Chapter 11 - Assessment and Care of Patients with Problems of Fluid and Electrolyte Balance
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
- Client behavior that changes from anxious to lethargic
- Deep furrows on the surface of the tongue
- Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
- Urine output of 950 mL for the past 24 hours
A. Client behavior that changes from anxious to lethargic
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply.
- Place the client on bed rest.
- Evaluate the electrolyte levels.
- Administer the ordered diuretic.
- Assess for orthostatic hypotension.
- Initiate cardiac monitoring
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
D. Assess for orthostatic hypotension.
E. Initiate cardiac monitoring
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply.
- Use a potassium infusion prepared by a registered pharmacist.
- Assess for burning or redness during infusion.
- Infuse at a rate of no more than 10 mEq per hour.
- Administer only through a central venous catheter.
- Administer by IV push only during cardiac arrest.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply.
- Assess daily weights.
- Encourage consumption of citrus fruits.
- Weigh the client weekly.
- Monitor serum potassium.
- Discourage intake of spinach.
- Monitor for bradycardia.
A. Assess daily weights.
B. Encourage consumption of citrus fruits.
D. Monitor serum potassium.
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client’s potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?
- Heart rate
- Blood pressure (BP)
- Increases in edema
- Sodium level
A. Heart rate
Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective?
- The client’s potassium level is 5.1 mEq/L (5.1 mmol/L).
- The client’s heart rate is 101 beats per minute.
- The client is free from adventitious breath sounds.
- The client has experienced a weight gain of 1 pound (0.5 kg).
C. The client is free from adventitious breath sounds.
The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement?
- “The client’s PT and INR may be prolonged while taking this medication.”
- “The client may develop hypoglycemia during treatment.”
- “Inverted T waves and a U wave may appear on the ECG.”
- “I need to tell the client to avoid salt substitutes.”
C. “Inverted T waves and a U wave may appear on the ECG.”
The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? Select all that apply.
- ACE inhibitors
- Salt substitute
C. ACE inhibitors
E. Salt substitute
The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?
- Monitoring urine output
- Encouraging sodium rich fluids and foods throughout the day
- Instructing the client not to ambulate without assistance
- Assessing deep tendon reflexes
C. Instructing the client not to ambulate without assistance
The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider?
- Peripheral edema
- Crackles ½ way up the lung fields
- Serum osmolarity of 294 mOsm/kg (294 mmol/kg)
- Urine output of 1300 mL over 24 hours
B. Crackles ½ way up the lung fields
The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?
- Monitoring 24-hour urine output
- Asking the client about feeling depressed
- Assessing the blood pressure hourly
- Monitoring the serum calcium levels
C. Assessing the blood pressure hourly
A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? Select all that apply.
- History of liver disease
- Use of salt substitute
- Use of an ACE inhibitor
- Potassium-sparing diuretics
- Prescription for insulin
B. Use of salt substitute
C. Use of an ACE inhibitor
D. Potassium-sparing diuretics
After receiving change-of-shift report, which client does the RN assess first?
- A client with nausea and vomiting who complains of abdominal cramps
- A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst
- A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg
- A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL
C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg
The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first?
- Administer sodium polystyrene sulfonate (Kayexalate) orally.
- Ensure that a potassium-restricted diet is ordered.
- Place the client on a cardiac monitor.
- Teach the client about foods that are high in potassium.
C. Place the client on a cardiac monitor.
The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)?
- Assessing oral mucosa for dryness
- Choosing appropriate oral fluids
- Monitoring skin turgor for tenting
- Offering fluids to drink every hour
D. Offering fluids to drink every hour
The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session?
- “Be careful not to overload them with too many oral fluids.”
- “Offer fluids that they prefer frequently and on a regular schedule.”
- “Restrict their fluids if they are incontinent.”
- “Wake them every 2 hours during the night with a drink.”
B. “Offer fluids that they prefer frequently and on a regular schedule.”
The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF?
- “I can gain 2 pounds (1 kg) of water a day without risk.”
- “I should call my provider if I gain more than 1 pound (0.5 kg) a week.”
- “Weighing myself daily can determine if my caloric intake is adequate.”
- “Weighing myself daily can reveal increased fluid retention.”
D. “Weighing myself daily can reveal increased fluid retention.”
The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first?
- Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L)
- Oral calcium supplements to a client with severe osteoporosis
- Oral phosphorus supplements to a client with acute hypophosphatemia
- Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)
D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)
Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?
- A client admitted with dehydration who has a heart rate of 126 beats/min
- A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home
- A client admitted yesterday with heart failure with dependent pedal edema
- A client who has just been admitted with severe nausea, vomiting, and diarrhea
C. A client admitted yesterday with heart failure with dependent pedal edema
A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate?
- Monitor for hyperactive reflexes
- Prepare for endotracheal intubation
- Institute teaching on avoiding magnesium rich foods
- Place the client on a cardiac monitor
D. Place the client on a cardiac monitor
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN?
- Calcium level of 9.5 mg/dL (2.4 mmol/L)
- Magnesium level of 4.1 mEq/L (2.1 mmol/L)
- Potassium level of 6.0 mEq/L (6.0 mmol/L)
- Sodium level of 120 mEq/L (120 mmol/L)
A. Calcium level of 9.5 mg/dL (2.4 mmol/L)
The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her?
- LPN/LVN who has floated from the hospital’s long-term care unit
- LPN/LVN who frequently administers medications to multiple clients
- RN who has floated from the intensive care unit
- RN who usually works as a diabetes educator
C. RN who has floated from the intensive care unit
The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first?
- Restrict the client’s intake of sodium
- Administer a diuretic
- Monitor the serum osmolarity
- Encourage fluid intake
D. Encourage fluid intake
The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first?
- The client with a random glucose reading of 123 mg/dL (6.8 mmol/L)
- The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L)
- The client whose potassium is 6.2 mEq/L (6.2 mmol/L)
- The client with a sodium level of 143 mEq/L (143 mmol/L)
C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L)
The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)?
- Consulting with a health care provider about a client’s laboratory results
- Infusing 500 mL of normal saline over 60 minutes
- Monitoring IV fluid to maintain the drip rate at 75 mL/hr
- Providing oral care every 1 to 2 hours
D. Providing oral care every 1 to 2 hours
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN?
- A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day
- A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L)
- A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg)
- An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest
C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg)
The nurse is caring for a client receiving lactated Ringer’s solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply.
- Blood serum glucose
- Blood pressure
- Pulse rate and quality
- Urinary output
- Urine specific gravity
B. Blood pressure
C. Pulse rate and quality
D. Urinary output
E. Urine specific gravity
The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription?
- Sodium polystyrene sulfonate (Kayexalate)
- Potassium phosphate
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?
- Draws blood for laboratory tests
- Elevates the head of the bed
- Places the extremities in a dependent position
- Puts the client in a side-lying position
B. Elevates the head of the bed
An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation?
- Assesses for dry oral mucous membranes
- Checks for orthostatic blood pressure changes
- Notes pulse rate is 72 beats/min and bounding
- Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)
B. Checks for orthostatic blood pressure changes
The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?
- Ask the client how much fluid was consumed yesterday.
- Place an indwelling catheter to measure urine output.
- Auscultate the lungs for adventitious sounds.
- Weigh the client daily, at the same time.
D. Weigh the client daily, at the same time.
A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? Select all that apply.
- Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
- Use a vein in the hand for better flow
- Use an IV pump to deliver the medication
- Check IV access for blood return after the infusion
- Push the medication over 5 minutes
A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
C. Use an IV pump to deliver the medication
A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide?
- Assessment of muscle tone and strength
- Education about potassium-rich foods
- Instruction on the proper use of drugs
- Measurement of the client’s weight
D. Measurement of the client’s weight