UNIT 2 CHAPTER 13 FLUID AND ELECTROLYES

Question 1

What is the Normal Range for Calcium?
What are the Signs and Symptoms for
HYPOCALCEMIA?

Answer 1

Calcium: 9-10.5 mg/dL

Confusion, anxiety
Numbness and tingling of extremities
Muscle cramps that progress to tetany and seizures
Hyperactive reflexes
Cardiac dysrhythmias
Positive Chvostek and
Trousseau signs
decreased cardiac output

TREATMENT

Monitor heart rate & rhythm
Cardiac monitor
Fall and seizure precautions
Give Calcium and Vit D as ordered

Eat foods rich in Ca
Cheese, ice cream, milk, yogurt, rhubarb, spinach, tofu

Question 2

What is the Normal Range for Calcium?
What are the Signs and Symptoms for
HYPERCALCEMIA?

Answer 2

Calcium: 9-10.5 mg/dL

Lethargy, stupor, coma
Decreased muscle strength and tone
Anorexia, nausea, and vomiting
Constipation
Pathologic fractures
Dysrhythmias
Renal calculi

TREATMENT

Monitor heart rate & rhythm
Cardiac monitor
Encourage increased fluids
Increase patient activity, including active rom
Restrict Ca foods

Question 3

What is the Normal Range for Sodium?
What are the Signs and Symptoms for
HYPONATREMIA?

Answer 3

Sodium: 135-145 mEq/L

Lethargy, confusion, weakness
Muscle cramping
Seizures
Anorexia, nausea, vomiting, diarrhea

TREATMENT

Administer IV fluids with Na

Eat foods with Na
Breads, cereals, chips, cheese, processed meats such as lunch meats, hot dogs, bacon, ham
Commercially canned foods
Table salt

Monitor V/s’s, i&O, labs
Administer hypertonic IV saline solutions as ordered

Question 4

What is the Normal Range for Sodium?
What are the Signs and Symptoms for
HYPERNATREMIA?

Answer 4

Sodium: 135-145 mEq/L

Thirst, dry and sticky mucous membranes,
weakness,
elevated temperature
Severe hypernatremia causing confusion and irritability,
decreased LOC levels of consciousness, hallucinations, and seizures

TREATMENT

Monitor v/s’s, LOC, LOC, labs
Increase water intake
Na restricted diets
Administer hypotonic iv solutions as ordered

Question 5

What is the Normal Range for Potassium?
What are the Signs and Symptoms for
HYPOKALEMIA?

Answer 5

Potassium: 3.5-5 mEq/L

Weak, irregular pulse
Fatigue, lethargy
Anorexia, nausea, vomiting
Muscle weakness and cramping
Decreased peristalsis, hypoactive bowel sounds
Paresthesia
Cardiac dysrhythmias
Increased risk for digitalis toxicity

TREATMENT

Monitor v/s’s, especially heart rate and rhythm, labs (k+)
Cardiac monitor
Administer K+ supplements, IV fluids with K+ as ordered
Never iv bolus or iv push k+

Eat foods rich in K
Fish, excluding shellfish; whole grains, nuts, broccoli, cabbage, carrots celery, cucumbers, potatoes with skins, spinach, tomatoes, apricots, bananas, cantaloupe, nectarines, oranges, tangerines

If taking diuretics, make sure they are K sparing diuretics

Question 6

What is the Normal Range for Potassium?
What are the Signs and Symptoms for
HYPERKALEMIA?

Answer 6

Potassium: 3.5-5 mEq/L

Anxiety,
irritability,
confusion
Dysrhythmias, including bradycardia and heart block
Muscle weakness, flaccid paralysis
Paresthesia- NUMBNESS
Abdominal cramping

TREATMENT

Monitor v/s’s, especially heart rate & rhythm, Labs (k+)
Cardiac monitor
Limit K+ foods
Kayexalate
Glucose & insulin moves k+ back into cell
Dialysis

Question 7

What is the Normal Range for Magnesium?
What are the Signs and Symptoms for
HYPOMAGNEISMIA?

Answer 7

Magnesium: 1.5-2.5 mEq/L

Irritable nerves and muscles
Hyperactive deep tendon reflexes
Seizures
Dysrhythmias, especially tachyarrhythmias
ECG changes
Altered level of consciousness
Mood swings
Delusions, hallucinations
Dysphagia, nausea, and vomiting

TREATMENT

Assess v/s’s, especially heart rate & rhythm
Cardiac monitor
Assess mental status, change LOc
Give Magnesium, assess swallowing before foods, fluids, meds

Eat foods rich in Mg
Cashews, halibut, Swiss chard and other green leafy vegetables, tofu, wheat germ, dried fruit

Avoid alcohol
Seizure precautions

Question 8

What is the Normal Range for Magnesium?
What are the Signs and Symptoms for
HYPERMAGNEISMIA?

Answer 8

Magnesium: 1.5-2.5 mEq/L

Warm, flushed appearance
Nausea, vomiting
Drowsiness, lethargy
Decreased muscle strength
Generalized weakness
Decreased deep tendon reflexes
Hypotension Dysrhythmias, especially bradycardia and heart block
Slow, shallow respirations;
respirator arrest

TREATMENT

Assess v/s’s, especially heart rate & rhythm
Cardiac monitor
Assess mental status, change loc
Assess neuromuscular status
Encourage increased oral intake, increase Iv fluids
Dialysis
Administer loop diuretic as ordered
Respiratory support as needed
Low magnesium diet

Question 9

What is the Normal Range for Chloride?
What are the Signs and Symptoms for
HYPOCHLOREMIA?

Answer 9

Chloride: 98-106 mEq/L

Irritable nerves and muscles.
tetany,
hypotension,
shallow breathing

Question 10

What is the Normal Range for Chloride?
What are the Signs and Symptoms for
HYPERCHLOREMIA?

Answer 10

Chloride: 98-106 mEq/L

Weakness, lethargy, deep breathing

Question 11

1. A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
   a. A 36 year old who is prescribed long-term steroid therapy.
   b. A 55 year old who recently received intravenous fluids.
   c. A 76 year old who is cognitively impaired.
   d. An 83 year old with congestive heart failure.

Answer 11

ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

Question 12

4. A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
   a. Client taking furosemide.
   b. Anxious client who has tachypnea.
   c. Client who is on fluid restrictions.
   d. Client who is constipated with abdominal pain.

Answer 12

ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

Question 13

5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
   a. Increased respiratory rate from 12 to 22 breaths/min
   b. Decreased skin turgor on the client9s posterior hand and forehead
   c. Increased urine specific gravity from 1.012 to 1.030 g/mL
   d. Decreased orthostatic changes when standing

Answer 13

ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

Question 14

6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates that the client correctly understood the teaching?
   a. Slices of smoked ham with potato salad
   b. Bowl of tomato soup with a grilled cheese sandwich
   c. Salami and cheese on whole-wheat crackers
   d. Grilled chicken breast with glazed carrots

Answer 14

ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

Question 15

11. The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
    a. Administer high-ceiling (loop) diuretics.
    b. Assess the client’s lung sounds every 2 hours.
    c. Place a pressure-relieving overlay on the mattress.
    d. Weigh the client daily at the same time on the same scale.

Answer 15

b. Assess the client’s lung sounds every 2 hours.

All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client9s respiratory status.

Question 16

13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?
    a. Notifies the pharmacy of the IV potassium order.
    b. Assesses the client9s IV site every hour during infusion.
    c. Sets the IV pump to deliver 30 mEq of potassium an hour.
    d. Double-checks the IV bag against the order with the precepting nurse.

Answer 16

ANS: C
IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

Question 17

15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?
    a. Encourage oral fluid intake.
    b. Connect the client to a cardiac monitor.
    c. Assess urinary output.
    d. Administer oral calcitonin.

Answer 17

ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

Question 18

16. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?
    a. Ask family members to speak quietly to keep the client calm.
    b. Assess urine color, amount, and specific gravity each day.
    c. Encourage the client to drink at least 1 L of fluids each shift.
    d. Dangle the client on the bedside before ambulating.

Answer 18

d. Dangle the client on the bedside before ambulating.

ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client9s urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.