Chapter 13: Fluid & Electrolyte & Imbalance Flashcards
Hypoalbuminemia results in which clinical finding?
Edema .
because low levels of albumin (protein) reduce osmotic pressure, leading to fluid leakage from blood vessels into surrounding tissue causing swelling.
insensible fluid loss
example: respiration during breathing.
fluid loss that cannot be seen or measure with the naked eye.
ADH purpose is to____
ADH is released by the Pituitary Gland in respond to dehydration (to hold on to fluids).
Aldosterone causes:
- Retention of sodium
- Retention of water
- Excretion of potassium.
Aldosterone is produced by Adrenal cortex.
Which cardiovascular change would the nurse expect to find in a
patient with fluid overload?
Flat jugular veins
Increased heart rate
Widened pulse pressure
Decreased blood pressure
Increased HR
Type of patients at risk for fluid overload
- kidney disease
- heart failure
- liver disease
Which parameter in the laboratory results would indicate internal hemorrhage as a reason for dehydration in a patient brought to the emergency department in an unconscious state?
-Increased osmolarity
-Absence of hemoconcentration
-Elevated levels of blood components
-Decreased hemoglobin level
Absence of hemoconcentration.
Because hemoconcentration is not present when dehydration is caused by
hemorrhage because loss of all blood and plasma products occurs together.
Which assessment finding indicates that a patient is
dehydrated? Select all that apply. One, some, or all responses
may be correct.
-Fever
-Hypertension
-Poor skin turgor
-Pulmonary crackles
-Low blood pressure
-Concentrated urine
fever
poor skin turgor
low BP
concentrated urine
Which factor would the nurse consider when assessing a
patient’s fluid balance? Select all that apply. One, some, or all
responses may be correct.
-Age
-Height
-Sex
-Body fat
-Cholesterol
age
sex
body fat
Which change in patient assessment over 2 days reflects that the
administered diuretic is effective?
weight loss and increased urine output
Which item will the nurse include when documenting a patient’s
fluid intake?
( any measureable intake).
enema, oral fluids and irrigation fluids
When concerned about a patient’s GI fluid losses, which parameter would the nurse assess to determine fluid loss?
Select all that apply.
Weight
Skin turgor
Urine output
Blood pressure
Blood urea nitrogen (BUN)
ALL are correct
Which sign would the nurse expect to find when assessing a
patient with fluid overload? Select all that apply.
Weight gain
Hypotension
Crackles in the lungs
Weak peripheral pulses
Pitting edema in the ankles and feet
weight gain
crackles in the lungs
pitting edema in ankle/ feet
Which condition would the nurse suspect for a patient has dry
skin, a heart rate of 115 beats/min, a respiratory rate of 28
breaths/min, and weight loss of 1 lb in 1 day?
Dehydration
Hyperkalemia
Fluid overload
Hyponatremia
dehydration
Which assessment finding in a 78-year-old patient with severe
diarrhea indicates that the patient may be dehydrated? Select all
that apply.
Distended neck veins
Bounding radial pulses
Temperature of 99.4°F (37.4C)
Dizziness when standing
Newly reported confusion
temperature of 99.4.
dizziness when standing.
newly reported confusion.
Low-grade fever is a common result of dehydration. Postural hypotension
causing dizziness may occur with dehydration. Because of decreased
perfusion to the brain, confusion is common in older adults. With
dehydration, neck veins are flat, not distended; peripheral pulses are weak, not bounding.
The nurse calculates the amount of body fluid the patient has lost
when the patient temperature has risen 2C from normal. Record
________ mL
1000 Ml.
When a patient’s temperature is above normal (98.6°F [37C]), the body will
lose 500 mL for every degree Celsius the temperature has risen. Therefore a
patient with a temperature 2C over normal would have lost 1000 mL of body
fluid.
Which intervention would the nurse include in caring for a patient
with generalized edema who is receiving a loop diuretic?
Encouraging oral fluids
Restricting dietary potassium
Applying antiembolic stockings
Turning the patient every 2 hours
Turn the patient every 2 hours.
The patient with generalized edema/fluid overload is at risk for developing
skin breakdown, especially at pressure points over bony prominences.
Changing position frequently reduces this risk. Fluids are more likely to be
restricted with fluid overload, not encouraged. Loop diuretics cause
potassium loss, so dietary potassium is encouraged, not restricted.
Antiembolic stockings have no role in generalized edema from fluid overload.
Which goal would the health team set for a 77-year-old woman
brought to the emergency department with a history diarrhea
for 3 days, not eating or drinking well, taking diuretics for
congestive heart failure, and having a potassium level of 7.0
mEq/L?
Maintaining proper diuresis and urine output
Elevating serum potassium levels to a safe range
Decreasing cardiac contractility and slowing the heart rate
Restoring fluid balance by controlling causes of dehydration
Restoring fluid balance by controlling causes of dehydration
Which intervention would the nurse include in the plan of care
for a patient with pitting edema of the right foot and ankle who
is prescribed diuretic therapy? Select all that apply.
Monitoring respiratory rate
Monitoring urine output
Assessing sodium and potassium values
Checking urine for specific gravity
Monitoring electrocardiogram (ECG) patterns
monitor urine output.
asesss Na and K values.
monitor ECG patterns.
Patients with fluid overload often have pitting edema, and diuretic therapy
focuses on removing the excess fluid. The nursing interventions would be
monitoring the patient’s response to drug therapy, especially increased urine
output and weight loss. Diuretic therapy is associated with electrolyte
imbalance; therefore sodium and potassium levels need to be monitored.
Severe electrolyte disturbances may result in arrhythmias. Therefore changes
in the ECG should be monitored. Diuretic therapy does not cause respiratory
depression or changes in respiratory rate, so the respiratory rate does not need to be monitored. Checking the urine specific gravity is beneficial in
patients to detect fluid overload. However it is not useful in patients on
diuretic therapy.
Which finding for a 70-year-old patient admitted to the unit with
severe dehydration requires immediate intervention by the nurse?
Deep furrows on the surface of the tongue
Urine output of 950 mL for the past 24 hours
Behavior that changes from anxious to lethargic and confused
Poor skin turgor with tenting for 2 minutes after the skin is pinched
Behavior changes from anxious to lethargic and confused.
confusion is caused by poor cerebral flow, or shrinkage or swelling of brain cells caused by fluid shifts.
Which intervention would the nurse implement to maintain fluid
balance for a patient who is experiencing tachypnea?
Encourage oral fluids.
Administer IV fluids.
Establish fluid restrictions.
Administer the prescribed diuretic.
administer IV fluids.
Tachypnea can lead to increased fluid loss through insensible losses (e.g., from rapid breathing) and may cause dehydration. IV fluids can help rapidly restore fluid balance
Which patient on a medical-surgical unit is at an increased risk
for insensible water loss?
A patient receiving humidified oxygen by nasal cannula
A patient receiving continuous gastrointestinal (GI) suctioning
postoperatively
A patient with decreased respirations because of opioid
administration for pain
A patient receiving continuous IV fluids after surgery
A patient receiving continuous gastrointestinal (GI) suctioning
postoperatively.
Which parameter would lead to a recommendation for fluid
replacement therapy for a dehydrated patient?
Urine output of 550 mL per day
Heart rate of 100 beats/min
Respiratory rate of 18 breaths/min
Body temperature of 104°F (40C) for more than 8 hours
Body temperature of 104°F (40C) for more than 8 hours.
because a really high temperature can cause dehydration.
Which intervention would the nurse plan for the patient who is
receiving IV fluid replacement therapy and has a bounding
pulse, difficulty breathing, and distended neck veins in the
upright position?
Monitoring for weight changes
Administering diuretic drug therapy
Increasing fluid replacement therapy
Continuing fluid replacement therapy
Administering diuretic drug therapy
