Fluids and Electrolytes

Question 1

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP)

Answer 1

3. An increase in blood pressure and increased respirations

Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of
consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

Question 2

The nurse reviews a client’s record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison’s disease
4. Uric acid level of 9.4 mg/dL (557 mcmol/L)

Answer 2

2. Requires nasogastric suction

Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL (240 to 501 mcmol/L).

Question 3

The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex

Answer 3

1. U waves
2. Inverted T waves
3. Depressed ST segment

Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

Question 4

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Answer 4

1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Monitor the IV site for signs of infiltration or phlebitis.
4. Ensure that the medication is diluted in the appropriate volume of fluid.
5. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.

Question 5

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau’s sign
4. Hypoactive deep tendon reflexes

Answer 5

1. Twitching

Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign.

Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

Question 6

The nurse is caring for a client with Crohn’s disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

1. U waves
2. Widened T wave
3. Prominent U wave
4. Prolonged QT interval
5. Prolonged ST segment

Answer 6

4. Prolonged QT interval
5. Prolonged ST segment

Rationale: A client with Crohn’s disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

Question 7

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

1. ST depression
2. Prominent U wave
3. Tall peaked T waves
4. Prolonged ST segment
5. Widened QRS complexes

Answer 7

3. Tall peaked T waves
4. Widened QRS complexes

Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

Question 8

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing’s syndrome
4. The client who is taking corticosteroids

Answer 8

1. The client who is taking diuretics

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia.

Question 9

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

1. Muscle twitches
2. Decreased urinary output
3. Hyperactive bowel sounds
4. Increased specific gravity of the urine

Answer 9

3. Hyperactive bowel sounds

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

Remember that increased bowel motility and hyperactive bowel sounds indicate hyponatremia.

Question 10

The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

1. Malnutrition
2. Renal insufficiency
3. Hypoparathyroidism
4. Tumor lysis syndrome

Answer 10

1. Malnutrition

Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide–based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

Question 11

The nurse is reading a primary health care provider’s (PHCP’s) progress notes in the client’s record and reads that the PHCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract

Answer 11

3. Integumentary output

Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

Question 12

The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations

Answer 12

1. A client with an ileostomy

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

Question 13

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
4. Increased respirations and increased blood pressure

Answer 13

1. Weight loss and poor skin turgor

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

Question 14

On review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess?

1. The client taking diuretics who has tenting of the skin
2. The client with an ileostomy from a recent abdominal surgery
3. The client who requires intermittent gastrointestinal suctioning
4. The client with kidney disease and a 12-year history of diabetes mellitus

Answer 14

4. The client with kidney disease and a 12-year history of diabetes mellitus

Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

Question 15

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

1. The client with colitis
2. The client with Cushing’s syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn

Answer 15

4. The client who has sustained a traumatic burn

Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Eliminate the client with colitis and the client overusing laxatives first, because they are comparable or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Also, remember that Cushing’s syndrome presents a risk for hypokalemia and that Addison’s disease presents a risk for hyperkalemia.