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Chapter 13 - Concepts of Fluid and Electrolyte Balance Nclex questions ScienceMedicineNursing NURSEBRH45Top creator on Quizlet Save What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L?Urge the client to drink more water.Notify the primary health care provider.Assess the client's deep tendon reflexes..Document the finding as normal The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures?Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period?

• Plasma volume osmolarity increases; blood pressure increases
• Plasma volume osmolarity decreases; blood pressure increases
• Plasma volume osmolarity increases; blood pressure decreases
• B. Plasma volume osmolarity decreases; blood pressure decreases

Rationale:

A 3% saline solution is hypertonic to body fluids and would immediately increase the osmolarity of the plasma volume, making it somewhat hypertonic to other body fluids. Not only does the 500 mL increase the plasma volume to raise blood pressure, the increased osmolarity of the plasma would cause the interstitial fluid to move into the plasma volume, contributing to blood pressure increase.

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply.

• Blood pressure
• Deep tendon reflexes
• Hand-grip strength
• Pulse rate and quality
• Skin turgor
• Urine output

Rationale:

The most important body fluid compartment to maintain for function is the plasma volume of circulating blood. The most reliable indicators for effectiveness of IV fluid replacement to increase this volume are blood pressure and pulse. Urine output is also very sensitive to changes in plasma volume and is a reliable indicator of adequacy of fluid replacement therapy. Skin turgor changes do not occur quickly enough to use for evaluation of fluid replacement adequacy. Hand-grip strength and deep tendon reflex changes are less reliable and are affected by other factors.The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

• Foot and ankle
• Forehead
• Sacrum
• Chest

Rationale:

In a client who is confined to bed, the most dependent area is the sacrum. This is the area that will show skin turgor changes first for dependent edema. The forehead, chest, and feet are not dependent what a client is in a recumbent position.

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia?

• 72-year-old taking the diuretic spironolactone for control of hypertension
• 62-year-old receiving an IV solution of Ringer’s lactate at a rate of 200 mL/hour
• 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours
• 22-year-old receiving an IV infusion of regular insulin to manage an episode of

ketoacidosis

Rationale:

Insulin increases the activity of the sodium-potassium pump and forces more potassium from the extracellular fluid into the intracellular fluid. Although this is a desired response when managing hyperkalemia, the drug can cause hypokalemia in a client whose serum potassium level is initially normal. Spironolactone is a potassium-sparing diuretic that has the potential to raise serum potassium levels, not lower them. Ringer’s lactate contains potassium and would not dilute serum potassium below normal. Infusions of red blood cells usually raise serum potassium levels, not lower them, because some blood cells are damaged during the infusion and release intracellular potassium.In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm?

• Deep tendon reflexes
• Oxygen saturation
• Pulse rate and rhythm
• Respiratory rate and depth

Rationale:

Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias. It is the most important assessment to perform for a client with an elevated serum potassium level. Respiratory rate and depth are more affected by hypokalemia because of the accompanying muscle weakness. The reduction then affects oxygen saturation. Although deep tendon reflexes may be increased with hyperkalemia, cardiac changes are more critical.