Preview Extract
Chapter 18
1. The nurse is planning care for a patient with severe burns. Which of the following is this patient at risk for developing?
1. Intracellular fluid deficit
2. Intracellular fluid overload
3. Extracellular fluid deficit
4. Interstitial fluid deficit
Answer: Intracellular fluid deficit
Rationale:
Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. The intracellular fluid is all fluid that exists within the cell cytoplasm and nucleus. The extracellular fluid is all fluid that exists outside the cell, including the interstitial fluid between the cells.
2. The nurse is instructing a healthy 60-kilogram client on nutritional and hydration needs. The nurse explains that the client will need how many 8-ounce glasses of water per day to help meet the body’s daily fluid requirements?
1. 8−11 glasses
2. 15−20 glasses
3. 5−6 glasses
4. 2−3 glasses
Answer: 8−11 glasses
Rationale:
The healthy 60-kg client will need between 60 and 90 ounces of water per day to meet the body’s normal daily fluid requirements. This equals between 8 and 11 (8-ounce) glasses of water per day. A client will have more fluid requirements with illness or increased physical activity. Less than 8 glasses of water will not meet the body’s daily fluid requirements.
3. A female client was admitted to an acute care unit with weakness and complaints of dizziness. Dehydration is suspected as the cause. The nurse would expect which of the following lab values?
1. Sodium of 150 mEq/L; potassium 5.1 mEq/L; hematocrit of 50%
2. Sodium of 132 mEq/L; potassium 3.1 mEq/L; hematocrit of 35%
3. Sodium of 145 mEq/L; potassium 3.9 mEq/L; hematocrit of 44%
4. Sodium of 140 mEq/L; potassium 3.1 mEq/L; hematocrit of 37%
Answer: Sodium of 150 mEq/L; potassium 5.1 mEq/L; hematocrit of 50%
Rationale:
For a dehydrated client, the nurse would expect the hematocrit, sodium, and potassium to be high (sodium of 150 mEq/L; potassium 5.1 mEq/L; hematocrit of 50%). For overhydration, the client would have low levels of sodium, potassium, and hematocrit (sodium of 132 mEq/L; potassium 3.1 mEq/L; hematocrit of 35%). Lab results within normal limits would not be expected with dehydration.
4. A female patient’s hematocrit is 38% with serum sodium of 140 mEq/L. The nurse realizes this patient is demonstrating:
1. Normal hydration status.
2. Over hydration.
3. Dehydration.
4. Sodium imbalance.
Answer: Normal hydration status.
Rationale:
The normal hematocrit level for a female is between 37% and 47%. The normal osmolality of the blood is 275 to 295 mOsm/kg of water. Serum osmolality can be roughly calculated by doubling the serum sodium value. This patient’s serum sodium is 140 mEq/L, which means the serum osmolality is roughly 280 mOsm/kg, or within normal limits. These findings indicate a normal hydration status. Values above 295 indicate a water deficit or dehydration. Values below 275 indicate a water excess or overhydration.
5. A marathon runner is taken to the emergency department (ED) following a race in which the runner became disoriented, complained of a significant headache, and was dizzy. The client reports drinking several bottles of water immediately following the race. A new ED nurse starts an IV of D5W on this client and the symptoms become worse. Another nurse notices the IV fluids and discusses her concerns regarding the IV fluid with the new nurse. What are the concerns?
1. D5W breaks down into free water when the glucose is metabolized and is increasing the degree of the client’s hyponatremia.
2. D5W is the IV fluid of choice and should be infusing at a faster rate.
3. D5W is only given to clients who are admitted to an acute care setting, not those in the ED.
4. D5W increases the sodium for this client too rapidly.
Answer: D5W breaks down into free water when the glucose is metabolized and is increasing the client’s hyponatremia.
Rationale:
The marathon runner is at risk for alteration in sodium—either hypernatremia due to the excessive sweating from physical exertion of running 26.2 miles or hyponatremia from losing excessive sodium. However, when the runner drank large quantities of water following the race, the runner’s risk for developing hyponatremia increased, especially if the runner’s electrolytes were already low. The D5W breaks down into free water when the glucose is metabolized and makes the circulating sodium levels even lower. D5W is not the IV fluid of choice when hyponatremia is suspected. D5W can be utilized for many other clients, as appropriate, in various settings, not just a medical surgical inpatient setting. D5W does not increase the sodium in a client.
6. A pregnant client with hyperemesis gravidarum is admitted to the hospital. Which of the following lab results would the nurse expect for this client?
1. Urine osmolality of 41 mOsm/kg; urine specific gravity of 1.038; serum osmolality of 300 mOsm/kg
2. Urine osmolality of 1210 mOsm/kg; urine specific gravity of 1.00; serum osmolality of 283 mOsm/kg
3. Urine osmolality of 1000 mOsm/kg; urine specific gravity of 1.03; serum osmolality of 290 mOsm/kg
4. Urine osmolality of 1100 mOsm/kg; urine specific gravity of 1.01; serum osmolality of 286 mOsm/kg
Answer: Urine osmolality of 41 mOsm/kg; urine specific gravity of 1.038; serum osmolality of 300 mOsm/kg
Rationale:
The client with hyperemesis gravidarum is at risk for dehydration. The nurse can expect that the client will have lab results that are abnormal and reflect greater water concentration and lower solutes, such as urine osmolality of 41 mOsm/kg; urine specific gravity of 1.038; serum osmolality of 300 mOsm/kg. When the urine osmolality is high and the urine specific gravity is low, such as urine osmolality of 1210 mOsm/kg; urine specific gravity of 1.00; serum osmolality of 283 mOsm/kg, the client is overhydrated. The lab results are within normal limits in the other answer choices.
7. A pregnant client is admitted with excessive thirst, increased urination, and has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
4. Ineffective Tissue Perfusion
Answer: Risk for Imbalanced Fluid Volume
Rationale:
The client with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus is at risk for imbalanced fluid volume due to the client’s excess volume loss that can increase the serum levels of sodium. Excess fluid volume is not an issue for clients with diabetes insipidus, especially during the early stages of treatment. Imbalanced nutrition and ineffective tissue perfusion do not apply.
8. The patient with renal disease is prescribed a diuretic. Which of the following laboratory values does the nurse expect would reflect the outcome of diuretic therapy?
1. Serum magnesium level 1.0 mg/dL
2. Serum potassium level 4.5 mEq/L
3. Serum sodium level 142 mEq/L
4. Serum calcium level 9.0 mg/dL
Answer: Serum magnesium level 1.0 mg/dL
Rationale:
Normal serum magnesium levels are 1.4 to 2.1 mg/dL. Excessive magnesium losses occur with diuretic therapy. The other laboratory values listed are within normal ranges.
9. An elderly client is received into the postanesthesia recovery room (PACU) following a 6-hour abdominal surgery. The client received several liters of IV fluids during the surgery. Which of the following lab results would the nurse most likely see with this client?
1. Sodium—128 mEq/L; potassium—3.0 mEq/L; chloride—96 mEq/L
2. Sodium—148 mEq/L; potassium—5.1 mEq/L; chloride—107 mEq/L
3. Sodium—140 mEq/L; potassium—4.0 mEq/L; chloride—100 mEq/L
4. Sodium—135 mEq/L; potassium—3.5 mEq/L; chloride—98 mEq/L
Answer: Sodium—128 mEq/L; potassium—3.0 mEq/L; chloride—96 mEq/L
Rationale:
This client has an excess fluid volume and the nurse would anticipate the electrolytes to be low (sodium—128 mEq/L; potassium—3.0 mEq/L; chloride—96 mEq/L). These values would be of greatest concern. If the electrolyte values are high (sodium—148 mEq/L; potassium—5.1 mEq/L; chloride—107 mEq/L), the nurse could anticipate the client to be dehydrated. For the answer response with the sodium—140 mEq/L; potassium—4.0 mEq/L; chloride—100 mEq/L, these reflect normal lab values. The sodium level of 135 mEq/L is just barely below normal limits; however, the client could still be at risk for excess fluid volume since all electrolytes are at the lower end of normal range.
10. The postoperative client has a nasogastric tube in place for 5 days. On the fifth day, the client begins to exhibit confusion and lethargy. The nurse anticipates which of the following?
1. The confusion is related to the gastric suctioning removing electrolytes from the stomach.
2. The confusion is a delayed effect from anesthesia.
3. The confusion is most likely age related.
4. The confusion is related to the gastric suctioning and has decreased the client’s fluid volume.
Answer: The confusion is related to the gastric suctioning removing electrolytes from the stomach.
Rationale:
Gastric suctioning via nasogastric tube may impact a client’s electrolyte balance by removing electrolytes via extracted gastric fluids. Confusion can occur as a result of hyponatremia. While confusion can occur as a result of anesthesia, it usually does not take 5 days to occur. Elderly clients are more susceptible to electrolyte imbalance, but electrolyte imbalance is not exclusive to the elderly client. Decreasing the client’s fluid volume is not the cause of electrolyte disturbance, but can also cause acid−base problems.
11. An elderly patient tells the nurse that she does not drink many fluids because she is on a “water pill” and does not want to “harm what the water pill is supposed to do.” Which of the following is the nurse’s best response to this patient?
1. “Taking a water pill does not mean you should not drink fluids. You can become dehydrated.”
2. “Limiting fluids will ensure that you won’t be overhydrated.”
3. “Just make sure you drink the things that you like, such as coffee and juice.”
4. “It’s not necessary for you to drink water throughout the day.”
Answer: “Taking a water pill does not mean you should not drink fluids. You can become dehydrated.”
Rationale:
The most common cause of dehydration or pure water deficit is the excessive loss of free water through urine as seen in people taking diuretics and not replacing fluids through drinking. Elderly individuals have decreased perception of thirst due to aging and may not replace fluids appropriately. The elderly are particularly vulnerable to dehydration because many are taking prescription diuretics. The nurse should explain that drinking fluids is important to avoid dehydration. The nurse should not support the patient’s reasoning that by limiting fluids, the diuretic would work more effectively. Everyone needs an intake of fluids every day.
12. A patient taking spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of:
1. Hyperkalemia.
2. Hypokalemia.
3. Hypercalcemia.
4. Hyopcalcemia.
Answer: Hyperkalemia.
Rationale:
Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes. Hypokalemia is seen in nonpotassium diuretics such as furosemide. Hypercalcemia has been associated with thiazide diuretics. Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use.
13. A patient is admitted with fluid-volume deficit. Which of the following will the nurse most likely assess in this patient?
1. Blood pressure 80/60 mm Hg
2. Blood pressure 150/86 mm Hg
3. Pitting edema lower extremities
4. Respiratory rate 26 per minute
Answer: Blood pressure 80/60 mm Hg
Rationale:
In fluid-volume deficit, the blood pressure will be lower than normal. A blood pressure higher than normal is indicative of fluid-volume excess. Pitting edema of the lower extremities and a respiratory rate of greater than 20 per minute are also indicative of fluid-volume excess.
14. A nurse is providing discharge instructions for a client with a history of heart failure. Until a scale is obtained, which of the following instructions would be most helpful if the client does not have a scale at home to weigh on?
1. Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter.
2. Wear a name band around the wrist to see if it gets tighter.
3. Wear a ball cap every day to determine whether there is an increase in head circumference.
4. Discuss taking extra medication if the client feels there is weight gain.
Answer: Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter.
Rationale:
If the client does not have access to a scale initially and is waiting to get one, the nurse can advise the client to utilize a piece of clothing, such as a belt, used in the same location, to help determine weight gain. Other methods might be to discuss awareness of socks or rings getting tight. The wrist and head circumference are not good locations to judge weight gain. Discussing taking extra medication based upon a client’s feeling like there is weight gain is not advised without consulting the health care provider. The most reliable measurement of weight gain is utilizing scales.
15. A patient is admitted with fluid-volume overload. The nurse realizes the laboratory value that supports this finding is:
1. Serum sodium level 130 mEq/L.
2. Serum potassium level 4.6 mEq/L.
3. Serum calcium level 9.8 mg/dL.
4. Serum phosphorous level 4.0 mg/dL.
Answer: Serum sodium level 130 mEq/L.
Rationale:
A low sodium level, such as serum sodium level 130 mEq/L, or hyponatremia, is seen in patients with extensive retention of water or fluid overload. The serum potassium, calcium, and phosphorous levels are all within normal ranges.
16. The nurse is planning care for a patient with fluid-volume overload and hyponatremia. Which of the following should be included in this patient’s plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.
Answer: Restrict fluids.
Rationale:
The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. The administration of intravenous fluids would be indicated in fluid-volume deficit and hypernatremia. Kayexalate is used in patients with hyperkalemia. The administration of normal saline with furosemide is used to increase calcium secretion.
17. If a client has hypocalcemia, the nurse should also evaluate the client for:
1. Other electrolyte disturbances.
2. Hypertension.
3. Visual disturbances.
4. Drug toxicity.
Answer: Other electrolyte disturbances.
Rationale:
The client who has hypocalcemia may also have high phosphorus or decreased magnesium levels. The hypocalcemic client may exhibit hypotension, not usually hypertension. Visual disturbances do not occur with hypocalcemia. Hypercalcemia is more commonly caused by drug toxicities.
18. A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this patient’s plan of care?
1. Request dietitian consult for selecting foods high in phosphorous.
2. Provide aluminum hydroxide antacids as prescribed.
3. Instruct patient to avoid poultry, peanuts, and seeds.
4. Instruct patient to avoid the intake of sodium phosphate.
Answer: Request dietitian consult for selecting foods high in phosphorous.
Rationale:
Treatment of hypophosphatemia includes treating the underlying cause and promoting a high-phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds, and whole grains. Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.
19. A client who experienced hypokalcemia is being discharged. Which of the following foods contain the best choices for increasing the client’s potassium?
1. Potatoes, tomatoes, artichokes, lima beans
2. Tomatoes, fresh mushrooms, onions, bread
3. Bananas, grapes, apple, chocolate chip cookies
4. Asparagus, cauliflower, lettuce, chocolate cake
Answer: Potatoes, tomatoes, artichokes, lima beans
Rationale:
Potatoes, tomatoes, artichokes, and lima beans all contain high levels of potassium. Each of the other combinations contains some level of potassium, but potatoes, tomatoes, artichokes, and lima beans collectively contain the most potassium.
20. Discharge teaching for the client with electrolyte disturbances is aimed at:
1. Identifying the underlying problem and preventing a reoccurrence.
2. Teaching the client to manage the underlying problem.
3. Identifying the client’s knowledge deficits and correcting misconceptions.
4. Review of the client’s health problems.
Answer: Identifying the underlying problem and preventing a reoccurrence.
Rationale:
The plan for the client’s discharge involves identifying the underlying cause for an electrolyte disturbance and preventing a reoccurrence by assisting the client with home management and prevention strategies. Teaching the client to manage the underlying problem, identifying the client’s knowledge deficits and correcting misconceptions, and review of the client’s health problems will all be part of the overall discharge plan.
21. The nurse is planning the care of a patient diagnosed with hyperkalemia. Which of the following should be included in this patient’s plan of care?
1. Providing oral Kayexalate as prescribed
2. Dietary consult to select foods low in calcium
3. Dietary consult to select foods high in sodium
4. Maintain fluid restriction
Answer: Providing oral Kayexalate as prescribed
Rationale:
Treatment for hyperkalemia includes reducing oral or IV intake of potassium while treating the underlying cause of the hyperkalemia by administering potassium-reducing agents such as oral Kayexalate combined with sorbitol to rapidly remove potassium from the gastrointestinal tract via diarrhea. The patient has not been diagnosed with hypercalcemia or hyponatremia. There is no evidence to support the patient needing to restrict fluids.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
