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Questions and Answers
What assessment finding would a nurse most likely note in a client suspected of experiencing fluid volume deficit?
What assessment finding would a nurse most likely note in a client suspected of experiencing fluid volume deficit?
- Increased respirations and increased blood pressure
- Weight loss and poor skin turgor
- Lung congestion and increased heart rate
- Decreased hematocrit and increased urine output (correct)
Who among the following clients would be at highest risk for developing fluid volume excess?
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 (correct)
- The client taking diuretics who has tenting of the skin
- The client who requires intermittent gastrointestinal suctioning
- The client with an ileostomy from a recent abdominal surgery
Which client is at highest risk for developing a potassium level of 5.5 mEq/L (5.5 mmol/L)?
Which client is at highest risk for developing a potassium level of 5.5 mEq/L (5.5 mmol/L)?
- The client with colitis
- The client with Cushing’s syndrome (correct)
- The client who has been overusing laxatives
- The client who has sustained a traumatic burn
Which laboratory finding would most support a diagnosis of fluid volume excess in a client?
Which laboratory finding would most support a diagnosis of fluid volume excess in a client?
Which assessment finding would be inconsistent with a diagnosis of fluid volume deficit in a client?
Which assessment finding would be inconsistent with a diagnosis of fluid volume deficit in a client?
Which client should the nurse prioritize assessment for fluid volume excess?
Which client should the nurse prioritize assessment for fluid volume excess?
What additional sign would the nurse expect to note in a client with hyponatremia?
What additional sign would the nurse expect to note in a client with hyponatremia?
Which condition most likely caused a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
Which condition most likely caused a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
Through which type of excretion does insensible fluid loss occur?
Through which type of excretion does insensible fluid loss occur?
In a group of clients, who is most likely at risk for a fluid volume deficit?
In a group of clients, who is most likely at risk for a fluid volume deficit?
Which symptom would not typically be observed in a client with hyponatremia?
Which symptom would not typically be observed in a client with hyponatremia?
Which electrolyte imbalance is commonly associated with generalized muscle weakness?
Which electrolyte imbalance is commonly associated with generalized muscle weakness?
What is the normal serum calcium level?
What is the normal serum calcium level?
What electrocardiographic changes occur in a client with hypocalcemia?
What electrocardiographic changes occur in a client with hypocalcemia?
What electrocardiographic changes are indicative of hypercalcemia?
What electrocardiographic changes are indicative of hypercalcemia?
In a client with Crohn’s disease, what calcium level indicates hypocalcemia?
In a client with Crohn’s disease, what calcium level indicates hypocalcemia?
What type of waves occur with myocardial infarction?
What type of waves occur with myocardial infarction?
Which electrolyte imbalance is associated with ST depression and prominent U waves on an ECG?
Which electrolyte imbalance is associated with ST depression and prominent U waves on an ECG?
What electrocardiographic changes are expected when hyperkalemia exists?
What electrocardiographic changes are expected when hyperkalemia exists?
What serum sodium level range is considered normal?
What serum sodium level range is considered normal?
Which condition is indicated by a serum sodium level of 130 mEq/L?
Which condition is indicated by a serum sodium level of 130 mEq/L?
Who is at risk for hypernatremia among the following?
Who is at risk for hypernatremia among the following?
Which of the following changes is NOT associated with hyperkalemia?
Which of the following changes is NOT associated with hyperkalemia?
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
What are insensible losses?
What are insensible losses?
Why are urination, wound drainage, and gastrointestinal tract losses considered sensible losses?
Why are urination, wound drainage, and gastrointestinal tract losses considered sensible losses?
Which of the following is an example of sensible fluid loss?
Which of the following is an example of sensible fluid loss?
Why can't fluid loss through the skin be measured accurately?
Why can't fluid loss through the skin be measured accurately?
What distinguishes insensible losses from sensible losses?
What distinguishes insensible losses from sensible losses?
Why are insensible losses considered difficult to measure accurately?
Why are insensible losses considered difficult to measure accurately?
Which clinical manifestation would the nurse expect to note in a client with hypocalcemia and lactose intolerance?
Which clinical manifestation would the nurse expect to note in a client with hypocalcemia and lactose intolerance?
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?
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?
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?
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?
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
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)?
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)?
Which electrolyte imbalance is associated with prolonged ST segment and tall peaked T waves on an ECG?
Which electrolyte imbalance is associated with prolonged ST segment and tall peaked T waves on an ECG?
What additional sign would the nurse expect to note in a client with hyponatremia?
What additional sign would the nurse expect to note in a client with hyponatremia?
Which client is most likely at risk for a fluid volume deficit?
Which client is most likely at risk for a fluid volume deficit?
What condition most likely caused the serum phosphorus level of 1.8 mg/dL?
What condition most likely caused the serum phosphorus level of 1.8 mg/dL?
What type of excretion does insensible fluid loss occur through?
What type of excretion does insensible fluid loss occur through?
What electrolyte imbalance is commonly associated with generalized muscle weakness?
What electrolyte imbalance is commonly associated with generalized muscle weakness?
Through which type of excretion does insensible fluid loss NOT occur?
Through which type of excretion does insensible fluid loss NOT occur?
What is the main reason why potassium chloride should always be diluted in IV fluid and infused via an infusion pump?
What is the main reason why potassium chloride should always be diluted in IV fluid and infused via an infusion pump?
Why should the nurse carefully monitor the IV site during the administration of potassium chloride?
Why should the nurse carefully monitor the IV site during the administration of potassium chloride?
What action should the nurse take if the urinary output during potassium chloride administration falls below 30 mL/hr?
What action should the nurse take if the urinary output during potassium chloride administration falls below 30 mL/hr?
Why is giving potassium chloride by IV push considered dangerous?
Why is giving potassium chloride by IV push considered dangerous?
What is the primary reason for the nurse to ensure that the IV bag containing potassium chloride is accurately labeled?
What is the primary reason for the nurse to ensure that the IV bag containing potassium chloride is accurately labeled?
Why is it important for the nurse to monitor for infiltration during the administration of potassium chloride?
Why is it important for the nurse to monitor for infiltration during the administration of potassium chloride?
Which electrocardiographic changes are expected in a client with hyperkalemia?
Which electrocardiographic changes are expected in a client with hyperkalemia?
What serum sodium level indicates hyponatremia?
What serum sodium level indicates hyponatremia?
Which client is at risk for hypernatremia?
Which client is at risk for hypernatremia?
What is the normal serum sodium level range?
What is the normal serum sodium level range?
Which condition can cause a serum sodium level of 130 mEq/L?
Which condition can cause a serum sodium level of 130 mEq/L?
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
What cognitive skill is required to recognize the expected electrocardiographic changes in hyperkalemia?
Which condition is most likely to cause a client to be at risk for fluid volume excess based on the text?
Which condition is most likely to cause a client to be at risk for fluid volume excess based on the text?
What electrolyte imbalance is associated with prolonged QT interval on an ECG?
What electrolyte imbalance is associated with prolonged QT interval on an ECG?
Which client condition would most likely lead to a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
Which client condition would most likely lead to a serum phosphorus level of 1.8 mg/dL (0.58 mmol/L)?
In a client with Crohn’s disease, what calcium level indicates hypercalcemia?
In a client with Crohn’s disease, what calcium level indicates hypercalcemia?
Which electrolyte imbalance is commonly associated with muscle tetany and Chvostek's sign?
Which electrolyte imbalance is commonly associated with muscle tetany and Chvostek's sign?
What cognitive skill is required to anticipate the effects of increased intravenous fluid replacement on a client's fluid balance?
What cognitive skill is required to anticipate the effects of increased intravenous fluid replacement on a client's fluid balance?
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
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Description
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.
