Ch. 11 Problems with Fluid and Electrolyte Balance
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1. The RN is assessing a
70-year-old client admitted
to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
Client behavior that changes
from anxious to lethargic
Deep furrows on the surface
of the tongue
Poor skin turgor with tenting
remaining for 2 minutes after
the skin is pinched
Client behavior that changes from anxious to
lethargic
**Immediate intervention by the nurse is required when a client's behavior changes from
anxious to lethargic. This change in mental
status suggests poor cerebral blood flow and
fluid shifts within the brain cells. Immediate
intervention is needed to prevent further cerebral dysfunction.Deep furrows on the surface
of the tongue, poor skin turgor, and low urine
output are all caused by the fluid volume
deficit, but do not indicate complications of
dehydration that are immediately life-threatening.
Urine output of 950 mL for
the past 24 hours
2. 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
Assess for orthostatic hypotension
Initiate cardiac monitoring
**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 weakPlace the client on bed rest. ness from a likely fluid volume deficit and
Evaluate the electrolyte lev- electrolyte imbalance. The nurse should reels.
view the laboratory and diagnostic results to
Administer the ordered di- detect likely loss of sodium, potassium, and
uretic.
magnesium secondary to diarrhea and diassess for orthostatic hyuretic us. Fluid volume deficit is likely with
potension.
diarrhea and diuretic use and leads to fluinitiate cardiac monitoring id and electrolyte imbalances, especially hy1 / 18
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pokalemia. 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.
3. 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.
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.
**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.
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4. 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.
5. The nurse is caring for a
client who takes furosemide
(Lasix) and digoxin (Lanoxin). The client's potassium
(K+) level is 2.5 mEq/L
(2.5 mmol/L). Which additional assessment will the nurse
make?
Heart rate
Blood pressure (BP)
Increases in edema
Assess daily weights
Encourage consumption of citrus fruits
Monitor serum potassium.
**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.
Heart rate
**The nurse must assess the heart rate for
bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac
muscle to digoxin and may result in digoxin
toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea,
and other symptoms of toxicity to digoxin.The
BP may decrease with low potassium level but monitoring the pulse is essential. The
diuretic would reduce edema, therefore as3 / 18
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Sodium level
6. Furosemide (Lasix) has been
ordered for a client with heart
failure, shortness of breath,
and 3+ pitting edema of the
lower extremities. Which assessment finding indicates
to the nurse that the medication has been effective?
The client's potassium level
is 5.1 mEq/L (5.1 mmol/L).
The client's heart rate is 101
beats per minute.
The client is free from adventitious breath sounds.
The client has experienced a
weight gain of 1 pound (0.5
kg).
7. The nurse is discussing
safety when administering
bumetanide with a nursing
student. The nurse recognizes that the student understands side effects of this
medication when the student
makes which statement?
sessing the heart rate is the priority. High
serum sodium levels would not be expected
in this scenario unless fluid volume deficit is
present.
The client is free from adventitious breath
sounds.
**The nurse recognizes that Furosemide is
effective when the client is free from adventitious breath sounds such as crackles. Other
positive outcomes to the diuretic include normal heart rate, weight loss with resolution of
edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is
normal. Changes in potassium levels such as
hypokalemia are side effects of furosemide,
not therapeutic effects. Although a fall in the
client's BP may occur with the decrease in
body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly
indicate the medication has been effective.
Weight loss, rather than weight gain, is often
the effect of Furosemide, caused by the diuresis.
"Inverted T waves and a U wave may appear
on the ECG."
**The nursing student understands the side
effects of Bumex when commenting that inverted T waves and a U wave may appear on
the EKG. Hypokalemia may cause depressed
ST segments, flat or inverted T waves or the
presence of a U wave on the ECG as well
"The client's PT and INR may as dysrhythmias. High-ceiling (loop) diuretbe prolonged while taking
ics, such as furosemide (Lasix, furosemide),
this medication."
promote loss of water, sodium, and potassi4 / 18
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"The client may develop
hypoglycemia during treatment."
"Inverted T waves and a U
wave may appear on the
ECG."
um.PT and INR are typically prolonged with
therapy with warfarin (Coumadin) or individuals with liver disease. Hypoglycemia may
occur with oral hypoglycemic medications or
insulin. Salt substitutes are typically avoided
when the client has hyperkalemia or is taking
an ACE inhibitor because many substitutes
contain potassium chloride.
"I need to tell the client to
avoid salt substitutes."
8. 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
Bananas
ACE Inhibitors
Salt substitute
**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.
9. The nurse is assessing a
instructing the client not to ambulate without
client with a sodium level
assistance
of 118 mEq/L (118 mmol/L).
Which activity takes priority? **Safety is the priority in this instance. Instructing the client not to ambulate without
Monitoring urine output
assistance is the priority for a client with a
sodium level of 118 mEq/L (118 mmol/L). This
encouraging sodium rich flu- sodium level denotes severe hyponatremia
ids and foods throughout the which makes depolarization slower and cell
day
membranes less excitable. This is manifested
as general muscle weakness which is worse
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instructing the client not to in the legs and arms. Additionally, this client
ambulate without assistance may have developed confusion from cerebral
edema.Monitoring urine output needs to be
assessing deep tendon re- done but is not the priority action in this situaflexes
tion. Generally, fluid is restricted, rather than
sodium rich foods offered, to minimize the
hyponatremia. While the nurse may assess
muscle strength and deep tendon reflex responses, safety is the priority.
10. The nurse is infusing 3%
saline for a client with syndrome of inappropriate secretion (SIADH). Which of
these complications does
the nurse report to the primary care provider?
Crackles ½ way up the lung fields
11. The nurse is caring for a
client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?
Assessing the blood pressure hourly
**The nurse needs to report to the PCP crackles heard ½ way up the lung fields when assessed on a client with SIADH receiving an
infusion of 3% saline. When a hyperosmotic
IV solution such as 3% saline is infused, the
interstitial fluid is pulled into the circulation in
Peripheral edema
an attempt to dilute the blood. As a result, the
plasma volume expands. The nurse needs to
Crackles ½ way up the lung evaluate the client for fluid volume excess and
fields
symptoms of heart failure including crackles.Peripheral edema may occur with SIADH.
Serum osmolarity of 294
A serum osmolarity of 294 mOsm/kg (294
mOsm/kg (294 mmol/kg)
mmol/kg) is normal. A urine output of 1300
mL over 24 hours is considered normal.
Urine output of 1300 mL over
24 hours
**Assessing hourly blood pressures is critical
when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom
of hypermagnesemia during magnesium inMonitoring 24-hour urine
fusion.Most clients who have fluid and elecoutput
trolyte problems will be monitored for intake and output, and will not immediately inAsking the client about feel- dicate problems with magnesium overdose.
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ing depressed
Low magnesium levels can cause psychological depression, but assessing this paraAssessing the blood pres- meter as the levels are restored would not
sure hourly
safely assess a safe dose or an overdose. Although administration of magnesium sulfate
Monitoring the serum calci- can cause a drop in calcium levels, this occurs
um levels
over a period of time and would not be the
best way to assess magnesium toxicity.
12. 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.
Use of salt substitute
Use of an ACE inhibitor
Potassium-sparing diuretics
**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
History of liver disease
client's potassium level. Insulin, which moves
Use of salt substitute
potassium into the cell, can be used as a
Use of an ACE inhibitor
treatment for hyperkalemia, in addition to diPotassium-sparing diuretics abetes. Taking insulin would lower the potasPrescription for insulin
sium level.
13. After receiving
A client receiving intravenous (IV) diuretics
change-of-shift report, which whose blood pressure is 88/52 mm Hg
client does the RN assess
first?
**The nurse must first assess the client receiving IV diuretics whose blood pressure is
A client with nausea and
88/52 mm Hg. This client with hypotension
vomiting who complains of may have developed hypoperfusion caused
abdominal cramps
by hypovolemia. Immediate interventions are
needed.The client with nausea and vomiting,
A client with a nasogastric the client with an NG tube complaining of
(NG) tube who has dry oral thirst, and the client receiving normal saline
mucosa and is complaining with an hourly urine output of 75 mL/hr have
of thirst
problems which are not urgent at this time.
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A client receiving intravenous (IV) diuretics whose
blood pressure is 88/52 mm
Hg
A client with normal saline
infusing at 150 mL/hr whose
hourly urine output has been
averaging 75 mL
14. The primary care provider
writes prescriptions for a
client who is admitted with
a serum potassium level of
6.9 mEq/L (6.9 mmol/L). What
does the nurse implement
first?
Place the client on a cardiac monitor.
**The nurse must first place this client on a
monitor. Because hyperkalemia can lead to
life-threatening bradycardia, placing the client
on a cardiac monitor permits early intervention in the event of dysrhythmias.Administering a potassium-reducing medication, recAdminister sodium polyommending a potassium-restricted diet, and
styrene sulfonate (Kayexteaching the client about diet are appropriate
alate) orally.
but will not immediately decrease the serum
potassium level and do not need to be imEnsure that a potassium-re- plemented as quickly as monitoring cardiac
stricted diet is ordered.
rhythm.
Place the client on a cardiac
monitor.
Teach the client about foods
that are high in potassium.
15. The nurse is planning care Offering fluids to drink every hour
for a 72-year-old resident of
a long-term care facility who **Offering oral fluids every hour is within the
has a history of dehydration. scope of practice for a UAP.Assessments of
Which action does the nurse oral mucosa, selection of appropriate fluids,
delegate to unlicensed assis- and assessment of skin turgor would be done
tive personnel (UAP)?
by licensed nursing staff, who have the need-
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Assessing oral mucosa for
dryness
ed education and scope of practice to implement these more complex actions.
Choosing appropriate oral
fluids
Monitoring skin turgor for
tenting
Offering fluids to drink every
hour
16. The nurse at a long-term care
facility is teaching a group of
unlicensed assistive personnel (UAP) about fluid intake
principles for older adults.
Which of these should be included in the education session?
"Offer fluids that they prefer frequently and on
a regular schedule."
17. The nurse is preparing a
client a diagnosis of congestive heart failure (CHF)
"Weighing myself daily can reveal increased
fluid retention."
**The long-term care nurse teaches the UAPs
to frequently offer older adults fluids that they
prefer and on a regular basis. Because of the
decreased thirst mechanism, older adults can
become dehydrated and must be offered oral
fluids every 2 hours. The likelihood of their
"Be careful not to overload accepting the fluid increases if it is one they
them with too many oral flu- prefer.Risk of overhydration, especially with
ids."
oral fluids, is minimal. Fluids would never be
restricted even if the client is incontinent. Re"Offer fluids that they prefer stricting fluids to incontinent clients is a comfrequently and on a regular mon mistake made by UAP in long-term care
schedule."
environments. It is not necessary to disturb
older adults during their sleep to offer fluids.
"Restrict their fluids if they However, they should be offered a drink durare incontinent."
ing waking hours at frequent intervals (e.g.,
every 2 hours).
"Wake them every 2 hours
during the night with a
drink."
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for discharge. Which statement by the client indicates
a correct understanding of
self-management of CHF?
"I can gain 2 pounds (1 kg) of
water a day without risk."
"I should call my provider if I
gain more than 1 pound (0.5
kg) a week."
"Weighing myself daily can
determine if my caloric intake is adequate."
"Weighing myself daily can
reveal increased fluid retention."
18. The nurse is caring for a
group of clients on a medical surgical unit. Which newly written prescription will
the nurse administer first?
**The client with CHF should weigh himself
daily to observe for increasing fluid retention,
which may not be visible. Rapid weight gain is
the best indicator of fluid retention and overload. Each pound (0.5 kg) of weight gained
(after the first half-pound [0.2 kg]) equates to
500 mL of retained water. The client must be
weighed at the same time every day (before
breakfast), and on the same scale.The client
would call the primary care provider if more
than 1 or 2 pounds (0.5 or 1 kg) are gained
in a 24-hour period or if more than 3 pounds
(1.4 kg) are gained in 1 week. Daily weights
are not an indication of effective dieting for
purposes of weight loss or gain. They will
show fluid retention after an especially high
sodium intake (in a client with fluid retention
problems), but caloric intake is related to food
intake rather than fluid retention problems.
Oral potassium chloride to a client whose
serum potassium is 3 mEq/L (3 mmol/L)
**The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum
Intravenous normal saline to potassium levels can cause life-threatening
a client with a serum sodium dysrhythmias.The electrolyte disturbances
of 132 mEq/L (132 mmol/L) (sodium level of 132 and low phosphorus
level) and the need for calcium in the other
Oral calcium supplements to clients are not immediately life-threatening.
a client with severe osteoporosis
Oral phosphorus supplements to a client with acute
hypophosphatemia
Oral potassium chloride to a
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client whose serum potassium is 3 mEq/L (3 mmol/L)
19. Which client is most appro- A client admitted yesterday with heart failure
priate for the nurse manager with dependent pedal edema
of the medical-surgical unit
to assign to the LPN/LVN?
**The most appropriate client to assign to the
LPN/LVN is the 64-year-old client admitted
A client admitted with dehy- yesterday with heart failure and dependent
dration who has a heart rate pedal edema. This client is the most stable
of 126 beats/min
of all the four clients.Dehydration, tachycardia, potassium overload, and GI signs and
A client just admitted with
symptoms in a client indicate that he or she
hyperkalemia who takes a
is unstable. Care must be given by the RN
potassium-sparing diuretic who can carry out assessments, prescripat home
tions, and participate interdisciplinary collaboration as needed.
A client admitted yesterday
with heart failure with dependent pedal edema
A client who has just been
admitted with severe nausea,
vomiting, and diarrhea
20. A client with hypermagnesemia is seen in the
emergency department (ED).
Which of these interventions
is most appropriate?
Place the client on a cardiac monitor
**Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring
is most appropriate.Reflexes are typically reMonitor for hyperactive re- duced in the presence of hypermagnesemia.
flexes
There is no indication that the client has signs
and symptoms of respiratory distress at this
prepare for endotracheal in- time, however the nurse would monitor the
tubation
client for respiratory weakness and respiratory failure. The nurse will institute teaching
Institute teaching on avoid- after the emergency passes and the cause of
ing magnesium rich foods
the magnesium excess is determined.
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Place the client on a cardiac
monitor
21. The nurse manager of a medical-surgical unit is completing assignments for the day
shift staff. The client with
which electrolyte laboratory value is assigned to the
LPN/LVN?
Calcium level of 9.5 mg/dL
(2.4 mmol/L)
Magnesium level of 4.1
mEq/L (2.1 mmol/L)
Calcium level of 9.5 mg/dL (2.4 mmol/L)
**The client with a calcium level of 9.5 mg/dL
(2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is
1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose
risk for dysrhythmia, and a sodium level of
120 mEq/L (120 mmol/L) may cause serious
cerebral dysfunction requiring assessments
and/or interventions by the RN.
Potassium level of 6.0 mEq/L
(6.0 mmol/L)
Sodium level of 120 mEq/L
(120 mmol/L)
22. The step down unit receives RN who has floated from the intensive care
a new admission who has un- unit
controlled diabetes, polyuria,
and a blood pressure of
**The RN who has floated from the intensive
86/46 mm Hg. Which staff
care unit needs to care for this clinically unmember is assigned to care stable woman with uncontrolled diabetes. The
for her?
clinical manifestations suggest that the client
is experiencing hypovolemia and possible hyLPN/LVN who has floated
povolemic shock from osmotic diuresis. The
from the hospital's long-term RN from the intensive care unit will have excare unit
tensive experience caring for clients with hypovolemia, hyperglycemia, and fluid volume
LPN/LVN who frequently ad- deficit/shock.The LPN/LVN who has floated
ministers medications to
from the long-term care unit or who frequentmultiple clients
ly administers medications to multiple clients
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will not be as familiar with care for critically
RN who has floated from the ill clients, or qualified to care for this clinicalintensive care unit
ly unstable client. Although the resource on
diabetes is helpful, the RN who works as a
RN who usually works as a diabetes educator will not be as familiar with
diabetes educator
care for acutely or critically ill clients.
23. The nurse is caring for an
older adult with hypernatremia. Which of these interventions does the nurse perform first?
Encourage fluid intake
24. The nurse is caring for a
group of clients with electrolytes and blood chemistry
abnormalities. Which client
will the nurse see first?
The client whose potassium is 6.2 mEq/L (6.2
mmol/L)
**When caring for an older adult with hypernatremia, the nurse first encourages the client
to take more fluid. Encouraging fluids in the
older adult is important to prevent dehydration
Restrict the client's intake of with resulting concentrated sodium levels.Hysodium
pernatremia and fluid loss typically occur in
tandem in the older adult. Restricting sodium
Administer a diuretic
does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid
Monitor the serum osmolari- volume deficit the client is experiencing. Monty
itoring the osmolarity will detect an abnormality, but not resolve the problem.
Encourage fluid intake
The client with a random glucose reading of 123 mg/dL
(6.8 mmol/L)
The client who has a magnesium level of 2.1 mEq/L (1.0
mmol/L)
The client whose potassium
is 6.2 mEq/L (6.2 mmol/L)
**The first client the nurse sees with electrolyte and blood chemistry abnormalities is
the client whose potassium is 6.2 mEq/L (6.2
mmol/L). A potassium value of 6.2 mEq/L (6.2
mmol/L) is elevated and the client has potential for cardiac dysrhythmias.A random or
casual glucose, taken at any time of day, is
elevated if e200mg/dL (>11.1mmol/L); a random value of 123 mg/dL (6.9 mmol/L) does
not require intervention. The other clients
with a magnesium value of 2.1 mEq/L (1.0
mmol/L) and a sodium value of 143 mEq/L
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(143 mmol/L) demonstrate normal laboratory
The client with a sodium level values and do not require intervention.
of 143 mEq/L (143 mmol/L)
25. The RN is caring for a client
who is severely dehydrated.
Which nursing action can be
delegated to the unlicensed
assistive personnel (UAP)?
Providing oral care every 1 to 2 hours
**Appropriate intervention by an UAP to a
client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent
oral care is important for a client with fluid
Consulting with a health care volume deficit.Consulting with a primary care
provider about a client's lab- provider about a client's laboratory results,
oratory results
infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would
Infusing 500 mL of normal
be performed by licensed personnel.
saline over 60 minutes
Monitoring IV fluid to maintain the drip rate at 75 mL/hr
Providing oral care every 1 to
2 hours
26. The charge nurse on a medical-surgical unit is completing assignments for the day
shift. Which client is most
appropriate to assign to the
LPN/LVN?
A 76-year-old with poor skin turgor who has
a serum osmolarity of 300 mOsm/kg (300
mmol/kg)
**The most appropriate client for the nurse
to assign to the LPV/LVN is the 76-year-old
adult with poor skin turgor and a serum osA 44-year-old with conges- molarity of 300 mOsm/kg (300 mmol/kg). Altive heart failure (CHF) who though the 76-year-old client has poor skin
has gained 3 pounds (1.4 kg) turgor, the serum osmolarity indicates normal
since the previous day
fluid balance. This client is the most stable
of the four clients described.The 44-year-old
A 58-year-old with chronic re- with CHF who has gained 3 pounds (1.4
nal failure (CRF) who has a kg) since the previous day requires additional
serum potassium level of 6 assessments and interventions which should
mEq/L (6.0 mmol/L)
be performed by an RN. The data about the
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58-year-old client with CRF and a serum
A 76-year-old with poor skin potassium level of 6 mEq/L (6.0 mmol/L) has
turgor who has a serum
a risk for dysrhythmia and instability. Assessosmolarity of 300 mOsm/kg ments and interventions performed by an RN
(300 mmol/kg)
are also needed on this client. The data about
the 80-year-old client with edema and conAn 80-year-old with 3+ pegested lungs indicate that the client is not
ripheral edema and crackstable, requiring ongoing assessments and
les throughout the posterior interventions by an RN.
chest
27. 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
28. The rapid response team
(RRT) is called to the bedside
of a client with heart rate of
38 beats per minute and a
potassium level of 7.0 mEq/L
(7.0 mmol/L). For which medication will the nurse anticipate a prescription?
Insulin
atropine
Blood pressure
Pulse rate and quality
Urinary output
Urine specific gravity
**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.
Insulin
**The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in
water. This may be prescribed to promote
movement of potassium from the blood into
the intracellular fluid.While atropine will treat
bradycardia, it does not address the underlying cause of bradycardia which is likely
hyperkalemia. Sodium polystyrene sulfonate
(Kayexalate)may be used for hyperkalemia,
but it will not act quickly enough in an emer15 / 18
Ch. 11 Problems with Fluid and Electrolyte Balance
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Sodium polystyrene sulfonate (Kayexalate)
potassium phosphate
29. A client develops fluid overload while in the intensive
care unit. Which nursing intervention does the nurse
perform first?
gency. Additional potassium such as contained in potassium phosphate will make the
client's condition more critical.
atropine
Elevates the head of the bed
**The nurse first needs to elevate the client's
head of bed when caring for a client with fluid
overload. Remember to follow the ABC's and
perform interventions that promote lung exDraws blood for laboratory pansion and oxygenation to relieve symptoms
tests
of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be
Elevates the head of the bed performed first. Placing the extremities in a
dependent position increases peripheral edePlaces the extremities in a ma, and positioning the client in a side-lying
dependent position
position increases the work of breathing.
Puts the client in a side-lying
position
30. An older adult is admitted to
the medical surgical unit with
dehydration. The nurse performs which of these assessments to determine whether
the client is safe for independent ambulation?
Checks for orthostatic blood pressure
changes
**When caring an older adult admitted for
dehydration, the nurse determines if the client
is safe for independent ambulation by assessing for orthostatic blood pressure. Blood
pressure measured with the client lying, then
Assesses for dry oral musitting, and finally standing is done to detect
cous membranes
orthostatic or postural changes. During low
blood volume states, especially when standChecks for orthostatic blood ing, insufficient blood flow to the brain may
pressure changes
cause hypotension and tachycardia upon
arising. This may cause light-headedness
Notes pulse rate is 72
and dizziness, which increases the risk for
beats/min and bounding
falls, especially in older adults.Assessment
of oral mucous membranes and the pulse
16 / 18
Ch. 11 Problems with Fluid and Electrolyte Balance
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Evaluates that the serum
rate can detect symptoms of dehydration, but
potassium level is 4.0 mEq/L these are not the best ways to assess for a fall
(4.0 mmol/L)
risk. Checking serum potassium does ensure
safety for ambulation nor assess for fall risk.
31. The nurse is assessing fluid balance in the client with
heart failure. Which of these
strategies will the nurse employ?
Ask the client how much fluid
was consumed yesterday.
Place an indwelling catheter
to measure urine output.
Auscultate the lungs for adventitious sounds.
Weigh the client daily, at the
same time.
32. 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
Weigh the client daily, at the same time.
**When assessing fluid balance on a client
with heart failure the nurse must weigh the
client at the same time every day. Changes
in daily weights are the best indicators of
fluid losses or gains. A weight change of 1
pound (0.5 kg) corresponds to a fluid volume
change of about 500 mL therefore the weight
must be compared to intake and output.The
nurse must weigh the client rather than rely
on client estimate or memory. An indwelling
catheter poses a risk for catheter associated urinary tract infection, and is reserved for
specific reasons. Auscultating for adventitious
lung sounds or crackles will demonstrate fluid
overload, but may not immediately show up.
Ensuring that the concentration is no greater
than 1?9?mEq/10?9?mL of solution
Use an IV pump to deliver the medication
**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
17 / 18
Ch. 11 Problems with Fluid and Electrolyte Balance
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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
33. A client with mild hypokalemia caused by diuretic use is discharged home.
The home health nurse delegates which of these interventions to the home health
aide?
be administered via IV push. Assess the IV
access for placement and an adequate blood
return before administering potassium-containing solutions.
Measurement of the client's weight
**The intervention that can be delegated to
the home health aide is to measure the
client's weight. Measuring the client's intake
and output and reporting it to the RN helps
determines if the plan of care has been effective.Assessment, education, and instrucAssessment of muscle tone tion are higher-level nursing actions within the
and strength
scope of practice of the professional nurse.
Education about potassium-rich foods
Instruction on the proper use
of drugs
Measurement of the client's
weight
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