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Ch. 16 Lewis Fluid and Electrolytes
Terms in this set (37)
The nurse is caring for a patient with a massive burn injury and possible
hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of
intravascular fluid loss because of the burn injury. This finding will require immediate intervention
to prevent the complications associated with systemic hypoperfusion. The poor oral intake,
decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid
intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care
provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output
indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with
SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before fluid
moves into the interstitial space and causes edema. Urine outputs do not take account of fluid
intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or
The home health nurse cares for an alert and oriented older adult patient with a
history of dehydration. Which instructions should the nurse give this patient related to fluid
a. "Drink more fluids in the late evening."
b. "Increase fluids if your mouth feels dry."
c. "More fluids are needed if you feel thirsty."
d. "If you feel confused, you need more to drink."
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the
evening to improve sleep quality. The patient will not be likely to notice and act appropriately
when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of
hypertension complains of generalized weakness. Which action is appropriate for the nurse
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the
metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur
with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the
patient is hypokalemic. Loose stools are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a
patient. Which statement by the patient indicates that the teaching about this medication has
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-
potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g.,
citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not
encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are
high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. When
making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..
The patient should be placed near the nurse's station if confused for the staff to closely monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused
patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not
hyponatremia. A confused patient could be distracting and disruptive for another patient in a
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause
cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this
route. Cardiac monitoring should be continued while patient is receiving potassium because of the
risk for dysrhythmias.
A postoperative patient who had surgery for a perforated gastric ulcer has been
receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127
mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
Because the patient's gastric suction has been depleting electrolytes, the IV solution should include
electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for
this patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy
placed to allow for continued mechanical ventilation. How should the nurse interpret the
following arterial blood gas results: pH 7.48, PaO2
85 mm Hg, PaCO2
32 mm Hg, and
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
The pH indicates that the patient has alkalosis and the low PaCO2
indicates a respiratory cause.
The other responses are incorrect based on the pH and the normal HCO3
The nurse notes that a patient who was admitted with diabetic ketoacidosis has
rapid, deep respirations. Which action should the nurse take?
a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction
of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to
allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication
that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory,
and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the
respiratory rate and increase the level of acidosis.
An older adult patient who is malnourished presents to the emergency
department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical
a. Pallor c. Confusion
b. Edema d. Restlessness
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in
plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion,
restlessness, and pallor are not associated with low serum protein levels.
A patient receives 3% NaCl solution for correction of hyponatremia. Which
assessment is most important for the nurse to monitor for while the patient is receiving this
a. Lung sounds c. Peripheral pulses
b. Urinary output d. Peripheral edema
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of
fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious
manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are
also important to monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
The long-term care nurse is evaluating the effectiveness of protein supplements
for an older resident who has a low serum total protein level. Which assessment finding
indicates that the patient's condition has improved?
a. Hematocrit 28% c. Decreased peripheral edema
b. Absence of skin tenting d. Blood pressure 110/72 mm Hg
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The
decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an
indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein
intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
A patient who is lethargic and exhibits deep, rapid respirations has the
following arterial blood gas (ABG) results: pH 7.32, PaO2
88 mm Hg, PaCO2
37 mm Hg,
16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
The pH and HCO3
indicate that the patient has a metabolic acidosis. The ABGs are inconsistent
with the other responses.
A patient who has been receiving diuretic therapy is admitted to the emergency
department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health
care provider immediately that the patient is on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The
nurse will also need to do more assessment regarding the other medications, but they are not of as
much concern with the potassium level.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which
nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau's and Chvostek's signs.
d. Encourage fluid intake up to 4000 mL every day.
To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL
daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with
hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of
hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds,
although these would be assessed every shift.
When caring for a patient with renal failure on a low phosphate diet, the nurse
will inform unlicensed assistive personnel (UAP) to remove which food from the patient's
a. Skim milk c. Mixed green salad
b. Grape juice d. Fried chicken breast
Foods high in phosphate include milk and other dairy products, so these are restricted on low-
phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in
phosphate and are not restricted.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help
the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect
on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral
supplements tend to increase magnesium levels.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse
asks the nurse why a peripherally inserted central catheter was inserted. Which response by
the nurse is accurate?
a. "The prescribed infusion can be given more rapidly when the patient has a central
b. "The hypertonic solution will be more rapidly diluted when given through a central
c. "There is a decreased risk for infection when 25% dextrose is infused through a
d. "The required blood glucose monitoring is based on samples obtained from a
The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions
with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not
more accurate when samples are obtained from a central line. The infection risk is higher with a
central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not
The nurse is caring for a patient who has a central venous access device
(CVAD). Which action by the nurse is appropriate?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient's face toward the CVAD during injection cap changes.
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for
clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion
site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A
provider's order is not necessary. The patient should turn away from the CVAD during cap
An older patient receiving iso-osmolar continuous tube feedings develops
restlessness, agitation, and weakness. Which laboratory result should the nurse report to the
health care provider immediately?
3.4 mEq/L (3.4 mmol/L) c. Na+
154 mEq/L (154 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4
-3 4.8 mg/dL (1.55 mmol/L)
The elevated serum sodium level is consistent with the patient's neurologic symptoms and
indicates a need for immediate action to prevent further serious complications such as seizures.
The potassium, phosphate, and calcium levels vary slightly from normal but do not require
immediate action by the nurse.
The nurse assesses a patient who has been hospitalized for 2 days. The patient
has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and
is NPO. Which assessment finding would be a priority for the nurse to report to the health
a. Oral temperature of 100.1°F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight
The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances:
extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or
metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change
in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and
serum sodium level also will be reported but do not indicate a need for rapid action to avoid
A nurse is assessing a newly admitted patient with chronic heart failure who
forgot to take prescribed medications and seems confused. The patient has peripheral edema
and shortness of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system,
initially causing confusion, which may progress to coma or seizures. Although skin turgor,
capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do
not have as immediate impact on patient outcomes as cerebral edema.
A patient with renal failure who arrives for outpatient hemodialysis is
unresponsive to questions and has decreased deep tendon reflexes. Family members report
that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension
(Maalox) at home for indigestion. Which action should the nurse take first?
a. Notify the patient's health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patient's chart.
d. Teach the patient about magnesium-containing antacids.
The health care provider should be notified immediately. The patient has a history and
manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent
serum magnesium level and make sure that blood is sent to the laboratory for immediate
electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The
patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of
potassium levels also is important for patients with renal failure, but the patient's current
symptoms are not consistent with hyperkalemia.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has
nasogastric suction. The patient complains of anxiety and incisional pain. The patient's
respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory
alkalosis. Which action should the nurse take first?
a. Check to make sure the nasogastric tube is patent.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when anxious.
The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain
and anxiety. The nurse's first action should be to medicate the patient for pain. The health care
provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain.
The patient will not be able to take slow, deep breaths when experiencing pain. Checking the
nasogastric tube can wait until the patient has been medicated for pain.
Which action can the registered nurse (RN) who is caring for a critically ill
patient with multiple IV lines and medications delegate to a licensed practical/vocational
a. Flush a saline lock with normal saline.
b. Verify blood products prior to administration.
c. Remove the patient's central venous catheter.
d. Titrate the flow rate of vasoactive IV medications.
A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with
normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and
removal of central catheters in critically ill patients require RN level education and scope of
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is
most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.
Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is
required to correct the patient's calcium level. The other data are also consistent with
hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.
Following a thyroidectomy, a patient complains of "a tingling feeling around
my mouth." Which assessment should the nurse complete?
a. Presence of the Chvostek's sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient's dressing
The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid
injury or removal during thyroidectomy. There is no indication of a need to check the potassium
level, the thyroid hormone level, or for bleeding.
A patient is admitted to the emergency department with severe fatigue and
confusion. Laboratory studies are done. Which laboratory value will require the most
immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%.
The serum calcium is well above the normal level and puts the patient at risk for cardiac
dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The
potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health
care provider about these values as well, but they are not immediately life threatening.
When assessing a pregnant patient with eclampsia who is receiving IV
magnesium sulfate, which finding should the nurse report to the health care provider
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling "sick to my stomach."
The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching
toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and
should be reported, but they are not as significant as the loss of deep tendon reflexes. The
decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent
A patient is receiving a 3% saline continuous IV infusion for hyponatremia.
Which assessment data will require the most rapid response by the nurse?
a. The patient's radial pulse is 105 beats/min.
b. There are crackles throughout both lung fields.
c. There is sediment and blood in the patient's urine.
d. The blood pressure increases from 120/80 to 142/94 mm Hg.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a
life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure
and the appearance of the urine should also be reported, but they are not as dangerous as the
presence of fluid in the alveoli.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has
chronic malnutrition. Which action should the nurse take next?
a. Monitor ionized calcium level.
b. Give oral calcium citrate tablets.
c. Check parathyroid hormone level.
d. Administer vitamin D supplements.
This patient with chronic malnutrition is likely to have a low serum albumin level, which will
affect the total serum calcium. A more accurate reflection of calcium balance is the ionized
calcium level. Most of the calcium in the blood is bound to protein (primarily albumin).
Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin
levels result in a drop in the total calcium level, although the level of ionized calcium is not
affected. The other actions may be needed if the ionized calcium is also decreased.
A patient comes to the clinic complaining of frequent, watery stools for the past
2 days. Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient's blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling.
Because the patient's history suggests that fluid volume deficit may be a problem, assessment for
adequate circulation is the highest priority. The other actions are also appropriate, but are not as
essential as determining the patient's perfusion status.
Which action should the nurse take first when a patient complains of acute
chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient's breath sounds.
d. Give prescribed PRN morphine sulfate IV.
The initial action should be to assess the patient further because the history and symptoms are
consistent with several possible complications of central line insertion, including embolism and
pneumothorax. The other actions may be appropriate, but further assessment of the patient is
needed before notifying the health care provider, offering reassurance, or administration of
After receiving change-of-shift report, which patient should the nurse assess
a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking
for a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive
deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for
seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but
they are not at risk for life-threatening complications.
During the admission process, the nurse obtains information about a patient
through a physical assessment and diagnostic testing. Based on the data shown in the
accompanying figure, which nursing diagnosis is appropriate?
a. Deficient fluid volume c. Risk for injury: seizures
b. Impaired gas exchange d. Risk for impaired skin integrity
The patient's muscle cramps and low serum calcium level indicate that the patient is at risk for
seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor
is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or
dehydration that might suggest that the patient is at risk for impaired skin integrity.
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