NUR 112 - IGGY Med Surg I Ch 13.txt
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Hypercalcemia (Ca2+): Is and Does
- > 10.5 mg/dL
- Calcium facilitates blood clotting and hypercalcemia causes faster clotting time to the point where they may occur when not needed. This can occur more easily vessels with slow blood flow.
- Like many electrolyte imbalances that affect the heart (te most serios affect of hyperCa), initially it causews inc P and BP, but then prolonged Ca imbalance depresses electrical conduction slowing the heart.
Hypercalcemia (Ca2+): Treatment
- > 10.5 mg/dL
- Drug therapy involves preventing increases in calcium, as well as drugs to lower calcium levels.
- IV solutions containing calcium (e.g., Ringers lactate) are stopped.
- Oral drugs containing calcium or vitamin D (e.g., calcium-based antacids) are discontinued.
- Fluid volume replacement can help restore normal serum calcium levels. IV normal saline (0.9% sodium chloride) is usually given because sodium increases kidney excretion of calcium.
- Thiazide diuretics are discontinued and are replaced with diuretics that enhance the excretion of calcium, such as furosemide (Lasix, Furoside^).
- Calcium chelators (calcium binders) help lower serum calcium levels. Such drugs include plicamycin (Mithracin) and penicillamine (Cuprimine, Pendramine).
- Drugs to prevent hypercalcemia include agents that inhibit calcium resorption from bone, such as phosphorus, calcitonin (Calcimar), bisphosphonates (etidronate), and prostaglandin synthesis inhibitors (aspirin, NSAIDs).
- Dialysis is used when severe hypercalcemia causes lifethreatening cardiac problems and drug therapy may not reduce serum calcium levels fast enough to prevent death.
- Methods of dialysis for rapid calcium reduction are usually hemodialysis or blood ultrafiltration.
- Cardiac monitoring of patients with hypercalcemia is needed to identify dysrhythmias and decreased cardiac output. Compare recent ECG tracings with the patient's baseline
- tracings. Especially look for changes in the T waves and the QT interval and changes in rate and rhythm.
Calcium & Phosphorus relationship?
- The book says that the product of their concentations remains the same.
- My gut tells me that the sum is more likely.
Hyperphosphatemia: Is and Does
- > 4.5 mg/dL
- This is well tolerated by most body systems.
- The problem is that it often coincides with Hypocalcemia because of the balanced relationship.
- Cardiac - peripher pulses are slow, diff to find, easy to block
- Prolonged Hyperphosphatemia causes progressive, but reversible, cardia muscle damage
- Musculoskeletal - may include acute muscle breakdown rhabdomyolysis
- Respiratory failure
- CNS - Not apparent until severe, then irratability, seizure, coma
Magnesium (Mg2+): Is & Does
- 1.3-2.1 mEq/L
- Adults have average 25 g magnesium, 60% is stored in bones and cartilage.
- Little magnesium is present in the extracellular fluid (ECF).
- Plasma levels of free magnesium range from 1.3 to 2.1 mg/dL.
- Much more magnesium is present in the intracellular fluid (ICF), and it has more functions inside the cells than in the blood.
- Magnesium is critical for skeletal muscle contraction, carbohydrate metabolism, adenosine triphosphate (ATP) formation, vitamin activation, and cell growth.
- Extracellular magnesium regulates blood coagulation and skeletal muscle contractility.
- Magnesium regulation occurs through the kidney and the intestinal tract although the exact mechanisms are not known.
- When blood magnesium levels are low, ingested magnesium is rapidly absorbed and kidney excretion of magnesium stops.
- When blood magnesium levels are high, little magnesium is absorbed from food and kidney magnesium excretion increases.
What are sodium imbalances associated with and why?
Fluid imbalances because the same hormones regulate both.
% water by weight for lean people
% water by weight for obese people, why & implications
50 because fat cells hold almost no water making obese people at higher risk for dehydration
Movement of water down hydrostatic pressure gradient through permeable membrane
Movement of solute down concentration gradient through permeable membrane
Movement of water only from higher osmolarity through semipermeable membrane
Facilitated diffusion o facilitated transport
The expenditure of ATP or membrane altering (like insulin) to move solutes across membrane
Accumulation of fluid in ISS. Pitting edema is measure by 0-4 scale where 1=2mm and 4=8mm
Osmolarity for plasma and other bodily fluids?
Age-related changes: endocrine
Adrenal atrophy leading to Poor regulation of sodium and potassium, predisposing the patient to hyponatremia and hyperkalemia
Age-related changes: muscular
Decreased muscle mass leading to Decreased total body water; Greater risk of dehydration
Age-related changes: renal
Decreased glomerular filtration; decreased concentrating capacity leading to Poor excretion of waste products; Increased water loss
Is turgor a reliable indicator of fluid status in the elderly?
No because of associated loss of elasticity and decreased turgor
Urine loss of fluids per day
Obligatory urine output?
400-600mL/day needed to excrete toxic waste products
If below Obligatory urine output?
Retained wastes can lead to lethal electrolyte imbalances, acidosis, and toxic nitrogen buildup
Fluid intake per day?
Adults: 1500mL fluid and additional 800mL from food
Insensible water loss? Amount?
Skin, lungs and stool - because you cannot control it. Adults: 500-100mL/day
Relationship between temperature and insensible water loss?
Every degree increase leads to a 10% inc
Endocrine system helps control fluid and electrolyte balance via three hormones:
- Antidiuretic hormone (ADH)
- Natriuretic peptide (NP).
A hormone secreted by the adrenal cortex whenever sodium level in the extracellular fluid (ECF) is decreased.
- Aldosterone prevents both water and sodium loss.
- When aldosterone is secreted, it acts on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood. This action increases
- blood osmolarity and blood volume.
- Also helps prevent blood potassium levels from becoming too high, that is it causes the secretion of K+
Antidiuretic hormone (ADH), or vasopressin, actions?
- Produced in the brain and stored in the posterior pituitary gland. ADH release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in
- blood osmolarity. The hypothalamus contains specialized cells (osmoreceptors) that are sensitive to changes in blood osmolarity. Increased blood osmolarity, especially an
- increase in the level of plasma sodium, results in a slight shrinkage of these cells and triggers ADH release from the posterior pituitary gland.
- ADH acts directly on kidney tubules and collecting ducts, making them more permeable to water. As a result, more water is reabsorbed by these tubules and returned to
- the blood, decreasing blood osmolarity by making it more dilute.
- When blood osmolarity decreases, especially when the plasma sodium level is below normal, the osmoreceptors swell slightly and inhibit ADH release. Less water is then
- reabsorbed, and more is lost from the body in the urine. As a result, the amount of water in the extracellular fluid (ECF) decreases, bringing osmolarity to normal.
Natriuretic peptides (NPs) actions?
- Hormones secreted by special cells that line the atria of the heart (atrial natriuretic peptide [ANP]) and the ventricles of the heart (brain natriuretic peptide [BNP]).
- They are secreted in response to increased blood volume and blood pressure, which stretch the heart tissue. NP binds to nephrons creating effects opposite of
- Reabsorption of Na is inhibited and glomerular filtration is increased causing increased urine output
- Leading to decreased blood volume and osmolarity.
No actual water loss, but a shift of water from plasma to ISS
Really it is a loss of fluid from the ECF leading to hypovolemia and inadequate tissue perfusion.
- Most common form
- loss of fluids and electrolytes
- Fluid is lost only from ECF inc plasma and ISS
Signs of dehydration on the Cardiac system?
- HR up
- BP down
- pulse weak
- neck veins flat
- orthostatic hypotension
Best indicator of dehydration?
Daily body weight gain/loss. Any weight loss over 0.5# per day is fluid loss
Neurological changes from dehydration?
Blood flow to brain is reduced because of hypovolemia leading to mental status changes, esp. confusion, and esp. in older adults
Renal changes from dehydration?
- Concentrated, i.e. SG above 1.030
- Color dark amber
- Strong odor
- Output below 500mL/day
Respirator effects of dehydration?
Increased because of low circ vol - hypoxia
Meds that affect fluids vol?
Diuretics and laxatives esp. in elderly
Signs of overhydration or fluid overload
- Distended neck veins
- Shortness of breath
- Crackles in lungs
Mechanisms of Hyponatremia problems?
- < 135 mEq/L
- reduced excitable depolarization
- cellular swelling
Common causes of low sodium levels?
- < 135 mEq/L
- Prolonged use or overuse of diuretics, especially in older adults
What cell types are most affected by hyponatremia?
- < 135 mEq/L
- cerebral, neuromuscular, and intestinal smooth muscle
Cerebral changes from hyponatremia?
- < 135 mEq/L
- Depressed and excessive activity and sometimes both can occur leading to acute confusion or increased confusion.
Neuromuscular changes of hyponatremia?
< 135 mEq/L
Deep tendon reflexes may diminish (those that function to keep muscles at more-or-less the same length.
- Test strength in arms (grip or curls) and legs push/pull. A weakness should lead to an eval of the respiratory effectiveness (S02) since ventilation depends on adequate
- muscle strength.
Intestinal changes from hyponatremia?
- < 135 mEq/L
- Increased motility. Sounds are hyperactive with rushes and gurgles over the splenic flexure and in LLQ. BMs are freq and watery.
Cardio changes from hyponatremia?
- < 135 mEq/L
- Hypovolemia w/ rapid weak thready peripheral pulses. May have severe orthostatic hypotension. Note hyponatremia can occur with hypervolemia -> rapid bounding pulses.
Therapy for and nurse�s responsibility for treatment of hyponatremia?
- < 135 mEq/L
- Drug (IV) or nutrition, but it is the nurse�s responsibility to monitor Pts. responsibility to therapy so that hypernatremia and/or fluid overload do not occur.
- Reduce drugs that increase sodium loss, e.g. diuretics
What about hyponatremia and fluid excess?
Osmotic diuretics such as mannitol (Osmitrol) which promote secretion of water but not sodium.
Mechanisms of Hypernatremia problems?
- > 145 mEq/L
- increases excitable depolarization
- severe cellular dehydration, which may render "excitable" dehydrated tissues no longer able to respond to stimuli
Nervous system changes from Hypernatremia?
- > 145 mEq/L
- with DECREASED fluid volume: short attention span, agitated or confused, manic episodes or seizures
- with INCREASED fluid volume: lethargic, drowsy, stuporous or even comatose
Neuromuscular changes of hypernatremia?
> 145 mEq/L
Deep tendon reflexes reduced or absent (those that function to keep muscles at more-or-less the same length. (SAME as hypO)
- At mild rises in Na+, muscle twitching and irregular contractions, but as condition worsens, muscle WEAKNESS, same as HYPO. Test strength in arms (grip or curls) and legs
- push/pull. A weakness should lead to an evaluation of the respiratory effectiveness (S02) since ventilation depends on adequate muscle strength.
Cardio changes from hypernatremia?
- > 145 mEq/L
- Hypovolemia w/ rapid weak thready peripheral pulses. May have severe orthostatic hypotension.
- Note hyponatremia can occur with hypervolemia -> slow to normal (NOT rapid) bounding pulses. BP, especially diastolic, is increased.
Therapy for and nurse�s responsibility for treatment of hypernatremia?
- > 145 mEq/L
- Drug (IV) or nutrition, but it is the nurse�s responsibility to monitor Pts. responsibility to therapy so that hyponatremia and/or dehydration do not occur.
- If life-threatening, then hemodialysis and blood ultrafiltration.
- Reduce drugs that increase sodium loss, e.g. diuretics
Drug therapy for hypernatremia?
- IV 0.225% or 0.45% NaCl
- When caused by poor renal excretion - diuretics that promote sodium loss: furosemide (Lasix, Furoside) or bumentanide
- Concentration is very small (3.5-5.0 mEq/L) and 98% of K+ is ICF
- 80% of K+ is removed via kidneys with aldosterone helping out.
- No hormone has been identified that enhance K+ reabsorption.
- K+ critical for excitable cell membrane depolarization for action potentials
- Also, protein synthesis and regulation of glucose use and storage
- < 3.5 mEq/L
- May be actual or relative
- Drugs such as diuretics, corticosteroids and beta-adrenergic agonists or antagonists can inc loss through kidneys
Respiratory changes from Hypokalemia?
- < 3.5 mEq/L
- skeletal muscle weakness results in shallow respirations
- Respiratory efficiency is critical because insufficiency is a major cause of death.
Intestinal changes from hypokalemia?
- < 3.5 mEq/L
- Decreased motility. Sounds are hypoactive. Pt may have nausea, vomiting, constipation and abdominal distention.
Treating Severe Hypokalemia
- IV potassium
- Dilute to no more than 1mEq/10mL of solution
- Max IV infusion rate 5-10 mEq/hr., never to exceed 20 mEq/hr. under any circumstances
- MUST be given via pump
- > 5.0 mEq/L
- Since 98% of K+ is ICF, increases in serum K+ reduce the difference between ICE and ECF concentrations of K+. This makes excitable membranes even more sensitive, even prone to spontaneous discharge. This is nowhere more important than the heart where high K+ values can cause dysrhythmias, which are the most severe problems from hyper-K and the most common cause of death. Ectopic (beats outside of normal conduction system) may occur.
- Sudden rises can cause severe problems in the 6-7 range, whereas a slow rise may not cause problems until 8.
- Hyperkalemia is rare in people with normal kidney function.
Neuromuscular changes of hyperkalemia?
> 5.0 mEq/L
tingling, burning and numbness of the hands and feet and around the mouth paresthesia
At mild rises in K+, muscle twitching and irregular contractions, but as condition worsens, muscle WEAKNESS, same as HYPO.
Respirator muscles are not affected until K+ reaches lethal levels.
Intestinal changes from hyperkalemia?
- > 5.0 mEq/L
- Increased motility. Sounds are hyperactive with rushes and gurgles over the splenic flexure and in LLQ. BMs are frequent and watery.
This is the same as Hyponatremia!!!!
Laboratory data to confirm hyperkalemia?
- > 5.0 mEq/L
- If caused by dehydration, levels of other electrolytes, hematocrit, and hemoglobin also are elevated.
- Hyperkalemia caused by renal failure occurs with elevated serum creatinine and blood urea nitrogen, decreased blood pH, and normal or low hematocrit and hemoglobin levels.
- Eliminate extra potassium by stopping potassium-containing infusions. Keeping the IV catheter open is useful in managing hyperkalemia. Withhold oral potassium supplements-
- and provide a potassium-restricted diet.
- Increasing potassium excretion helps reduce hyperkalemia if renal function is normal. Potassium-excreting diuretics, such as furosemide, are prescribed. For a patient with
- renal problems drug therapy to increase potassium excretion includes cation exchange resins that promote intestinal sodium absorption and potassium excretion, such as sodium
- polystyrene sulfonal (Kayexalate). However, this therapy may take many hours to reduce potassium levels. It potassium levels are dangerously high, additional measures, such
- as dialysis, are needed.
- Move K+ from ECF to ICF with insulin and glucose IV
For Hyperkalemia what is one possible option?
Insulin to move K+ out of ECF to ICF
- Closed related to phosphorus and magnesium
- It is a divalent cation (+2 charge) that exists in the body bound usually attached to serum proteins, especially albumin.
- It also exists as a free ion in the blood and other ECF
- It is important for:
- bone strength and density
- activating enzymes
- skeletal and cardiac muscle contraction
- controlling nerve impulse transmission
- allowing blood clotting
Ca2+ Level control mechanism
- When more calcium is needed, parathyroid hormone (PTH) is released from the parathyroid glands. PTH increases serum calcium levels by releasing free calcium from bone
- storage sites (bone resorption of calcium), stimulating vitamin D activation to help increase intestinal absorption of dietary calcium, inhibiting kidney calcium excretion,
- and stimulating kidney calcium reabsorption.
- When excess calcium is present in plasma, PTH secretion is inhibited and the secretion of thyrocalcitonin (TCT), a hormone secreted by the thyroid gland, is increased. TCT
- causes the plasma calcium level to decrease by inhibiting bone reabsorption of calcium, inhibiting vitamin D-associated intestinal uptake of calcium, and increasing kidney
- excretion of calcium in the urine.
To assess Hypocalcemia:
- Assess for Hypocalcemia by testing for Trousseaus and Chvosteks signs. To test for Trousseaus sign, place a blood pressure cuff around the upper arm, inflate the cuff to
- greater than the patients systolic pressure, and keep the cuff inflated for 1 to 4 minutes. Under these hypoxic conditions, a positive Trousseaus sign occurs when the hand
- and fingers go into spasm in palmar flexion
- To test for Chvosteks sign, tap the face just below and in front of the ear (over the facial nerve) to trigger facial twitching of one side of the mouth, nose, and cheek
Hypocalcemia intestinal changes
Increased peristaltic activity
Electrolyte and the "hypo...emia" it gives rise to:
- Sodium (Na+): hypoNATREMIA
- Potassium (K+): hypoKALEMIA
- Calcium (Ca2+): hypoCALCEMIA
- Chloride (Cl-): --- not applicable ---
- Magnesium (Mg2+): hypoMAGNESEMIA
- Phosphorus (P): hypoPHOSPHATEMIA
Define Cloride Shift
- Only a small amount of cloride is in the cells because the negative charge on the cell membrane repels chloride and prevents it from crossing the membrane.
- Cloride from the ECF can cross into the ICF if it is exchanged fr another anion. Bicarbonate (HCO3-) is the anion most often exchanged for Cl-
Hypocalcemia skeletal changes
bones break easily
Lactose Intolerance: Who & What
- 75-90% of all Asians, African Americans & American Indians suffer from it.
- Since dairy producrts are such a good source of calcium, these people may have difficulty maintaining Ca in the blood and bones.
1. The older adult client is placed on furosemide (Lasix) for peripheral edema. Which assessment most directly identifies a risk for falls?
- A) a. Oral membranes
- B) b. Orthostatic blood pressure
- C) c. Pulse rate
- D) d. Serum potassium
2. The client has a serum potassium of 3.1 mEq/L. What is the safe way to administer parenteral potassium-containing solution to this client?
- A) a. Administer KCl, 5 mEq, given intramuscularly.
- B) b. Dilute KCl, 200 mEq, in 1 liter of normal saline and infuse at 100 mL/hr.
- C) c. Infuse KCl, 10 mEq, over 1 hour.
- D) d. Push KCl, 5 mEq, through a central line.
3. The client is on intake and output and daily weights. When the night nurse asks for the morning weight from the nursing assistant before the morning shift report, the
- assistant says, ''She was sleeping so well, I didn't want to wake her to get her up for her weight.'' What is the best response by the nurse?
- A) a. ''That was a good idea. She needs the rest.''
- B) b. ''Get the information before I write you up for not doing your job.''
- C) c. ''I will do it myself.''
- D) d. ''Please get the information. It is important that it be done the same time each day.''
4. Fluid intake must be increased in which situations because of ''insensible water loss''? (Select all that apply.)
- A) a. Diarrhea
- B) b. Dry, hot weather
- C) c. Fever
- D) d. Increased respiratory rate
- E) e. Nausea
5. Which clients have an increased risk for fluid and electrolyte imbalances? (Select all that apply.)
- A) a. 24-year-old male athlete
- B) b. 76-year-old bedridden woman
- C) c. 45-year-old man on diuretics
- D) d. 47-year-old man traveling to South America
- E) e. 22-year-old pregnant woman in her third trimester
6. The nurse instructs the older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs?
- A) a. Alpha antagonists
- B) b. Beta blockers
- C) c. Corticosteroids
- D) d. Loop diuretics
7. The nurse is instructing the client being discharged with a diagnosis of congestive heart failure. Which statement by the client indicates understanding of the disorder?
- A) a. ''I can gain 2 pounds of water a day without risk.''
- B) b. ''I should call my provider if I gain more than 1 pound a week.''
- C) c. ''Weighing myself daily can determine if my diet is effective.''
- D) d. ''Weighing myself daily can indicate increased fluid retention.''
8. The client with which condition is at greatest risk for hypernatremia?
- A) a. Excessive sweating
- B) b. Hyperglycemia
- C) c. On hypotonic fluids
- D) d. Low-salt diet
9. Which common physiologic change resulting from the aging process alters hydration status in the older adult?
- A) a. Adrenal growth
- B) b. Decreased muscle mass
- C) c. Increased thirst reflex
- D) d. Poor skin turgor
10. In reviewing serum electrolytes for a newly-admitted client, the nurse is most concerned with which result?
- A) a. Glucose, 97
- B) b. Magnesium, 2.1
- C) c. Potassium, 5.9
- D) d. Sodium, 143
11. After drug therapy for hyperkalemia, the nurse hopes to see which potassium level result in the client indicating that therapy was effective?
- A) a. 7.6 mEq/L
- B) b. 5.6 mEq/L
- C) c. 4.6 mEq/L
- D) d. 2.6 mEq/L
12. The client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse prioritize?
- A) a. Temperature
- B) b. Pulse
- C) c. Respirations
- D) d. Blood pressure
13. The client develops fluid overload while in the intensive care unit. Which intervention does the nurse perform?
- A) a. Draws blood for laboratory tests
- B) b. Elevates the head of the bed
- C) c. Lowers the head of the bed
- D) d. Places the extremities in a dependent position
14. In providing care to the client with hyponatremia, which finding requires immediate action by the nurse?
- A) a. Diminished bowel sounds
- B) b. Heightened acuity
- C) c. Muscular weakness
- D) d. Urine output of 35 mL/hr.
15. A nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them?
- A) "Be careful not to overload them with too many oral fluids."
- B) "Offer fluids that they prefer frequently and on a regular schedule."
- C) "Restrict their fluids in the evening hours if they are incontinent."
- D) "Wake them every 2 hours during the night with a drink."
16. A nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate (MgSO4). Which assessment parameter is critical?
- A) 24-hour urine output
- B) Asking the client about feeling depressed
- C) Hourly deep tendon reflexes (DTRs)
- D) Monitoring of serum calcium levels
17. The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN?
- A) 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day
- B) 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L
- C) 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L
- D) 80-year-old with 3+ peripheral edema who has crackles throughout the posterior chest
18. The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46. Which staff member is assigned to care for her?
- A) LPN/LVN who has floated from the hospital's long-term care unit
- B) LPN/LVN who frequently administers medications to multiple clients
- C) RN who has floated from the intensive care unit
- D) RN who usually works as a diabetic educator
19. A nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed
- assistive personnel (UAP)?
- A) Assessing oral mucosa for dryness
- B) Choosing appropriate oral fluids
- C) Monitoring skin turgor for tenting
- D) Offering fluids to drink every hour
20. An RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?
- A) Assessing skin integrity and abdominal distention
- B) Drawing blood from a central venous line for electrolyte studies
- C) Evaluating laboratory study results for the presence of hypokalemia
- D) Placing the client in a semi-Fowler's position
21. Which newly written physician prescription does the nurse administer first?
- A) Intravenous (IV) normal saline to a client with a serum sodium of 132 mEq/L
- B) Oral calcium supplements to a client with severe osteoporosis
- C) Oral phosphorus supplements to a client with acute hypophosphatemia
- D) Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L
22. A physician writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first?
- A) Administering sodium polystyrene sulfonate (Kayexalate) orally.
- B) Ensuring that a potassium-restricted diet is ordered.
- C) Placing the client on a cardiac monitor.
- D) Teaching the client about foods that are high in potassium.
23. The nurse manager of the medical-surgical unit assigns which client to the LPN/LVN?
- A) 44-year-old admitted with dehydration who has a heart rate of 126
- B) 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home
- C) 64-year-old admitted yesterday with heart failure who still has dependent pedal edema
- D) 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea
24. An RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
- A) Inserting a small-gauge needle for intravenous (IV) access
- B) Evaluating a headache that develops during the transfusion
- C) Explaining to the client the purpose of the blood transfusion
- D) Obtaining baseline vital signs before blood administration
25. An RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)?
- A) Consulting with a health care provider about a client's lab results
- B) Infusing 500 mL of normal saline over 60 minutes
- C) Monitoring IV fluid to maintain the drip rate at 75 mL/hr.
- D) Providing oral care every 1 to 2 hours
26. After receiving change-of-shift report, which client does the RN assess first?
- A) 26-year-old with nausea and vomiting who complains of dizziness when standing
- B) 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst
- C) 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg
- D) 56-year-old with normal saline infusing at 150 mL/hr. whose hourly urine output has been averaging 75 mL
27. An RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
- A) Client behavior that changes from anxious and restless to lethargic and confused
- B) Deep furrows on the surface of the tongue
- C) Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
- D) Urine output of 950 mL for the past 24 hours
28. The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the
- A) Calcium level of 9.5 mg/dL
- B) Magnesium level of 4.1 mEq/L
- C) Potassium level of 6.0 mEq/L
- D) Sodium level of 120 mEq/L
29. A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit?
- A) Dialysis/Home Care
- B) Geriatric/Rehabilitation
- C) Medical-Surgical
- D) Telemetry/Cardiac Step-Down
Because hypermagnesemia causes changes in the electrocardiogram that may result in cardiac arrest, the client should be admitted to the Telemetry/Cardiac Step-Down unit
30. A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide?
- A) Assessment of muscle tone and strength
- B) Education about potassium-rich foods
- C) Instruction on the proper use of drugs
- D) Measurement of the client's urine output
31. A nurse is planning care for a client with Hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?
- A) Collaborating with the dietitian to provide calcium-rich foods for the client
- B) Evaluating the client's laboratory results
- C) Implementing Seizure Precautions for the client
- D) Transferring the client from the bed to a stretcher using a lift sheet
32. A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first?
- A) Auscultating bowel sounds
- B) Checking deep tendon reflexes (DTRs)
- C) Determining the level of consciousness (LOC)
- D) Obtaining a pulse oximetry reading
Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first
33. Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Laboratory results include a potassium level of 7.0 mEq/L. Which medication(s) does the nurse anticipate administering?
- A) Insulin (regular insulin) and dextrose (D20W)
- B) Loperamide (Imodium)
- C) Sodium polystyrene sulfonate (Kayexalate)
- D) Supplemental potassium
34. Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not
- been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L.
- What is the primary goal of drug therapy for this client?
- A) Decreasing cardiac contractility and slowing the heart rate
- B) Elevating serum potassium levels to a safe range
- C) Maintaining proper diuresis and urine output
- D) Restoring fluid balance by controlling the causes of dehydration
Drug therapy for dehydration is directed at restoring fluid balance and controlling the causes of dehydration.
35. Situation: A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flu-like symptoms for the past week
- and has been unable to drink for the past 48 hours. The physician requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse
- A) 0.45% saline
- B) 5% dextrose in 0.45% saline
- C) 5% dextrose in Ringer's lactate
- D) 5% dextrose in water (D5W)
36. Situation: A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flu-like symptoms for the past week and has
- been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician
- orders an IV potassium supplement. How does the nurse administer this medication?
- A) Added to an IV, not to exceed 20 mEq/hr.
- B) Added to an IV, not to exceed 30 mEq/hr.
- C) Rapid IV push, a 25-mEq dose
- D) Slow IV push, a 30-mEq dose
37. Situation: A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her current
- medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because
- she did not think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is
- A) Decreased blood pressure (BP)
- B) Increased heart rate
- C) Increased urine output
- D) Weight gain
When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output
38. Situation: A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not
- think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Ten (10) hours after receiving the Lasix, the client's potassium (K+)
- level is 2.5 mEq/L. Knowing all of the client's medications, what problem(s) does the nurse anticipate in this client?
- A) Clinical manifestations of digoxin toxicity
- B) Increased heart rate and blood pressure (BP)
- C) Increased signs of congestive heart failure (CHF)
- D) Signs and symptoms of hypernatremia
Hypokalemia increases the sensitivity of cardiac muscle to Lanoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range
39. Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What
- clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply.
- A) Blood serum glucose
- B) Pulse rate and quality
- C) Urinary output
- D) Urine specific gravity levels
The two most important areas to monitor during rehydration are pulse rate and quality and urine output; however, decreasing specific gravity of urine is also an indication of rehydration
40. Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What
- does the nurse include in the client's medication teaching? Select all that apply.
- A) Daily weights are a poor indicator of fluid loss or gain.
- B) Diuretics can lead to fluid and electrolyte imbalances.
- C) Diuretics increase fluid retention.
- D) Laxatives can lead to fluid imbalance.
41. Situation: A 68-year-old man is admitted to the hospital with dehydration. Initial laboratory results include a potassium level of 2.7 mEq/L. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. In time, he recovers from his dehydration and low potassium levels. He says to the nurse, "I would like to take fewer medications and eat foods that contain high amounts of potassium."
What foods does the nurse recommend? Select all that apply.
- B) Bananas
- C) Broccoli
- D) Oranges
- E) Spinach
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