What assessment finding should the nurse identify in a client with fluid volume excess?

The nurse at a family picnic on a hot day in July is aware that which person is at greatest risk for dehydration while playing softball?

a. 32yo male cousin who is a professional hockey player.

b. 28yo female cousin who has type 1 diabetes mellitus.

c. 72yo grandmother who is 15 pounds overweight.

d. 72yo grandfather who takes 81 mg of aspirin daily.

c. 72yo grandmother who is 15 pounds overweight.

* An older adult has less total body water than a younger adult.

* Many older adults have decreased thirst sensation.

* Older adults may have difficulty with walking or other motor skills needed for obtaining fluids.

* Older adults may take drugs such as diuretics, antihypertensives, and laxatives that increase fluid excretion.

* Women of any age have less total body water than men of similar sizes and ages because women have less muscle mass and more body fat (muscle contains mostly water; fat contains almost no water).

* An obese person has less total water than a lean person of the same weight because fat cells contain almost no water.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is SOB, appears restless, and has a RR of 28/min. The client's ABG results are pH 7.52, PaO2 89 mmHg, PaCO2 28 mmHg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take?

a. Instruct the client to cough forcefully.

b. Assist the client with ambulation.

c. Provide calming interventions.

c. Provide calming interventions.  

* The client's RR is above the expected range. Calming the client should decrease the RR, which will cause the client's CO2 levels to increase to the expected levels of 35-45 mmHg, and lower the pH to expected levels of 7.35-7.45. The nurse should instruct the client to breath slowly.

* Coughing frequently will not treat the underlying cause.

* Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time.

* Discontinuing the PCA pump will not treat the underlying cause and could exacerbate the client's respiratory distress.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first?

a. Monitor the client's bowel sounds.

b. Review the client's daily laboratory results.

c. Auscultate the client's lungs.

d. Palpate the client's peripheral pulses.A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse t

c. Auscultate the client's lungs.

* An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

* The nurse should monitor the client's bowel sounds for increased or decreased peristalsis due to hypokalemia, but this not the priority action.

* The nurse should review the client's daily lab results, especially his potassium level, but this is not the priority action.

* The nurse should palpate the client's peripheral pulses to assess for cardiovascular changes, such as a thready and weak pulse, but this is not the priority action.

While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take?

a. Implement seizure precautions.

b. Administer phosphate.

c. Initiate diuretic therapy.

d. Prepare the client for hemodialysis.

a. Implement seizure precautions.  

* The client is at risk for seizures due to low excitation threshold as a result of decreased calcium level (normal reference range = 8.5-10.5 mg/dL). The nurse should initiate seizure precautions to prevent injury.

* Administering phosphate can further decrease the client's calcium levels.

* Diuretic therapy can further decrease the client's calcium levels.

* Hemodialysis is administered to treat HYPERCALCEMIA, not hypocalcemia.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?

a. Hepatic failure.

b. Abdominal pain.

c. Slow peripheral pulses.

d. Increase in cardiac output.

c. Slow peripheral pulses.

* This phosphorus level is below the expected reference range (2.5-4.5 mg/dl). The nurse should expect the client to have slow peripheral pulses and might find that the client's pulses are difficult to find and easy to block.

* Hypophosphatemia = manifestations of kidney failure, not hepatic failure.

* Hypophosphatemia does not cause abdominal pain. It causes weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown.

* The nurse should expect a decrease in cardiac output.

A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the following lab values should the nurse expect?

a. Hemoglobin 20 g/dL.

b. Hematocrit 34%.

c. BUN 25 mg/dL.

d. Urine specific gravity 1.050.

b. Hematocrit 34%.

* The nurse should identify that a client who has fluid volume excess can have a Hct level that is below the expected reference range of 35 to 44.5% for females and 38 to 50% for males. Fluid volume excess can cause hemodilution and a decreased Hct level.

* Hgb reference range = 13.5-17.5 for males & 12-15.5 for females, therefore, the listed value is above the reference range. Fluid volume excess can cause hemodilution and a decreased Hgb level.

* Fluid volume excess can cause a decrease in BUN (normal reference range = 10-20 mg/dL). The BUN level listed is increased, which is associated with dehydration.

* Fluid volume excess can cause a decrease in urine specific gravity (normal reference range = 1.010-1.025). The urine specific gravity listed is increased, which is associated with dehydration.

A nurse is reviewing the medical record of a client who has DM and is receiving regular insulin by continuous IV infusion to treat DKA. Which of the following findings should the nurse report to the provider?

a. Urine output of 30 mL/hr.

b. Blood glucose of 180 mg/dL.

c. Serum K+ 3.0 mEq/L.

d. BUN 18 mg/dL

* The expected reference range for serum K+ is 3.5-5.5 mEq/L. Therefore, this patient has hypokalemia, which is a serious complication when a pt with DKA is receiving insulin.

* Urine output of 30 mL/hr is within the expected reference range.

* A blood glucose of 200 mg/dL or less is an indication that the client's DKA is resolving and is within the expected reference range for a casual glucose level.

* A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur due to dehydration for a client who has DKA.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following lab findings indicates that the fluid therapy has been effective?

a. BUN 26 mg/dL.

b. Serum Na+ 138 mEq/L.

c. Hct 56%

d. Urine specific gravity 1.035

* Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 138 mEq/L is within the expected reference range.

* BUN of 26 mg/dL is above. Elevated BUN indicates dehydration.

* Hct of 56% is elevated and an indicator of dehydration.

* Urine specific gravity of 1.035 is elevated and an indicator of dehydration.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His RR is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range is the client is experiencing respiratory alkalosis?

a. PaO2

b. PaCO2

c. Sodium

d. Bicarbonate

* Decreased PaCO2 in respiratory alkalosis due to hyperventilation.

* PaO2 will be within the expected reference range.

* Sodium levels will be within the expected reference range.

* Bicarbonate level within the expected reference range (bicarbonate levels increase in METABOLIC alkalosis).

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?  

a. Skin turgor.

b. Urine output.

c. Weight.

* The greatest risk to the client is injury from a fall due to a decline in the client's mental status.

* The nurse should assess skin turgor, urine output, and weight, but mental status is the priority assessment.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following is the priority for the nurse to assess?

a. Deep-tendon reflexes.

b. Cardiac rhythm.

c. Peripheral sensation.

d. Bowel sounds.

* When using the ABC approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range (8.5-10.5 mg/dL). Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.

* The nurse should assess the client's DTR because hypocalcemia can cause neuromuscular changes, but not priority assessment.

* The nurse should assess peripheral sensation because paresthesias can occur with hypocalcemia due to neuromuscular changes, but not priority assessment.

* The nurse should assess bowel sounds for hypermotility r/t hypocalcemia, but not priority assessment.

A nurse is providing teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium?

a. 1/2 cup chopped celery.

b. 1 cup plain yogurt.

c. 1 slice whole-grain bread.

d. 1/2 cup cooked tofu.

b. 1 cup plain yogurt.    
* Contains 380g of potassium.   

* Celery contains 132g.  

* 1 slice of whole grain bread contains 60g.  

* Cooked tofu contains 164g.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

a. Administer a hypertonic solution.

b. Repeat the potassium level.

c. Withhold the medication.

d. Monitor for paresthesia.

c. Withhold the medication.

* The greatest risk with hyperkalemia = bradycardia, hypotension, and life-threatening cardiac complications. Hyperkalemia = >5.0 mEq/L. Priority action = withhold and notify provider.

* The nurse should administer a hypertonic solution to correct hyperkalemia, but after withholding medication and notifying provider.

* The nurse should repeat the potassium level to evaluate for effective treatment, but after withholding medication and notifying provider.

* The nurse should monitor the client for paresthesia because numbness and tingling are indications, but after withholding medication and notifying provider.

A nurse is caring for a client who requires NG suctioning. Which of the following sets of lab results indicates that the client has metabolic alkalosis?

a. pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L

b. pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 26 mEq/L

c. pH 7.31, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 23 mEq/L

d. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L

a. pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3- 31 mEq/L  

* An elevated pH (>7.45) with an elevated PaCO2 (or within expected reference range sometimes) indicates metabolic alkalosis.

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?

a. Increased urine specific gravity.

b. Hypoactive bowel sounds.

c. Bounding peripheral pulses.

d. Decreased respiratory rate.

c. Bounding peripheral pulses.  

* Increased vascular volume results in full, bounding peripheral pulses.

* Increased urine specific gravity indicates a greater concentration of urine, which occurs with dehydration, not fluid volume overload.

* Increased GI motility is a manifestation of fluid volume overload, not hypoactive.

* Increased RR is a manifestation of fluid volume overload, not decreased.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first?

a. Assist with intubation.

b. Initiate high-flow oxygen therapy.

c. Administer a rapid-acting diuretic.

d. Provide cardiac monitoring.

b. Initiate high-flow oxygen therapy.  

* When using the ABC approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5-6 L/min to keep the client's oxygen saturation above 90%.

* The nurse should administer a rapid-acting diuretic IV bolus to a client to relieve pulmonary congestion, after initiating high-flow oxygen therapy.

* The nurse should provide cardiac monitoring because premature ventricular contractions and dysrhythmias are manifestations of pulmonary edema, but after initiating high-flow oxygen therapy.

* The nurse should prepare to assist the provider with intubation and mechanical ventilation if less invasive measures are ineffective only.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer?

a. Sodium polystyrene sulfonate 30 g/day.

b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr.

c. Bumetanide 8 mg/day.

d. 100 mL of dextrose 10% in water with 10 units of insulin.

b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr.    

* This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5-10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% NaCl.

* Sodium polystyrene sulfonate is an electrolyte cation exchange medication that is given to treat hyperkalemia, not hypokalemia.

* High-ceiling loop diuretics, like bumetanide, are given to treat hyperkalemia, not hypokalemia.

* Dextrose 10% in water with 10 units of insulin is an IV solution given to treat hyperkalemia, not hypokalemia.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmHg, PaCO2 56 mmHg, and HCO3- 26 mEq/L. The nurse should interpret these lab values as which of the following imbalances?

a. Respiratory acidosis.

b. Respiratory alkalosis.

c. Metabolic acidosis.

* Status asthmaticus causes inadequate gas exchange, resulting in low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range.

* pH >7.45 in both respiratory and metabolic ALKALOSIS.

* Metabolic acidosis = pH <7.35, but the PaCO2 is either within or below the expected reference range, and the HCO3- is decreased.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following lab values supports this finding?

a. Sodium 152 mEq/L

b. Chloride 102 mEq/L

c. Magnesium 1.8 mEq/L

* Hyperkalemia (K+ >5.0 mEq/L) can cause a prolonged PR intervale, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?

a. 1 large hard-boiled egg.

b. 1 cup bran cereal.

c. 1/2 cup almonds.

a. 1 large hard-boiled egg.    

* bran cereal, almonds, and cooked spinach contain magnesium levels greater than 100 mg, whereas the hard-boiled egg only contains 5 mg.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?  

a. Hyperactive deep-tendon reflexes.

b. Increased bowel sounds.

c. Drowsiness.

d. Decreased blood pressure.

a. Hyperactive deep-tendon reflexes.

* Hyperactive DTR is an expected finding of hypomagnesemia, along with muscle cramps, numbness, and tingling.

* Decreased bowel sounds are expected with hypomagnesemia, not increased.

* Insomnia, not drowsiness, is an expected finding for clients with hypomagnesemia.

* Increased BP, not decreased, is an expected finding for a client who has hypomagnesemia.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?

a. pH 7.51, PaO2 94 mmHg, PaCO2 38 mmHg, HCO3- 29 mEq/L

b. pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3- 24 mEq/L

c. pH 7.36, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3- 26 mEq/L

d. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L

d. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3- 20 mEq/L  

* A pH <7.35 is an indication of acidosis. HCO3- <22 mEq/L is an indication of metabolic acidosis.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

a. "If my stockings feel tight, I'll just roll them down for awhile."

b. "I'll put on my elastic stockings at the first sign of swelling."

c. "When I sit down to watch television, I'll be sure to put my feet up."

d. "It's OK to cross my legs as long as it's for less than an hour."

c. "When I sit down to watch television, I'll be sure to put my feet up."

* Elevating the feet will increase the venous return to the heart. The client should elevated feet for at least 20 minutes several times a day.

* Do not roll down stockings because the rolled part can become a constricting band around the leg which can impede circulation.

* Put stockings on upon awakening and remove them at bedtime. Wearing the stocking throughout the day prevents swelling of the extremities and improves circulation.

* Crossing of the legs can further impair circulation of the lower extremities.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?

a. Dextrose 5% in 0.9% sodium chloride.

b. Dextrose 5% in lactated Ringer's.

c. 3% NaCl.

*A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution, such as 0.45% NaCl to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.

* Dextrose 5% in 0.9% sodium chloride & 3% NaCl are hypertonic solutions.

* Dextrose 5% in lactated Ringer's contains sodium and other electrolytes and is not indicated for hypernatremia.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?

a. "I will eat more cheese because I can't drink milk."

b. "I need to avoid foods with vitamin D because I am allergic to milk."

c. "I will stop taking my calcium supplements if they irritate my stomach."

d. "I will add broccoli and kale to my diet."

d. "I will add broccoli and kale to my diet."

* Broccoli and kale are a good sources of non-dairy calcium.    

* Vitamin D is necessary for calcium absorption and is unlikely to trigger an allergic reaction in a client with a dairy allergy.

* Take the calcium supplements with food to prevent gastric upset

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?  

a. Decreased muscle strength.

b. Decreased gastric motility.

c. Increased heart rate.

d. Increased blood pressure.

a. Decreased muscle strength.    

* The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea.

* The nurse should expect increased, not decreased, gastric motility, including abdominal cramps and diarrhea.

* The nurse should expect the client to experience bradycardia.

* The nurse should expect the client to experience hypotension.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

a. Hypotension

b. Peripheral edema

c. Facial flushing

d. Hyperreflexia

* Hypotension with respiratory acidosis due to vasodilation.

* Facial flushing and warmth are manifestations of METABOLIC acidosis. Pale, dry skin is a manifestation of respiratory acidosis.

* Hyporeflexia is a manifestation of respiratory acidosis.

* Peripheral edema is not a manifestation of respiratory acidosis.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care?

(SATA)

a. Administer IV fluids to the client evenly over 24 hr.

b. Provide the client with a salt substitute.

c. Assess the client for pitting edema.

d. Encourage the client to rise slowly when standing up.

e. Weigh the client every 8 hr.

a. Administer IV fluids to the client evenly over 24 hr.  

d. Encourage the client to rise slowly when standing up.

e. Weigh the client every 8 hr.    

* Excessive fluid loss is treated with prescribed IV replacement fluids. Do not administer too rapidly because patient would be at risk for fluid volume overload.

* Rise slowly to prevent injury from falls caused by orthostatic hypotension.

* Weigh the client every 8 hr to provide information regarding fluid balance.

* No reason to limit sodium intake with excessive fluid loss (where water goes, sodium follows).

* Dehydration does not have pitting edema.

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?

a. Hyperactive deep-tendon reflexes.

b. Orthostatic hypotension.

c. Rapid, deep respirations.

d. Strong, bounding pulse.

b. Orthostatic hypotension.  

* Manifestation of hypokalemia.

* Hyporeflexia occurs with hypokalemia, along with weak hand grip strength.

* Weakening of the respiratory muscles and shallow respirations are manifestations of hypokalemia.

* Weak, thready pulse is a manifestation of hypokalemia.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following lab values should the nurse report to the provider?

a. Sodium 128 mEq/L

b. Potassium 4.8 mEq/L

c. Calcium 9.1 mg/dL

* SODIUM THINK NEURO!! 128 is below expected reference range (135-145). Monitor for weakened respiratory effort after reporting to provider!

* Potassium expected reference range = 3.5-5

* Calcium expected reference range = 8.5-10.5

* Magnesium expected reference range = 1.3-2.1

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?

a. "I should conserve energy by limiting my physical activity."

b. "I will wait until my pain is at least six out of ten before I use the PCA."

c. "I will limit my daily fluid intake to 2-3 glasses."

d. "I will use the incentive spirometer every hour."

d. "I will use the incentive spirometer every hour."  

* Respiratory depression and limited chest expansion are both causes of respiratory acidosis.

* Encourage ambulation and position changes to prevent postoperative complications.

* Encourage client to use the PCA when she feels acute pain to prevent the pain from worsening.

* Dehydration can cause metabolic acidosis - encourage client to take in ~2,200 mL of fluid daily (6-8 glasses of fluid containing 240 mL each) plus the liquids obtained from eating solid foods.

Osmolality expected reference range
> = ? < = ?

275-295 mmol/kg
"HIGH AND DRY"
If osmolality is >295 = dehydrated!! FVD If osmolality is <275 = fluid excess!! FVE

What would you assess for fluid volume excess?

Which of the following findings indicates that the client is experiencing fluid volume excess?

What would be your nursing considerations for a client with fluid volume excess?

What manifestation of extracellular fluid volume excess does the nurse anticipate finding?