Prep U Fluids and Electrolytes

Question 1

The nurse should ensure _______ when the client is to receive intravascular therapy for more than 6 days?

Answer 1

Peripherally inserted central catheter (PICC)
When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or peripherally inserted central catheter (PICC) is preferred to a short peripheral catheter. In adult clients, use of the femoral vein for central venous access should be avoided. Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.

Question 2

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?

Answer 2

“I sleep on three pillows each night.”

Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

Question 3

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. The nurse should instruct the client to do?

Answer 3

Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation. (less)

Question 4

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Answer 4

Lactated Ringer’s solution
with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn’t give half-normal saline solution because it’s hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic. (less)

Question 5

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

Answer 5

Leg edema:
Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

Question 6

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Answer 6

Normal saline solution is used for administering blood transfusions. Lactated Ringer’s solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a “no priming” method without NSS.

Question 7

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Answer 7

Jugular vein distention
SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn’t associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

Question 8

What is the primary goal of nursing care during the emergent phase after a burn injury?

Answer 8

Replace lost fluids.
During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.

Question 9

A client is brought to the emergency department with abdominal trauma following an automobile accident. Vital signs are as follows: HR 132, RR 28, BP 84/58, temp 97.0 (36.1 C), and oxygen saturation of 89% on room air. Which of the following orders from the health care provider should the nurse implement first?

Answer 9

Administer 1 liter 0.9% saline IV.
The client is demonstrating vital signs consistent with fluid volume deficit, likely from bleeding, hypovolemic shock, or both resulting from the automobile accident.

Question 10

Because cervical effacement and dilation aren’t progressing in a client in labor, the physician orders I.V. administration of oxytocin. Why must the nurse monitor the client’s fluid intake and output closely during oxytocin administration?

Answer 10

Oxytocin causes water intoxication.
The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death.

Question 11

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which of the following?

Answer 11

Passage of a liquid stool with a watery ring.
The mother demonstrates understanding of the discharge instructions when she says that she should contact the pediatrician if the baby has a liquid stool with a watery ring,

Question 12

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink:

Answer 12

At least 3,000 mL of fluids daily.
Instructions should be as specific as possible, and the nurse should avoid general statements such as “a lot.” A specific goal is most useful

Question 13

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Answer 13

Hypokalemia
A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

Question 14

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

Answer 14

Hypertonic
The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution’s osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution’s osmolarity is lower than serum’s. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment.

Question 15

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. The plan should include which of the following? Select all that apply.

Answer 15

Report signs of redness or inflammation at the site.
• Call the health care provider for a temperature above 100 degrees F (37.8 degrees C).
• Cleanse the port with alcohol.

Question 16

After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:

Answer 16

Meet the fluid and nutritional needs of the client.
The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client

Question 17

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?

Answer 17

A sunken fontanel
In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

Question 18

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Answer 18

Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition

Question 19

A client is receiving total parenteral nutrition (TPN), and the nurse is concerned about the complication of fluid volume overload. Which of the following nursing actions is most appropriate in the administration of TPN to prevent this complication?

a) Weigh the client every day.
b) Reduce the ordered flow rate by half.
c) Continuously monitor the infusion rate.
d) Use an infusion pump to administer the TPN solution.

Answer 19

Use an infusion pump to administer the TPN solution.
Complications of TPN include fluid overload, electrolyte imbalances, infection, hyperglycemia and hypoglycemia, air embolism, and pneumothorax.

Question 20

Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

Answer 20

Auscultation of moist crackles.
An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later

Question 21

A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/l), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/l), and platelet count of 150,000 ul (150 X 109/l). Based on the child’s values, what is the highest priority nursing intervention?

Answer 21

Encourage meticulous handwashing by client and visitors.
A WBC of 2000 mm3 (2 X 109/l) is low and increases the child’s risk for infection. Meticulous handwashing is a standard/routine precaution and the first line of defense in combating infection. A platelet count of 150,000 ul (150 X 109/l) is within normal range, so there is no need to transfuse the child with platelets. Mouth care will help decrease the risk of infection; however, handwashing is the priority because it will have the greatest effects on diminishing the risk of infection. A Hgb of 12.5 g/dL (125 g/l) and a HCT of 36.8% (0.37) are within normal range so there is no need to transfuse packed red blood cells.

Question 22

The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis for edema. Which finding is expected for this child?

Answer 22

Pallor.
With edema, pallor can occur owing to hemodilution as intestinal fluid moves to the vascular space. The child would exhibit pulmonary crackles secondary to pulmonary congestion .

Question 23

A client reports vomiting every hour for the past 8 to 10 hours. The nurse should assess the client for risk of which of the following? Select all that apply:

Answer 23

Metabolic alkalosis
• Hypokalemia
Gastric acid contains a substantial amount of potassium, hydrogen ions, and chloride ions. Frequent vomiting can induce an excessive loss of these acids to alkalosis.

Question 24

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?

Answer 24

Tomato juice.
Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been remove .

Question 25

A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values?

Answer 25

Increased serum amylase and lipase levels.
Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.

Question 26

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

Answer 26

phosphorus.
PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.

Question 27

A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the highest priority for the nurse?

Answer 27

Administering IV fluids with electrolyte correction
Severe vomiting and diarrhea cause fluid and electrolyte imbalances. Water loss can be greater than the sodium loss, causing dangerously high serum sodium levels.

Question 28

The nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which of the following electrolyte imbalances is a common cause of digoxin toxicity?

Answer 28

Hypokalemia.
is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

Question 29

A client with Addison’s disease is admitted to the medical unit. The client has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client’s oral intake increases, which of the following fluids would be most appropriate?

Answer 29

Bouillon and juice.
Electrolyte imbalances associated with Addison’s disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee’s diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

Question 30

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which of the following indicates that adequate fluid replacement has been achieved in the client?

Answer 30

Urine output greater than 35 ml/hour.
A urine output of 30 to 50 ml/hour indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

Question 31

Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss?

Answer 31

Systolic blood pressure less than 90 mm Hg.
Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

Question 32

The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following?

Answer 32

Decreased abdominal girth.
Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth.

Question 33

client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for:

Answer 33

Hypokalemia.
Loss of electrolytes from the gastrointestinal tract through vomiting, diarrhea, or nasogastric suction is a common cause of potassium loss, resulting in hypokalemia.

Question 34

Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss?

a) Pulse rate less than 60 bpm.
b) Respiratory rate of 4 breaths/minute.
c) Systolic blood pressure less than 90 mm Hg.
d) Pupils unequally dilated.

Answer 34

Systolic blood pressure less than 90 mm Hg.
Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

Question 35

A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority?

a) Decrease venous congestion.
b) Prevent injury to lower extremities.
c) Maintain body temperature.
d) Maintain normal respirations.

Answer 35

Decrease venous congestion.
Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client’s legs above the level of the heart to achieve this goal. The client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the swollen extremity; however, this is not the priority.

Question 36

Select all answer choices that apply.
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has prescribed a 250-ml bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 ml normal saline with 40 mEq (40 mmol/L) of potassium chloride at 100 ml/hour. The nurse should: Select all that apply.
a) Increase the I.V. infusion rate to 250 ml/hour for 1 hour.
b) Contact the physician regarding continuation of the primary I.V. infusion during the bolus infusion.
c) Administer the normal saline bolus via an I.V. infusion pump.
d) Add 250 ml of normal saline to the current infusion bag and continue at 100 ml/hour.
e) Connect a 250-ml bag of normal saline to the Y-connection and calculate to infuse over 1 hour.

Answer 36

Connect a 250-ml bag of normal saline to the Y-connection and calculate to infuse over 1 hour.
• Contact the physician regarding continuation of the primary I.V. infusion during the bolus infusion.
• Administer the normal saline bolus via an I.V. infusion pump.
The additional fluids should run through a separate line using a Y connector. The nurse must contact the surgeon to clarify if the client should receive the additional 100 ml/hour of I.V. fluids containing potassium chloride during the bolus infusion. Rapid infusion of potassium chloride can cause hyperkalemia with adverse cardiac outcomes such as arrhythmias. Bolus infusions of I.V. fluids should be run via an infusion pump to avoid excess fluid administration. Increasing the current I.V. infusion rate or adding additional fluids to the existing infusion is not safe because the current infusion contains potassium.

Question 37

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which of the following?

a) Passage of a liquid stool with a watery ring.
b) Ability to fall asleep easily after each feeding.
c) Production of one to two light brown stools daily.
d) Spitting up of a tablespoon of formula after feeding.

Answer 37

Passage of a liquid stool with a watery ring.
The mother demonstrates understanding of the discharge instructions when she says that she should contact the pediatrician if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration.

Question 38

A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider?

a) Sugar is a good source of nutrition when rehydrating a child.
b) Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes.
c) A child who has three wet diapers each day isn’t considered dehydrated.
d) If symptoms persist for more than 72 hours, contact the physician.

Answer 38

Give 1 to 3 teaspoons (5-15 mL) of fluid every 10 to 15 minutes.
Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child’s tolerance level. Simple sugars aren’t a good source of hydration because of their osmotic effects.

Question 39

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

a) phosphorus.
b) potassium.
c) magnesium.
d) sodium.

Answer 39

phosphorus.
PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.

Question 40

A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority?

a) Maintain body temperature.
b) Prevent injury to lower extremities.
c) Decrease venous congestion.
d) Maintain normal respirations.

Answer 40

Decrease venous congestion.
Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client’s legs above the level of the heart to achieve this goal. The client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the swollen extremity; however, this is not the priority.