Fluid and Electrolytes SATA

Fluid and Electrolytes SATA Leave the first rating Students also studied Terms in this set (40) Save Nclex electrolyte and acid/base 50 terms sierra_marie317 Preview Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Nclex style questions fluids and ele...61 terms kim_green7Preview Module 38 terms sara 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, B, D, E

RATIONALE:

Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.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, B, C

RATIONALE:

Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein.There is no circumstance where potassium is given by IV push.

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, B, D

RATIONALE:

Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client must be weighed at the same time each day, using the same scale and wearing approximately the same amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.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.

• Apples
• Bananas
• ACE inhibitors
• Grapes
• Salt substitute

B, C, E

RATIONALE:

While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.Apples and grapes are considered lower potassium-containing foods.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, C, D,

RATIONALE:

When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking insulin would lower the potassium level.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, C, D, E

RATIONALE:

The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.Blood glucose changes do not have a direct relation to a client's hydration status; lactated ringers are free from glucose.

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, C

RATIONALE:

Best practice technique for administering IV potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr. Potassium would never be administered via IV push.Assess the IV access for placement and an adequate blood return before administering potassium-containing solutions.The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.

1.Ensure adequate oxygenation.

2.Provide assistance to prevent falls.

3.Monitor medication administration of diuretics.

4.Monitor for numbness and tingling around the mouth.

5.Prevent complications during potassium administration.Ensure adequate oxygenation.Provide assistance to prevent falls.Monitor medication administration of diuretics Prevent complications during potassium administration.Rationale:The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex Inverted T waves U waves Depressed ST segment

Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0

mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply.

1.Ensure adequate fluid intake.

2.Implement safety measures to prevent falls.

3.Encourage low-fiber foods to prevent diarrhea.

4.Instruct the client about foods that contain potassium.

5.Encourage the client to obtain assistance to ambulate.

1.Ensure adequate fluid intake.

2.Implement safety measures to prevent falls.

4.Instruct the client about foods that contain potassium.

5.Encourage the client to obtain assistance to ambulate.Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury.Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value?Select all that apply.

1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment Prolonged QT interval Prolonged ST segment The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia.Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply.

1.Blood transfusions 2.Metabolic alkalosis 3.Bleeding or hemorrhage 4.Decreased sodium excretion 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium 1.Blood transfusions 3.Bleeding or hemorrhage 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply.

• Milk
• Beef
• Poultry
• Green vegetables
• Liver

Ans: A, C, E

Feedback:If the patient experiences mild hypophosphatemia, foods such as milk

and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults.What factors contribute to this phenomenon? Select all that apply.

• Decreased kidney mass
• Increased conservation of sodium
• Increased total body water
• Decreased renal blood flow
• Decreased excretion of potassium

Ans: A, D, E

Feedback:Dehydration in the elderly is common as a result of decreased kidney

mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.