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20 Cards in this Set

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A nurse is reading physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 ml daily. "The nurse understands that this type of fluid loss can occur through:
The skin
Sensible losses are those of which the person is aware, such as through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.
A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which clients is at risk for fluid volume deficit?
A client with a colostomy.
cause of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiration or diarrhea,conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with CHF or decreased kidney function or a client receiving frequent wound irrigations is at risk for fluid volume excess.
A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for a fluid volume excess?
The client with renal failure.
The causes of fluid volume excess include decreased kidney function, congestive heart failure (CHF), the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client with an ileostomy, the client on diuretics, and the client on GI suctioning are a t risk for fluid volume deficit.
The nurse is caring for a client with CHF. On assessment, the nurse notes that the client is dyspnea and that rales are heard on auscultation. The nurse suspects fluid volume excess. what additional signs would the nurse expect to note in this client if fluid volume excess is present?
Increase in blood pressure.
Assessment findings associated with fluid volume excess include cough, dyspnea, rales, tachypnea, tachycardia, an elevated BP and a bounding pulse, an elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention,altered level of consciousness, and a decreased hematocrit.
A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because the client:
Is on nasogastric (NG) suction.
Potassium-rich GI fluids are lost through GI suction, placing the client at risk for hypokalemia. The client with renal disease or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.
A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2,Eq/L. Which of the following would the nurse note on the ECG as a result of the laboratory value?
U waves
A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is a relatively common electrolyte imbalance and is potentially life threatening. ECG changes include inverted T waves, ST segment depression, heart block, and prominent U wave.
A nurse prepares to administer IV potassium chloride as prescribed to a client with hypokalemia. Which of the following would not be a part of the nurse's plan in regard to the preparation and administration of the potassium?
Prepare the medication for bolus administration.
potassium chloride administered by IV must always be diluted in IV fluid and infused by a pump or controller. The usual concentration of IV potassium chloride is 20 to 40mEq/L. Potassium chloride is never given by bolus (IV push).
A Nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is?
Apples
A medium appple provides approximately 159mg of potassium. Spinach (31/2oz) provides 470 mg. A large carrot provides 3341 mg and a medium avocado provides 1097 mg of potassium.
A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory reports. The nurse understands that which client is at most risk for the development of a potassium value at this level?
The client who has sustained a traumatic burn.
A serum potassium level grater the 5.1,Eq/L is indicative of hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as in trauma, burns, or sepsis or with metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cusing's syndrome or colitis are risk for hypokalilmia.
A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of the laboratory value?
Tall T waves
A serum potassium level above 5.4 mEq.L is indicative of hyperkalemia. ECG changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall T waves.
A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory reports. The nurse understands that which client is at most risk for the development of a sodium value at this level?
The client who is taking diuretics.
hyponatremia is evidenced by a serum sodium level of less than 135 mEq/L. Hyponatremia can occur in the client taking high-ceiling diuretics. The client taking corticosteroids and the client with renal failure or hyperaldoseronism are at risk for hypernatremia.
A nurse is caring for a client with acute congestive heart failure who is receiving high doses of high-ceiling diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sighs would the nurse expect to note in this client if hyponatremia is present?
Hyperactive bowel sounds.
hyperactive bowel sounds are indicative of hyponatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry, flaky skin occurs in fluid volume deficit.
A nurse is caring for a client with a nasogastric (NG) tube. NG tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a p potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. On the basis of these laboratory findings, the nurse selects which solution to use for the NG tube irrigation?
Normal saline.
A potassium level of 4.5 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, normal (isotonic) saline should be used rather than water for GI or urinary tract irrigations.
A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician, and the physician prescribes dietary instructions based on the sodium level. Which food item dose the nurse instruct the client to avoid?
Processed oat cereals.
The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L is indicative of hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.
A nurse is reviewing a client's laboratory reports and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?
Prolonged bed rest.
The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 is experiencing hypocalcemia. The excessive administration of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease rather than renal insufficiency is a cause of hypocalcemia. Prolonged can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.
A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following assessment sighs/symptoms would not be an indication of this diagnosis?
Hypoactive bowel sounds.
hypoactive bowel sounds are noted in hypercalcemia, Sighs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety, GI bowel sounds, abdominal cramping, and diarrhea.
A nurse caring for a client with hypocalcemia would expect to note which of the fowl lowing changes on the electrocardiogram (ECG)?
Prolonged QT interval.
ECG changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave are seen in hypercalcemia. Prominent U waves are seen in hypokalemia.
A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which ECG change would the nurse expect to note based on the magnesium level?
Depressed ST segment.
The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment.
A nurse reviews the serum phosphorus level and notes that the client's level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
Alcoholism.
The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation, and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparaghyroidism, renal insufficiency, and tumor lysis syndrome are causative factors of hyperphosphatemia.
A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which assessment finding would be noted in a client with this condition?
Decreased central venous pressure (CVP)
Assessment findings in a client with a fluid volume deficit include increase reputations and heart rate, decreased CVP,. weight loss, poor skin turgor, dry mucous membranes. decreased urine volume, increased specific gravity of the urine, increased hematocrit,k and altered level of consciousness. the normal CVP is between 4 and 11 mm H2O. A client with dehydration has a low CVP.