prepU: fluid and electrolyte balance

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next?

ask another nurse to attempt to start a peripheral intravenous line. explanation: Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess?

number of wet diapers in the last 24 hours explanation: A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. This helps to determine the severity of the dehydration. Knowing the amount of fluid intake for 24 hours also helps assess the severity of the dehydration. If the baby is bottle fed the mother could give a specific amount. If breast fed the nurse would want to know how many times fed and for how long each time. Just knowing the number of feeds in 24 hours will not give accurate information to determine dehydration status. The number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and capillary refill assessment could indicate a perfusion problem.

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

hyperkalemia explanation: Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination does not help reverse the effects of hypercalcemia, hypernatremia, or hypermagnesemia.

A multigravid client thought to be at 14 weeks' gestation reports that they are experiencing such severe morning sickness that they "have not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?

hypokalemia explanation: Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting.

The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?

hypokalemia explanation: Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias. Sodium, magnesium, and calcium levels are not significantly affected by the use of digoxin.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?

"I should drink more water when feeling thirsty or becoming irritable." explanation: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?

"I sleep on 3 pillows each night." explanation: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number.

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A preschooler has vomiting, diarrhea, a potassium level of 3 mEq/L (3 mmol/L), and a sodium level of 137 mEq/L (137 mmol/L). Which prescribed treatment will the nurse implement first?

IV infusion of saline, dextrose, and potassium solution explanation: A child with vomiting and diarrhea loses excessive fluids and electrolytes, putting them at risk for dehydration and cardiac arrhythmia. The first action by the nurse is to start the IV fluid and electrolyte replacement. The nurse would then administer the promethazine to reduce nausea and vomiting and then place the nasogastric tube to low intermittent suction. Loperamide is not recommended in children under age 6, so the nurse should seek clarification for this prescription.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

Lactated Ringer's solution explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudo-diabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

A client prescribed propranolol calls the clinic to report a weight gain of 3 lb within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?

have the client come to the clinic in order to assess the lungs explanation: The client needs to be assessed for the heart failure, a potential adverse effect of beta blockers. The other answer choices will not rule out the possibility of the development of pulmonary edema.

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess

Trousseau's sign explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homan's sign (pain on dorsiflexion of the foot) indicated DVT. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.

A client is brought to the emergency department with abdominal trauma following an automobile crash. The vital signs are temperature 97.0, heart rate 132 bpm, respiration rate 28 breaths/min, blood pressure 84/58 mmHg, and oxygen saturation 89% on room air. Which prescription should the nurse implement first?

administer 1L 0.9% normal saline intravenously explanation: The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding or hypovolemic shock as a result of the automobile crash. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

An infant is admitted to the hospital's pediatric unit with gastroenteritis. The nurse will include what nursing actions in the plan of care? Select all that apply

begin prescribed rehydration measures, establish intake and output, weigh the infant, review arriving laboratory reports, protect skin from diarrheal stool, provide time for the parents to hold infant. explanation: All the listed actions are appropriate for the plan of care. In this case, the focus is on fluid balance and protecting skin integrity. Rehydration measures, monitoring of input and output, monitoring weight, and reviewing lab reports are all necessary components of correcting and maintaining fluid balance. Although there could be contact precautions needed if this is infectious diarrhea, the parents would still be encouraged to hold the infant and offer comfort.

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

cardiac rhythm explanation: Manifestations of CKD result from loss of the renal regulatory functions of filtering metabolic waste products and maintaining fluid and electrolyte balance. These laboratory results indicate CKD, but the most significant result is the potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum creatinine level ranges from 0.7 to 1.5 mg/dL.

The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which is the best measure that the nurse should suggest?

elevate the head of the child's bed explanation: The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops or limiting television may be comforting but will not relieve the swelling.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment finding would alert the nurse to suspect hypermagnesemia?

decreased deep tendon reflexes explanation: Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

When caring for the pregnant client with hyperemesis gravidarum, the nurse would further assess the client for which problem?

dehydration explanation: Based on this client's history of hyperemesis gravidarum, the nurse needs to assess for signs and symptoms of possible dehydration, such as scanty urine output, lassitude, or fever.Abdominal pain is not associated with hyperemesis gravidarum and should not be present. Abdominal pain may be suggestive of a gastric ulcer.The client should not experience any leaking amniotic fluid.A pinkish vaginal discharge or bright red bleeding is not associated with hyperemesis gravidarum and should not be present.

The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding?

document the finding, and complete routine postpartum assessment. explanation: It is normal for the client to experience diuresis in the first 24 hours after birth (whether vaginal or cesarean). An amount of 3 liters in 24 hours is not unusual. Also, the client will have received IV fluids during labor, which increases input significantly. There is no indication of kidney dysfunction. If preecamplia is suspected, urine output would be decreased, not increased; this makes testing for protein unwarranted. The client may have edema present, for which elevating the legs can encourage further diuresis, but there is not reason to restrict fluid intake.

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?

hypotension explanation: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, a prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with the administration of epidural anesthesia.

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

increased serum amylase and lipase levels explanation: Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.

The nurse is planning care for a client who had surgery 24 hours ago to create an ileostomy. Which goal has the highest priority?

maintaining fluid and electrolyte balance explanation: A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

muscle weakness and a weak, irregular pulse explanation: The serum potassium level of 3.2 mEq/L is an indication of hypokalemia. Only 2% of the potassium is found in the extracellular fluid, and it is primarily responsible for neuromuscular activity. Muscle weakness and heart irregularities would be evident with hypokalemia. Potassium deficit is caused by diarrhea. Tetany and tremors are associated with hypocalcemia. Headaches and poor tissue turgor are associated with hyponatremia.

Blood administration is ordered for a client receiving chemotherapy. The nurse is obtaining all supplies needed for infusion. Which intravenous solution is obtained?

normal saline explanation; Normal saline solution (0.9 NS) is the only fluid compatible with blood administration. Lactated Ringers and dextrose solutions are not infused with blood products due to compatibility.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

normal saline as this is considered an isotonic solution explanation: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS.

What is the primary goal of nursing care during the emergent phase after a burn injury?

replace lost fluids explanation: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

to prevent signs of hypovolemic shock and restore circulation explanation: Lactated Ringer's is infused to restore circulating fluid volume and prevent signs of hypovolemic shock. IV administration of dextrose to restore glucose is not the priority at this time. The client has severe burns, so improving skin integrity is not an issue at this time.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate?

urine output below 1 ml/hour explanation: Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed, not bulging, fontanels; excessive weight loss, not gain; decreased skin turgor; dry mucous membranes; and urine specific gravity above, not below, 1.012.

After completing discharge instructions for a primiparous client who is bottle-feeding their term neonate, the nurse determines that the parent understands the instructions when the parent says they should contact the health care provider (HCP) if the neonate exhibits which sign or symptom?

passage of a liquid stool with a watery ring explanation: The parent demonstrates an understanding of the discharge instructions when they say that they should contact the HCP if the baby has a liquid stool with a watery ring because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal; however, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?

serum potassium level of 2.6 mEq/L explanation: Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis explanation: Projectile vomiting is a classic symptom of pyloric stenosis, which typically occurs within the first weeks of life. Upper GI X-rays confirm this diagnosis. Gastroschisis, diaphragmatic hernia, and imperforate anus would have been evident in the hours immediately after birth, and the reported symptoms don't characterize these conditions.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply.

report signs of redness or inflammation at the site, call the health care provider for a temperature over 100, cleanse the port with alcohol wipes explanation: When IV therapy must be administered in the home setting, teaching is essential. Written instructions as well as demonstration and return demonstration help reinforce key points. The client or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/outcomes, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection and also report an elevated temperature. Before changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.

After being sick for three days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). Which diagnostic test will the nurse prioritize in monitoring?

serum potassium level explanation: The nurse would prioritize the monitoring of the client's potassium level because potassium leaves the cell during periods of acidosis, causing hyperkalemia, which may cause cardiac arrhythmias. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser effect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias, which the nurse would consider a priority.

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes explanation: When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss. A focused assessment would usually indicate increased bowel sounds associated with the cramping. Kidney suppression would not be associated with diarrhea lasting 2 days; it might present with severe dehydration and hypovolemic shock. There is a loss of bicarbonate through the diarrhea, which would result in metabolic acidosis, not alkalosis.

The nurse in the health care provider's office is teaching a 58-year-old male client, with heart failure, about a new prescription for spironolactone due to increasing fluid retention.

the nurse explains that taking spironolactone places the client at risk for hyperkalemia and that the client needs to avoid foods high in potassium. explanation: The client taking spironolactone, a potassium-sparing diuretic, is at risk for hyperkalemia, an elevated potassium level. Because spironolactone is a potassium-sparing diuretic, the client should be instructed to avoid foods high in potassium. Spironolactone can cause hyponatremia and hypocalcemia, not hypernatremia and hypercalcemia. The client with heart failure should not be instructed to increase intake of sodium because this can lead to increased fluid volume. There is no need for the client with heart failure and who is taking spironolactone to avoid dairy products.

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30 mL per hour explanation: Ensuring a urine output of 30 to 50 mL per hour is the best measure of adequate fluid resuscitation. The heart rate is elevated, but this is not an indicator of adequate fluid balance. The blood pressure is low, likely related to hypovolemia, but the urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.

A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals

worsening dyspnea explanation: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.

A client in the ICU has a critically low potassium level of 1.9 mEq/l. What would be the best way to replace this client's potassium?

administer two potassium chloride 10 mEq in 100 ml 0.9% sodium chloride IVPB, over 1 hour each explanation: The nurse should administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each to safely and rapidly correct this client's potassium. IV potassium will be absorbed more fully and more quickly than oral potassium replacement. Potassium should never be given as an IV bolus, as it can result in severe cardiac dysrhythmias and sudden death. Sodium polystyrene is used in the treatment of hyperkalemia, and lowers potassium levels, so it is not indicated for this client.