60 Questions
What assessment finding would a nurse most likely note in a client suspected of experiencing fluid volume deficit?
Decreased hematocrit and increased urine output
Who among the following clients would be at highest risk for developing fluid volume excess?
The client with kidney disease that developed as a complication of diabetes mellitus
Which client is at highest risk for developing a potassium level of 5.5 mEq/L (5.5 mmol/L)?
The client with Cushing’s syndrome
Which laboratory finding would most support a diagnosis of fluid volume excess in a client?
High BUN and creatinine levels
Which assessment finding would be inconsistent with a diagnosis of fluid volume deficit in a client?
Bounding pulses
Which client should the nurse prioritize assessment for fluid volume excess?
The client with ascites from liver cirrhosis
What additional sign would the nurse expect to note in a client with hyponatremia?
Muscle twitches
Which condition most likely caused a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
Renal insufficiency
Through which type of excretion does insensible fluid loss occur?
Integumentary output
In a group of clients, who is most likely at risk for a fluid volume deficit?
A client with an ileostomy
Which symptom would not typically be observed in a client with hyponatremia?
Flushed skin
Which electrolyte imbalance is commonly associated with generalized muscle weakness?
Hypomagnesemia
What is the normal serum calcium level?
9 to 10.5 mg/dL
What electrocardiographic changes occur in a client with hypocalcemia?
Prolonged QT interval and prolonged ST segment
What electrocardiographic changes are indicative of hypercalcemia?
Shortened ST segment and widened T wave
In a client with Crohn’s disease, what calcium level indicates hypocalcemia?
9 mg/dL
What type of waves occur with myocardial infarction?
Peaked T waves
Which electrolyte imbalance is associated with ST depression and prominent U waves on an ECG?
Hypocalcemia
What electrocardiographic changes are expected when hyperkalemia exists?
Tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR interval
What serum sodium level range is considered normal?
135 to 145 mEq/L
Which condition is indicated by a serum sodium level of 130 mEq/L?
Hyponatremia
Who is at risk for hypernatremia among the following?
Client with hyperaldosteronism
Which of the following changes is NOT associated with hyperkalemia?
Narrow QRS complexes
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
Clinical Judgment/Cognitive Skill
What are insensible losses?
Losses that occur through skin and lungs
Why are urination, wound drainage, and gastrointestinal tract losses considered sensible losses?
Because they are comparable and alike
Which of the following is an example of sensible fluid loss?
Fluid loss through urination
Why can't fluid loss through the skin be measured accurately?
It can only be approximated
What distinguishes insensible losses from sensible losses?
Awareness of the person experiencing the loss
Why are insensible losses considered difficult to measure accurately?
Because they are non-voluntary and unconscious
Which clinical manifestation would the nurse expect to note in a client with hypocalcemia and lactose intolerance?
Twitching
In a client with Crohn’s disease and a calcium level of 8 mg/dL (2 mmol/L), which electrocardiogram pattern should the nurse monitor for?
Peaked T wave
For a client with chronic kidney disease and a potassium level of 5.7 mEq/L (5.7 mmol/L), what ECG change might the nurse observe?
Tall peaked T waves
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
The client with hyperaldosteronism
What would be a concerning sign in a client with chronic kidney disease and a potassium level of 5.7 mEq/L (5.7 mmol/L)?
Widened QRS complexes
Which electrolyte imbalance is associated with prolonged ST segment and tall peaked T waves on an ECG?
Hypokalemia
What additional sign would the nurse expect to note in a client with hyponatremia?
Muscle twitches
Which client is most likely at risk for a fluid volume deficit?
A client with an ileostomy
What condition most likely caused the serum phosphorus level of 1.8 mg/dL?
Hypoparathyroidism
What type of excretion does insensible fluid loss occur through?
Integumentary output
What electrolyte imbalance is commonly associated with generalized muscle weakness?
Hypophosphatemia
Through which type of excretion does insensible fluid loss NOT occur?
Urinary output
What is the main reason why potassium chloride should always be diluted in IV fluid and infused via an infusion pump?
To avoid cardiac arrest
Why should the nurse carefully monitor the IV site during the administration of potassium chloride?
To monitor for vein irritation and phlebitis
What action should the nurse take if the urinary output during potassium chloride administration falls below 30 mL/hr?
Contact the physician
Why is giving potassium chloride by IV push considered dangerous?
It can result in cardiac arrest
What is the primary reason for the nurse to ensure that the IV bag containing potassium chloride is accurately labeled?
To know the quantity of potassium in the fluid
Why is it important for the nurse to monitor for infiltration during the administration of potassium chloride?
To detect potential complications early
Which electrocardiographic changes are expected in a client with hyperkalemia?
Peaked T waves, flat P waves, widened QRS complexes, prolonged PR interval
What serum sodium level indicates hyponatremia?
130 mEq/L (130 mmol/L)
Which client is at risk for hypernatremia?
A client with hyperaldosteronism
What is the normal serum sodium level range?
135 to 145 mEq/L (135 to 145 mmol/L)
Which condition can cause a serum sodium level of 130 mEq/L?
Hyponatremia
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
Recognizing cues
Which condition is most likely to cause a client to be at risk for fluid volume excess based on the text?
Hypothyroidism
What electrolyte imbalance is associated with prolonged QT interval on an ECG?
Hypokalemia
Which client condition would most likely lead to a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
Diabetic ketoacidosis (DKA)
In a client with Crohn’s disease, what calcium level indicates hypercalcemia?
$12$ mg/dL
Which electrolyte imbalance is commonly associated with muscle tetany and Chvostek's sign?
Hypomagnesemia
What cognitive skill is required to anticipate the effects of increased intravenous fluid replacement on a client's fluid balance?
Analysis
Study Notes
Fluid and Electrolyte Imbalance
- A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body
- Causes of fluid volume deficit:
- Vomiting
- Diarrhea
- Conditions that cause increased respirations or increased urinary output
- Insufficient intravenous fluid replacement
- Draining fistulas
- Presence of an ileostomy or colostomy
Hyponatremia
- Normal serum sodium level: 135-145 mEq/L (135-145 mmol/L)
- Serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia
- Can occur in clients taking diuretics
- Clients taking corticosteroids and clients with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia
Hypocalcemia
- Normal serum calcium level: 9-10.5 mg/dL (2.25-2.75 mmol/L)
- Serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia
- Electrocardiographic changes:
- Prolonged QT interval
- Prolonged ST segment
- Clients with Crohn's disease are at risk for hypocalcemia
Hyperkalemia
- Electrocardiographic changes:
- Tall peaked T waves
- Flat P waves
- Widened QRS complexes
- Prolonged PR interval
- Clients with chronic kidney disease are at risk for hyperkalemia
Insensible Fluid Loss
- Occurs daily through the skin and lungs
- Cannot be measured accurately, only approximated
- Example: 800 mL daily
Potassium Chloride Administration
- Must be diluted in IV fluid and infused via an infusion pump
- Never given by IV push
- Monitor for signs of infiltration or phlebitis
- Monitor urinary output and contact physician if less than 30 mL/hr
Test your knowledge on the signs and symptoms of hyponatremia in a client with heart failure receiving high doses of diuretics. Choose the additional sign that the nurse would expect to note in a client with hyponatremia.
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