NCLEX - saunders - fluids and electrolytes Flashcards
- The nurse is caring for a client with heart failure who has a magnesium level of 0.75 mg/dL. Which action should the nurse take?
A. Monitor the client for irregular heart rhythms.
B. Encourage the intake of antacids with phosphate.
C. Teach the client to avoid foods high in magnesium.
D. Provide a diet of ground beef, eggs, and chicken breast.
A. Monitor the client for irregular heart rhythms. - The normal magnesium level ranges from 1.2 to 2.6 mg/dL; therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client’s risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
- The nurse is caring for a client with hypertension receiving torsemide (Demadex) 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
A. A chloride level of 98 mEq/L
B. A sodium level of 135 mEq/L
C. A potassium level of 3.1 mEq/L
D. A blood urea nitrogen (BUN) level of 15 mg/dL
C. A potassium level of 3.1 mEq/L - Torsemide (Demadex) is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option C is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L. The normal chloride level is 98 to 107 mEq/L. The normal sodium level is 135 to 145 mEq/L. The normal BUN level ranges from 8 to 25 mg/dL.
The home care nurse is developing a plan of care for an older client with type 1 diabetes mellitus who has gastroenteritis. To maintain food and fluid intake to prevent dehydration, which action should the nurse plan to take?
A. Offer water only until the client is able to tolerate solid foods.
B. Withhold all fluids until vomiting has ceased for at least 4 hours.
C. Encourage the client to take 8 to 12 ounces of fluid every hour while awake.
D. Maintain a clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the bowel to dissipate.
C. Encourage the client to take 8 to 12 ounces of fluid every hour while awake. - Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may promote it in this client.
The nurse plans care for a client requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
A. Bounding pulse rate
B. Chronic kidney disease
C. Isolated syncope episodes
D. Rapid, weak, and thready pulse
E. Serum electrolyte abnormalities
F. Abnormal serum and urine osmolality levels
D. Rapid, weak, and thready pulse
E. Serum electrolyte abnormalities
F. Abnormal serum and urine osmolality levels - Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body’s water balance; fluid restrictions may be used.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which findings does the nurse expect to find documented in the client’s medical record? Select all that apply.
A. Edema
B. Anemia
C. Polyuria
D. Bradycardia
E. Hypotension
F. Osteoporosis
A. Edema
B. Anemia
- The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
- A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
A. Bleeding ulcer
B. Myocardial infarction
C. Deep vein thrombosis
D. Streptococcal infection
D. Streptococcal infection - The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.
The nurse is assigned to care for a client with nephrotic syndrome. Which important parameter should the nurse assess on a daily basis?
A. Weight
B. Albumin levels
C. Activity tolerance
D. Blood urea nitrogen (BUN) level
A. Weight - The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client’s activity level is adjusted according to the amount of edema and water retention. As edema increases, the client’s activity level should be restricted
- The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
A. Prednisone orally
B. Fludrocortisone (Florinef) orally
C. Spironolactone (Aldactone) intramuscularly
D. Methylprednisolone sodium succinate (Solu-Medrol) intravenously
D. Methylprednisolone sodium succinate (Solu-Medrol) intravenously - A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Aldactone is a potassium-sparing diuretic.
A client with acute kidney injury is prescribed to be on a fluid restriction of 1500 mL per day. Which step is best for the nurse to take in assisting the client in maintaining this restriction?
A. Removing the water pitcher from the bedside
B. Using mouthwash with alcohol for mouth care
C. Prohibiting beverages with sugar to minimize thirst
D. Asking the client to calculate the IV fluids into the total daily allotment
A. Removing the water pitcher from the bedside - The nurse can help the client maintain fluid restriction through a variety of means. The water pitcher should be removed from the bedside to aid in compliance. Frequent mouth care is important; however, alcohol-based products should be avoided because they are drying to mucous membranes. Beverages that the client enjoys are provided and are not restricted based on sugar content. The client is not asked to keep track of IV fluid intake; this is the nurse’s responsibility. The use of ice chips and lip ointments is another intervention that may be helpful to the client on fluid restriction.
- The client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication?
A. During dialysis
B. Just before dialysis
C. The day after dialysis
D. Upon return from dialysis
D. Upon return from dialysis - Antihypertensive medications, such as enalapril (Vasotec), are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
The nurse is preparing to administer an intermittent tube feeding through a nasogastric (NG) tube and assesses for residual volume. What is the purpose of the nurse assessing the residual volume before administering tube feeding?
A. Confirm proper NG tube placement.
B. Determine the client’s nutritional status.
C. Evaluate the adequacy of gastric emptying.
D. Assess the client’s fluid and electrolyte status.
C. Evaluate the adequacy of gastric emptying. - All stomach contents are aspirated and measured before administering a tube feeding to determine the gastric residual volume. If the stomach fails to empty and propel its contents forward, the tube feeding accumulates in the stomach and increases the client’s risk of aspiration. If the aspirated gastric contents exceed the predetermined limit, the nurse withholds the tube feeding and collaborates with the health care provider on a plan of care. Assessing gastric residual volume does not confirm placement or assess fluid and electrolyte status. The nurse uses clinical indicators including serum albumin levels to determine the client’s nutritional status.
- A client with acute pyelonephritis has nausea and is vomiting and is scheduled for an intravenous pyelogram. The nurse places priority on which action?
A. Ask the client to sign the informed consent.
B. Explain the procedure thoroughly to the client.
C. Place the client on hourly intake and output measurements.
D. Request a prescription for an intravenous infusion from the health care provider.
D. Request a prescription for an intravenous infusion from the health care provider. - The highest priority of the nurse would be to request a prescription for an intravenous infusion. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure, and will assist with the elimination of the dye after the procedure. Explanation of the procedure and obtaining the signed informed consent are done once the client’s physiological needs are met. The intake and output should be measured, but this will not assist in preventing dehydration.
- A client taking diuretics is at risk for hypokalemia. The nurse monitors for which clinical manifestations of hypokalemia? Select all that apply.
A. Muscle twitches
B. Tall T waves on electrocardiogram (ECG)
C. Deep tendon hyporeflexia
D. Prominent U wave on ECG
E. General skeletal muscle weakness
F. Hypoactive to absent bowel sounds
C. Deep tendon hyporeflexia D. Prominent U wave on ECG E. General skeletal muscle weakness F. Hypoactive to absent bowel sounds - Hypokalemia is a serum potassium level less than 3.5 mEq/L. Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.
Before administering an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Which should the nurse implement as a result of this finding?
A. Discard the aspirate and record as client output.
B. Mix with new formula to administer the feeding.
C. Dilute with water and inject into the nasogastric tube.
D. Reinstill the aspirate through the nasogastric tube via gravity using a syringe.
D. Reinstill the aspirate through the nasogastric tube via gravity using a syringe. - After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client’s fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client’s fluid and electrolyte balance unless the client is dehydrated.
- The nurse is caring for a client with multiple myeloma who is receiving intravenous hydration at 100 mL per hour. Which finding indicates a positive response to the treatment plan?
A. Creatinine of 1.0 mg/dL
B. Weight increase of 1 kilogram
C. Respirations of 18 breaths per minute
D. White blood cell count of 6000 cells/mm3
A. Creatinine of 1.0 mg/dL - Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal status. Options C and D are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.
- The nurse is caring for a client who has undergone transsphenoidal resection of a pituitary adenoma. What should the nurse measure to detect occurrence of a common complication of this type of surgery?
A. Pulse rate
B. Temperature
C. Urine output
D. Oxygen saturation
C. Urine output - A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client’s urine output to determine whether this complication is occurring. Polyuria of 4 to 24 liters per day is characteristic of this complication. Options A, B, and D are not specifically related to a common complication after this surgery.
- A client is receiving desmopressin (DDAVP) intranasally for management of diabetes insipidus. Which assessment parameters should the nurse check to determine the effectiveness of this medication?
A. Daily weight
B. Temperature
C. Apical heart rate
D. Pupillary response
A. Daily weight - DDAVP is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client’s fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options B, C, and D are not related to this medication.
The nurse is caring for an infant who has diarrhea. The nurse should monitor the infant for which early sign of dehydration?
A. Cool extremities
B. Gray, mottled skin
C. Capillary refill of 3 seconds
D. Apical pulse rate of 200 beats per minute
D. Apical pulse rate of 200 beats per minute - Dehydration causes interstitial fluid to shift to the vascular compartment in an attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory failure occurs. The blood pressure will decrease and the pulse rate will increase. This will be followed by peripheral symptoms. Options A, B, and C are not early signs, and these assessment findings relate to peripheral circulatory status.
- A client has a total serum calcium level of 7.5 mg/dL. Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.
A. Constipation
B. Muscle twitches
C. Hypoactive bowel sounds
D. Hyperactive deep tendon reflexes
E. Positive Trousseau’s sign and positive Chvostek’s sign
F. Prolonged ST interval and QT interval on electrocardiogram (ECG)
B. Muscle twitches
D. Hyperactive deep tendon reflexes
E. Positive Trousseau’s sign and positive Chvostek’s sign
F. Prolonged ST interval and QT interval on electrocardiogram (ECG)
- Hypocalcemia is a total serum calcium level less than 8.6 mg/dL. Clinical manifestations of hypocalcemia include decreased heart rate, diminished peripheral pulses, hypotension, and prolonged ST interval and QT interval on ECG. Neuromuscular manifestations include anxiety and irritability; paresthesia followed by numbness; muscle twitches, cramps, tetany, and seizures; hyperactive deep tendon reflexes; and positive Trousseau’s and Chvostek’s signs. Gastrointestinal manifestations include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
- A client undergoes a thyroidectomy, and the nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which findings indicate damage to the parathyroid glands?
A. Fever
B. Neck pain
C. Hoarseness
D. Tingling around the mouth
D. Tingling around the mouth - The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s signs. Fever may be expected in the immediate postoperative period but is not an indication of damage to the parathyroid glands. However, if a fever persists the health care provider is notified. Neck pain and hoarseness are expected findings postoperatively.
- The nurse is conducting a health history on a client with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
A. “Do you have tremors in your hands?”
B. “Are you experiencing pain in your joints?”
C. “Have you had problems with diarrhea lately?”
D. “Do you notice any swelling in your legs at night?”
B. “Are you experiencing pain in your joints?” - Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options A and C relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.
