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Adult Health 1 NCLEX practice Fluids and Electrolytes ScienceMedicineNursing Howey2 Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Adult Health 1 (Exam 1) Fluid, Electr...40 terms giliamfPreview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview Pharma 100 term dsg Which serum potassium result best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours?

• 3.1 mEq/L
• 3.9 mEq/L
• 4.6 mEq/L
• 5.3 mEq/L
• the normal potassium range is 3.5-5. since this medication would increase potassium, we want to pick the one that is less than the normal

range You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy?

• Sodium falling to 138 mEq/L
• Potassium rising to 4.1 mEq/L
• Magnesium rising to 2.9 mg/dL
• Phosphorus falling to 2.1 mg/dL
• Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Normal

phosphorus levels are 2.4-4.4 mg/dL.

.You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician?

• Antibiotics
• Loop diuretics
• Bronchodilators
• Antihypertensives
• Loop diuretics cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen

the hypokalemia, putting the patient at risk for dysrhythmias.Instead, the prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?

• Notify the physician and complete an incident report.
• Slow the rate to keep vein open until next bag is due at noon.
• Obtain a new bag of IV solution to maintain patency of the site.
• Listen to the patient's lung sounds and assess respiratory status.
• ABCs!!! After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and

you should assess the patient's respiratory status and lung sounds as the priority action to check for pulmonary edema and then notify the physician for further orders.When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume?

• Polyuria
• Decreased pulse
• Difficulty breathing
• General restlessness
• AMS! Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the

dehydration is left untreated, cerebral signs could progress to confusion and later coma.Which nursing intervention is most appropriate when caring for a patient with dehydration?

• Auscultate lung sounds every 2 hours.
• Monitor daily weight and intake and output.
• Monitor diastolic blood pressure for increases.
• Encourage the patient to reduce sodium intake.
• Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening,

whereas weight gain would indicate restoration of fluid volume.When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report?

• 60 mL urine output in 90 minutes
• 1200 mL urine output in 24 hours
• 300 mL urine output per 8-hour shift
• 20 mL urine output for 2 consecutive hours
• The minimal urine output necessary to maintain kidney function is 30 mL/hr.

.When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

• Fluid movement from the blood vessels into the cells
• Fluid movement from the interstitial spaces into the cells
• Fluid movement from the blood vessels into interstitial spaces
• Fluid movement from the interstitial space into the blood vessels
• In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to

restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient?

• 500 to 1500 mL
• 1200 to 2200 mL
• 2000 to 3000 mL
• 3000 to 4000 mL
• Daily fluid intake and output is usually 2000 to 3000 mL.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient?

• Weakness
• Paresthesia
• Facial spasms
• Muscle tremors
• Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial

spasms, and muscle tremors are symptoms of hypocalcemia.The nurse is caring for a patient with a pituitary tumor. The nurse assesses the urine and reviews the lab results. The urine specific gravity is 1.075 and urine output is minimal. What would the nurse expect the sodium level to be in this patient?

• 125
• 155
• 135
• 140
• 125, sodium would be low because urine retention is high. Hypervolemic.

What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused?

• risk of dehydration
• risk of kidney damage
• risk of stroke
• risk of bleeding

Answer: 1

As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate?

• Imbalanced nutrition
• Excess Fluid Volume
• Risk for Imbalanced Fluid Volume
• Ineffective Tissue Perfusion

Answer: 3

The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium.A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?

• fluid volume excess
• fluid volume deficit
• seizure activity
• liver failure

Answer: 1

Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery.This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?

• infection
• seizure
• neutropenic
• high-risk fall

Answer: 2

Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care?

• Administer IV fluids
• Restrict fluids
• Provide Kayexalate.
• Administer intravenous normal saline with furosemide.
• The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist

sodium increase & to prevent the sodium level from dropping further due to dilution.When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?

• other electrolyte disturbances
• hypertension
• visual disturbances
• drug toxicity

Answer: 1

The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.