Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Flashcards
A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
A 76-year-old who is cognitively impaired
Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his
or her need for fluids known is at high risk for dehydration
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
Apply oxygen by mask or nasal cannula
Assess client further for fall risk.
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best
response is to do a more thorough evaluation of the client’s risk for falls.
After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching?
I will weigh myself each morning before I eat or drink
One liter of water weighs 1 kg; (2.2lb) therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss.
Note: when addressing dehydration think fluid status. When assessing fluid status, what is the best method? A daily weight report is the best measurement for fluid status.
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
Anxious client who has tachypnea
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
Decreased orthostatic changes when standing
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?
Grilled chicken breast with glazed carrot
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first
for potential hyponatremia?
A 34-year-old on NPO status who is receiving intravenous D5W
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia.
A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching?
Read food labels to determine sodium content.
“Call your primary health care provider for diarrhea.”
Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care
provider if this is noticed.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium
1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
Depth of respirations
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation.
A nurse cares for a client who has a serum potassium of 6.5 (7.5) mEq/L (6.5 (7.5) mmol/L) and is exhibiting cardiovascular changes. Which
intervention will the nurse implement first?
Prepare to administer dextrose 20% and 10 units of regular insulin IV push
Glucose and insulin are administered together to decrease serum potassium levels. A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia.
A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
Client with pancreatitis who has continuous nasogastric suctioning
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia.
A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
Assess the clients respiratory rate, rhythm, and depth.
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of
hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood pressure should be assessed after assessing respiratory status.
After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding.
Which dietary meal selection indicates the client correctly understands the teaching?
Sausage, one slice of whole-wheat toast, half cup of raisins, and a glass of milk
Meat, dairy products, and dried fruit have high concentrations of potassium.
A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond?
Berries, cherries, apples, and peaches are low in potassium.
Not all fruit is potassium-rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.
