Fluid and Electrolyte Nur 112

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11 terms tracy_edwards75 Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview Nur 112 Teacher ytfg The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?

• Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

B.Furosemide (Lasix) 20 mg PO now

• Oxygen via face mask at 8 L/min
• KCl 20 mEq PO two times per day

ANS: A

A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure.Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician?

• Swollen ankles in patient with compensated heart

failure

• Positive Chvostek's sign in patient with acute

pancreatitis

• Dry mucous membranes in patient taking a new

diuretic

• Constipation in patient who has advanced breast

cancer

ANS: B

Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment.Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician.Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?

• Weight gain of 2 pounds since last week

b.Dry mucous membranes and skin tenting c.Urine output 8 mL/hr d.Blood pressure 98/58

ANS: C

Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?

• Vomiting all day and not replacing any fluid
• Tumor that secretes excessive antidiuretic hormone

(ADH)

• Tumor that secretes excessive aldosterone
• Tumor that destroyed the posterior pituitary gland

ANS: B

ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration?

• Development of ankle or sacral edema
• Increased skin tenting and dry mouth
• Postural hypotension and tachycardia
• Decreased level of consciousness

ANS: D

Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

• The patient with which diagnosis should have the

highest priority for teaching regarding foods that are high in magnesium?a.Severe hemorrhage b.Diabetes insipidus c.Oliguric renal disease d.Adrenal insufficiency

ANS: C

When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician.Nursing assessment indicates that heart rhythm is regular.What is the most important nursing intervention for this patient now?a.Raise bed side rails due to potential decreased level of consciousness and confusion.b.Examine sacral area and patient's heels for skin breakdown due to potential edema.c.Establish seizure precautions due to potential muscle twitching, cramps, and seizures.d.Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D

Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls.Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a.Bilateral ankle edema b.Weaker leg muscles than usual c.Postural blood pressure and heart rate d.Positive Trousseau's sign e.Flat neck veins when upright f.Decreased patellar reflexes

(B, C, D)

Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea.What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a.Test for skin tenting.b.Measure rate and character of pulse.c.Measure postural blood pressure and heart rate.d.Check Trousseau's sign.e.Observe for flatness of neck veins when upright.f.Observe for flatness of neck veins when supine.

ANS: A, B, F

ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations.Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.What substance is released from the posterior pituitary gland and promotes water retention in the renal system?

• Renin
• Aldosterone

C.Angiotensin

• Antidiuretic hormone (ADH)

ANS: D

ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone.Nurses should be alert for increased fluid requirements in which circumstance?

• Fever
• Mechanical Ventilation
• Congestive Heart Failure
• Increased intracranial pressure

ANS: A

Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children.

What factor predisposes an infant to fluid imbalances?

• Decreased surface area
• Lower metabolic rate
• Immature kidney functioning
• Decreased daily exchange of extracellular fluid

ANS: C

The infants kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.What is the required number of milliliters of fluid needed per day for a 14-kg child?

A. 800

B. 1000

C. 1200

D. 1400

ANS: C

For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed.10 kg 100 ml/kg/day = 1000 ml4 kg 50 ml/kg/day = 200 ml1000 ml + 200 ml = 1200 ml/dayEight hundred to 1000 ml is too little; 1400 ml is too much.An infant is brought to the emergency department with

the following clinical manifestations: poor skin turgor,

weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?

• Water excess
• Sodium excess
• Water depletion
• Potassium excess

ANS: C

These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

• Hyperreflexia
• Abdominal cramps
• Cardiac dysrhythmias
• Dry, sticky mucous membranes

ANS: D

Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.What laboratory finding should the nurse expect in a child with an excess of water?

• Decreased hematocrit
• High serum osmolality
• High urine specific gravity d. Increased blood urea

nitrogen

ANS: A

The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the childs ability to correct the fluid imbalance.What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

• nausea, vomiting
• weakness, fatigue
• muscle hypotonicity
• neuromuscular irritability

ANS: D

Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia.