kwalacav Preview - ScienceMedicineNursing Rafael_Gallo6 Save Med S...

Med Surg-Chapter 16 Fluids and Electrolytes ScienceMedicineNursing Rafael_Gallo6 Save Med Surge Ch. 10 - Fluid & Electroly...10 terms kwalacavPreview Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview Lewis M 88 terms per A nurse is caring fro a critically ill patient with a urinary retention catheter, Which hourly urine output should the nurse first alert the nurse that the primary health-care provider should be notified?

• 20ml

2.30ml 3.60ml 4.120ml (2). The circulating blood volume purfuses the kidneys producing a glomerular filtrate to which varying amounts are either reabsorbed or excreted to maintain fluid balance. When a person's urinary output is only 30ml, it indicates a deficienet circulating fluid volume, inadequate renal perfusion, and or kidney disease. The HCP should be notified.A nurse is caring for a patient that has depended edema. Which pressure has caused the excess fluid in the interstitial compartment?

• Oncotic pressure
• Diffusion pressure
• Hydrostatic pressure
• Intraventricular pressure

(3) Hydrostatic pressure is the pressure exerted by a fluid within a compartment, such as blood within the vessels. Hydrostatic pressure moves fluid from an area of greater pressure to an area of lower pressure. Hydrostatic pressure within the vessels of the body moves fluid from the intravascular compartment into the interstitial compartment. Interstitial fluid is extracelluar fluid that surrounds the cells.

A nurse evaluates the pts. fluid balance by monitoring the patient's intake and output. Which must the nurse understand about the ratio of the patient's fluid intake to output?

• Intake should be slightly more than the output.
• Intake should be higher than the fluid output.
• Intake should be lower than the urine output.
• Intake should be equal to the urine output.

(1) The volume and the composition of body fluids are kept in a delicate balance by a harmonious interaction of the kidneys and the endocrine, respiratory, cardiovascular, integumentary, and gastrointestinal systems.Hydrochlorothiazise (HCTZ) a diruretic, is prescribed for a patient who is retaining fluid. The nurse should encourage the pt. to ingest nutrients that contain which electrolyte?

• Magnesium
• Potassium
• Calcium
• Sodium

(2) Most diuretics affect the renal mechanisms for tubular secretion and reabsorption of electrolytes, particularly potassium. Because of potassium's narrow therapeutic window of 3.5-5.0 mEq/L and its role in the sodium potassium pump and muscle contraction, depleted potassium MUST be supplemented by increasing the dietary intake of foods high in potassium and or potassium drug therapy.The most common cause of respiratory alkalosis is

• hyperventilation
• hypoventilation

hyperventalation Which should a nurse do to encourage a confused patient to drink more fluid?

• Serve the fluid that a tepid temperature.
• Explain the reason for the desired intake.
• Offer the patient something to drink every hour.
• Leave a pitcher of water at the patient's bedside.

(3) frequent smaller volumes of fluid 50 to 100 mL per hour are better tolerated physiologically and psychologically than in frequent larger volumes of fluid.A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult?

• intake and output results
• Serum laboratory values
• Condition of the skin
• Presence of tenting

(2) Laboratory studies provide objective measurements of indicators of fluid, electrolytes, and acid-base balance. Common diagnostic test include serum blood studies of electrolytes osmolarity, hemoglobin, hematocrit, and arterial blood gases

A patient has continuous bladder irrigation. Which of the nurse do with the irrigant when calculating the fluid balance for this patient?

• Add to the oral intake column.
• Deducted from my total urine output.
• Subtract it from the intravenous flow sheet as output.
• Document the intake hourly in the urine output call him.

(2) when continuous bladder irrigation is in use, drainage from the urinary bladder will consist of both urine and the instilled irrigant.To determine the patient's urinary output, the amount of the irrigant instilled must be deducted from the total urinary output.A nurse is caring for two patients, one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both these patients?

• Diarrhea
• Cachexia
• Fluid volume deficit
• Impaired skin integrity

(3) The production of excessive amounts of urine by the kidneys without an increase in fluid intake can precipitate a fluid volume deficit.Oliguria, the production of excessively small amounts of urine by the kidney, is reflected as a negative balance in the intake and output a negative balance of intake and output is characteristic of fluid volume deficit.A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals perfuse diaphoresis, dry sticky mucous membranes, weakness disorientation, and a decreased level of consciousness. Which electrolyte imbalance does this data support?

• Hyperkalemia
• Hypercalcemia
• Hypernatremia
• Hypermagnesemia

(3) with profuse diaphoresis , the water loss exceeds the sodium loss, resulting in hypernatremia. Excess serum sodium precipitates changes in the musculoskeletal (weakness), neaurological (disorientation and decreased level of consciousness) and decreased integumentary systems (dry sticky mucous membranes) A patient exhibits and increasing blood pressure and 2 pound weight gain over two days. Which additional clinical manifestation can be clustered with these data?

• Decrease in heart rate
• Increase in skin turgor
• Increase in pulse volume
• Decrease in pulse pressure

(3) with an excess fluid volume and amount of circulating blood volume increases, resulting in full, bounding peripheral pulses Several patients are taking supplemental calcium daily. The nurse teaches them to maintain their fluid intake at a minimum of 2500 mL. The nurse explains that this intervention is designed to prevent which complication?

• Mobilization of calcium from bone
• Irritation of the bladder mucosa
• Occurrence of muscle cramps
• Formation of kidney stones

4- A high fluid intake increases the volume of urine produced. The resulting frequent urination of dilute urine prevents the formation of renal calculi, which may occur occur because of the increase precipitation of calcium salts associated with calcium supplementation

A patient receiving an enteral feeding developed diarrhea . Which characteristic of the feeding formula does the nurse to include precipitated the diarrhea?

• Icteric
• Isotonic
• Hypotonic
• Hypertonic

4- hypertonic solutions have a greater concentration of solute then does the blood. The high osmolarity of a hypertonic enteral feedings exerts an osmotic force that pulls fluid into the gastrointestinal tract, resulting in intestinal cramping and diarrhea A nurse is monitoring a patient who is receiving IV fluids. Which clinical findings indicate the patient has a fluid overload?

• Chills, fever, and generalized discomfort
• Blood in the two been close to the insertion site
• Dyspnea, headache, and increased blood pressure
• Pallor, sweating, and discomfort at the insertion site

3- IV fluid flows directly into the circulatory system via a vein. Excess intravascular volume (hypervolemia) causes, hypertension, Pulmonary edema, and headache.A nurse is assessing a patient's fluid status. Which assessment indicates the patient has a deficient fluid volume? Select all that apply.

• Negative balance of I/Os
• Decreased body temperature
• Increased body temperature
• Shortness of breath
• Flat jugular veins
• Weight loss

1,5,6 A Nurse assesses a patient for electrolyte imbalances. Which clinical manifestations indicate that the patient may have a potassium deficiency?Select all that apply

• Ventricular dysrhythmias
• Increased blood pressure
• Muscle weakness
• Chest pain
• Dry hair

1,3 A nurse is conducting an admission assessment on a client who has been diagnosed with diabetes insipidus. Which findings does the nurse anticipate during the assessment? Select all that apply

• Extreme polyuria
• Excessive thirst
• Elevated systolic blood pressure
• Low urine specific gravity
• Bradycardia

1,2,4