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fluid and electrolyte nclex ScienceMedicineNursing AlexusLSingh Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluids and Electrolytes NCLEX 53 terms SetfiretoitPreview Fluids and Electrolytes NCLEX Teacher 41 terms anogu023Preview NCLEX 69 terms clro The nurse is administering a blood transfusion to a client who is hemorrhaging. In which fluid compartment should the nurse identify that the client is experiencing a​ deficit?​Rationale: Blood loss causes a deficit in the intravascular fluid​ compartment, which is a subcompartment of extracellular fluid​ (ECF). Transcellular and interstitial​ fluids, along with​ lymph, make up the other compartments of ECF. Intracellular fluid is the other major fluid compartment in the body.The nurse reviews the care needs for a group of clients. Which condition should the nurse realize occurs from a fluid volume​ deficit?​Rationale: Fluid volume​ deficit, or​ dehydration, can occur when excessive amounts of fluids are lost through diarrhea or vomiting. Kidney failure causes water​ retention, leading to fluid volume​ excess, not deficit. Water intoxication results from excessive fluid intake and leads to fluid volume excess. Fluid volume​ excess, not​ deficit, can result in hypertension.The nurse is reviewing the fluid needs for a group of clients. Which characteristic of the intracellular fluid compartment of the body should the nurse​ identify?​Rationale: The intracellular fluid compartment makes up about two thirds of total body fluid in adults and is found within cells. It is a medium for metabolic processes. Extracellular fluid makes up the other one third of total body fluid and is divided into​ intravascular, interstitial, and transcellular fluids. Cerebrospinal and peritoneal fluids are examples of transcellular fluids.The nurse is preparing material on fluid compartments in the body. Which fluids should the nurse identify as the components of extracellular​ fluid?​Rationale: Body fluids found outside of the cell include​ intravascular, interstitial, and transcellular fluids.​ Conversely, intracellular fluids are found inside the cell.

The nurse prepares intravenous fluid for a client. Which mechanism should the nurse recall that represents the movement of fluid across cell membranes from an area of less concentration to an area of higher​ concentration?​Rationale: Osmosis is the movement of water across cell​ membranes, from the​ less-concentrated solution to the​ more-concentrated solution.Filtration is the process by which fluid and solutes move together across a membrane from one compartment to another. Active transport is a process by which substances move across the cell membrane and must combine with a carrier for​ transportation, requiring metabolic energy.With​ diffusion, the molecules move from a solution of higher concentration to a solution of lower concentration.The nurse is caring for a hospitalized client who is experiencing​ anxiety-related hyperventilation. When calculating the​ client's intake and​ output, where would the nurse anticipate the need for an adjustment in fluid​ loss?​Rationale: With increased​ respirations, the client will experience a​ greater-than-normal insensible loss of fluid through the lungs.Hyperventilation will not affect the amount of fluid lost through the​ urine, sweat, or feces.The nurse is completing a physical assessment with a client. On which part of the body should the nurse focus when determining fluid and electrolyte​ status? (Select all that​ apply.) ​Rationale: Physical assessment for fluid and electrolyte status focuses on the​ skin, oral cavity and mucous​ membranes, eyes, cardiovascular and respiratory​ systems, and neurologic and muscular status. The ears and endocrine system are not a focus of fluid and electrolyte status assessment.The nurse is determining a​ client's fluid balance. Which method should the nurse use to identify this​ client's fluid volume excess or​ deficit?​Rationale: Daily weight is the best indicator of fluid volume excess or deficit. Skin​ turgor, blood​ pressure, and intake and output are assessments that would be included in the care of a client with fluid​ imbalances, but daily weight is the best indicator of changes in fluid status.The nurse is performing an assessment on a client with fluid volume excess. Which finding should the nurse identify that supports fluid volume​ excess? (Select all that​ apply.) ​Rationale: Pitting​ edema, weight​ gain, and crackles in the lungs upon auscultation are indicative of fluid volume excess. Tenting of skin and thirst are found in fluid volume deficit.The nurse is assessing a client with fluid volume deficit. Which finding should the nurse identify that supports fluid volume​ deficit?​Rationale: Increased hematocrit is a finding consistent with fluid volume deficit. Edema and weight gain are consistent with fluid volume overload. Wheezes upon auscultation of the lungs is not related to fluid imbalances.The school nurse notes that a​ school-age child is experiencing mild heat exhaustion after playing outside during recess. Which recommendation should the nurse make to help prevent future occurrences of​ heat-related illness?​Rationale: To prevent​ heat-related illness, it would be best to move recess from the hottest part of the day to a cooler part of the day. Children should be encouraged to take frequent water breaks and drink before they begin to feel​ thirsty, not just when they feel thirsty or only before recess. Children should also be encouraged to take frequent rest breaks during​ recess, not just afterward.The nurse is teaching a client ways to prevent fluid imbalances. Which fluids should the nurse encourage the client to​ avoid?​Rationale: Coffee should be avoided due to its diuretic effects.​ Water, Pedialyte, and juice are acceptable drinks to avoid fluid imbalances.

A client is prescribed furosemide. Which information should the nurse provide about this​ medication?​Rationale: Daily weight is recommended for a client taking furosemide. Increasing sodium intake and decreasing potassium intake can lead to fluid and electrolyte imbalances. It would be recommended to take furosemide in the morning due to the diuresis effect of the medication.The nurse instructs a client with fluid volume excess about dietary choices. Which meal choice should indicate to the nurse that teaching was​ effective?​Rationale: A meal of egg​ whites, turkey​ bacon, oatmeal, and wheat toast is the best choice to decrease the amount of​ sodium, because turkey bacon has the least amount of sodium. Choices that contain​ sausage, bacon, or ham are high in sodium and should be avoided.The nurse reviews intake and output with a graduate nurse. Which statement by the graduate nurse should cause the nurse​ concern?​Rationale: Accurate measurement and recording of fluid​ I&O provides important data about the​ client's fluid balance. Ice cream would be considered intake because it is a food that becomes liquid at room temperature. The other answers are appropriate. Other intake includes all oral​ fluids, ice​ chips, IV​ fluids, IV​ medications, tube​ feedings, and catheter or tube irrigants. Output would include urinary​ output, vomitus, liquid​ feces, tube​ drainage, and wound drainage.Next Question The nurse is teaching a marathon runner about the importance of maintaining fluid and electrolyte balance. Which situation puts runners at a higher risk for fluid and electrolyte​ imbalances?​Rationale: It is common for athletes to use electrolyte replacement fluids during exercise. The nurse should be sure that the athlete understands that these fluids could alter the delicate balance of individual electrolytes. Supplemental protein and calcium intake do not typically affect fluid and electrolyte balance. Although water is lost during​ sweating, it does not usually create issues during exercise.The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. For which imbalance should the nurse assess this​ client?​Rationale: The client receiving intravenous​ (IV) colloids or any IV fluid is at risk for fluid overload. It​ is, therefore, important to monitor the client for manifestations of fluid overload. Fluid​ deficit, hyperkalemia, and hypernatremia do not typically result when infusing colloids.The nurse is evaluating the laboratory work of a client who is receiving replacement therapy for hypokalemia. Which value should the nurse identify that evaluates the effectiveness of the replacement​ therapy?​Rationale: Hypokalemia is a potassium level less than 3.5​ mEq/L. A serum potassium of 4.2​ mEq/L indicates improvement in hypokalemia. Serum chloride and serum calcium are not used to evaluate potassium level.The nurse is assessing the urinalysis of a client with fluid volume deficit. On which component of the urinalysis should the nurse focus to determine the​ client's fluid​ balance?​Rationale: Specific gravity measures the concentration of urine. Glucose found in the urine is indicative of diabetes mellitus. Nitrites in the urine indicate a possible bacterial infection. Leukocyte esterase also can be indicative of a possible bacterial infection.A nurse is caring for a client who has lost a large percentage of circulating body fluids as a result of excessive diuresis. Which medication would the nurse anticipate this client​ needing?​Rationale: Colloids expand fluid volume by the replacement of proteins or other large molecules. Diuretics are used to promote urine​ output, particularly associated with fluid overload. Electrolyte supplements are used to replace lost electrolytes. Crystalloids contain both electrolytes and other substances that mimic the​ body's extracellular fluid. These medications will assist in the replacement of depleted fluids while promoting urine output.

A client is admitted with complaints of​ nausea, vomiting, and diarrhea. Which clinical manifestation should the nurse anticipate the client will​ exhibit?If a client has complaints of​ nausea, vomiting, and​ diarrhea, a decrease in fluid volume would be expected because fluid loss has occurred through other routes. Other symptoms of fluid volume​ deficit, or​ dehydration, include dry mucous membranes and an increased heart rate. Body temperature may increase during episodes of dehydration.The nurse is preparing a presentation on monitoring fluid and electrolytes for new nurses during orientation training. Which of the following should the nurse include as an example of a​ cation?Calcium is a​ cation, an ion that produces a positive charge. Other cations are​ sodium, potassium, and magnesium.​ Chloride, bicarbonate, and sulfate are​ anions, ions that produce a negative charge.The client admitted has a diagnosed fluid and electrolyte imbalance. In planning the care for this​ client, the nurse should determine that which of the following goals regarding fluid and electrolyte balance is most​ appropriate?In planning​ care, you want the client to attain the following goals regarding fluid and electrolyte​ balance: bullet• The client will maintain or restore normal fluid balance.bullet The client will maintain or restore normal electrolyte balance bullet The client will maintain or restore normal respiratory rate and pattern. bullet The client will maintain cardiac output and neurologic function.The nurse is caring for a client diagnosed with congestive heart failure. The client has gained 6.6 pounds in one week. Using the measurement that 1 kg​ (2.2 lb.) of weight gain equals one liter of fluid​ gain, the nurse should estimate the client has gained how many liters of​ fluid?Weight is an appropriate indicator of fluid loss or gain. 1 kg​ (2.2 lb) of weight gain or loss equals 1 L of fluid gain or loss. 6.6 lb would be equal to approximately 3 kg​ (6.6/2.2 =​ 3) and an estimated 3 L of fluid gain. Two liters would be a weight gain of approximately 4.4 lb. One liter would be a weight gain of approximately 2.2​ lb, and 4 L would be a weight gain of approximately 8.8 lb.The nurse has explained how solutions may move across a semipermeable membrane by​ diffusion, or osmosis to a nurse during orientation.Which of the following descriptions of osmosis should indicate to the nurse that the new nurse needs no further instruction about diffusion or​ osmosis?Osmosis is the diffusion of water across the cell membrane from a lower concentration to a higher concentration.The nurse implements nursing interventions that promote and maintain fluid and electrolyte balance as well as​ cardiac, renal, and respiratory function depending on the​ client's needs. Which is an appropriate intervention related to fluid and electrolyte​ balance?Monitor daily weight and measure​ 24-hr intake and output