Fluid and Electrolyte Lecture 3

Question 0

Monitor symptoms and Provide safe environment

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 0

A: Dehydration

Question 1

ACCURATE intake/output

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 1

A: Dehydration

Question 2

Maintain IV access as ordered

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 2

A: Dehydration

Question 3

Watch for s/sx of cerebral edema when replacing fluids

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 3

A: Dehydration

Question 4

Monitor serum sodium, urine osmolality and specific gravity

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 4

A: Dehydration

Question 5

Monitor Daily Weights

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 5

A: Dehydration

Study Tip: daily weights must be taken on patients with IVs, diuretics, and cardiac meds because of increased risk for fluid and electrolyte imbalances.

Question 6

Skin and oral care

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 6

A: Dehydration

Question 7

Assess vital signs and monitor response to treatment

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 7

A: Hypervolemia

Study Tip: bounding pulse is common s/sx. Dog jumps pulse jumps. Caused by increased volume in a closed space, decreased blood pressure, and decreased cardiac output.

Question 8

Monitor respiratory status for worsening distress

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 8

A: Hypervolemia
Rationale: Watery crackles in the lungs

Question 9

Monitor ABGs

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 9

A: Hypervolemia

ABGs must be monitored on patients with IVs, diuretics, and cardiac meds because of increased risk for fluid and electrolyte imbalances.

Question 10

Watch for distended neck or hand veins

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 10

A: Hypervolemia

Question 11

Record I/O hourly:
Foley if needed
Restrict fluids PRN
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 11

A: Hypervolemia

Study Tip: take very accurate intake/output measured by the exact mL. Eyeball measurements is fine when the patient does not have an imbalance. Monitor first for subtle changes before they get bad.

Question 12

Assess breath sounds regularly to check for pulmonary edema

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 12

A: Hypervolemia

Study Tip: Assess for respiratory breath sounds, respiratory effort, dyspnea, difficulty breathing, usage of accessory muscles, and shortness of breath.

Question 13

Elevate head of bed to facilitate breathing

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 13

A: Hypervolemia

Study Tip: raise the head of the bed for someone in respiratory distress.

Question 14

Maintain IV access

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 14

A: Hypervolemia

Study Tip: IV axis is a collaborative nursing intervention it can only be done without an order in code situations.

Question 15

Give diuretics and other meds as ordered

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 15

A: Hypervolemia

Study Tip: this is a collaborative intervention.

Question 16

Watch for edema (especially dependent)

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 16

A: Hypervolemia

Study Tip: when replacing fluids edema can occur depending on the tonicity of the fluid to monitor closely to prevent cerebral edema. Dependent Adema occurs with gravity. If sitting feet will get edema. If laying down it is the same side that the patient is laying that will get the edema.

Question 17

Check for S3

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 17

A: Hypervolemia

Study Tip: A common s/sx of hypervolemia is an S3 developing because there’s too much blood for the ventricles to pump. An S3 is an abnormality and should not be heard.

Question 18

Frequent oral care and skin care

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 18

A: Hypervolemia

Study Tip: Drop your patients hand below their waist and palpate the veins in the hand then raise their hands above their heart when you palpate at this time the blood should empty from the veins in the hands if the blood doesn’t empty in 20 seconds this could be a sign of increased fluid volume.

Question 19

Evaluate Daily weights

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 19

A: Hypervolemia

Study Tip: most accurate way to detect a fluid volume imbalance. Foleys need to be checked for accurate output.

Question 20

Provide Emotional support and Document any changes in condition.
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 20

A: Hypervolemia

Study Tip: anxiety can occur with difficulty breathing so that is why you offer emotional support.

Question 21

Monitor Ca+ & other electrolytes, Digoxin levels, and Vital Signs
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 21

Hypercalcemia

Question 22

Neuro and Cardiovascular assessments

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 22

Hypercalcemia

Question 23

Monitor I/O, encourage 3-4 L/day

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 23

Hypercalcemia

Question 24

Maintain IV access
Hydrate before diuresing
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 24

Hypercalcemia

Question 25

Strain urine for calculi

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 25

Hypercalcemia

Question 26

Mobilize patient to prevent bone loss of Ca
– If chronic use care to avoid fractures
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 26

Hypercalcemia

Question 27

Closely monitor post parathyroid or thyroid surgery patients

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 27

Hypocalcemia

Question 28

Monitor VS, Digoxin labs

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 28

Hypocalcemia

Question 29

Trach tray at the bedside in the event of laryngospasm

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 29

Hypocalcemia

Question 30

Maintain IV access
Assess ability to perform ADLs
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 30

Hypocalcemia

Question 31

Check for Chvostek’s and Trousseau’s signs

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 31

Hypocalcemia

Question 32

Cardiac monitoring

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 32

Hypocalcemia

Question 33

Administer IV Ca+ carefully: infiltration can cause tissue necrosis and sloughing
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 33

Hypocalcemia

Question 34

Administer PO as ordered: 1 – 1 ½ hours pc

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 34

Hypocalcemia

Question 35

Monitor Ca+ levels

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 35

Hypocalcemia

Question 36

Encourage Ca+ supplements

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 36

Hypocalcemia

Question 37

Seizure precautions, safe environment

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 37

Hypocalcemia

Question 38

Teach s/sx and common dietary sources

This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?

Answer 38

Hypocalcemia

Question 39

Thorough history of meds/diet
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?
Hyperkalemia

Monitor EKG
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?
Hyperkalemia

Monitor Peripheral nervous system
– Muscle weakness – progresses from legs to torso
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?
Hyperkalemia

– Respiratory muscles may be weakened
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?
Hyperkalemia

– Paresthesia of face, feet, hands tongue
This nursing intervention would be appropriate to use for what fluid and electrolyte imbalance?
Hyperkalemia

• General anxiety and irritability
• Monitor VS
• Monitor I/O: May have low urine output
• Maintain IV access
• If receiving repeated insulin and glucose: monitor for hypoglycemia
• If giving Kayexalate monitor sodium levels
• Monitor all electrolyte levels
• Monitor digoxin if patient is taking

Answer 39

Hyperkalemia