Fluid and Electrolyte Flashcards
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor’s order?
Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The
IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV
and place an additional load on the failing heart. Diuretics such as furosemide are appropriate
to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek’s sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
Positive Chvostek’s sign in patient with acute pancreatitis
Positive Chvostek’s sign indicates increased neuromuscular excitability, which can progress
to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately
life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with
ECV deficit; however, additional assessments of ECV deficit are required before reporting to
the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek’s sign
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58
Urine output 8 mL/hr
Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?
Tumor that secretes excessive antidiuretic hormone (ADH)
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration
Decreased level of consciousness
Tube feedings pose a risk for hypernatremia unless adequate water is administered between
tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances.
Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.
The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?
Oliguric renal disease
When renal excretion is decreased, magnesium intake must be decreased also, to prevent
hypermagnesemia.
The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?
Institute fall precautions due to potential postural hypotension and weak leg muscles
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the
lower extremities. Both of these increase the risk of falls
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Multiple Response)
We PB PTS
Weaker leg muscles than usual
Postural blood pressure and heart rate
Positive Trousseau’s sign
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium,
calcium, and magnesium. ppropriate assessments include postural blood pressure and heart
rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau’s sign for hypocalcemia and hypomagnesemia.
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Multiple Response)
TOM
Test for skin tenting.
Measure rate and character of pulse
Observe for flatness of neck veins when supine.
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when
supine, which can be assessed in this patient.
