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22 Cards in this Set
- Front
- Back
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Which diagnostic test assesses kidney function?
Hemoglobin Serum creatinine Hematocrit Serum osmolality |
A diagnostic test used to assess kidney function is serum creatinine levels. Hemoglobin and hematocrit are used to assess hemoconcentration in the blood. Serum osmolality helps to differentiate isotonic fluid loss from water loss.
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Which electrolyte imbalance is treated with calcium gluconate? Hypernatremia
Hyponatremia Hypochloremia Hyperkalemia |
Calcium gluconate is used to treat hyperkalemia. Hypernatremia is treated with fluid replacement. Hypochloremia is treated with increasing dietary salt and adding chloride to the IV fluid. Hyponatremia is treated by increasing dietary sodium and administering sodium containing IV fluids.
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Which interventions would you include in a plan of care for a client with fluid volume excess?(Select all that apply.)
Monitoring daily weight Reading food labels to note fiber content Elevating legs and feet when sitting Reducing intake of caffeinated drinks Keeping track of how many cups of fluid they drink |
For a client with fluid volume excess, appropriate interventions would include monitoring fluid intake to stay within fluid restrictions; monitoring weight daily and reporting significant increases to the healthcare provider; and elevating the legs and feet to reduce dependent edema. The client should read labels on food products for sodium content. Caffeinated drinks produce a diuretic effect and would not need to be reduced.
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How often should the nurse reposition a client with fluid volume deficit?
Every 30 minutes Every 120 minutes Every 90 minutes Every 180 minutes |
The client with fluid volume deficit should be repositioned every 2 hours, or 120 minutes.
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When ADH and aldosterone are secreted, what change occurs in the body?
Intracellular fluid is depleted. Urine output is increased. Third-space shifting occurs. Sodium and water are retained by the kidneys |
The release of ADH and aldosterone causes sodium and water to be retained by the kidneys. The secretion of ADH and aldosterone are part of the renindash–angiotensindash–aldosterone system.
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What is the result of the fluid in third spacing?
Fluid returns to the intracellular space. Fluid shifts into the subcutaneous tissue. Fluid is excreted from the body through stimulation of urine production. Fluid from the vascular space becomes unavailable for physiological functioning. |
In third spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may locate into the peritoneal space or pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss attributable to third spacing may be difficult to detect because the client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.
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You are providing care for James Dand, who has been determined to have fluid volume excess. Laboratory values indicate that Mr. Dand is experiencing hypokalemia. Which therapy do you anticipate will be prescribed for Mr. Hernandez based on this information?Isotonic electrolyte solutions
Loop diuretics Potassium-sparing diuretics Oral fluid solutions |
A client experiencing fluid volume excess with hypokalemia would be prescribed potassium-sparing diuretics. Loop diuretics would be prescribed for a client with hyperkalemia. Oral fluid solutions and isotonic electrolyte solutions are appropriate therapies for a client with fluid volume deficit, not excess
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You are providing discharge instructions for Mr. Dickson, who has had frequent episodes of fluid volume excess requiring hospitalization. He will continue to take furosemide(Lasix) after discharge. Which statement by Mr. Dickson would indicate that there is a need for additional instruction?"I will wear shoes that fit well and not walk barefoot.""It is important to change positions frequently.""I will weigh myself weekly and notify my healthcare provider if I gain more than 1 pound.""I will eat a banana every day.
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It is important for the client to weigh himself daily, not weekly, after discharge for fluid volume excess. Eating foods rich in potassium, wearing shoes that fit well and not walking barefoot, and changing positions frequently are all responses that indicate understanding of the discharge instructions provided by the nurse.
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Mrs. Rivera reports experiencing vomiting and diarrhea for the past 2 days, resulting in a 5% weight loss. In addition to diminished skin turgor, which assessment would you expect to note with Mrs. Rivera?
Tachycardia Warm, flushed skin Ascites Dyspnea |
When a client experiences a deficiency in fluid volume, the heart rate will increase(tachycardia) in an attempt to improve circulation. Warm, flushed skin is typically seen with a fever. Ascites and dyspnea are frequently noted with fluid volume excess.
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The nurse is planning care for a client admitted for congestive heart failure who has a priority problem of fluid volume excess. What is occurring in the body that places the client at risk for retaining fluids?
Low serum osmolality level stimulates the thirst center Impaired renal excretion of potassium Decrease in ADH and aldosterone Retention of water and sodium |
fluid volume excess results from conditions that cause retention of water and sodium. Impaired renal excretion of potassium is not related to fluid volume excess. There will be an increase in ADH and aldosterone when the stress response is activated with fluid volume excess. An increase in serum osmolality stimulates the thirst center, not a low serum osmolality, which could affect fluid volume.
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The nurse is completing discharge teaching with a client diagnosed with congestive heart failure. Which symptoms will the nurse teach the client to immediately report to the healthcare provider? (Select all that apply.)
Dry mouth Cough with increased sputum production. Dizziness when standing Urine output of 320 mL in 8 hours Five-pound weight gain in a week |
The client with congestive heart failure it at risk for developing fluid volume excess. Weight gain of more than 5 pounds in a week and a cough with increased sputum production are indications of excess fluid volume, and the healthcare provider must be notified of these findings. Dizziness when standing and a dry mouth are not signs of fluid volume excess and do not need to be reported to the healthcare provider. A urine output of 320 mL in 8 hours is not a finding that needs to be reported to the healthcare provide
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The nurse is reviewing client data to begin planning care. Which client is at greatest risk for developing fluid volume excess?
A client admitted for overuse of laxatives A client admitted for cirrhosis A client admitted for nausea and vomiting A client admitted for oral surgery |
A client admitted for liver cirrhosis is at greatest risk for developing fluid volume excess. Clients admitted for nausea and vomiting, overuse of laxatives, or oral surgery are not at risk for developing fluid volume excess.
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A client admitted for nausea and vomiting has a urine-specific gravity of 1.061. Upon assessment of the client, the nurse finds that the client is experiencing orthostatic hypotension and has dry skin and flat neck veins. What is the priority nursing diagnosis for this client when planning care?
Impaired skin integrity Ineffective tissue perfusion Impaired gas exchange Deficient fluid volume |
Fluid volume deficit can be caused by nausea and vomiting with assessment findings of orthostatic hypotension, dry skin, and flat neck veins, which will lead to the priority nursing diagnosis of deficient fluid volume. The client is demonstrating fluid volume deficit. Therefore, ineffective tissue perfusion, impaired gas exchange, and impaired skin integrity are not priority nursing diagnoses for this client. Ideally, urine specific gravity results will fall between 1.002 and 1.030 if your kidneys are functioning at a normal
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A client is admitted with a serum sodium level of 140 mEq/L, hematocrit level of 31%, and generalized edema. Which priority intervention is indicated for this client?
Increase sodium intake in the diet Encourage the client to drink ginger ale Prepare to administer a blood transfusion Restrict fluid intake |
This client is experiencing fluid volume excess. Therefore, the priority nursing intervention is restricting fluid intake. Preparing to administer a blood transfusion, encouraging the client to drink ginger ale, and encouraging the client to increase sodium intake are not priority nursing interventions because this client is experiencing fluid volume excess.
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Normal Hematocrit ranges for Men and Women are? |
Results from your hematocrit are reported as the percentage of blood cells that are red blood cells. The normal range is 38.8 to 50 percent for men and 34.9 to 44.5 percent for women. The normal range for children 15 years of age and younger varies by age and sex
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The healthcare provider ordered a diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. The nurse recognizes that this medication is part of what class of diuretics? Osmotic
Potassium sparing Thiazide Loop. |
Loop diuretics inhibit sodium and chloride reabsorption in the ascending loop of Henle. Thiazide diuretics promote the excretion of sodium, chloride, potassium, and water by decreasing absorption in the distal tubule. Potassium-sparing diuretics promote excretion of sodium and water by inhibiting sodiumdash–potassium exchange in the distal tubule. Osmotic diuretics do not inhibit sodium and chloride reabsorption in the ascending loop of Henle.
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A client is admitted for diarrhea. Which laboratory value indicates that the client is experiencing dehydration? Hematocrit, 57%
Sodium, 132 mEq/L Urine specific gravity, 1.000 Hemoglobin, 9.0 g/dL |
An elevated hematocrit indicates dehydration caused by intravascular volume loss and hemoconcentration. An increased urine specific gravity or an increase in the sodium or hemoglobin level indicates dehydration. (These were all below the normal range which is the opposite problem) The normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.
Normal range for hematocrit is different between the sexes and is approximately 45% to 52% for men and 37% to 48% for women. The normal range for blood sodium levels is 135 to 145 milliequivalents per liter (mEq/L) normal urine gravity is from 1.005 to 1.030 |
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A client is admitted with end stage renal disease and a potassium level of 7.1. The nurse anticipates which medication prescription from the healthcare provider?
Calcium gluconate 1.5 g IV Lactated ringers, 500 ml IV bolus Magnesium 1 gm IV Potassium, 20 mEq IV |
7.1 is a critically high potassium level. Pharmacologic treatment includes calcium gluconate. The other options are not appropriate prescriptions for a client experiencing hyperkalemia.
FYI: Lactated Ringer's contains ions of sodium 130 mEq/L, potassium 4 mEq/L, calcium 2.7 mEq/L, chloride 109 mEq/L, and lactate 28 mEq/L |
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The nurse is caring for a client who is experiencing diarrhea. Which data indicates that the client is experiencing fluid volume deficit? (Select all that apply.)
Increased heart rate Poor skin turgor Weight gain Increased urine output Orthostatic hypotension |
Orthostatic hypotension, increased heart rate, and poor skin turgor are acute manifestations of fluid volume deficit. Increases in urine output and weight gain are not acute manifestations of fluid volume deficit.
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The nurse is planning care for a client who has congestive heart failure and is experiencing generalized edema. Which interventions will the nurse plan for the client who is at risk for altered skin integrity secondary to edema?
(Select all that apply.) Monitoring for evidence of skin breakdown Turning the client every 2 hours Observing mental status Obtaining daily weight Instructing the client to stand slowly |
Turning the client every 2 hours and monitoring for evidence of skin breakdown are nursing interventions to prevent alterations in skin integrity. Obtaining the daily weight is the nursing intervention for addressing the problem of fluid retention, not for addressing the problem of impaired skin integrity. Instructing the client to stand slowly is a nursing intervention for addressing the potential problem of risk of injury, not for addressing the problem of impaired skin integrity. Observing mental status does not address the problem of impaired skin integrity.
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The nurse is planning care for a client admitted for dehydration. Which assessment finding indicates that current interventions are not improving the client's hydrationstatus?
Warm, dry skin Weight gain of 1.2 kg Hypotension Urine output of 40 mL/hr |
Hypotension indicates hypovolemia. This assessment finding would indicate that the client's status is not improving. Urine output is normally 30 to 60 mL/hr. A urine output of 40 mL/hr is within normal limits and indicates that the client's status is improving. Weight changes reflect fluid balance. A client who has gained 1.2 kg of body weight is experiencing an increase in body fluid, which indicates that the client's status is improving. Pale, cool skin indicates fluid volume deficit. Warm, dry skin indicates that the client's fluid status is improving.
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The nurse is caring for a client admitted for dehydration. What assessment finding indicates a loss of fluid over a period of time?
Dry, sticky mucous membranes Polyuria Increase in tongue size Bradycardia |
Dry, sticky mucous membranes are an assessment finding indicating fluid loss over an extended period of time. Polyuria, bradycardia, and increased tongue size are not assessment findings indicating fluid loss over an extended period of time.
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