Chapter 39 Fluid and Electrolyte Imbalance

Question 1

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client’s fluid status?

Answer 1

daily weights

Explanation:
Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client’s daily weight may be the more accurate measurement of a client’s fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.

Question 2

Which statement most accurately describes the process of osmosis?

Answer 2

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Explanation:
Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the re absorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

Question 3

What commonly used intravenous solution is hypotonic?

Answer 3

0.45% NaCl

Explanation:
0.45% NaCl is hypotonic. Normal saline and lactated Ringer’s are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

Question 4

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

Answer 4

every 72 hours

Explanation:
IV tubings are generally changed every 72 hours or as per the facility’s policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

Question 5

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client’s blood pressure. Which medical diagnosis may be responsible?

Answer 5

hypovolemia

Explanation:
The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

Question 6

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

Answer 6

60 drops/mL

Explanation:
Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

Question 7

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

Answer 7

maintenance of cell size

Explanation:
The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body’s cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

Question 8

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Answer 8

Sacral area

Explanation:
The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.

Question 9

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intramuscular volume?

Answer 9

isotonic

Explanation:
Isotonic fluids have an osmolarity of 250–375 mOsm/L, which is the same osmotic pressure as that found within the cell.

Question 10

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

Answer 10

hypertonic

Explanation:
Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

Question 11

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

Answer 11

intracellular

Explanation:
Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

Question 12

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Answer 12

Metabolic alkalosis

Explanation:
Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

Question 13

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded?

Answer 13

Fruit consumption

Explanation:
Any water consumption must be recorded in order to closely monitor a client who has congestive heart failure. Many of these clients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

Question 14

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address?

Answer 14

increased hydrostatic pressure

Explanation:
The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

Question 15

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

Answer 15

O negative

Explanation:
Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.

Question 16

The student nurse asks, “What is intravascular fluid?” What is the appropriate nursing response?

Answer 16

“Watery plasma, or serum, portion of blood.”

Explanation:
Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

Question 17

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

Answer 17

• 100 mL from melted -ice chips
• serving of jello
• infusion of -intravenous solution
• cup of ice cream

Explanation:
The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake. A bowl of chili is a solid food as is a barbecue sandwich. While the amount eaten may be documented in the chart, it is not part of the fluid intake.

Question 18

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Answer 18

Offer small amounts of preferred beverage frequently.

Explanation:
Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

Question 19

The nurse is caring for a client who has had severe diarrhea for 24 hours. Which fluid does the nurse anticipate infusing?

Answer 19

hypotonic

Explanation:
A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. The water also passes through capillary walls and becomes distributed within other body cells and the interstitial spaces. Hypotonic solutions, therefore, are an effective way to rehydrate clients experiencing fluid deficits.

Question 20

A nurse is reviewing the client's serum electrolyte levels which are as follows:
Sodium: 138 mEq/L (138 mmol/L)
Potassium: 3.2 mEq/L (3.2 mmol/L)
Calcium: 10.0 mg/dL (2.5 mmol/L)
Magnesium: 3.89 mg/dL (1.6 mmol/L)
Chloride: 100 mEq/L (100 mmol/L)
Phosphate: 5.75 mg/dL (1.8 mEq/L)

Based on these levels, the nurse would identify which imbalance?

Answer 20

Hypokalemia

Explanation:
All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore the client has hypokalemia.

Question 21

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Answer 21

Apply a warm compress.

Explanation:
Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client’s head, position the client on the left side, or apply antiseptic and a dressing. The client’s head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

Reference:

Question 22

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

Answer 22

1+

Explanation:
The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

Question 23

A client with dehydration will have an increase in:

Answer 23

aldosterone

Explanation:
The rennin-angiotensin-aldosterone and natriuretic peptide hormone systems regulate the volume within narrow limits by adjusting fluid intake and the urinary excretion of sodium, chloride, and water.

Question 24

When the nurse reviews the client’s laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client’s:

Answer 24

low calcium.

Explanation:
Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L).

Question 25

The passageways of the kidney permit the urine to flow to the bladder and:

Answer 25

selectively reabsorb or secrete substances to maintain fluids and electrolytes.

Explanation:
The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out.

Question 26

Which client would be a candidate for total parenteral nutrition?

Answer 26

a client with colitis and bloody diarrhea

Explanation:
Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest.

Question 27

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply.

Answer 27

clients with major trauma or burns
clients with liver and renal failure
clients with inflammatory bowel disease

Explanation:
The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.

Question 28

The nurse writes a nursing diagnosis of “Fluid Volume: Excess.” for a client. What risk factor would the nurse assess in this client?

Answer 28

renal failure

Explanation:
Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

Question 29

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Answer 29

-Intravenous therapy
-Electrolyte
management
- Nutrition management

Explanation:
If a client is at a fluid volume deficit, intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess.

Question 30

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

Answer 30

“I should drink 2,500 mL/day of fluid.”

Explanation:
In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.