the nurse should assess the client for sensitivity to iodine prior to the procedure. The nurse should use a cathartic or enema to empty the colon of feces and gas. An IVP does need a consent form since the procedure is invasive. The nurse has the client remove all metal objects before performing a magnetic resonance imaging (MRI) procedure. The nurse instructs the client to lie still during a computed tomographic (CT) scan procedure; during an IVP the client may be asked to turn certain ways.
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances?
Extracellular fluid volume (ECV) deficit. Hypokalemia. Hypocalcemia.
When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. What response should the nurse critically assess on this client?
Fluid deficit. Dehydration is a danger because of fluid loss with gastrointestinal (GI) suction. Based on the data provided, edema, belching, and excessive salivation are not likely to occur.
A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity, 1.015; urine output, 50 mL/hr; hematocrit, 42 (0.42 volume fraction); albumin, 3.6 g/dL (36 g/L); and pulmonary arterial wedge pressure, 10 mm Hg. Which conclusion will the nurse draw based upon the laboratory results?
Fluid therapy is successful. All the values provided are within expected limits for an adult, indicating successful fluid therapy. Urine output is greater than 30 ml/hr. The albumin is in the expected range for an adult. There is no evidence of kidney failure; all the values provided are within expected limits for an adult. The hematocrit is within the expected limits for an adult; with hemoconcentration the hematocrit is elevated.
Which complications does the nurse expect in the client with a renal disorder who has a blood urea nitrogen (BUN)/creatinine ratio of 28?
Fluid volume deficit. Obstructive uropathy. The normal range of blood urea nitrogen (BUN)/creatinine ratio is 6 to 25. The BUN/creatinine ratio of 28 is a higher value than the normal; the client may have complications like fluid volume deficit and obstructive uropathy. A decrease in BUN levels indicates malnutrition and severe hepatic damage. Increased serum creatinine levels indicate kidney impairment
What electrolyte imbalance is associated with hyperparathyroidism?
Hypercalcemia. Levels of Calcium > 10.5 mg/dL.
What electrolyte imbalance is associated with hypoparathyroidism?
Hypocalcemia. Levels of Calcium < 8.0 mg/dL.
Where is Calcium absorbed?
In the duodenum actively, jejunum passively.
A client with a history of Crohn disease develops an intestinal obstruction. A nasogastric tube is inserted and connected to low continuous suction. The nurse monitors the client for fluid volume deficit. What clinical finding does the nurse expect if the client becomes dehydrated?
Inelastic skin turgor. When there is a fluid volume deficit, fluid moves from the intracellular and interstitial compartments into the intravascular compartment in an attempt to maintain blood volume. Cellular dehydration is manifested by poor (inelastic) tissue turgor; tissue turgor is assessed by the rapidity with which skin returns to its original position after being pinched. Lethargy and fatigue, not restlessness, are expected with dehydration. With an intestinal obstruction, there is an absence of bowel movements; constipation is not a good indicator of dehydration in this situation. Hypotension, not hypertension, is associated with hypovolemia.
When administering albumin intravenously, what fluid shifts does the nurse anticipate?
Interstitial compartment to the intravascular compartment. Intravenous albumin increases colloid osmotic pressure, resulting in a pull of fluid from the interstitial compartments to the intravascular compartment. Intravascular compartment to the interstitial compartment and extracellular compartment to the intracellular compartment are opposite to the actual shift of fluids when albumin is administered.
A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client?
Intracellular to intravascular as a result of hyperosmolarity. 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.
The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine?
Ketones. As a result of fat metabolism, ketone bodies are formed, and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low-carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.
What fluids are used in fluid resuscitation for burn victim?
Lactated Ringer's; Hypertonic LR for burns over 25% total body surface area (TBSA)
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency?
Leg cramps, 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.
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift?
Lethargy and constipation from hypercalcemia. Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.
The mother of an adolescent reports that her child does not eat properly, performs strenuous physical exercise, and is very introverted. What nursing interventions would be appropriate?
Monitoring the adolescent's fluid and electrolyte status. Monitoring the adolescent for disturbances in family interactions. Checking for evidence of self-induced vomiting. Developing a mutually agreeable targeted daily caloric intake goal. Abnormal habits that involve not eating properly, performing strenuous physical exercise, and being introverted may be signs of anorexia. Adolescents with anorexia may have fluid and electrolyte imbalances due to a reduced intake of nutritious food, which may lead to cardiac problems. Disturbances in family interaction may result in an adolescent's introverted behavior. Self-induced vomiting is a characteristic feature of eating disorders. Because the adolescent may have a low nutrient intake, a mutually agreeable targeted daily caloric intake goal should be crafted. Personal hygiene and sanitation counseling is not appropriate in this case.
What are normal urine levels? (Specific gravity, pH, protein)
Normal urine specific gravity: 1.000 - 1.030 Average urine pH: 6 Normal urine protein: 0 - 0.8 mg/dL
A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect?
Pallor, Agitation, Tachycardia, Narrow pulse pressure. Pale skin (pallor), agitation, tachycardia, and narrow pulse pressure are signs of cardiogenic shock. Decreased respirations are not expected with cardiogenic shock.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color?
Phenazopyridone.
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?
Plasma proteins moving out of the intravascular compartment. The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider?
Potassium 3.0 mEq/L (3.0 mmol/L). A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm 3is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L).
An older client comes to the emergency department after three days of diarrhea and is admitted to the hospital for rehydration therapy. In addition to sodium, what electrolyte should the nurse be concerned about most when the client's laboratory results are documented?
Potassium. 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.
What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)?
Providing frequent oral care. Instituting fall risk precautions. Monitoring for and reporting neurologic changes. The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output, increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk precautions are instituted to protect the client from injury that might occur as a result of neurologic changes associated with declining serum sodium. The nurse monitors for and reports changes in neurologic status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that antidiuretic hormone release should be decreased.
The laboratory reports of a client reveal that the serum creatinine value is 7 mg/dL (618.8 mmol/L) and the blood urea nitrogen (BUN) value is 240 mg/dL (85.68 mmol/L). Which integumentary manifestations can be noticed in this client?
Pruritus, Ecchymosis, Uremic frost. Elevated serum creatinine and BUN levels indicate chronic kidney disease, the integumentary manifestations of which include pruritus, ecchymosis, uremic frost, decreased skin turgor, yellow-gray pallor, dry skin, purpura, and soft-tissue calcifications. Clubbing is the integumentary manifestation of heart and lung diseases from chronic hypoxia. Cyanosis is the manifestation of decreased peripheral circulation and deoxygenated blood
Nasogastric (NG) tube irrigations are prescribed for a client after abdominal surgery. The nurse instills 30 mL of saline solution, and 10 mL is returned. How should the nurse proceed?
Record 20 mL as intake. This 20 mL must be accounted for in the intake and output, either by including it as intake or by subtracting it from the total gastric drainage. High suction may lead to adherence of mucosa to the tube and potential injury. Repositioning the nasogastric tube is unnecessary. Return of 10 mL indicates patency; more frequent irrigations are not indicated.
A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?
Restoring fluid volume. In the first 48 hours after a severe burn, fluid moves into the tissues surrounding the injured area. Fluid also is lost in drainage and from evaporation; this fluid loss results in a decreased circulating blood volume, which can cause hypovolemic shock. Although pain relief is an important aspect in the care of clients with burns, the immediate priority is to replace fluid losses to prevent death. If fluid losses are not replaced immediately, the client may die before the development of an infection. Blood loss usually is minimal; the loss of fluid, colloids, and electrolytes is what causes the hypovolemia.
A nurse is assessing a client admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?
Retention of sodium and water. Increased levels of steroids and aldosterone cause sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. Hyperglycemia is sustained and not restricted to the morning hours.
A nurse is caring for a client who had a kidney transplant. Which test is most important for the nurse to monitor to determine whether a client's newly transplanted kidney is working effectively?
Serum creatinine. Serum creatinine, a test of renal function, measures the kidneys' ability to excrete metabolic wastes; creatinine, a nitrogenous product of protein breakdown, is elevated in renal insufficiency. A renal scan will not provide information about the filtering ability of the transplanted kidney. Although intake and output will be monitored, this will not provide information about the ability of kidney to excrete metabolic wastes. The WBC count will not reflect functioning of a transplanted kidney.
A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns?
Serum potassium. The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.
The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client's fluid replacement is adequate?
Slowing of a previously rapid pulse rate. The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/hr indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/hr. Central venous pressure decreasing from 5 to 1 mm Hg indicates hypovolemia.
A client with a history of excessive alcohol use develops hepatic portal hypertension and an elevated serum aldosterone level. For which complications should the nurse assess this client?
Sodium retention and fluid accumulation. Aldosterone, a corticosteroid, causes sodium and water retention and potassium excretion by the kidneys. Hypovolemia will not occur with increased aldosterone levels because sodium and water are retained. Potassium is excreted in the presence of aldosterone and therefore will not accumulate and cause dysrhythmias. Calcium is unaffected by aldosterone.
A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate?
Tachycardia is expected with dehydration because of a decrease in circulating fluid volume.
The 1-day urine sample results of a client reveal that the calcium level is 800 mg/24 hr. What does the finding indicate?
The client has hyperparathyroidism. In hyperparathyroidism the levels of parathormone in the body are increased and there is decalcification of bones and excretion of high-levels of calcium in the urine. Therefore a urine calcium level of 800 mg/24 hr, which is double the normal range of 100 to 400 mg/24 hr (2.50-7.50 mmol/kg/24 hr), indicates hyperparathyroidism. In nephritis, nephrosis, and hypocalcemia, the urine calcium level is decreased and the level is less than 100 mg/24 hr (2.50 mmol/kg/24 hr).
A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid?
They both contain the same kinds of ions. Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition. The osmotic pressure is the same. The composition is the same. The main cation of both extracellular fluids is sodium.
While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?
To prevent further edema. A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help to build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help to reduce pain by reducing the transmission and perception of pain impulses.
What formula should be used to manage fluid restriction?
Urinary output for past 24 hrs + 600 ml.
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis?
Urine osmolarity. Polydipsia and polyuria are signs of diabetes insipidus. When a water deprivation test is performed, urine osmolarity is increased dramatically from 100 to 600 mOsm (mmol)/kg in clients with central diabetes insipidus. But in nephrogenic diabetes insipidus, the urine osmolarity may not be greater than 300 mOsm (mmol)/kg. The urine output is 2 L to 20 L/day in all types of diabetes insipidus. The specific gravity is less than 1.005 in all types of diabetes insipidus and the serum osmolarity is also greater than 295 mOsm (mmol)/kg in all types of diabetes insipidus.
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit?
Vomiting, Muscle weakness, Irregular heart rate. Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle, and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.
A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema?
Weighing daily. Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb (1 kg). Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.
A nurse is conducting an assessment of a young infant who is dehydrated. Which clinical sign is the most important indication of the degree of dehydration?
Weight loss. Loss of fluid as a result of dehydration is most objectively assessed by weighing the infants daily because total body water accounts for approximately 75% of an infant's body weight. One liter of fluid weighs approximately 2.2 lb (1 kg). Dry skin may be indicative of conditions other than dehydration. A sunken fontanel is a clinical sign of dehydration, but is not an accurate measurement of dehydration. Decreased urine output cannot always be measured accurately in infants and children who are not toilet trained.
A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to:
allow the intestinal tract to rest
What is osmolality?
concentration of molecules per weight of water
