Fluid Electrolyte Nursing Test Questions PDF

Nursing: A Concept-Based Approach to Learning, 2e (Pearson) Module 6 Fluids and Electrolytes The Concept of Fluids and Electrolytes 1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit and documents that the client is...

Nursing: A Concept-Based Approach to Learning, 2e (Pearson) Module 6 Fluids and Electrolytes The Concept of Fluids and Electrolytes 1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit and documents that the client is experiencing the following symptoms: tachycardia; pale, cool skin; and a decreased urine output. The nurse knows that these symptoms are caused by: A) The body's natural compensatory mechanisms. B) Cardiac failure. C) Pharmacological effects of a diuretic. D) Effects of rapidly infused intravenous fluids. Answer: A Explanation: A) The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this client. B) The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this client. C) The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this client. D) The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this client. Page Ref: 339-340 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1. Summarize the physiology of the various body systems involved in the maintenance of fluid and electrolyte balance. 1 Copyright © 2015 Pearson Education, Inc. 2) The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? A) Measure vital signs every 8 hours. B) Assist the client to ambulate around the room at least three times daily. C) Irrigate the client's Foley catheter daily. D) Assist the client to turn, cough, and deep breathe every 2 hours. Answer: B Explanation: A) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. None of the other options is related to the development of hypercalcemia. B) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. None of the other options is related to the development of hypercalcemia. C) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. None of the other options is related to the development of hypercalcemia. D) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. None of the other options is related to the development of hypercalcemia. Page Ref: 341 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 2. Examine the relationship between fluid and electrolyte balance and other concepts. 2 Copyright © 2015 Pearson Education, Inc. 3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is 2.0 mg/dL. The nurse is planning care for this client. Which nursing intervention would address this client's phosphorus level? A) Enforce contact precautions. B) Encourage consumption of a high-calorie carbohydrate diet. C) Strain all urine. D) Encourage consumption of milk and yogurt. Answer: D Explanation: A) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine. B) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine. C) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine. D) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine. Page Ref: 342 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Identify commonly occurring alterations in fluid and electrolyte balance and their related therapies. 3 Copyright © 2015 Pearson Education, Inc. 4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Which nurse response is most appropriate? A) "You should bring the infant in to be seen by the doctor." B) "Give your baby at least 2 ounces of juice every 2 hours." C) "Give your baby 50 mL of glucose water every hour." D) "Measure your baby's urine output for 24 hours and call back tomorrow." Answer: A Explanation: A) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. B) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. C) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. D) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. Page Ref: 344 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Differentiate common assessment procedures used to examine fluid and electrolyte balance across the life span. 4 Copyright © 2015 Pearson Education, Inc. 5) A home health nurse is seeing a client with congestive heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Which food would the nurse encourage this client to choose from the dinner menu? A) Baked fish B) Iced tea C) Banana D) Peas Answer: C Explanation: A) A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is banana. B) A potassium level of 3.4 is low, so the client should be encouraged to consume potassium- rich foods. Of the foods listed, the highest in potassium is banana. C) A potassium level of 3.4 is low, so the client should be encouraged to consume potassium- rich foods. Of the foods listed, the highest in potassium is banana. D) A potassium level of 3.4 is low, so the client should be encouraged to consume potassium- rich foods. Of the foods listed, the highest in potassium is banana. Page Ref: 341 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's fluid and electrolyte balance. 5 Copyright © 2015 Pearson Education, Inc. 6) The nurse is caring for a client receiving a blood transfusion. Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. Which is the priority intervention for this client? A) Decrease the rate of the transfusion. B) Notify the client's physician. C) Prepare to resuscitate the client. D) Discontinue the transfusion. Answer: D Explanation: A) The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Slowing the rate of the transfusion allows additional blood to be infused. At this point, there is no need to prepare for resuscitation. B) The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Slowing the rate of the transfusion allows additional blood to be infused. At this point, there is no need to prepare for resuscitation. C) The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Slowing the rate of the transfusion allows additional blood to be infused. At this point, there is no need to prepare for resuscitation. D) The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Slowing the rate of the transfusion allows additional blood to be infused. At this point, there is no need to prepare for resuscitation. Page Ref: 352 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Explain management of fluid and electrolyte balance and prevention of imbalances. 6 Copyright © 2015 Pearson Education, Inc. 7) A client is being seen in the Emergency Department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The physician has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have been successful? A) 40 mL per hour B) 20 mL per hour C) 25 mL per hour D) 30 mL per hour Answer: A Explanation: A) Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. The only option that indicates adequate urine output is 40 mL per hour. B) Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. The only option that indicates adequate urine output is 40 mL per hour. C) Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. The only option that indicates adequate urine output is 40 mL per hour. D) Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. The only option that indicates adequate urine output is 40 mL per hour. Page Ref: 350 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Explain management of fluid and electrolyte balance and prevention of imbalances. 7 Copyright © 2015 Pearson Education, Inc. 8) An elderly client is admitted to the hospital after a fall. The client appears intermittently confused. What is a primary concern of the nurse regarding fluid and electrolytes when caring for this client? A) Risk of kidney damage B) Risk of dehydration C) Risk of stroke D) Risk of bleeding Answer: B Explanation: A) As an adult ages, the thirst mechanism declines. In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. B) As an adult ages, the thirst mechanism declines. In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. C) As an adult ages, the thirst mechanism declines. In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. D) As an adult ages, the thirst mechanism declines. In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. Page Ref: 344 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in fluid and electrolyte balance. 8 Copyright © 2015 Pearson Education, Inc. 9) The nurse is caring for an elderly client who has been receiving intravenous fluids at 150 mL/hr. The nurse assesses that the client has crackles, shortness of breath, and jugular vein distention. The nurse would recognize these findings as an indication of which complication of IV fluid therapy? A) Speed shock B) Fluid volume excess C) Pulmonary embolism D) An allergic reaction Answer: B Explanation: A) Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options. B) Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options. C) Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options. D) Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options. Page Ref: 347 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Differentiate common assessment procedures used to examine fluid and electrolyte balance across the life span. 9 Copyright © 2015 Pearson Education, Inc. 10) When monitoring indicates that a client has a severe fluid and electrolyte imbalance, a nurse should be prepared to execute physician's orders to: Select all that apply. A) Initiate intravenous therapy. B) Initiate hypodermoclysis. C) Administer antibiotics. D) Administer diuretics. Answer: A, B, D Explanation: A) Intravenous fluids may be ordered for the client with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults. Antibiotics are not used for fluid and electrolyte imbalance. Diuretics may be ordered to reduce fluid volume excess. B) Intravenous fluids may be ordered for the client with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults. Antibiotics are not used for fluid and electrolyte imbalance. Diuretics may be ordered to reduce fluid volume excess. C) Intravenous fluids may be ordered for the client with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults. Antibiotics are not used for fluid and electrolyte imbalance. Diuretics may be ordered to reduce fluid volume excess. D) Intravenous fluids may be ordered for the client with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults. Antibiotics are not used for fluid and electrolyte imbalance. Diuretics may be ordered to reduce fluid volume excess. Page Ref: 353 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for clients with alterations in fluid and electrolyte balance. 10 Copyright © 2015 Pearson Education, Inc. 11) The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. What should the nurse explain to the client about the purpose of this medication? A) It is vital in regulating muscle contraction and relaxation. B) It is needed to maintain skeletal, cardiac, and neuromuscular activity. C) It controls and regulates water balance in the body. D) It is used in the body to synthesize ingested protein. Answer: B Explanation: A) Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the body to synthesize ingested protein. B) Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the body to synthesize ingested protein. C) Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the body to synthesize ingested protein. D) Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the body to synthesize ingested protein. Page Ref: 341 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1. Summarize the physiology of the various body systems involved in the maintenance of fluid and electrolyte balance. 11 Copyright © 2015 Pearson Education, Inc. 12) The nurse is concerned that a client with a fluid imbalance is at risk for an alteration in perfusion. Which assessment findings indicate that the client's perfusion status is being maintained? Select all that apply. A) Skin turgor 20 seconds B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time E) Bowel sounds sluggish in all four quadrants Answer: B, C, D Explanation: A) In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status. B) In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status. C) In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status. D) In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status. 12 Copyright © 2015 Pearson Education, Inc. E) In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status. Page Ref: 345 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 2. Examine the relationship between fluid and electrolyte balance and other concepts. 13 Copyright © 2015 Pearson Education, Inc. 13) A client's serum sodium level is 150 mg/dL. Which interventions should the nurse plan for this client? Select all that apply. A) Monitor heart rate and rhythm. B) Elevate the head of the bed. C) Instruct on a low-sodium diet. D) Administer diuretics as prescribed. E) Administer potassium supplement as prescribed. Answer: C Explanation: A) For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low-sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented. B) For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low- sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented. C) For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low- sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented. D) For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low- sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented. 14 Copyright © 2015 Pearson Education, Inc. E) For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low- sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented. Page Ref: 341 Cognitive Level: Creating Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 3. Identify commonly occurring alterations in fluid and electrolyte balance and their related therapies. 15 Copyright © 2015 Pearson Education, Inc. 14) During an assessment, the nurse becomes concerned that an older client is at risk for dehydration. What did the nurse assess to come to this conclusion? A) Poor skin turgor B) Ingests 2 glasses of water each day. C) Blood pressure 140/98 mmHg D) Body mass index 20.5 Answer: B Explanation: A) A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the client only ingests 2 glasses of water each day, this could indicate a reduction in the normal thirst response. Skin turgor is a poor indicator of fluid balance in an older client. An elevated blood pressure could indicate fluid volume overload or sodium sensitivity. A body mass index within normal limits would not contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water. B) A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the client only ingests 2 glasses of water each day, this could indicate a reduction in the normal thirst response. Skin turgor is a poor indicator of fluid balance in an older client. An elevated blood pressure could indicate fluid volume overload or sodium sensitivity. A body mass index within normal limits would not contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water. C) A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the client only ingests 2 glasses of water each day, this could indicate a reduction in the normal thirst response. Skin turgor is a poor indicator of fluid balance in an older client. An elevated blood pressure could indicate fluid volume overload or sodium sensitivity. A body mass index within normal limits would not contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water. D) A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the client only ingests 2 glasses of water each day, this could indicate a reduction in the normal thirst response. Skin turgor is a poor indicator of fluid balance in an older client. An elevated blood pressure could indicate fluid volume overload or sodium sensitivity. A body mass index within normal limits would not contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water. Page Ref: 344 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome: 4. Differentiate common assessment procedures used to examine fluid and electrolyte balance across the life span. 16 Copyright © 2015 Pearson Education, Inc. 15) The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should the nurse identify as supporting the diagnosis of dehydration? A) Serum osmolality 230 mOsm/kg B) Hematocrit 30% C) Hematocrit 53% D) Serum potassium 3.8 mEq/L Answer: C Explanation: A) The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration. A normal hematocrit value for a female is 37% to 47%. The hematocrit level will decrease in overhydration. Serum osmolality is a measure of the solute concentration of the blood and are used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine an alteration in fluid balance. Serum sodium values would be more appropriate. B) The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration. A normal hematocrit value for a female is 37% to 47%. The hematocrit level will decrease in overhydration. Serum osmolality is a measure of the solute concentration of the blood and are used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine an alteration in fluid balance. Serum sodium values would be more appropriate. C) The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration. A normal hematocrit value for a female is 37% to 47%. The hematocrit level will decrease in overhydration. Serum osmolality is a measure of the solute concentration of the blood and are used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine an alteration in fluid balance. Serum sodium values would be more appropriate. 17 Copyright © 2015 Pearson Education, Inc. D) The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration. A normal hematocrit value for a female is 37% to 47%. The hematocrit level will decrease in overhydration. Serum osmolality is a measure of the solute concentration of the blood and are used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine an alteration in fluid balance. Serum sodium values would be more appropriate. Page Ref: 351 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's fluid and electrolyte balance. 18 Copyright © 2015 Pearson Education, Inc. 16) The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. What should the nurse conclude about the client's treatment for dehydration? A) Treatment needs to include a diuretic. B) Treatment has not been effective. C) Treatment is effective and should continue. D) Treatment has been effective and should end. Answer: C Explanation: A) Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, the client is dehydrated. The extra fluid intake is being used to improve body fluid balance. The client's output is 40 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance. B) Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, the client is dehydrated. The extra fluid intake is being used to improve body fluid balance. The client's output is 40 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance. C) Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, the client is dehydrated. The extra fluid intake is being used to improve body fluid balance. The client's output is 40 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance. D) Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, the client is dehydrated. The extra fluid intake is being used to improve body fluid balance. The client's output is 40 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance. Page Ref: 350 Cognitive Level: Evaluating Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome: 6. Explain management of fluid and electrolyte balance and prevention of imbalances. 19 Copyright © 2015 Pearson Education, Inc. 17) During an assessment, the nurse learns that a client seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The air temperature is 88 degrees and the client states that water has been ingested several times throughout the day because of heavy sweating. What should the nurse instruct the client at this time? A) Eat something sweet when drinking water. B) Eat something salty when drinking water. C) Double the amount of water being ingested. D) Drink juices and carbonated sodas. Answer: B Explanation: A) Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium. Eating something sweet will not help replace the loss of sodium. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations. Juices and carbonated sodas will not help to replace the loss of sodium. B) Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium. Eating something sweet will not help replace the loss of sodium. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations. Juices and carbonated sodas will not help to replace the loss of sodium. C) Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium. Eating something sweet will not help replace the loss of sodium. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations. Juices and carbonated sodas will not help to replace the loss of sodium. D) Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium. Eating something sweet will not help replace the loss of sodium. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations. Juices and carbonated sodas will not help to replace the loss of sodium. Page Ref: 348 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for clients with alterations in fluid and electrolyte balance. 20 Copyright © 2015 Pearson Education, Inc. Exemplar 6.1 Fluid and Electrolyte Imbalance 1) An 86-year-old client is brought to the Emergency Department from a long-term care facility. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. The nurse would interpret this finding to be consistent with which of the following? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging Answer: B Explanation: A) The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema. B) The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema. C) The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema. D) The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema. Page Ref: 357 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fluid and electrolyte imbalance. 21 Copyright © 2015 Pearson Education, Inc. 2) The nurse has just received a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. The nurse is reviewing the assignment and determines that which child is at greatest risk for dehydration? A) A 4-year-old child with a broken leg B) A 15-month-old child with tachypnea C) A 16-year-old child with migraine headaches D) A 10-year-old child with cellulitis of the left leg Answer: B Explanation: A) The pediatric client with the greatest risk is under 2 years of age and has a condition that increases insensible fluid loss, such as tachypnea. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. B) The pediatric client with the greatest risk is under 2 years of age and has a condition that increases insensible fluid loss, such as tachypnea. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. C) The pediatric client with the greatest risk is under 2 years of age and has a condition that increases insensible fluid loss, such as tachypnea. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. D) The pediatric client with the greatest risk is under 2 years of age and has a condition that increases insensible fluid loss, such as tachypnea. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. Page Ref: 356 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 2. Identify risk factors and prevention methods associated with fluid and electrolyte imbalance. 22 Copyright © 2015 Pearson Education, Inc. 3) The nurse is teaching a group of children and their parents about the importance of exercise. The topic for this specific session is preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught? A) "It is important for my child to wear dark clothing while exercising in the heat." B) "Water is the drink of choice to replenish fluids that are lost during exercise." C) "My child only needs to hydrate at the end of an exercise session." D) "I will have my child stop every 15-20 minutes during the activity for fluids." Answer: D Explanation: A) During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. B) During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. C) During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. D) During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. Page Ref: 344 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fluid and electrolyte imbalance. 23 Copyright © 2015 Pearson Education, Inc. 4) The nurse is planning care for a client admitted to the unit with dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines an appropriate nursing diagnosis to be electrolyte imbalance. Which condition is known to result in fluid loss that is characterized by a proportionately greater loss of sodium than water? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure Answer: C Explanation: A) Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver. B) Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver. C) Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver. D) Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver. Page Ref: 355 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with fluid and electrolyte imbalance. 24 Copyright © 2015 Pearson Education, Inc. 5) The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. What is the best response by the nurse? A) "Fluid volume excess is caused by new onset liver failure caused by the surgery." B) "Fluid volume excess is caused by the intravenous fluids." C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D) "Fluid volume excess is caused by inactivity." Answer: C Explanation: A) Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. A fluid volume deficit would not occur with the administration of intravenous fluids. Liver failure is not caused by the surgery. Fluid volume excess is not caused by inactivity. B) Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. A fluid volume deficit would not occur with the administration of intravenous fluids. Liver failure is not caused by the surgery. Fluid volume excess is not caused by inactivity. C) Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. A fluid volume deficit would not occur with the administration of intravenous fluids. Liver failure is not caused by the surgery. Fluid volume excess is not caused by inactivity. D) Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. A fluid volume deficit would not occur with the administration of intravenous fluids. Liver failure is not caused by the surgery. Fluid volume excess is not caused by inactivity. Page Ref: 364 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with fluid and electrolyte imbalance and his or her family in collaboration with other members of the healthcare team. 25 Copyright © 2015 Pearson Education, Inc. 6) The nurse is caring for a client who is experiencing a multisystem fluid volume deficit following hemodialysis. The nursing assessment reveals the client is tachycardic; has pale, cool skin; and has a decreased urine output. The nurse determines that the client has not met which expected outcomes for a client on hemodialysis? A) Cardiac decompensation B) The pharmacological effects of a diuretic infused in the dialysate C) The effects of rapidly infused intravenous fluids D) A reduction of extracellular fluid Answer: D Explanation: A) The client on hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the client at risk. Diuretics and IV fluids are not administered during hemodialysis. Cardiac decompensation would not be an expected outcome of treatment. B) The client on hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the client at risk. Diuretics and IV fluids are not administered during hemodialysis. Cardiac decompensation would not be an expected outcome of treatment. C) The client on hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the client at risk. Diuretics and IV fluids are not administered during hemodialysis. Cardiac decompensation would not be an expected outcome of treatment. D) The client on hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the client at risk. Diuretics and IV fluids are not administered during hemodialysis. Cardiac decompensation would not be an expected outcome of treatment. Page Ref: 384 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with fluid and electrolyte imbalance. 26 Copyright © 2015 Pearson Education, Inc. 7) The nurse is caring for a client with congestive heart failure who is admitted to the medical- surgical unit with acute hypokalemia. The client is on multiple medications. Which medication may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin Answer: B Explanation: A) Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia. B) Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia. C) Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia. D) Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia. Page Ref: 355 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with fluid and electrolyte imbalance. 27 Copyright © 2015 Pearson Education, Inc. 8) The nurse is caring for a male client with a potassium level of 5.9 mEq/L. The physician orders the nurse to administer both glucose and insulin to the client. The client's wife says, "He doesn't have diabetes, so why is he getting insulin?" What is the best response by the nurse? A) "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood." B) "Insulin is safer than other medications that can lower potassium levels." C) "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted." D) "The insulin will help his kidneys excrete the extra potassium." Answer: A Explanation: A) Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose. B) Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose. C) Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose. D) Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells. Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. Insulin does not promote renal excretion of potassium. Serum potassium is lowered by entering the cells; this is not controlled by serum glucose. Page Ref: 372 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with fluid and electrolyte imbalance and his or her family in collaboration with other members of the healthcare team. 28 Copyright © 2015 Pearson Education, Inc. 9) A client in the Emergency Department is being admitted for fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal Answer: C Explanation: A) The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit. B) The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit. C) The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit. D) The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit. Page Ref: 354-355 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fluid and electrolyte imbalance. 29 Copyright © 2015 Pearson Education, Inc. 10) The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. What should the nurse include in this teaching? Select all that apply. A) Drink diet soda. B) Drink more fluids during hot weather. C) Drink flat cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea. E) Exercise during the hours of 10 am and 2 pm. Answer: B, C, D Explanation: A) Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. Diet soda can contain caffeine. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. B) Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. Diet soda can contain caffeine. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. C) Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. Diet soda can contain caffeine. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. D) Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. Diet soda can contain caffeine. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. E) Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. Diet soda can contain caffeine. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. Page Ref: 363 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 2. Identify risk factors and prevention methods associated with fluid and electrolyte imbalance. 30 Copyright © 2015 Pearson Education, Inc. 11) A child weighing 33 lbs. is prescribed to receive 50 mL/kg of oral fluids for the next 4 hours. How many total mL of fluid should the nurse provide to the client? Calculate to the nearest whole number. Answer: 750 mL Explanation: For children with mild to moderate dehydration, oral rehydration therapy is the first intervention, given in frequent, small amounts. For the first 2-4 hours of treatment, 50 mL of fluid for each kilogram of weight should be the target intake. The child weighs 33 lbs. Calculate the weight in kg by dividing 33 lbs. by 2.2 = 15 kg. Then multiply the volume of fluid by the weigh or 50 mL × 15 = 750 mL. The nurse should provide 750 mL of fluid to the child over 4 hours. Page Ref: 361 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fluid and electrolyte imbalance. 12) The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client with heart failure. Which assessment finding supports the use of this diagnosis for the client? A) Shortness of breath with ambulation B) Productive cough C) + 3 pitting edema both feet D) Heart rate 104 and regular Answer: C Explanation: A) Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Impaired Perfusion would be a diagnosis applicable for a heart rate of 104 and regular. B) Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Impaired Perfusion would be a diagnosis applicable for a heart rate of 104 and regular. C) Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Impaired Perfusion would be a diagnosis applicable for a heart rate of 104 and regular. D) Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Impaired Perfusion would be a diagnosis applicable for a heart rate of 104 and regular. Page Ref: 368 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with fluid and electrolyte imbalance. 31 Copyright © 2015 Pearson Education, Inc. 13) A client with heart failure is prescribed an oral fluid restriction of 1,200 mL per day. How many ounces of fluid should the nurse teach the client is permitted during the daylight shift? A) 200 mL B) 300 mL C) 400 mL D) 600 mL Answer: D Explanation: A) When calculating a fluid restriction, 50% of the total amount is allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shift or 33% of the remaining volume can be provided on the evening shift with the balance used during the night shift. For a fluid restriction of 1,200 mL, the client is permitted 600 mL of fluid on the day shift. The balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift. B) When calculating a fluid restriction, 50% of the total amount is allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shift or 33% of the remaining volume can be provided on the evening shift with the balance used during the night shift. For a fluid restriction of 1,200 mL, the client is permitted 600 mL of fluid on the day shift. The balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift. C) When calculating a fluid restriction, 50% of the total amount is allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shift or 33% of the remaining volume can be provided on the evening shift with the balance used during the night shift. For a fluid restriction of 1,200 mL, the client is permitted 600 mL of fluid on the day shift. The balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift. D) When calculating a fluid restriction, 50% of the total amount is allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shift or 33% of the remaining volume can be provided on the evening shift with the balance used during the night shift. For a fluid restriction of 1,200 mL, the client is permitted 600 mL of fluid on the day shift. The balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift. Page Ref: 367 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with fluid and electrolyte imbalance. 32 Copyright © 2015 Pearson Education, Inc. 14) The nurse is instructing a client with heart failure about a prescribed sodium-restricted diet. Which client statement indicates that additional teaching is required? A) "I can use as much salt substitute as I want." B) "I have to read the labels on foods to find out the sodium content." C) "I have to limit the intake of food with baking soda or baking powder." D) "I can use spices and lemon juice to add flavor to food when cooking." Answer: A Explanation: A) Low-sodium salt substitutes are not really sodium-free. They may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium and should be restricted on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking. B) Low-sodium salt substitutes are not really sodium-free. They may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium and should be restricted on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking. C) Low-sodium salt substitutes are not really sodium-free. They may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium and should be restricted on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking. D) Low-sodium salt substitutes are not really sodium-free. They may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium and should be restricted on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking. Page Ref: 369 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 7. Evaluate expected outcomes for an individual with fluid and electrolyte imbalance. 33 Copyright © 2015 Pearson Education, Inc. Exemplar 6.2 Acute Renal Failure 1) The nurse is caring for a client admitted with a diagnosis of acute renal failure. The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" What is the appropriate nurse response? A) "No, don't think that. You're going to be fine." B) "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." C) "Kidney transplantation is highly likely, and it would be a good idea to start talking to family members." D) "When the doctor comes to see you, we can talk about whether you will need a transplant." Answer: B Explanation: A) Acute renal failure is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know. B) Acute renal failure is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know. C) Acute renal failure is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know. D) Acute renal failure is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know. Page Ref: 376 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of acute renal failure. 34 Copyright © 2015 Pearson Education, Inc. 2) A client with frequent urinary tract infections in being seen in the urology clinic. The client asks the nurse if there is a chance of acute renal failure. The nurse explains that which risk factor can lead to acute renal failure? Select all that apply. A) Dehydration B) Renal calculi C) Ineffective would healing D) Low serum albumin E) Hypertension Answer: A, B, E Explanation: A) Dehydration, renal calculi, and hypertension can all precipitate acute renal failure (ARF). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause ARF. B) Dehydration, renal calculi, and hypertension can all precipitate acute renal failure (ARF). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause ARF. C) Dehydration, renal calculi, and hypertension can all precipitate acute renal failure (ARF). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause ARF. D) Dehydration, renal calculi, and hypertension can all precipitate acute renal failure (ARF). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause ARF. E) Dehydration, renal calculi, and hypertension can all precipitate acute renal failure (ARF). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause ARF. Page Ref: 377-378 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 2. Identify risk factors and prevention methods associated with acute renal failure. 35 Copyright © 2015 Pearson Education, Inc. 3) A 5-year-old child is in the hospital with acute renal failure following a streptococcus infection. The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse what mistake they made that caused the child to be so sick. What is the most appropriate response by the nurse? A) "Your child does not have enough dietary protein." B) "Your child has a congenital defect that led to renal failure." C) "Your child's renal failure has been caused by a low calcium level." D) "Your child's recent infection precipitated the renal failure." Answer: D Explanation: A) Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute renal failure (ARF). A low-protein or low-calcium diet will not lead to ARF. B) Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute renal failure (ARF). A low-protein or low-calcium diet will not lead to ARF. C) Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute renal failure (ARF). A low-protein or low-calcium diet will not lead to ARF. D) Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute renal failure (ARF). A low-protein or low-calcium diet will not lead to ARF. Page Ref: 390 Cognitive Level: Evaluating Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with acute renal failure. 36 Copyright © 2015 Pearson Education, Inc. 4) The nurse is planning care for the client with acute renal failure. The nurse selects Excess Fluid Volume as a nursing diagnosis based on what assessment finding? A) Pitting edema in the lower extremities B) Bowel sounds positive in 4 quadrants C) Wheezing in the lungs D) Generalized weakness Answer: A Explanation: A) The client in acute renal failure will likely be edematous, as the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma. Bowel sounds in 4 quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the renal failure. B) The client in acute renal failure will likely be edematous, as the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma. Bowel sounds in 4 quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the renal failure. C) The client in acute renal failure will likely be edematous, as the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma. Bowel sounds in 4 quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the renal failure. D) The client in acute renal failure will likely be edematous, as the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma. Bowel sounds in 4 quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the renal failure. Page Ref: 379 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with acute renal failure. 37 Copyright © 2015 Pearson Education, Inc. 5) A client with renal failure is being treated with peritoneal dialysis. The nurse is explaining the process to the client. Which statement would the nurse include in a discussion with the client and family? A) "The peritoneum is more permeable because of the presence of excess metabolites." B) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration." C) "The peritoneum acts as a semi-permeable membrane through which wastes move by diffusion and osmosis." D) "The solutes in the dialysate will enter the bloodstream through the peritoneum." Answer: C Explanation: A) The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. B) The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. C) The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. D) The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. Page Ref: 383 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with acute renal failure. 38 Copyright © 2015 Pearson Education, Inc. 6) The nurse is caring for a client who has been diagnosed with acute renal failure. The nurse is reviewing the client's most recent laboratory data. Which lab result is an indicator to the nurse that a client with acute renal failure has met the expected outcomes? Select all that apply. A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN) levels C) Decreasing neutrophil count D) Decreasing lymphocyte count E) Decreasing erythrocyte count Answer: A, B Explanation: A) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. B) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. C) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. D) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. E) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. Page Ref: 380 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with acute renal failure. 39 Copyright © 2015 Pearson Education, Inc. 7) The nurse is administering peritoneal dialysis on a client with acute renal failure. The nurse notes the presence of a cloudy dialysate return. Which action does the nurse initiate after notifying the physician? A) Measure abdominal girth. B) Document the cloudy dialysate. C) Culture the dialysate return. D) Increase dialysate instillation. Answer: C Explanation: A) The return should be clear. The presence of cloudy drainage might indicate peritonitis, and the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate and nursing actions taken would be necessary, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and although increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection. B) The return should be clear. The presence of cloudy drainage might indicate peritonitis, and the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate and nursing actions taken would be necessary, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and although increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection. C) The return should be clear. The presence of cloudy drainage might indicate peritonitis, and the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate and nursing actions taken would be necessary, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and although increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection. D) The return should be clear. The presence of cloudy drainage might indicate peritonitis, and the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. Documenting the cloudy dialysate and nursing actions taken would be necessary, but is not the next-priority action. Measurement of abdominal girth is performed prior to the dialysis procedure, and although increased girth could indicate peritonitis, culturing the return is more important. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection. Page Ref: 400 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with acute renal failure and his or her family in collaboration with other members of the healthcare team. 40 Copyright © 2015 Pearson Education, Inc. 8) A client with renal failure will be discharged to home in the next few days. The nurse plans to reinforce dietary teaching for the client. The nurse teaches the client to choose proteins that are high in biological value. Which client statement indicates that teaching has been effective? A) "I will be sure to include eggs in my diet." B) "I should include vegetables at every meal." C) "Legumes should be included in my diet, as they are complete proteins." D) "I will eat nuts daily because they are high in protein." Answer: A Explanation: A) Eggs are an excellent source of essential amino acids and are recommended as part of the diet for a client with renal failure who is on a protein-restricted diet. Legumes, nuts, and vegetables do contain protein, but they are incomplete protei