caused by a massive burn injury. Which of the following assessment data will be of greatest concern?

Fluid and Electrolytes NCLEX

• The nurse obtains all of the following assessment data about a patient with deficient fluid volume

caused by a massive burn injury. Which of the following assessment data will be of greatest concern?

• The blood pressure is 90/40 mm Hg.
• Urine output is 30 ml over the last hour.
• Oral fluid intake is 100 ml for the last 8 hours.

d. There is prolonged skin tenting over the sternum. - ANS: A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

• A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of

inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for

• increased total urinary output.
• elevation of serum hematocrit.
• decreased serum sodium level.

d. rapid and unexpected weight loss. - ANS: B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

• When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with

multiple draining wounds, the most accurate assessment to include is

• skin turgor.
• daily weight.
• presence of edema.

d. hourly urine output. - ANS: B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

• When caring for an alert and oriented elderly patient with a history of dehydration, the home health

nurse will teach the patient to increase fluid intake

• in the late evening hours.
• if the oral mucosa feels dry.
• when the patient feels thirsty.

d. as soon as changes in level of consciousness (LOC) occur. - ANS: B

An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice

• A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach

the patient to report symptoms of adverse effects such as

• personality changes.
• frequent loose stools.
• facial muscle spasms.

d. generalized weakness. - ANS: D

Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

• Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which

statement by the patient indicates that the teaching about this medication has been effective?

• "I will try to drink at least 8 glasses of water every day."
• "I will use a salt substitute to decrease my sodium intake."
• "I will increase my intake of potassium-containing foods."
• "I will drink apple juice instead of orange juice for breakfast." - ANS: D

Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits.Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

• When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate

taking?

• Restrict patient's oral free water intake.
• Avoid use of electrolyte-containing drinks.
• Infuse a solution of 5% dextrose in 0.45% saline.

d. Administer vasopressin (antidiuretic hormone, [ADH]). - ANS: A

To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the patient's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further.

• Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe

hypokalemia. Which action should the nurse take?

• Administer the KCl as a rapid IV bolus.
• Infuse the KCl at a rate of 20 mEq/hour.
• Give the KCl only through a central venous line.

d. Add no more than 40 mEq/L to a liter of IV fluid. - ANS: B

Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

• A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium

level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question?

• Infuse 5% dextrose in water at 125 ml/hr.
• Administer IV morphine sulfate 4 mg every 2 hours PRN.
• Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

d. Administer 3% saline if serum sodium drops to less than 128 mEq/L. - ANS: A

Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

• A patient who has required prolonged mechanical ventilation has the following arterial blood gas

results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as

• metabolic acidosis.
• metabolic alkalosis.
• respiratory acidosis.

d. respiratory alkalosis. - ANS: D

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

• The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep

respirations. Which action should the nurse take?

• Notify the patient's health care provider.
• Give the prescribed PRN lorazepam (Ativan).
• Start the prescribed PRN oxygen at 2 to 4 L/min.

d. Encourage the patient to take deep, slow breaths. - ANS: A

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider.Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Ativan administration will slow the respiratory rate and increase the level of acidosis.

DIF: Cognitive Level: Application REF: 323 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological

• The home health nurse notes that an elderly patient has a low serum protein level. The nurse will

plan to assess for

• pallor.
• edema.
• confusion.

d. restlessness. - ANS: B

Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

• A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the

solution, the most important assessment for the nurse to monitor is

• lung sounds.
• urinary output.
• peripheral pulses.

d. peripheral edema. - ANS: A

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of