Fluids and Electrolytes - Mod 6 Flashcards
The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit. In the assessment, the nurse documents that the client is experiencing tachycardia, decreased urine output, and pale, cool skin. Based on this information, which should the nurse anticipate as the cause of the client's current symptoms? A) Natural compensatory mechanisms B) Cardiac failure C) Pharmacological effects of a diuretic D) Rapidly infused intravenous fluids
A - Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client.
The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client’s lab values and notes that the client’s calcium levels have increased since before the surgery. Which intervention should the nurse implement to decrease the client’s possibility of developing hypercalcemia?
A) Measure the client’s vital signs every 8 hours.
B) Assist the client in ambulating around the room at least three times daily.
C) Irrigate the client’s Foley catheter daily.
D) Help the client turn, cough, and deep breathe every 2 hours.
B - Hypercalcemia can occur from immobility. Ambulation helps prevent leaching of calcium from the bones into the serum. None of the other options listed here is related to the development of hypercalcemia.
The nurse is reviewing the lab values for a client being cared for on the unit. The client’s phosphorus level is currently 2.0 mg/dL. Based on this data, which nursing intervention is most appropriate for the nurse to implement?
A) Enforce contact precautions.
B) Encourage consumption of a high-calorie carbohydrate diet.
C) Strain all urine.
D) Encourage consumption of milk and yogurt.
D - A phosphorus level of 2.0 is low, so the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client’s carbohydrate calorie intake, or to strain all urine.
A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Based on this information, which response by the nurse is most appropriate?
A) “You should bring the infant in to be seen by the doctor.”
B) “Give your baby at least 2 ounces of juice every 2 hours.”
C) “Give your baby 50 mL of glucose water every hour.”
D) “Measure your baby’s urine output for 24 hours and call back tomorrow.”
A - Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
A home health nurse is providing care for a client diagnosed with heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Based on this data, which food should the nurse encourage the client to consume? A) Baked fish B) Iced tea C) Banana D) Peas
C - A potassium level of 3.4 mEq/L is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, banana is the highest in potassium.
Which of the following total serum calcium levels would be considered normal in an adult client? A) 9.88 mg/dL B) 2.21 mg/dL C) 4.87 mg/dL D) 7.03 mg/dL
A - Normal total serum calcium levels, which represent both bound and unbound calcium, range from 9 to 11 mg/dL.
A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The healthcare provider has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. Which urinary output would indicate that efforts to rehydrate this client have been successful? A) 40 mL per hour B) 20 mL per hour C) 25 mL per hour D) 30 mL per hour
A - Normal urine output for an adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. Thus, the only option that indicates adequate urine output is 40 mL per hour.
An older adult client is admitted to the hospital after a fall. The client is intermittently confused. Based on age and current data, which of the following conditions is the client most at risk for developing? A) Kidney damage B) Dehydration C) Stroke D) Bleeding
B - As an adult ages, the thirst mechanism declines. Also, an altered level of consciousness can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.
The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate? A) Speed shock B) Fluid volume excess C) Pulmonary embolism D) An allergic reaction
B - Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options.
The nurse is providing care to a client who is exhibiting clinical manifestations of a severe fluid and electrolyte imbalance. Based on this data, which of the following orders should the nurse anticipate from the healthcare provider? Select all that apply. A) Initiate intravenous therapy. B) Initiate hypodermoclysis. C) Administer antibiotics. D) Administer diuretics. E) Administer red blood cells.
A, B, D - If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.
The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. Which information about the purpose of this medication should the nurse explain to the client?
A) It is vital in regulating muscle contraction and relaxation.
B) It is needed to maintain skeletal, cardiac, and neuromuscular activity.
C) It controls and regulates water balance in the body.
D) It is used to synthesize protein and DNA within the body’s cells.
B - Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the cells to synthesize protein and DNA.
The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply.
A) Skin turgor 20 seconds
B) Peripheral pulses present and full
C) Capillary refill of nail beds 3 seconds
D) Oriented to person, place, and time
E) Bowel sounds sluggish in all four quadrants
B, C, D - To determine whether the client’s perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client’s perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client’s elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client’s elimination status.
The nurse reviewing lab results on one of her adult clients notices the client’s serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this client? Select all that apply.
A) Monitor heart rate and rhythm.
B) Elevate the head of the bed.
C) Instruct on a low-sodium diet.
D) Administer diuretics as prescribed.
E) Administer potassium supplement as prescribed.
C, D - For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client’s fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.
During an assessment, the nurse becomes concerned that an older adult client is at risk for dehydration. Which of the following assessment findings would cause the nurse to come to this conclusion?
A) The client has poor skin turgor.
B) The client reports ingesting two glasses of water each day.
C) The client’s blood pressure is 140/98 mmHg.
D) The client’s body mass index is 20.5.
B - Poor intake of water (in this case, only two glasses per day) could indicate a loss of the thirst response, which is a normal age-related change that increases the risk for dehydration. Skin turgor is a poor indicator of fluid balance in older adult clients, as the skin’s elasticity naturally decreases with age. The client’s blood pressure is elevated, but this could indicate either fluid volume overload or sodium sensitivity. The client’s body mass index is within normal limits and thus would not contribute to dehydration. Note, however, that a body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.
The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse? A) Serum osmolality 230 mOsm/kg B) Hematocrit 30% C) Hematocrit 53% D) Serum potassium 3.8 mEq/L
C - The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. A client’s hematocrit increases with dehydration and decreases with overhydration. A normal hematocrit value for a female is 37% to 47%. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit, whereas a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine alterations in fluid balance. Serum sodium values would be more appropriate for that purpose.
The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lb and had a 24-hour intake of 2000 mL and urine output of 1200 mL. Based on this data, which conclusion by the nurse is the most appropriate?
A) Treatment needs to include a diuretic.
B) Treatment has not been effective.
C) Treatment is effective and should continue.
D) Treatment has been effective and should end.
C - Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1500-2000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, this client is dehydrated, so the extra fluid intake is being used to improve body fluid balance. The client’s output is 50 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client’s fluid balance.
During an assessment, the nurse learns that a client who is seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The current air temperature outside is 88 degrees, and the client reports drinking water several times throughout the day because of heavy sweating. Based on this data, which instruction is most appropriate for the nurse to give the client?
A) “Eat something sweet when drinking water.”
B) “Eat something salty when drinking water.”
C) “Double the amount of water you are drinking.”
D) “Drink juices and carbonated sodas instead of water.”
B - Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. Thus, the client should be instructed to eat something salty when drinking water to help replace the lost sodium. Eating something sweet will not help replace sodium, nor will consuming juices and carbonated sodas. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.
Which of the following electrolytes would be classified as a cation? A) Chloride B) Bicarbonate C) Phosphate D) Potassium
D - Electrolytes are ions, or charged particles, that are capable of conducting electricity when dispersed in water. Electrolytes may be positively or negatively charged. Positively charged electrolytes are called cations and include sodium, potassium, calcium, and magnesium. Negatively charged electrolytes are called anions and include chloride, bicarbonate, phosphate, and sulfate.
Which statement is true?
A) A dehydrated client would be considered to be in a hypotonic state because the client would have a lower concentration of solutes in the body in relation to water.
B) A dehydrated client would be considered to be in a hypertonic state because the client would have a lower concentration of solutes in the body in relation to water.
C) A dehydrated client would be considered to be in a hypotonic state because the client would have a higher concentration of solutes in the body in relation to water.
D) A dehydrated client would be considered to be in a hypertonic state because the client would have a higher concentration of solutes in the body in relation to water.
D - Tonicity represents the balance between the amounts of water on either side of a membrane. Different states of balance can exist relative to the sides of the membrane. A patient may be in a hypotonic condition if there is a lower concentration of solutes to water. The opposite exists in hypertonic states when there is a higher concentration of solutes in relation to water. Dehydrated clients are hypertonic because there is a reduced percentage of water in their bodies and thus a higher concentration of solutes to water.
Which of the following lab values is indicative of hypokalemia? A) Serum potassium of 3.25 mEq/L B) Serum potassium of 5.45 mEq/L C) Serum sodium of 125 mEq/L D) Serum sodium of 155 mEq/L
A - Hypokalemia is a deficit in potassium. Normal serum potassium levels range from 3.5 to 5.3 mEq/L, so of the choices listed, only a serum potassium of 3.25 mEq/L would be considered indicative of hypokalemia.
\_\_\_\_\_\_\_\_ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure. A) Osmosis B) Filtration C) Active transport D) Diffusion
B - Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Active transport is the process by which substances move across cell membranes from a less concentrated solution to a more concentrated one.
An older adult client is brought to the emergency department. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis should the nurse most anticipate for this client? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging
B - Older adult clients are less able to concentrate their urine, and they have a blunted perception of thirst. Both of these characteristics make them susceptible to dehydration. However, fever, nausea, and vomiting are not considered normal. The client’s symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing this client at even higher risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.
The nurse receives a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client should the nurse plan to assess first based on an increased risk for dehydration?
A) A 4-year-old child with a broken leg
B) A 15-month-old child with tachypnea
C) A 16-year-old child with migraine headaches
D) A 10-year-old child with cellulitis of the left leg
B - The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age and experiencing tachypnea, which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at lower risk for dehydration than is a toddler with a condition that increases insensible water loss.
The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the session?
A) “It is important for my child to wear dark clothing while exercising in the heat.”
B) “Water is the drink of choice to replenish fluids that are lost during exercise.”
C) “My child only needs to hydrate at the end of an exercise session.”
D) “I will have my child stop every 15 to 20 minutes during physical activity to drink fluids.”
D - During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids lost during exercise. Light-colored, lightweight clothing is preferable; wearing dark colors can increase sweating.
The nurse is planning care for a client admitted to the unit with a diagnosis of dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines that Risk for Electrolyte Imbalance is an appropriate nursing diagnosis. Which medical condition supports this nursing diagnosis? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure
C - Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.
The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. Which response by the nurse is the most appropriate?
A) “Fluid volume excess commonly occurs due to new onset liver failure caused by the surgery.”
B) “Fluid volume excess is frequently caused by the administration of intravenous fluids.”
C) “Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery.”
D) “Fluid volume excess is frequently caused by inactivity.”
C - Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
Which of the following terms refers to severe, generalized edema, which may occur as a result of fluid volume excess? A) Ascites B) Anasarca C) Hypervolemia D) Orthopnea
B - Anasarca refers to severe, generalized edema, which may occur due to fluid volume excess. Ascites refers to excess fluid in the peritoneal cavity. Hypervolemia is an excess of intravascular fluid. Orthopnea is difficulty breathing when supine.
The nurse is caring for a client diagnosed with heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which drug on the client's medication administration record may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin
B - Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare provider prescribes both glucose and insulin for the client. The client’s spouse asks, “Why is insulin needed?” Which response by the nurse is the most appropriate?
A) “The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood.”
B) “Insulin is safer than other medications that can lower potassium levels.”
C) “The insulin lowers his blood sugar levels and causes the extra potassium to be excreted.”
D) “The insulin will help his kidneys excrete the extra potassium.”
A - Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.
A client in the emergency department is being admitted with a diagnosis of fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal
C - The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply.
A) Drink diet soda.
B) Drink more fluids during hot weather.
C) Drink flat caffeine-free cola or ginger ale if vomiting.
D) Reduce the intake of coffee and tea.
E) Exercise between the hours of 10 a.m. and 2 p.m.
B, C, D - Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
