Fluid & Electrolytes

What are the some of the methods by which body fluids move across fluid compartments? (Select all that apply.)

A) Third spacing
B) Compensation
C) Filtration
D) Hypoperfusion
E) Osmosis

C) Filtration
E) Osmosis

Compensation is the body’s attempt to adjust for a fluid and electrolyte imbalance. Hypoperfusion is decreased blood flow through an organ. Third spacing is a shifting of fluid into interstitial spaces. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Filtration is a process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure.

A 6-month-old infant is admitted with severe dehydration. Effectiveness of therapy is evaluated with which of the following assessment measures? (Select all that apply.)

A) Level of consciousness
B) Abdominal girth
C) Daily weights
D) Intake and output
E) Mucous membrane assessment for moisture

A) Level of consciousness
C) Daily weights
D) Intake and output
E) Mucous membrane assessment for moisture

All of the choices represent assessment measures that measure the effectiveness of therapy except abdominal girth, which does not provide information regarding hydration status.

A client is admitted to the emergency department with hypovolemia. Which intravenous solution would the nurse anticipate administering?

A) Ringer’s solution
B) 3% sodium chloride
C) 10% dextrose in water
D) 0.45% sodium chloride

A) Ringer’s solution

Ringer’s solution is an isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance. Hypertonic solutions such as 10% dextrose and 3% sodium chloride pull interstitial and intracellular fluid into the vascular system, leading to cellular dehydration. A hypotonic solution such as 0.45% sodium chloride may be used to treat cellular dehydration.

When assessing a client with fluid volume deficit, the nurse would expect to find:

A) Orthostatic hypotension and flat neck veins.
B) Increased pulse rate and blood pressure.
C) Headache and muscle cramps.
D) Dyspnea and respiratory crackles.

A) Orthostatic hypotension and flat neck veins.

In fluid volume deficit, there is less volume in the vascular system, which decreases venous return and cardiac output, leading to manifestations of dizziness, orthostatic hypotension, and flat neck veins. The heart rate increases and the blood pressure falls. Dyspnea and crackles usually are associated with excess fluid volume. Headache and muscle cramps are often due to electrolyte imbalance, not fluid loss.

Laboratory results for a client show a serum potassium level of 2.2 mEq/L. Which of the following nursing actions is of highest priority for this client?

A) Keep the client on bed rest.
B) Initiate cardiac monitoring.
C) Initiate seizure precautions.
D) Start oxygen at 2 L/min.

B) Initiate cardiac monitoring.

Hypokalemia affects nerve impulse transmission, including the transmission of cardiac impulses. The client may develop ECG changes and atrial or ventricular dysrhythmias. Although hypokalemia can lead to muscle weakness and activity intolerance, bed rest generally is unnecessary. Starting oxygen would be appropriate only if the client is in respiratory distress. The client is more likely to experience cardiac arrest, not seizures; in any case, the priority is cardiac monitoring. The client is not hypoxic, so oxygen is not needed.

The nurse caring for a client with acute hypernatremia includes which of the following in the plan of care? (Select all that apply.)

A) Restrict fluids to 1500 mL per day.
B) Conduct frequent neurologic checks.
C) Limit length of visits.
D) Maintain intravenous access.
E) Orient to time, place, and person frequently.

B) Conduct frequent neurologic checks.
D) Maintain intravenous access.
E) Orient to time, place, and person frequently.

Frequent neurological checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function (including orientation to time, place, and person), as can rapid correction of hypernatremia. Fluid replacement is the primary treatment for hypernatremia. Maintaining intravenous access is necessary for administration of fluids and possible emergency medications. There is no reason to limit visit length.

The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than are older children. Which of the following parent comments would indicate that further education is needed?

A) “Infants maintain their temperature by losing heat through their heads.”
B) “Infants have a higher metabolic rate than older children do.”
C) “Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do.”
D) “An infant has little body water for reserve, as compared with an adult.”

A) “Infants maintain their temperature by losing heat through their heads.”

Losing heat through their heads will have minimal effect on fluid loss in infants. All the other answers are appropriate responses.

A client with chronic renal failure has been prescribed diuretics. What are some important nursing activities for this client’s care? (Select all that apply.)

A) Check temperature regularly
B) Monitor client for anxiety
C) Monitor intake and output
D) Check for swallowing problems
E) Check hydration status

C) Monitor intake and output
E) Check hydration status

Temperature alteration, anxiety, and swallowing disorders are not normally associated with the administration of diuretics. The accurate measurement of intake and urine output is significant since diuretics increase urine excretion of both water and electrolytes. Understanding Diuretics can affect hydration status.

What is the most important nursing interventions to prevent acute renal failure in a critically ill client?

A) Administering antihypertensive drugs.
B) Assessing for a history of diabetes or systemic lupus erythematosus.
C) Avoiding all potentially nephrotoxic drugs.
D) Maintaining fluid volume and cardiac output.

D) Maintaining fluid volume and cardiac output.

Ischemia is the most common cause of acute renal failure (ARF); therefore, maintaining fluid volume, cardiac output, and renal output are the highest-priority nursing interventions to prevent renal failure. The other options are viable interventions but do not take precedence over maintaining fluid volume and cardiac output.

The nurse evaluates client teaching as effective when the client recovering from acute renal failure states:

A) “I will limit my intake to 1500 mL or less per day.”
B) “I will self-catheterize for residual urine at least once a week.”
C) “I will consume only vegetable proteins.”
D) “I will avoid taking drugs that may be nephrotoxic.”

D) “I will avoid taking drugs that may be nephrotoxic.”

Nephrotoxic drugs, including over-the-counter products, can produce further damage to the kidney cells and should be avoided. Depending on urinary output, fluid intake generally is not restricted during the recovery phase of acute renal failure. Vegetable proteins are not complete proteins, and therefore are not recommended if protein intake is restricted. Self-catheterization by the client is performed when the client has urinary retention or nerve damage to the bladder.

The nurse caring for a client preparing to undergo hemodialysis will include which in the plan of care? (Select all that apply.)

A) Monitor serum creatinine, BUN, and hematocrit levels.
B) Determine urine specific gravity and pH.
C) Obtain weight and orthostatic vital signs.
D) Restrict fluid and protein intake.
E) Assess blood pressure of extremity where fistula has been created.

A) Monitor serum creatinine, BUN, and hematocrit levels.
C) Obtain weight and orthostatic vital signs.
E) Assess blood pressure of extremity where fistula has been created.

Weight and orthostatic vital signs are indicators of fluid volume status and electrolyte balance. Laboratory tests are monitored to evaluate the effects of treatment. Restriction of fluid and food during dialysis is not necessary and may contribute to decreased fluid volume. The client does not produce urine to be tested. Blood pressure is never taken in the arm where the fistula is placed.

Which nursing actions are instituted for the client with kidney trauma?

A) Observe for hypertension and check urine for hematuria.
B) Monitor vital signs for hypotension and bradycardia.
C) Monitor level of consciousness and urine output.
D) Observe urine for oliguria and proteinuria.

A) Observe for hypertension and check urine for hematuria.

Damage to the kidney resulting in reduced renal perfusion will stimulate the renin-angiotensin system causing hypertension and reducing the ability of the kidney to prevent blood from escaping into the urine. Monitoring level of consciousness is appropriate for the client but not necessarily for kidney trauma. The client is more likely to have hypertension and tachycardia. The client may eventually have oliguria or proteinuria if renal failure results, but initially the nurse is observing for hypertension and hematuria as the best sign that the kidneys have sustained damage.

After a client has returned from surgery, the nurse needs to report which urinary output?

A) 300 mL per 8 hours
B) 400 mL per 8 hours
C) 20 mL per hour
D) 40 mL per hour

C) 20 mL per hour

Urine output of less than 30 mL/hr should be reported, specifically urine output of less than 30 mL/hr on average over a 4-hour period of time.

A client who has experienced a burn injury over 40 percent of the body is at risk for acute tubular necrosis. What will the nurse do to prevent renal failure in this client? (Select all that apply.)

A) Maintain blood pressure.
B) Maintain adequate fluid balance.
C) Reduce sodium intake.
D) Increase fluids to prevent crystal formation.
E) Prevent infection.

A) Maintain blood pressure.
B) Maintain adequate fluid balance.
E) Prevent infection.

Acute tubular necrosis results from burns and hypovolemia sepsis. The nurse should prevent ischemia by maintaining blood flow to the kidney and prevent hypotension and infection. Because sodium and water are lost in equal amounts, there is no need to limit sodium intake. The nurse does not increase fluids without an order; however, fluid resuscitation in a burn client is carefully calculated to prevent kidney failure.

When caring for a client with acute renal failure, the nurse would plan which treatment goal for the client?

A) Increase fluids to prevent nephrolithiasis.
B) Maintain adequate nutrition by encouraging a high-protein and high-calorie diet.
C) Compensate for renal impairment by restoring fluid balance.
D) Prevent infection by administering antibiotics.

C) Compensate for renal impairment by restoring fluid balance.

The treatment goals for acute renal failure include identifying and correcting underlying cause, preventing kidney damage, restoring urine output and kidney function, and compensating for renal impairment. Antibiotics are administered for a documented infection. Preventing nephrolithiasis is a medical goal. High-protein and high-calorie diets will contribute to kidney failure.

The nurse is caring for a client with acute renal failure. When providing the dietary instruction, the nurse would evaluate that the client has understood the instructions when the client makes which statement?

A) “I will avoid tilapia, baked macaroni and cheese, and stewed tomatoes.”
B) “I will avoid cereal with bananas and orange juice.”
C) “I will avoid coffee, eggs, and rye toast.”
D) “I will avoid meatloaf, green beans, and country biscuits.”

B) “I will avoid cereal with bananas and orange juice.”

A client with renal failure should avoid foods high in potassium and sodium. Foods high in potassium include nonsalt seasoning mixes, potatoes, bananas, and orange juice. The other foods listed are not typically high in potassium or sodium.

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